Eosinophilic Liver Abscess of Unknown Etiology

Abstract

Introduction: Case of a 60-year-old man who arrives to the emergency department due to complaints of 1-week evolution of abdominal discomfort. The symptoms had evolved after consuming a meal of grouper with creole sauce, which later precipitated symptoms of burning epigastric pain and reflux, unquantified fever, and chills. He denied any nausea or vomiting, changes in bowel habits, melena, hematochezia, dysphagia, weight loss, early satiety, and sick contacts. Methods: Physical evaluation was unremarkable. Admission laboratories revealed leukocytosis (18.5 x10-3/uL) with predominance in eosinophils of 60%. Abdomino/pelvic CT scan with contrast was performed showing extremely heterogenous attenuation in the liver with multiple ill-defined hypodensities throughout its parenchyma, as well as antral thickening. Due to the marked eosinophilia and leukocytosis without a clear focus of infection, ova, and parasites for 7 days, Strongyloides, Toxocara, Fasciola hepatica, and Schitosoma titers were ordered. GI service performed an upper endoscopy, which revealed normal mucosa. Colonoscopy was performed to rule out metastatic colon cancer to liver, which was also unremarkable. Liver biopsy was then performed, which was negative for ova/parasites, bacteria, acid fast bacili, or malignant cells identified by cytology. Hematology/oncology service was consulted to rule out malignancy. Work-up for chronic eosinophilic leukemia was negative. He was discharged home for follow-up at GI clinics. Results: Follow-up laboratories 2 months later were remarkable for resolved esosinophilia. Titers for Shistosoma IgG, Strongyloides IgG, Toxocara cani, and Fasciola were all negative. Given multiple liver lesions and patient’s presentation, diagnosis was suggestive of eosinophilic liver abscess. Liver MRI was done and showed complete resolution of multiple scattered hepatic lesions on the basis of known aseptic abscess. No new lesions were noted. Conclusion: Eosinophilic liver abscess (ELA) is clinically diagnosed on the basis of peripheral eosinophilia and typical computed tomography (CT) findings. Underlying etiology is often related to parasitic infection, drug hypersensitivity, allergic disease, collagen vascular disease, or malignancy. However, in clinical practice, underlying causes cannot be identified in many cases. The clinical manifestations and underlying mechanisms is poorly recognized and known in the medical literature. Here, we present a case in which clinical presentation and radiologic findings strongly support a diagnosis of ELA. It pursues a benign course and is detected as incidental finding in asymptomatic individuals with peripheral eosinophilia (>500). Course is followed by image studies, and resolution of ELA occurs at a median of 6 months.