A 32 years old male was admitted to our hospital with complaints of abdominal pain, diarrhea, fatigue, nausea, loss of appetite, cough, night sweats and weight loss. Lasting for 2 months except for mild diarrhea lasting for 3 days. His history was unremarkable for travelling, animal husbandry, hunting, drugs and agriculture. There were no similar symptoms in his family and neighbours. His axillary body temperature was 37.2 C, blood pressure was 120/80 mmHg, heart rate was 82/min, and respiration rate was 22/min. Physical examination revealed urticarial lesions on his back.
His laboratory tests were as follows: leukocytes 7800/mm3, eosinophils 3900/mm3 (%49), platelets 293000/mm3, hemoglobin 13,8 g/dL, hematocrit %42.6, C-Reactive Protein (CRP) 35 mg/dl. Peripheric blood smear revealed eosinophilia as high as 46% of white blood cells. Routine biochemical tests, urine analysis, and serum IgE were in normal range. Hepatitis B virus surface antigen (HBsAg), anti-hepatitis C virus antibodies (Anti-HCV), anti-human immunodeficiency virus antibodies (Anti-HIV), venereal disease research laboratory (VDRL), Epstein-Barr virus virus capsid antigen (EBV-VCA) IgM, cytomegalovirus (CMV) IgM, anti-rubella IgM, Rose-Bengal, Wright agglutination, and Grubel-Widal tests were negative. The chest radiogram was also normal. Nonpruritic skin lesions on his back were diagnosed as dermographic urticaria after consulting with a dermatologist (Figure 1). Desloratadin and hydroxyzine were administered. The skin lesions were not resolved with these drugs. The patient was hospitalized to investigate the possible infectious causes of hypereosinophilia.
The bacteriological cultures of urine, blood, and sputum and tuberculosis culture of the sputum were
No bacteria were seen in Gram and Ehrlich-
Ziehl-Neelsen stainings of the sputum. There was no parasite in stool examination performed on five consecutive days. Mebendazole 200 mg daily was given for possible helmintic infestation for five days. As well as, no clinical or laboratory response was achieved. Anti-nuclear antibody, anti-double-stranded DNA, perinuclear antineutrophil cytoplasmic antibody (p-ANCA) and cytoplasmic antineutrophil cytoplasmic antibody (c-ANCA) tests were negative. Abdominal ultrasound (US) was normal. The electrocardiogram revealed an extension in PR duration and echocardiography revealed pleural effusion in the neighbourhood of the right ventricle. Computed tomography (CT) scan of the thorax was normal. However, multipl hypodense lesions were detected in periportal areas of the liver in upper abdominal sections of the CT scan. The largest lesion's size reached 3x4 cm, the others had approximately 1-1.5 cm diameters. There was no enhancement on lesions (Figure 2).
Serum of the patient was sent to The Refik Saydam Hygiene Center Presidency for serological tests of Toxacara canis and F. hepatica. Although serology for T. canis was negative, F. hepatica indirect hemagglutination (IHA) test was positive at a titer of 1/1280. His history was reviewed repeated and we figured out that he had eaten raw watercress on riverside 3 months before his hospital admission. Triclabendazole (Egaten ) 10mg/kg single dose was started and repeated after 2 weeks. His complaints resolved in 3 weeks of treatment. The hemogram and peripheric blood smear revealed normal eosinophil count, then. CRP level in serum was reduced to normal range too.