• Jie Yang, Ya-Han Zhang, Jia-Yan Huang, and Qiang Lu.
• Department of Ultrasound.
• Medicine (Baltimore). 2021 Apr 2; 100 (13): e25178e25178.

RationalFungal liver infection mostly occurs in immunocompromised patients, and is often associated with delayed diagnosis and high mortality rates. Dynamic contrast enhanced imaging is crucial for the diagnosis of fungal liver infection and has been reported having variable manifestations.Patient ConcernsA 38-year-old Chinese man, with a history of diabetes and chronic hepatitis B, was admitted to our hospital due to prolonged fever of unknown cause. He had a medical history of receiving broad-spectrum antibiotic treatment for pulmonary inflammation at the local hospital. The blood test results showed that the white cell count (14.0 × 109/L) and neutrophil count ratio (77.0%) were subtly elevated. C-reactive protein (92.0 mg/l) and cancer antigen (CA)-125 (904.50 U/ml) were elevated. Non-small cell lung cancer antigen was within the normal limit. Hepatitis B virus DNA load was 3.28 × 103 IU/ml. Sputum and blood cultures were normal. Abdominal ultrasonography (US) found a large heterogeneous mass, with diffused echogenic foci without infiltrating the surrounding vascular, which exhibiting "rapid wash in and out" on contrast-enhanced ultrasound (CEUS).DiagnosisThe diagnosis of liver fungal infection was confirmed pathologically via ultrasound-guided biopsy.InterventionsAntibiotic and antifungal therapy with imipenem and voriconazole.OutcomesThe patient's body temperature had been controlled and the huge mass disappeared on follow-up ultrasound 1-year later.LessonsThis case highlights the unusual imaging features of fungal liver infection, presenting as huge heterogeneous mass with diffusive echogenic foci without infiltrating the surrounding vascular on grayscale US and the enhancement pattern of "rapid wash in and out" on CEUS. Additionally, ultrasound-guided biopsy is necessary for the correct diagnosis of suspected liver lesions.Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.

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