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Woman With Fever of Unknown Origin

Woman With Fever of Unknown Origin

A 47-year-old woman was referred for evaluation of fever of unknown origin. Her symptoms included persistent daily fevers (temperature up to 38.8°C [102°F]), weight loss, and severe right flank pain of 3 months’ duration. Review of systems was notable for nausea, rigors, pruritus, and urticaria. The patient’s symptoms began shortly after she returned from a trip to India, Thailand, and New Zealand.

Laboratory test results revealed a microcytic anemia (hemoglobin level, 111 g/L; mean corpuscular volume, 75.1 fL) and a normal leukocyte count (5 x 106/L), with 17.5% eosinophils. Serum liver enzyme levels were normal. The patient’s erythrocyte sedimentation rate (ESR) was 105 mm/h, and her serum IgE level was 550 IU/mL (normal range, 0 to 100 IU/mL). A CT scan of the abdomen showed multiple cystic areas in the liver (Figure 1). Test results for hepatitis, malaria, and tuberculosis were negative. Results of a test for Toxocara canis IgG were negative.

Trichrome staining of stool specimens showed no ova or parasites. Hematoxylin-eosin stain of a liver biopsy specimen revealed noncaseating granulomas with eosinophilic infiltrate (Figure 2). Eggs of Capillaria hepatica were also found in one of the biopsy specimens. Periodic acid–Schiff and acid-fast stains yielded negative results. The Armed Forces Institute of Pathology, which provided these results, reported eosinophilic abscess with necrosis and numerous Charcot-Leyden crystals.

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