Multifocal fatty sparing areas in a steatotic liver mimicking hepatic lesions: a case report and review of the literature

Fatty liver disease is a major global health problem that can be challenging to diagnose, particularly when focal fatty-sparing mimics hepatic neoplasms. These imaging findings can result in undue concern and may prompt invasive procedures that could otherwise be avoided. Accurate differentiation between benign focal fat-related changes and malignant lesions requires careful correlation of imaging features with clinical and laboratory findings. A 34-year-old Arab female with a history of hyperlipidemia and hypothyroidism was hospitalized for acute appendicitis. During her admission, multiple hepatic nodules were incidentally detected. Abdominal ultrasound revealed a diffusely fatty liver with multiple hypoechoic nodules suspicious for malignancy. However, contrast-enhanced computed tomography scan (CT scan) and magnetic resonance imaging (MRI) characterized these lesions as multifocal fatty-sparing areas rather than true neoplasms. Laboratory evaluation supported a diagnosis of nonalcoholic fatty liver disease (NAFLD) with dyslipidemia. Follow-up imaging demonstrated stability of the lesions, confirming their benign etiology. This case highlights the diagnostic challenge of distinguishing focal fatty sparing from malignant hepatic lesions in patients with NAFLD. Advanced imaging techniques, combined with clinical and laboratory correlation, are essential for accurate diagnosis and to avoid unnecessary invasive interventions.