J Ultrasound Med 7:695 - 698, 1988
3. Niloff JM, Knapp RC, Schaetzl E, et al: CA125 antigen
levels in obstetric and gynecologic patients. Obstet Gyne-
col 64:703, 1984
To the Editor:-Rak et aP describe accentuated peripor-
tal echogenicity and diminished parenchymal echogen-
icity in the liver ("starry sky" pattern) that they ascribe to
Burkitt's lymphoma, yet they offer no histologic proof of
hepatic lymphomatous infiltration in their patient. In
other cases, Burkitt's lymphoma of the liver has pro-
duced discrete, hypoechoic intrahepatic masses. 2 - 4 Al-
though diffuse hepatic sinusoidal infiltration has been
reported in Burkitt's lymphoma, no imaging findings
were described. 5
Consider possible alternative explanations for the
findings of Rak et al. Liver transplant recipients often
develop transient postoperative periportal increased
echogenicity6 that yields a "starry sky" appearance (Fig.
1). Evidence exists that this phenomenon is caused by
dilated periportal lymphatic channels? In the patient
REFERENCES
1. Rak K, Hopper KD, Parker SH: The "starry sky" liver with
Burkitt's lymphoma. J Ultrasound Med 7:279, 1988
2 Siegel MJ, Melson GL: Sonographic demonstration of he-
patic Burkitt's lymphoma. Pediatr Radio! 11:166, 1981
3. Charboneau JW, James EM, Reading CC: Sonography case
of the day. AJR 142:1075, 1984
4. Vade A, Blane CE: Imaging of Burkitt's lymphoma in pedi-
atric patients. Pediatr Radio! 15:123, 1985
LE1TERS TO THE EDITOR 697
4. van Dalen A, Favier J, Easthan WN: Preliminary observa-
tions with new monoclonal antibody in ovarian card·
noma. Tumor diagnostik &t Therapie 5:67, 1984
reported by Rak et al the retroperitoneal lymphadenopa-
thy and/or the ascites itself may have mechanically im-
peded hepatic lymphatic drainage, leading to increased
periportal echogenicity. Periportal edema might pro·
duce the same finding. The diminished hepatic paren-
chymal echogenicity could have been a product of re-
duced gain as the ultrasonographer compensated for the
presence of massive ascites.
Given the altogether nonspecific nature of the "starry
sky" pattern, the assertion that hepatic lymphomatous
infiltration must have produced these findings is not
compelling in the absence of supportive histologic evi-
dence.
..6("DELBERT BoweN, MD
Children's Hospital of Pittsburgh
Pittsburgh, Pennsylvania
Figure 1 Transverse image of liver
two days after hepatic transplantation.
"Starry sky" pattern produced by peri~
portal increased echogenicity.
5. Linder J, Woodard BH, Kinney TR, et al: Recurrent Bur-
kitt's lymphoma mimicking toxic vena-occlusive disease
of the liver. Am J Pediatr Hematol Oncol 6:93, 1984
6. Claus D, Clapuyt P: Liver transplantation in children: Role
of the radiologist in the preoperative assessment and the
postoperative follow-up. Transplant Proc 19:3344, 1987
7. Marincek B, Barbier PA, Becker CD, et al: CT appearance of
impaired lymphatic drainage in the liver transplants. AJR
1986
698 LETI'ERS TO TilE EDITOR
To the Editor:- In their informative article "The 'Starry
Sky' Liver With Burkitt's Lymphoma," Rak et al 1 cor-
rectly quote Needleman et a1,2 who list the causes of the
"bright liver" as fatty infiltration, chronic hepatitis,
acute alcoholic hepatitis, chronic passive congestion,
and cirrhosis.
Other causes of the bright liver have been described.
Ginaldi et aP have reported the same appearance in
lymphoma (though not Burkitt's) and we• found it in
eight biopsy proven cases of miliary tuberculosis of the
liver (uncomplicated by cirrhosis). Miliary tuberculosis
often produces a confusing clinical picture, sometimes
including ascites, as in the patient with Burkitt's lym-
phoma.' A cough may be absent. A chest radiograph
should therefore be obtained in all patients with hepato-
megaly and a bright liver pattern.
W.K. ANDRBW
Eugene Marais Hospital
L,e, Marais, Pretoria
Response: - We appreciate the contributions of Drs. An-
drew and Bowen to our article and to the differential
diagnosis of a "starry sky" liver. Though most com-
monly reported with hepatitis or leukemia, this sana-
graphic pattern can occasionally be seen with lym-
phoma, periportal edema, and post-transplantation. We
found especially interesting Dr. Andrew's comments on
miliary tuberculosis.
The sonographic presentation of our patient, how-
ever, is not artifact. Several Acuson examinations were
performed by highly qualified sonographers and radiol-
ogists, all of whom confirmed the "starry sky" liver. The
postulate raised by Dr. Bowen that this appearance may
be secondary to lymphatic obstruction in the liver is a
valid point. However, it has been reported, as Dr. Bowen
himself states, that Burkitt's lymphoma can be hypo-
echoic and has been reported to produce diffuse hepatic
infiltration. For several reasons, we feel that in our case
the "starry sky" appearance is less likely due to lym-
phatic blockage than due to infiltration with lymphoma.
J Ultrasound Med 7:695-698, 1988
REFERENCES
1. Rak I<, Hopper KD, Parker SH: The "starry sky" liver wilh
Burkitt's lymphoma. J Ultrasound Med 7:219, 1988
2. Needleman L, Kurtz AB, Rifkin MD, et al: Sonography of
diHuse benign liver disease: Accuracy of pattern recogni-
tion and grading. AJR 146:10U, 1986
3. Ginaldi S, Bernardino ME, Jing BS, et al: Ultrasound pat-
terns of hepatic lymphoma. Radiology 136:427, 1980
4. Andrew WK, Glyn Thomas R, Gollach BL: Miliary tuber-
culosis of the liver-another cause of the "bright liver'' on
ultrasound examination. S Ah Med J62:808, 1982
First, there was extensive pathologic proof from laparot·
omy including peritoneal and lymph node biopsies. Sec-
ond, periportal lymphatic edema from the ascites is un·
likely as the ascites worsened whereas the hepatic
sonotexture returned to normal. The resolution of the
patient's "starry sky" liver progressed rapidly after ini-
tiation of chemotherapy and paralleled the diminishing
retroperitoneal adenopathy and improving hepatic
functions. Following treatment, this patient was fol-
lowed extensively by laboratory tests and sonography
over the next 14 months and never again developed liver
enzyme elevation, evidence of acute or chronic hepatitis,
or an abnormal texture sonographically of the liver.
CPT. KEVIN M. RAK, MD
MAJ. KENNETH D. HOPPER, MD
MAJ. STEVE H. PARKER, MD
Department of Radiology
riZSimmons Army Medical Center
Aurora, Colorado