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Bladder and Liver Involvement of Visceral Larva Migrans May Mimic Malignancy

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Bladder and Liver Involvement of Visceral Larva Migrans May Mimic Malignancy 학회지(46-4)_in 14. 10. 8. 오후 1:20 페이지 419 pISSN 1598-2998, eISSN 2005-9256 Cancer Res Treat. 2014;46(4) :419-424 http://dx.doi.org/10.4143/crt.2013.104 Case Report Open Access Bladder and Liver Involvement of Visceral Larva Migrans May Mimic Malignancy Eun Joo Kang, MD, PhD Visceral larva migrans (VLM) syndrome is a clinical manifestation of systemic organ Yoon Ji Choi, MD involvement by Toxocara species. VLM with involvement of the bladder and liver is a rare finding. A 62-year-old woman presented with diffuse bladder wall thickening and Jung Sun Kim, MD MD multiple liver masses with peripheral eosinophilia and urinary symptoms. We Byung Hyun Lee, considered malignancy or eosinophilic cystitis through clinical manifestations and MD Ka-Won Kang, imaging findings. However, no suspicious malignant lesions were observed on Hong Jun Kim, MD cystoscopy and liver mass biopsy revealed the presence of eosinophilic necrotizing Eun Sang Yu, MD granuloma without malignant cells. Anti- Toxocara antibodies were detected by Yeul Hong Kim, MD, PhD western blotting and the patient was diagnosed with VLM syndrome. After taking prednisolone, urinary symptoms disappeared. On abdominal computed tomography scan taken after three months, the size of multiple liver masses and bladder wall thickening had decreased. VLM syndrome should be suspected in patients with an atypical imaging pattern and peripheral eosinophilia. Division of Medical Oncology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea + + + + + + + + + + + + + + + + + + + + Key words + C +o r+re s+p o +n d +e n +c e :+ Y +eu l+ H +o n +g K+i m +, M+ D +, P+h D + + + Visceral larva migrans, Toxocariasis, Urinary bladder, + D +i v +is i o+n +o f +M e+d i+ca l+ O +n c +ol o +g y +, + + + + + + + Liver, Neoplasm + D +e p+a r +tm +en +t o +f I n+t e +rn a+l M + e d+i c +in e+, + + + + + + + K +o r+e a +U n+i v +er s+it y + C +o l l+eg e+ o +f M +e d+i c i+n e +, + + + + + 7 +3 I +n c h+o n+- r +o, S+e o+n g+b u +k -+g u +, S e+o u+l 1+3 6 +-7 0+5 , +K o+r e +a + T +e l :+ 8 2 +-2 -+9 2 +0- 5 +5 6 +9 + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + F +a x +: 8 2+- 2 +-9 2+6 - 4+5 3+4 + + + + + + + + + + + + + E +-m +a i l+: y +h k +02 1+5 @+k o+r e+a . a+c . k+r + + + + + + + + + + + + + + + + + + + + + + + + + + + + + R +e c +ei v +e d + J u+l y + 3 , +2 0 +13 + + + + + + + + + + + + A +c c +e p +te d + A +u g+u s+t 2+3 , +20 1+3 + + + + + + + + + + + + + + + + + + + + + + + + + + + + + Introduction migration of the larvae of T. canis , T. cati , and various organs may be involved; the liver, lung, and eye are most commonly affected [2-4]. Toxocariasis is the clinical term for infection in the human VLM syndrome is found throughout the world, even in host by either Toxocara canis or Toxocara cati . Both of these developed countries. Cats and dogs are the definitive hosts organisms are ascarid nematodes in the order Ascaridida, of T. canis and T. cati , and human infection is caused by superfamily Ascaridoidea, family Toxocaridae. Visceral larva swallowing the eggs shed by these animals. In the small migrans (VLM) syndrome, a clinical manifestation of bowel, the eggs release larvae, which penetrate the wall of systemic toxocariasis, was first described by Beaver et al. in the intestine and from there can enter the portal venous New Orleans in 1952 [1]. This syndrome is caused by circulation and hepatic parenchyma [5]. In the liver, they │http://www.cancerresearchandtreatment.org │ Copyright ⓒ 2014 by the Korean Cancer Association 419 │http://www.e-crt.org │ This is an Open-Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/3.0/)which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 학회지(46-4)_in 14. 10. 8. 오후 1:20 페이지 420 Cancer Res Treat. 2014;46(4) :419-424 A B C D Fig. 1. Abdominal computed tomography (CT) scan of the case patient shows multiple ill-defined hepatic nodules and bladder wall thickening. (A, B) Contrast-enhanced CT scan shows multiple ill-defined hypodense lesions in both lobes of the liver as well as enlarged portocaval lymph nodes. (C, D) Nodular enhancing lesion in the right anterior wall of the bladder and diffuse thickening of the wall were found. move through the parenchyma and cause necrosis and inter - Case Report stitial edema [5]. The larvae cause disease not only in the liver but also in the heart and brain [6,7]. Lesions caused by T. canis or T. cati infection can be observed on imaging A 62-year-old Korean woman who was a homemaker was studies, such as those obtained by computed tomography referred to Korea University Medical Center from a local (CT) or magnetic resonance imaging, as mass-like lesions hospital for evaluation of abnormal findings of bladder and that may confuse clinicians [8]. We report on a case of VLM liver mass lesions on CT images. The patient had experienced with involvement of the bladder and liver. urinary urgency and frequency for the past three months. Therefore, she visited the local hospital and underwent abdominal ultrasound and CT. Imaging studies showed thickening of the urinary bladder wall and several nodular lesions on the liver. The patient had undergone bladder surgery for treatment of stress incontinence four years previously, and she did not suffer from any urinary symptoms after surgery. She had 420 CANCER RESEARCH AND TREATMENT 학회지(46-4)_in 14. 10. 8. 오후 1:20 페이지 421 Eun Joo Kang, Visceral Larva Migrans Mimicking Malignancy diagnosed with asthma 20 years before and was taking montelukast, a beta-2 agonist (Ventolin, GlaxoSmithKline, Madrid, Spain), and an inhaled combination corticosteroid and beta-2 agonist (Seretide, GlaxoSmithKline, London, UK). She had no other prior medical history. She had not been living with animals and had no history of eating raw meat or any recent travel history. The patient did not complain of any other symptoms (i.e., visual symptoms or respiratory symptoms, chest pain, nausea, vomiting, melena, or hematochezia) except for urinary frequency and urgency. She denied any history of fever, abdominal pain, or hematuria. Her weight had not changed. A On physical examination, the patient appeared well. Her sclera and skin were anicteric, and heart and lung examination revealed no abnormal findings. Abdominal examination revealed no palpable hepatic or splenic mass, and she did not complain of low abdominal tenderness or costovertebral angle tenderness. There was no edema of either lower extremity. Neurologic examination revealed no focal deficits. There was no cervical, axillary, or inguinal lymphadenopathy. Initial laboratory studies showed no abnormal urinalysis findings. Her white blood cell count was 5,660/ μL, and showed 21% eosinophil granulocytes, with an absolute value of 1,188/ μL. Her serum electrolyte concentrations were B within the normal ranges. Liver function tests showed that her aspartate aminotransferase, alanine aminotransferase, Fig. 2. Histology of the case patient’s liver biopsy sample. and bilirubin levels were within normal limits, but her (A) Liver biopsy shows several necrotizing granulomas protein level was high (11.2 g/dL), with relative hypoalbu - with associated fibrosis and mixed cell infiltrate with minemia (3.1 g/dL). Serum tests for the presence of viral prominent eosinophils and lymphoplasma cells (H&E hepatitis, human immunodeficiency virus, and syphilis were staining, ×40). (B) On medium power, central eosinophilic all negative. The circulating levels of various tumor markers necrosis, surrounded by epithelial histiocytes and multi - (carcinoembryonic antigen, carbohydrate antigen [CA] 19-9, nucleated giant cells are found. In the necrotic area, there alpha-fetoprotein, CA 125, and CA 15-3) were within normal are many Charcot-Leyden crystals. At the periphery of limits. In urine analysis, there were no red blood cells or granulomas, irregular amphophilic degenerated materials white blood cells, and no organism was found in the urine are phagocytized by multinucleated giant cells (H&E culture. staining, ×100). At Korea University Medical Center, abdominal CT was repeated and detected a nodular enhancing lesion in the right anterior wall of the bladder with suspicious perivesicular invasion. In addition, multiple ill-defined hypodense mass lesions reminiscent of metastasis were observed on the liver three times and revealed no malignant cells. The urologist (Fig. 1A-D). Multiple enlarged lymph nodes were also noted recommended a bladder biopsy to confirm eosinophilic in the external iliac, inguinal, aortocaval, paraaortic, cystitis, but the patient refused. For further evaluation of the portocaval, right pericardiac, and subphrenic areas. liver findings, a core biopsy of a liver mass was taken. Because malignancy was suspected, gastrofiberscopy and Histologic examination of the biopsy sample revealed the colonoscopy were performed to search for the origins of the presence of eosinophilic necrotizing granuloma. No larvae masses. No suspicious malignant lesion was observed. We were found in the tissue samples, and the other liver tissues referred the patient to an urologist for bladder examination. showed non-specific reactive changes (Fig. 2A and B). These Cystoscopy was performed and showed no evidence of findings were suggestive of parasitic granulomas or cancer on the bladder wall. Urine cytology was repeated reminiscent of larva migrans lesions. We tested for anti- VOLUME 46 NUMBER 4 OCTOBER 2014 421 학회지(46-4)_in 14. 10. 8. 오후 1:20 페이지 422 Cancer Res Treat.
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