Fever, cough, and nodules on ankles

Abstract

A 26-year-old woman with fever; headache, and a dry cough was admitted in September, 1998, to the Hyogo College of Medicine Hospital with multiple nodules on her chest radiograph. She had no relevant medical history and was in good general health. She had not travelled abroad. Her job was in an electrical appliance shop. Examination on admission showed cervical lymphadenopathy, leucocytosis 16·8×106/L, and eosinophilia (61%). There were no neurological abnormalities and her optic fundae were normal. Chest radiography and computed tomography (CT) showed multiple nodules in both lung fields. The size and location of these shadows changed during her stay in hospital. CT, magnetic resonance imaging (MRI), and ultrasonography of the liver were done. Non-contrast CT showed multiple low-density hepatic nodules. Hepatic-arterial-dominant phase-contrast CT showed several well-defined hepatic nodules. Portal-venous-dominant phase-contrast CT showed homogeneous enhancement of the lesions. MRI findings also suggested an inflammatory process, not a malignant tumour or haemangioma. Histological examination of specimens obtained from liver biopsy and transbronchial lung biopsy showed only extensive eosinophilic infiltration. There were elevated concentrations of immunoglobulin E (IgE, radioimmunosorbent test 8980 U/mL), specific IgE against Ascaris lumbricoides (radioallergosorbent test 74 UA/mL), and specific IgE against Anisakis simplex (radioallergosorbent test 1·81 UA/mL). Ouchterlony's double diffusion test showed a strong precipitin band against the larval excretory-secretory antigen of Toxocara canis. ELISA with the larval excretory-secretory antigen of T canis was positive. There was a small brown itchy nodule on her left ankle on admission. This was thought to be prurigo and was treated unsuccessfully with topical steroids. Similar skin lesions then appeared on the opposite leg.