CASE REPORT 

Annals of Nuclear Medicine Vol. 5, No. 4, 171-173, 1991 

Hypereosinophilic syndrome appearing as a focal defect on liver scan 

Susumu SHIOMI,* Tetsuo KUROKI,* Tadashi UEDA,* Naoko IKEOKA,* Kenzo KOBAYASHI* and Hironobu OCHI** 
*Third Department of Internal Medicine and **Division of Nuclear Medicine, Osaka City University Medical School 

The case reported here is of a 34-year-old man diagnosed as having hypereosinophilic syndrome. Blood tests showed a large increase in the number of eosinophils and a slight increase in asparate aminotransferase and alkaline phosphatase. In scintigraphy of the liver with Tc-99m-phytate and with Ga-67-citrate, a focal defect was found in the outer part of the right lobe of the liver. Abdominal computed tomography showed a low density lesion in the same area. Histological inspection of the biopsy specimen showed heavy periportal infiltration with eosinophils. The results suggested that the focal defect seen in liver scintigraphy arose from a circulatory disturbance arising from infiltration by eosinophils. 

Key words : 
hypereosinophilic syndrome, liver scintigraphy, Tc-99m-phytate 

INTRODUCTION 
AN INCREASED NUMBER of eosinophils in the peripheral blood has been found in subjects with allergic reactions, parasitic, microbial, or fungal infections, malignant diseases such as leukemia,1 and collagen disease.2 The hypereosinophilic syndrome, which is of unknown etiology, involves the infiltration of various organs by a large number of eosinopils.3-6 Reports of such infiltration of the liver are few.7 Here we report a patient with a large increase in the number of eosinophils and eosinophil infiltration of subcutaneous tissue from the lower back to the lower part of the left thigh. Marked infiltration by eosinophils was found in the biopsy specimen of the liver, and the results of liver scintigraphy were of interest. 

Received July 1, 1991, revision accepted August 30, 1991. For reprints contact: Susumu Shiomi, M.D., Third Department of Internal Medicine, Osaka City University Medical School, 1-5-7 Asahimachi, Abeno-ku. Osaka 545 JAPAN. 

CASE REPORT 
The subject,a 34-year-old man,developed swelling of the lower back accompanied by itching, but he did not seek medical attention. Then the swelling spread to include the left thigh, and the patient was hospitalized when a blood test showed a large increase in the number of eosinophils. The results of tests at that time were white blood cells 22,400/mm3 eosinophils 78 %, total protein 7.1 g/dl, gamma-globulin 16.9%, erythrocyte sedimentation rate 38 mm/hr, total bilirubin 1.1 mg/dl, asparate aminotransferase 77 IU, alkaline phosphatase 11.3 KAU, and gamma-glutamyltransferase 24 U/L. Bone marrow examination showed an increased number of eosinophils (23.3 %), but the results of a cytogenetic study of the bone marrow were normal (l09,000/ mm3). An abdominal CT showed a low density lesion in the outside part of the right lobe of the liver (Fig. 1). A focal defect was found in the same area of the right lobe of the liver in Tc-99m-phytate liver imaging (Fig. 2). The image obtained with Ga-67-citrate showed a focal defect in the same area (Fig. 3). Ultrasonogram of the liver looked normal, including the area with abnormalities seen on the scintigram. Histological examination of the biopsy specimen showed marked periportal infiltration by eosinophils, but the lobular structure was maintained (Fig. 4). A subcutaneous biopsy specimen taken from the lower back showed heavy infiltration by eosinophils. Prednisolone was given at the dose of 40 mg/day. One week after the start of this treatment, the swelling of the lower back and thigh had disappared, and eosinophils were 3 %.

DISCUSSION 
An increase in the number of eosinophils is found in various conditions, but most often in persons with allergy or parasitic infection, and the extent of the increase is often great in these persons. However, there is also a specific syndrome with characteristic clinical and pathological findings, which Hardy and Anderson3 named the hypereosinophilic syndrome. As their diagnostic criterion, Parrillo et al.4 used an eosinophil count of more than 1,500 cells/mm3 which persisted at this high level. There was no evidence that the disease involved allergy, parasitic infection, or other such causes; and there were findings that indicate that the eosinophil infiltration may have caused organ damage. The onset of the syn-drome has been reported in persons aged 5 to 80 years, with persons in their 40s at onset most numerous. Men account for about 85 % of patients with the disease.5 Organ damage is generally of the heart and the circulatory system, followed by the skin, muscle, and nervous system. Changes found in the digestive organs include swelling of the liver, and at times, increases in total bilirubin, asparate aminotransferase, and alkaline phosphatase.3-6 In one of the few reports of liver damage in this disease being assessed by imaging techniques, White et al.7 have reported that neither CT nor ultra-sonography, done at hospitalization, showed abnormalities. They found multiple focal defects by liver scintigraphy in their patient, and found severe in-filtration by eosinophils in a periportal biopsy specimen taken soon after hospitalization. In ultra-sonography we detected no abnormalities in our patient, but found a low density area by CT and a defect in liver scintigraphy. The lobular structure of the liver was maintained in the biopsy specimen, but eosinophil infiltration was severe, suggesting that the focal defect found in liver scintigraphy with Ga-67-citrate and Tc-99m-phytate arose because of a circulatory disturbance caused by the eosinophil infiltration of the periportal area. The CT done by White et al.7 was taken when eosinophils had de-creased to 2.5%, which may be one reason for the difference between the CT findings in their patient and ours. 

REFERENCES 
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