Visceral Larva Migrans Mimicking Lymphoma* Claude Bachmeyer, MD; Ge ´rard Lamarque, MD; Rodica Morariu, MD; Thierry Molina, MD; Patrice Boure ´e, MD; and Alain Delmer, MD We report a case of visceral larva migrans in an adult with fever, night sweats, weight loss, hilar and medias- tinal lymphadenopathy, bilateral pleural effusion, and eosinophilia-mimicking lymphoma. Visceral larva mi- grans was diagnosed subsequently because of negative findings for malignancy and positive serologic test result for Toxocara canis. Progressive improvement was observed with albendazole therapy. (CHEST 2003; 123:1296 –1297) Key words: albendazole; eosinophilia; hilar and mediastinal lymphadenopathy; visceral larva migrans Abbreviation: VLM = visceral larva migrans V isceral larva migrans (VLM) is an infection mainly due to Toxocara canis, a common worldwide ascarid spe- cially of children  6 years of age. 1 A wide spectrum of manifestations has been described from asymptomatic infection to fulminant disease. 1 These mainly include fever, hepatomegaly, leukocytosis, eosinophilia, and hypergamma globulinemia. We report a case of VLM with hilar and mediastinal lymphadenopathy in an adult mim- icking lymphoma. Case Report A 65-year-old French man with no medical history was admitted to the hospital in June 2001 for temperature of 39°C and night sweats evolving for 2 weeks. He denied ingestion of any drug and had traveled to the French West Indies 6 months previously. On hospital admission, the patient appeared fa- tigued and had lost 5 kg in weight. The physical examination was otherwise unremarkable. The WBC count showed 10,800/L, with 50% neutrophils, 17% lymphocytes, and 26% eosinophils (absolute count, 2,830/L). Erythrocyte sedimen- tation rate was 86 mm/h. C-reactive protein was 85 mg/L (normal  13 mg/L). Electrolytes, liver function test results, serum creatinine level, and lactate dehydrogenase level were normal. Serum electrophoresis showed an albumin level of 32.8 g/L (normal  39 g/L);  2 -globulin, 9.8 g/L (normal  7 g/L); and polyclonal -globulinemia, 16.9 g/L (normal  10 g/L). Search for antinuclear, anti– double-stranded DNA, antineutrophil cytoplasmic antibodies, and rheumatoid factor was negative. Infectious inquiry included blood and urine cultures and search for mycobacteria in sputum; sero- logic study findings for Chlamydia psittaci and Chlamydia pneumoniae, Coxiella burnetii, Legionnella pneumophilia, and Mycoplasma pneumoniae were negative. Chest radiography and thoracoabdominal CT scan showed bilateral hilar and mediastinal lymphadenopathy 2 to 5 cm in diameter, and discrete bilateral pleurisy (Fig 1). Fiberoptic bronchoscopy demonstrated a diffuse inflammation with a nonspecific in- flammation on lung biopsy; direct search for pathogens and culture findings were negative. Treatment with ceftriaxone, amikacin, and metronidazole, then amoxicillin/clavulanic acid and ofloxacin was ineffective. Medias- tinoscopy with partial lymphadenectomy was performed. Analysis of lymph nodes specimens showed destruction of their architec- ture with a polymorphic cellular infiltrate consisting of eosino- phils, histiocytes, fibroblasts, and plasmocytes, and vascular hy- perplasia. Immunophenotyping and analysis of IgH and T-cell receptor gene rearrangements failed to detect any monoclonal T-cell or B-cell population. Bacterial culture results of lymph nodes remained negative. Bone marrow biopsy results were normal. Therefore, the patient was referred to us in July of 2001. A parasitic infection was considered, and treatment with albenda- zole was administered at 400 mg/d for 10 days. Search for parasites in feces was negative. All helminthiasis serology results were negative, but T canis enzyme-linked immunosorbent assay serology was highly positive (optical density/optical density threshold 0.720; positive  0.3), with antibodies directed against 24-kd and 35-kd antigens. The patient said that he had been in daily contact with a dog during the previous months. Progressive improvement of the general symptoms was observed. In August 2001, he felt well, had no fever, the eosinophil count was normal, the serology for T canis was stable, and mediastinal lymph nodes and pleurisy had almost disappeared. Discussion We report the case of a patient with fever, night sweats, weight loss, hilar and mediastinal lymphadenop- athy, and eosinophilia related to VLM. This diagnosis was supported by the positive result of the enzyme- linked immunosorbent assay test for T canis and pro- gressive improvement after treatment with albendazole. Other conditions responsible for eosinophilia, such as drug reactions, allergic diseases, autoimmune disorders, and idiopathic hypereosinophilic syndrome, were easily ruled out. Diagnosis of malignancy—particularly lym- phoma—was initially suspected, but extensive investi- gations failed to demonstrate any neoplasm. Because of negative findings, a parasitic infection was subsequently considered. Pulmonary symptoms mainly consist of cough and wheezing and are reported in 20 to 85% of cases in children with VLM. 1 Bilateral areas of infiltration are observed in 40 to 50% of patients with pulmonary symptoms. 1 Diffuse noncavitating nodules are unusual. 2 Severe symptoms seem to be very rare in adults. Eosinophilic pneumonia responsible for acute respira- tory disease, important pleural effusion sometimes as- sociated with tamponade, and severe asthma have been *From De ´ partement de Me ´ decine Interne (Dr. Bachmeyer) and Service de Pneumologie (Dr. Lamarque), Center Hospitalier Lae ¨ nnec, Creil; Service d’He ´ matologie (Drs. Morariu and Delmer), Ho ˆ pital Ho ˆ tel Dieu, Paris; Laboratoire d’Anatomo- Pathologie (Dr. Molina), Ho ˆ pital Ho ˆ tel Dieu, Paris; and Labo- ratoire de Parasitologie (Dr. Boure ´ e), Ho ˆ pital Bice ˆ tre, Le Krem- lin-Bice ˆ tre, France. Manuscript received March 21, 2002; revision accepted August 1, 2002. Reproduction of this article is prohibited without written permis- sion from the American College of Chest Physicians (e-mail: permissions@chestnet.org). Correspondence to: Claude Bachmeyer, MD, De ´partement de Me ´decine Interne, Center Hospitalier Lae ¨nnec, Boulevard Lae ¨nnec, B. P. 72, F-60109 Creil Cedex, France; e-mail: claude. bachmeyer@ch-creil.fr 1296 Selected Reports Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21992/ on 03/31/2017