2010, Cilt 23, Sayı 1, Sayfa(lar) 045-050
[ Özet ] [ PDF ] [ Benzer Makaleler ] [ Yazara E-Posta ] [ Editöre E-Posta ]
COMPUTED TOMOGRAPHY AND ULTRASONOGRAPHIC FINDINGS OF HEPATIC INVOLVEMENT RELATED TO EOSINOPHILIA MIMICKING LIVER METASTASES: REPORT OF 2 CASES
Elif Karadeli1, Esra Meltem Kayahan Ulu1, Erkan Yıldırım1, Gulhan Kanat Unler2, Halil Kıyıcı3
1Başkent Üniversitesi Tıp Fakültesi, Radyoloji Ana Bilim Dalı, Ankara, Türkiye
2Başkent Üniversitesi Tıp Fakültesi , Gastroenteroloji Ana Bilim Dalı , Ankara, Türkiye
3Başkent Üniversitesi Tıp Fakültesi , Patoloji Ana Bilim Dalı , Ankara, Türkiye
Keywords: Hypereosinophilic syndrome, Liver, Computed Tomography
Abstract
The hypereosinophilic syndrome is a severe disease affecting multiple organ systems as the heart, skin, liver, spleen, urinary, gastrointestinal, nervous, and hematopoietic systems. The most important findings are eosinophilic infiltration and peripheral eosinophilic leukocytosis.

Here, we report liver involvement and abdominal computed tomography (CT) and ultrasonography (US) characteristics of the hypereosinophilic syndrome in two patients.

  • Top
  • Abstract
  • Introduction
  • Case Presentation
  • Disscussion
  • References
  • Introduction
    The hypereosinophilic syndrome is a severe disease affecting multiple organ systems caused by eosinophilic infiltration and peripheral eosinophilic leukocytosis. In particular, the heart, skin, liver, spleen, urinary, gastrointestinal, nervous, and hematopoietic systems, are affected. Clinical findings depend on the degree of organ involvement1. This syndrome, first described by Hardy and Anderson in 1968, is known as idiopathic eosinophilia2. It is characterized by persistent peripheral eosinophilia of 1500 eosinophils/ mm3 or more for more than 6 months. In addition, other causes of eosinophilia including parasitic infestations, allergic reactions, connective tissue disorders, dermatoses, neoplastic diseases, and organ involvement are absent3.

    There have been reports of ultrasonography (US) and abdominal computed tomography (CT) findings of liver involvement related to eosinophilia4-6. Here, we report 2 cases. In the first, we report the helical abdominal CT, US, and pathologic findings of hepatic involvement of eosinophilia-related necrosis mimicking hepatic metastases. In the second case, we report the helical CT findings during eosinophilia and during normal eosinophil levels.

  • Top
  • Abstract
  • Introduction
  • Case Presentation
  • Disscussion
  • References
  • Case Presentation
    Case Report 1
    A previously healthy 57-year-old man with dull pain in the right upper quadrant of the abdomen and epigastric discomfort was admitted to the gastroenterology department of our hospital. The patient was evaluated by abdominal US, which showed diffuse, coarse parenchymal echogenicity without any focal mass, and heterogeneous, hypoechoic, ill-defined areas in the left lobe of the liver. The patient had mild liver dysfunction, with slightly elevated alanine aminotransferase and aspartate aminotransferase levels. The peripheral white blood cell (WBC) count was 9430/mm3, with 46.7% eosinophils (normal range, less than 7% of WBCs). The results of microbiologic and immunologic, alfa feto protein (AFP), prostat spesifik antijen (PSA), and erythrocyte sedimentation rate tests were normal. The patient had no history of allergic diseases, and the results of stool and skin tests for parasites were negative.

    The patient underwent triphasic dynamic helical CT scanning (MX8000, Philips, Holland ) with a bolus injection of 150 mL nonionic contrast medium via a power injector. Precontrast and arterial phase CT images showed hypodense, nodular areas in the hepatic parenchyma. There were multiple, hypodense nodules with relatively ill-defined margins in the left and right hepatic lobes on portal venous phase CT images. The lesions appeared clearer during the portal venous phase than during the hepatic arterial phase. In particular, lesions in the left lobe were compositely and bigger than were the lesions in the right lobe. On equilibrium phase images, minimal contrast enhancement was observed around hypodense nodules which had poorly defined margins. Some lesions appeared as patchy subtle hypodense areas rather than as focal nodules. The portal and hepatic veins were normal. The patient had no pathologic lymphadenopathy, and results of a thoracic CT scan were normal. Because of the CT findings, we believed the lesions to be metastatic lesions. Results of an endoscopy and colonoscopy were normal. After sonographic localization of the lesions, a sonographically guided percutaneous biopsy of the poorly defined hypoechoic areas in the left lobe was performed using an 18-gauge automated biopsy gun.

    Microscopically, the biopsy specimen showed foci of hepatocellular necrosis, fibrosis, marked inflammatory cell infiltrates that were composed predominantly of eosinophils and degenerate polymorphonuclear leukocytes in the necrotic areas. Specifically, there was severe infiltration of the periportal area by eosinophils and mononuclear leukocytes. No pathologic microorganisms were observed on histology. No atypical or metastatic cells were seen. The pathologic diagnosis was concordant with necrosis and an inflammatory change that formed an abscess.

    Case Report 2
    A 51-year-old woman complaining of epigastric discomfort was admitted to the gastroenterology department of our hospital. The patient was evaluated with abdominal US, which showed multiple peripheral isoechoic and hypoechoic solid lesions with a surrounding “halo.” Results of standard laboratory analyses demonstrated 11700 / mm3 leukocytes with 16.7% eosinophils (normal WBC range, < 7%). The results of microbiologic and immunologic tests, AFP, CEA were normal. The patient’s history was not significant for any allergic diseases, and the results of stool and skin tests for parasites were negative.

    The patient underwent a triphasic, dynamic, helical CT scan with a bolus injection of 120 mL nonionic contrast medium. Precontrast and arterial phase CT images showed multiple, oval or wedge-shaped, hypodense nodular lesions of varying sizes in the hepatic parenchyma. Portal venous phase CT images demonstrated segmental and/or subsegmental involvement in both lobes of the liver . Most of the lesions showed contrast enhancement on equilibrium phase images. The portal and hepatic veins appeared normal. Owing to the CT findings, we believed the lesions to be metastatic lesions. Endoscopy was concordant with gastritis. Abdominal CT images obtained 2.5 months after the start of gastritis, medical therapy showed a decrease in the sizes and the number of lesions. The patient’s WBC count was 8640 mm3 with 5.6% eosinophils. The patient’s eosinophilia improved and the number of lesions decreased and so, we believed that these lesions might be related to hypereosinophilia.


    Click Here to Zoom
    Figure 1: A 57-year-old man with dull pain in the right upper quadrant of the abdomen: a) transverse sonogram of the liver shows hypoechoic, patchy areas in the left lobe, b and c) CT images on arterial and portal phase show multiple hypodense lesions in the left and right lobes of the liver, d) the equilibrium phase image shows contrast enhancement of these lesions, e) a photomicrograph of a needle biopsy specimen shows hepatocellular necrosis and numerous mononuclear inflammatory cell infiltrates predominantly composed of eosinophils (H&E, × 200).


    Click Here to Zoom
    Figure 2: A 51-year-old woman presented with epigastric discomfort: a) CT images in the portal venous phase show multiple, round, oval or wedge-shaped hypodense lesions of both liver lobes, b) control CT images obtained 2.5 months after medical treatment showing a decrease in the number and size of the lesions.

  • Top
  • Abstract
  • Introduction
  • Case Presentation
  • Disscussion
  • References
  • Discussion
    Eosinophilia can depend on many diseases, such as neoplastic diseases, parasitic infestations, allergic reactions, and hypereosinophilic syndromes. Some parasitic infestations manifest as focal lesions in the hepatic parenchyma via penetration or hematogenous migration of the parasite to the liver7. Lymphoma, leukemia, and carcinoma may be associated with eosinophilia. However, these patients have a primary tumor mass. Eosinophilia may resolve following extraction of the primary mass8. Neither a parasitic infestation nor a primary tumor mass was found in our patients.

    The hypereosinophilic syndrome is a spectrum of disorders characterized by marked eosinophilic leukocytosis without organ dysfunction and with no known cause. Liver involvement may be present, and hepatomegaly and abnormal results on liver tests are present in 40% to 90% of patients with the disorder1,2,5. Men constitute approximately 85% of the patients with the hypereosinophilic syndrome, which occurs primarily in middle age. The most frequent complaints are weight loss, dry cough, and weakness, although symptoms and signs vary. WBC counts generally range from 10 000 to 100.000/mm3, and peripheral eosinophil percentages are 30%-70% in the majority of patients1,2,9. Because our first patient had eosinophilia, minimally abnormal results on his liver function tests, no allergic reactions, and his complaints were nonspecific, we thought that he might have the hypereosinophilic syndrome.

    There are reports of pathologic changes from eosinophil-related hepatic damage on CT and US4-6,10. The most common pathologic findings are severe infiltration by eosinophils in the periportal area, eosinophilic abscess, and hepatocellular necrosis. The first patient had foci of hepatocellular necrosis, fibrosis, severe infiltration of the periportal area by eosinophils and mononuclear leukocytes, and inflammatory changes to produce an abscess.

    In the hypereosinophilic syndrome, findings on US are hepatomegaly, diffuse, coarse parenchymal echogenicity without focal mass; or multiple, hypoechoic, isoechoic, or hyperechoic focal nodular lesions in the liver. The margins of lesions may be ill-defined or well-defined5,6. In our first case, there was diffuse hyperechogenicity of the liver without any focal mass on US. The left liver lobe showed hypoechoic patchy areas with poorly defined margins. In the second case, the lesion margins were well-defined on US. In previous reports, abdominal CT images have demonstrated oval or round, hypodense lesions, particularly in areas adjacent to the portal veins. These lesions were well-defined or ill-defined, with an average diameter of 2 cm (range, 1-4 cm). Most lesions were visible during the portal venous phase more so than during the hepatic arterial phase. During the equilibrium phase, some lesions showed contrast enhancement and disappeared5,6,11. Similarly, in our first patient, there were multiple hypodense lesions with relatively poorly defined margins during the portal phase. Some of this patient’s lesions during the equilibrium phase showed minimal contrast enhancement. Contrast enhancement of lesions during the equilibrium phase was more pronounced in our second patient. According to previous reports, the isodense appearance results from the fact that contrast material diffuses more easily into small, hypodense lesions6. As reported earlier, we found that CT, as compared with US, demonstrated a greater number of lesions, of greater sizes, with more clearly defined margins. Kim and associates reported that CT images obtained 2 to 6 months after the start of corticosteroid or antihistamine therapy showed a nearly normal appearance of the liver5. The percentage of eosinophils in peripheral blood has been associated with the number of lesions6. In the second patient in this report, we did not apply a specific therapy because the patient’s eosinophil count was normal and the number of lesions decreased after 2.5 months and we believed that the lesions might have arisen from eosinophilia-related hepatic damage.

    If the CT and US findings of eosinophil-related liver necrosis are nonspecific, it may be difficult to differentiate them from metastatic lesions. There have been reports in the literature of some imaging findings that can help differentiate these lesions from metastatic hepatic lesions—specifically, that focal hepatic lesions in the portal or hepatic vein might be indicative of benign parenchymal lesions. However, malignant neoplasms are rarely observed in these vessels without mass effect6,12 Unfortunately, these lesions were not distinguished from metastatic lesions by us on the basis of the above knowledge.

    In summary, if a patient has eosinophilia in the peripheral blood, eosinophil-related liver involvement and liver necrosis should be considered. CT images provide a greater degree of information than does US about eosinophil-related liver involvement. Additionally, the number of lesions in the liver is correlated with the amount of eosinophils in the peripheral blood. Therefore, follow-up CT is important in this patient population. To differentiate these lesions from metastatic lesions on CT images, a liver biopsy and a control CT should be performed.

  • Top
  • Abstract
  • Introduction
  • Case Presentation
  • Discussion
  • References
  • References

    1) Fauci AS, Harley JB, Roberts WC, Ferrans VJ, Gralnick HR, Bjornson BH. NIH conference. The idiopathic hypereosinophilic syndrome. Clinical, pathophysiologic, and therapeutic considerations. Ann Intern Med. 1982 Jul;97:78-92.

    2) Hardy WR, Anderson RE. The hypereosinophilic syndromes. Ann Intern Med. 1968 Jun;68:1220-1229.

    3) Chusid MJ, Dale DC, West BC, Wolff SM. The hypereosinophilic syndrome: analysis of fourteen cases with review of the literature. Medicine (Baltimore). 1975 Jan;54:1-27.

    4) White WL, Wahner HW, Brown ML, James EM. Sequential liver imaging in the hypereosinophilic syndrome: discordant images with scintigraphy, ultrasound, and computed tomography. Clin Nucl Med. 1981 Feb;6:75-77.

    5) Kim GB, Kwon JH, Kang DS. Hypereosinophilic syndrome: imaging findings in patients with hepatic involvement. AJR Am J Roentgenol. 1993 Sep;161:577-580.

    6) Lee WJ, Lim HK, Lim JH, Kim SH, Choi SH, Lee SJ. Foci of eosinophil-related necrosis in the liver: imaging findings and correlation with eosinophilia. AJR Am J Roentgenol. 1999 May;172:1255-1261.

    7) Farid Z, Kilpatrick ME, Chiodini PL. Parasitic diseases of the liver. In: Schiff L, Schiif ER, eds. Diseases of the liver. 6th ed. Philadelphia: Lippincott; 1993:1338-1355.

    8) Wasserman SI, Goetzl EJ, Ellman L, Austen KF. Tumor-associated eosinophilotactic factor. N Engl J Med. 1974 Feb 21;290:420-424.

    9) Epstein DM, Taormina V, Gefter WB, Miller WT. The hypereosinophilic syndrome. Radiology 1981 Jul;140:59-62.

    10) Lim JH, Lee WJ, Lee DH, Nam KJ. Hypereosinophilic syndrome: CT findings in patients with hepatic lobar or segmental involvement. Korean J Radiol 2000 Apr-Jun;1:98-103.

    11) Cha SH, Park CM, Cha IH, et al. Hepatic involvement in hypereosinophilic syndrome: value of portal venous phase imaging. Abdom Imaging 1998 Mar-Apr;23:154-157.

    12) Apicella PL, Mirowitz SA, Weinreb JC. Extension of vessels through hepatic neoplasms: MR and CT findings. Radiology 1994 Apr;191:135-136.

  • Top
  • Abstract
  • Introduction
  • Case Presentation
  • Discussion
  • References
  • [ Başa Dön ] [ Özet ] [ PDF ] [ Benzer Makaleler ] [ Yazara E-Posta ] [ Editöre E-Posta ]