Hypereosinophilic syndrome: CT findings in patients with hepatic lobar or segmental involvement

Severe Acute Respiratory Distress in a Child with Hypereosinophilic Syndrome: A Case Report

Hypereosinophilic syndrome with respiratory distress and multiorgan involvement is not so common in children. It is essential to identify this entity based on clinical, laboratory, and imaging features. Corticosteroids should be instituted at the earliest to stabilize the patient and prevent organ damage. Tropical infections are a common secondary cause in children warranting the administration of Diethylcarbamazine. We present a case of an adolescent male in respiratory distress with marked eosinophilia and organs involving the lungs (pulmonary infiltrates with effusion), heart (pericardial effusion), and abdomen (ascites with infiltrates in the liver) which was managed with steroids and anthelmintics. The case highlights the importance of identifying patients with Hypereosinophilic syndrome in pursuing thorough evaluation and commencing therapy.

Idiopathic hypereosinophilic syndrome with hepatic sinusoidal obstruction syndrome: A case report and literature review

BACKGROUND

Hypereosinophilic syndrome (HES) is classified as primary, secondary or idiopathic. Idiopathic HES (IHES) has a variable clinical presentation and may involve multiple organs causing severe damage. Hepatic sinusoidal obstruction syndrome (HSOS) is characterized by damage to the endothelial cells of the hepatic sinusoids of the hepatic venules, with occlusion of the hepatic venules, and hepatocyte necrosis. We report a case of IHES with HSOS of uncertain etiology.

CASE SUMMARY

A 70-year-old male patient was admitted to our hospital with pruritus and a rash on the extremities for > 5 mo. He had previously undergone antiallergic treatment and herbal therapy in the local hospital, but the symptoms recurred. Relevant examinations were completed after admission. Bone marrow aspiration biopsy showed a significantly higher percentage of eosinophils (23%) with approximately normal morphology. Ultrasound-guided hepatic aspiration biopsy indicated HSOS. Contrast-enhanced computed tomography (CT) of the upper abdomen showed hepatic venule congestion with hydrothorax and ascites. The patient was initially diagnosed with IHES and hepatic venule occlusion. Prednisone, low molecular weight heparin and ursodeoxycholic acid were given for treatment, followed by discontinuation of low molecular weight heparin due to ecchymosis. Routine blood tests, biochemical tests, and imaging such as enhanced CT of the upper abdomen and pelvis were reviewed regularly.

CONCLUSION

Hypereosinophilia may play a facilitating role in the occurrence and development of HSOS.

CT and MRI findings in focal eosinophilic infiltration of the liver

OBJECTIVES

To investigate the findings of computed tomography (CT) and magnetic resonance imaging (MRI) of focal eosinophilic infiltration (FEI) of the liver.

METHODS

A retrospective study including 29 patients with confirmed FEI of the liver was performed. We evaluated the lesions' number, distribution, size, shape, margin, attenuation or signal intensity characteristics, the enhancement pattern, and some special features. Spearman correlation analysis was used to analyze the correlation between the number of lesions and the eosinophil counts in peripheral blood.

RESULTS

In all, 108 lesions were detected in 29 cases, including two cases with single lesion and the remaining 27 cases with multiple lesions. The mean size of all lesions was 34 mm (range, from 3 to 61 mm). 95 (88%) lesions were located in subcapsular parenchyma or surrounding the portal vein. Most (66%) subcapsular lesions were wedge shaped and all lesions surrounding portal vein were round shaped. However, the hepatic parenchymal lesions were irregular or round shaped. All lesions showed ill-defined margins. On pre-contrast CT images, the lesions showed slightly low attenuation or iso-attenuating. On T1-weighted and T2-weighted images, the lesions were slightly iso-/hypointense and hyperintense, respectively. A total of 23 (79.3%) cases were gradually enhanced. Branches of portal vein went through the lesions in all cases; 12 had 'stripe sign' and 16 had 'halo ring sign.' Spearman analysis indicated a significant correlation between the number of lesions and the increased eosinophils in peripheral blood (r = 0.627, p = 0.0003).

CONCLUSIONS

Special CT and MRI features and increased eosinophils may strongly suggest the diagnosis of FEI of the liver.

Hepatic visceral larva migrans, a resilient entity on imaging: Experience from a tertiary liver center

INTRODUCTION

Hepatic visceral larva migrans (VLM) is an uncommon parasitic manifestation seen in the liver. It presents as coalescing, conglomerated, or solitary abscess cavities in the liver on imaging. We conducted a retrospective clinico-radiological analysis of 24 patients with biopsy proven VLM who were reviewed and followed up at our tertiary liver institute over a period of 4 years.

MATERIALS AND METHODS

The study was performed to correlate the radiological features and imaging response to therapy for hepatic VLM. The disease course, imaging findings, progressive, absolute eosinophil counts (AEC), hydatid serology, and the extent of radiological regression of the liver lesions, on follow-up were analyzed.

RESULTS

Imaging showed a diagnostic accuracy of 42%. Hydatid serology was positive in 46% patients before starting treatment. The median pretreatment AEC of 507 showed a significant posttreatment AEC decline to median value of 117. The Wilcoxon signed ranks test showed significant decline in the AEC (P < 0.001). Radiological regression was present in all lesions. However, patients showed residual abscesses on imaging, up to 2 years on follow-up.

CONCLUSION

This study reveals that AEC has a significant predictive value in diagnosis and as a marker for disease regression. Complete radiological resolution of hepatic lesions does not correlate with total clinical remission. This finding warrants the need for further studies to look into the role of prolonged medical therapy or surgery as an alternate to current therapy module in cases of hepatic visceral larva abscesses.

Clinical features of clinically diagnosed eosinophilic liver abscesses

PURPOSE

Eosinophilic liver abscesses (ELAs) are frequently encountered in the clinical field based on typical computed tomography (CT) findings and the presence of peripheral eosinophilia. In this study, the authors evaluated the clinical features and natural course of CT diagnosed ELAs.

METHODS

The medical records of patients that underwent abdominal CT from July 2004 to February 2008 at Seoul National University Hospital were retrospectively evaluated. ELA was clinically diagnosed by the presence of peripheral eosinophilia (≥500 μL(-1)) and typical CT findings. The presumptive causes of clinically diagnosed ELA were divided into three categories, namely, parasitic infections, malignancies, and unidentified etiologies. Clinical courses and responses to treatment were evaluated.

RESULTS

Clinically diagnosed ELAs were identified in 164 patients and the incidence of ELA was 0.68%. Of these patients, 118 (71.9%) showed radiologic resolution of clinically diagnosed ELA at a median 6.2 (0.2-33.1) months. In addition, 79 (48.2%) patients also achieved normalization of peripheral eosinophilia with radiologic resolution of clinically diagnosed ELA. In patients without identified etiologies, mean time to radiologic resolution was significantly shorter for patients treated empirically with an anti-parasitic drug than for those not treated [4.4 (0.9-26.3) vs. 12.2 (1.5-33.2) months, median (range), P = 0.001].

CONCLUSIONS

Clinically diagnosed ELA adopts a relatively benign course. Empirical anti-parasitic treatment in patients without an identified etiology may shorten the duration of clinically diagnosed ELA.

Focal eosinophilic necrosis on superparamagnetic iron oxide-enhanced MRI

OBJECTIVE

The purpose of our study was to evaluate the usefulness of superparamagnetic iron oxide (SPIO)-enhanced MRI for distinguishing focal eosinophilic necrosis (FEN) from hepatic metastasis.

MATERIALS AND METHODS

Forty-one cases of FEN in 41 patients and 40 hepatic metastases in 40 patients were analyzed on unenhanced and SPIO-enhanced T2-weighted MRI retrospectively. Depending on the extent of the remaining hyperintense area on SPIO-enhanced T2-weighted images compared with the unenhanced images, the lesions were classified into four categories--category 1, less than 25%; category 2, 25-49%; category 3, 50-75%; and category 4, more than 75%--by two independent readers. Contrast-to-noise ratio (CNR) was measured using the same region of interest on unenhanced and SPIO-enhanced T2-weighted images. In three pathologic specimens of FEN, the number of Kupffer cells was compared with that of background hepatic parenchyma.

RESULTS

All metastases were classified as category 4, whereas FEN showed various distributions overall (category 1, 45.2%; category 2, 24.6%; category 3, 13.4%; category 4, 17.1%). FEN showed a decrease in CNR (from 7.9 +/- 5.8 to 6.1 +/- 5.6, p < 0.05), and metastases showed an increase in CNR (from 33.7 +/- 27.0 to 55.0 +/- 44.3, p < 0.05) after SPIO administration. In biopsy specimens, FEN had many more Kupffer cells (174.7 +/- 120.3 cells/high-power field [hpf]) than background hepatic parenchyma (23.7 +/- 9.8 cells/hpf). When using signal loss categories 1, 2, or 3 or CNR decrease, the accuracy of SPIO enhancement was 88.3%.

CONCLUSION

Unlike hepatic metastases, most of the cases of FEN showed a reduction in the extent of hyperintense area or a decrease in CNR after SPIO administration on the T2-weighted images. Therefore, SPIO-enhanced T2-weighted MRI can help to differentially diagnose FEN from metastases.

Hepatic Visceral Larva Migrans ofToxocara canis: CT and Sonographic Findings

OBJECTIVE

The aim of this study was to describe the CT and sonographic findings of hepatic visceral larva migrans of Toxocara canis.

MATERIALS AND METHODS

Fifty-four patients (44 men, 10 women; age range, 30-80 years; mean age, 53 years) with serologically confirmed visceral larva migrans of Toxocara canis underwent evaluation of the liver with CT (n = 25), sonography (n = 48), or both. Two radiologists used consensus for retrospective evaluation of CT and sonographic findings. Correlation between the presence and severity of hepatic abnormalities on images and the degree of peripheral eosinophilia was assessed.

RESULTS

Seventeen (68%) of 25 patients who underwent CT had single or multiple ill-defined, oval or elongated, small, low-attenuating lesions in the liver. Eighteen (38%) of 48 patients who underwent sonography had single or multiple small, poorly defined, oval or elongated, hypoechoic scattered focal lesions in the liver. In the 19 patients who underwent both CT and sonography, the two techniques had no significant difference in rate of detection of hepatic lesions (p = 0.375, McNemar test). The lesion numbers on CT and sonography showed excellent linear correlation (r = 0.844, p = 0.001) by Pearson's correlation test. An independent samples t test showed that eosinophil count and percentage in the peripheral blood were significantly higher in patients with hepatic lesions on CT and sonography than in patients without lesions.

CONCLUSION

CT and sonographic findings of hepatic visceral larva migrans of T. canis are multiple, ill-defined, oval or elongated, small, nodular lesions scattered in the liver parenchyma. The presence of hepatic lesions on images was associated with higher peripheral eosinophil count and percentage.

Contrast-enhancing hepatic eosinophilic abscess during the hepatic arterial phase: a mimic of hepatocellular carcinoma

OBJECTIVE

Our objective was to review CT, MR, angiographic, and sonographic images obtained in patients with histopathologically proven contrast-enhancing hepatic eosinophilic abscesses during the hepatic arterial phase.

CONCLUSION

On CT, MR, and angiographic images, eosinophilic abscess in the liver can show contrast enhancement during the hepatic arterial phase. If patients have peripheral hypereosinophilia or are at low risk for hepatocellular carcinoma or hepatic metastasis, those with small arterial-enhancing hepatic nodules need further preoperative evaluation, such as a sonographically guided biopsy.

Focal Eosinophilic Necrosis Versus Metastasis in the Liver: The Usefulness of Two-Phase Dynamic CT

OBJECTIVE

The purpose of our study was to evaluate the usefulness of dual-phase dynamic CT in the differentiation of focal eosinophilic necrosis of the liver and metastasis.

CONCLUSION

Undetected isoattenuating lesions on arterial phase images that have an indistinct margin, a nonspherical shape, and a homogenous enhancement pattern on portal venous phase images suggest focal eosinophilic necrosis rather than metastasis. Two-phase dynamic CT was found to be useful at differentiating focal eosinophilic necrosis from metastasis.

MR Findings in Eosinophilic Infiltration of the Liver

OBJECTIVE

This study describes the findings of magnetic resonance imaging (MRI) of focal eosinophilic infiltration of the liver.

METHODS

Contrast-enhanced MR images of 8 patients with focal hepatic eosinophilic infiltration were reviewed retrospectively. We evaluated the signal intensity of focal lesions in T1-weighted and T2-weighted images and the pattern of enhancement in a dynamic contrast study.

RESULTS

A total 22 focal hepatic lesions were observed; the lesions were isointense (55%) or hypointense (45%) on T1-weighted images and isointense (14%) or hyperintense (86%) on T2-weighted images. The arterial phase of the contrast study revealed 11 hyperintense lesions (50%). During the portal and delayed phases, 18 (82%) and 17 lesions (77%) were hyperintense, respectively.

CONCLUSION

The focal eosinophilic infiltrations showed homogeneous enhancement in the portal and delayed phases in the dynamic contrast MR study. These findings should help to distinguish focal eosinophilic infiltration, especially from metastasis in patients with malignancy.

Focal eosinophilic necrosis of the liver in patients with underlying gastric or colorectal cancer: CT differentiation from metastasis

OBJECTIVE

To determine the helical CT findings which help differentiate between focal eosinophilic necrosis (FEN) of the liver and metastasis in patients with underlying gastric or colorectal cancer.

MATERIALS AND METHODS

In 21 patients with underlying gastric and colorectal cancer examined during a recent 18-month period, the presence of FEN (n=90) was proven at CT. The diagnosis was verified by biopsy in eight patients and by the transient nature of the findings related to peripheral eosinophilia (>10%) in the remainder. For comparison, 20 consecutive patients with pathologically proven hepatic metastasis from gastric or colorectal cancer (n=158) were selected. Single-phase helical CT images (7-mm collimation, pitch 1:1) were independently analyzed in a random order by two blinded readers. The parameters evaluated included the margin (depicted border, fuzzy), shape (spherical, non-spherical), attenuation (subtle hypoattenuation, hypoattenuation), and the presence or absence of rim enhancement.

RESULTS

FEN far more frequently showed a fuzzy margin (81%, 84%), subtle hypoattenuation (89%, 91%), and a non-spherical shape (84% for both readers) than metastasis, for which the respective findings were 6%, 22%; 20%, 39%; and 15%, 23%. Rim enhancement was seldom found in FEN (0%, 2%), but was recognized by both readers in 40% of metastases. For all parameters, the results were statistically significant (p < .01), and showed that both readers correctly differentiated FEN from metastasis in 78% of the patients (32/41). Interobserver agreement was, in addition, excellent (kappa = 0.66).

CONCLUSION

When focal hepatic lesions with a fuzzy margin, non-spherical shape and subtle hypoattenuation without rim enhancement are found, the possibility of FEN should be considered even in patients with underlying gastrointestinal malignancy.