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Letter to the Editor
Hepatic eosinophilic infiltration: Cancer or parasite?
Infiltración eosinofílica hepática: ¿cáncer o parásito?
Miguel Sogbea,b, Andrés Blanco-Di Matteoa,
Corresponding author
ablancod@unav.es

Corresponding author.
, Isberling Madeleine Di Friscoc, Ana Ezpondad, José Luis del Pozoa
a Servicio de Enfermedades Infecciosas y Microbiología, Clínica Universidad de Navarra, Pamplona, Navarra, Spain
b Departamento de Medicina Interna, Clínica Universidad de Navarra, Pamplona, Navarra, Spain
c Departamento de Neumología, Clínica Universidad de Navarra, Pamplona, Navarra, Spain
d Departamento de Radiología, Clínica Universidad de Navarra, Pamplona, Navarra, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Hypereosinophilia is a rare finding defined as an absolute eosinophil count &#62;1500&#47;&#181;l&#46; Eosinophilia can cause infiltration in different organs&#44; with liver and gastrointestinal tract involvement being the most common&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The purpose of this letter to the editor is to describe hepatic eosinophilic infiltration &#40;HEI&#41; in the context of hypereosinophilic syndrome secondary to <span class="elsevierStyleItalic">Strongyloides stercoralis</span> infection&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">This was a 62-year-old male&#44; residing in Africa&#44; with a history of left partial nephrectomy for clear cell carcinoma&#44; who attended a urological check-up asymptomatic&#46; Computed tomography &#40;CT&#41; of the abdomen was performed&#44; showing a hypointense lesion measuring 29&#8239;mm in diameter in segment V of the liver&#44; and abnormal perfusion &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Laboratory tests showed hypereosinophilia of 1840&#47;&#181;l with no other findings&#46; Suspecting metastasis&#44; a liver biopsy was performed&#44; revealing sinusoidal infiltration of eosinophils &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#44; for which Infectious Diseases were asked to assess&#46; A microbiological study was carried out with serology for&#58; schistosomiasis&#44; amoebiasis&#44; anisakiasis&#44; cysticercosis&#44; strongyloidiasis&#44; fascioliasis&#44; hydatidosis and visceral larva <span class="elsevierStyleItalic">migrans</span>&#46; A thick blood smear was also obtained&#44; with no evidence of pathogens&#44; as with the examination of faeces for parasites&#46; The serology results were negative&#44; except for IgG strongyloidiasis&#44; which was positive &#40;index&#58; 4&#46;337&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">After ruling out <span class="elsevierStyleItalic">Loa loa</span> coinfection by serology&#44; the patient was started on ivermectin 200&#8239;&#181;g&#47;kg for two days&#46; At follow-up four months later&#44; CT of the abdomen to monitor for liver damage showed resolution of the focal lesion in segment V &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41; and analysis showed return to normal of the patient&#39;s eosinophil count &#40;290&#47;&#181;l&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">HEI can manifest with radiological findings suggestive of neoplasia&#44; so malignancy has to be ruled out&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> CT images of HEI are usually of small&#44; poorly defined&#44; hypointense lesions&#44; more noticeable in the portal phase&#46; The presence of a liver lesion associated with hypereosinophilia is suggestive of HEI&#46; The combination of clinical and laboratory data may be enough to distinguish an HEI from a malignant lesion&#46; In addition&#44; in our case&#44; the epidemiological risk&#44; normal liver function tests&#44; and the absence of elevated inflammatory parameters made the diagnosis of HEI more likely&#46; Biopsy could have been saved for the event of not responding to anthelmintic treatment or the case of malignancy being strongly suspected&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The most common causes of hypereosinophilia include parasitic infections&#44; hypersensitivity reactions&#44; connective tissue diseases&#44; vasculitis&#44; cancers and paraneoplastic syndromes&#46; Some of the most common parasitic infections are caused by&#58; <span class="elsevierStyleItalic">Toxocara canis</span>&#44; <span class="elsevierStyleItalic">Fasciola hepatica</span>&#44; <span class="elsevierStyleItalic">Clonorchis sinensis</span>&#44; <span class="elsevierStyleItalic">Paragonimus westermani</span>&#44; <span class="elsevierStyleItalic">Taenia solium</span> and <span class="elsevierStyleItalic">S&#46; stercoralis</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Strongyloidiasis is an infection caused by the helminth <span class="elsevierStyleItalic">S&#46; stercoralis</span>&#44; which is able to complete its life cycle inside the human host&#46; Approximately 75&#37; of all infections worldwide occur in Southeast Asia&#44; Africa and the Western Pacific regions&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a> The most common mode of transmission is through skin contact with contaminated soil&#46; Strongyloidiasis can be asymptomatic or associated with non-specific complaints in more than half of cases&#44; particularly in the chronic forms&#46; In patients with subclinical infection who subsequently become immunosuppressed &#40;corticosteroids&#44; organ transplantation&#41;&#44; larval reproduction can lead to disseminated infection&#46; Chronic infection can become apparent in the form of eosinophilia and liver lesions&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a> Liver lesions caused by <span class="elsevierStyleItalic">S&#46; stercoralis</span> are the result of parasite migration in the liver parenchyma in the context of a disseminated disease caused by hyperinfection&#46; However&#44; they do not normally cause hypereosinophilia and the parasite is usually visible in the liver biopsy&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Serology testing is the preferred diagnostic method&#44; as it is more sensitive than stool analysis&#46; Most serology tests measure the IgG response to an extract of larvae obtained from experimentally infected animals or related species of <span class="elsevierStyleItalic">Strongyloides</span> spp&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a> The treatment of choice is ivermectin&#46; In patients from areas endemic for Loiasis&#44; a screening for loasis microfilaraemia &#40;blood smear&#41; should be performed prior to administration&#44; as treatment with ivermectin in cases of a high parasite load may precipitate a potentially fatal Mazzotti reaction &#40;fever&#44; hypotension&#44; encephalitis&#44; etc&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors declare that they received no funding to conduct this study&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">Jos&#233; Luis del Pozo has participated in training or consulting activities funded by Pfizer&#44; MSD&#44; Gilead and Novartis&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The other authors have no conflicts of interest to declare&#46;</p></span></span>"
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