Case Discussion 【Presentation of a Case 】      A 38-year-old male patient was admitted because of abdominal pain at the right upper quadrant for about one month.      He had been previously well and worked in Canton Province of the mainland China over the past years. About one month prior to this admission, he began to feel pain at the right upper quadrant. The characters of pain were dull and intermittent with radiation to the right flank region. There was no fever, jaundice, vomiting, weight change, or respiratory symptoms. He was seen at a clinic in China where abdominal sonography revealed gall stones. He was treated with herbal remedies with mild improvement of the symptoms. About one week earlier before this entry, he came back to Taiwan and experienced similar bouts of symptoms associated with fever and chills for which he sought medical help at this hospital.     He denied exposure to chemical agents, taking herbal medicines after the first treatment in China, or consumption of alcohol. He recalled ingestion of uncooked freshwater fish for three times about two to three months earlier before this admission.      At admission, blood pressure was 100/70 mmHg, temperature 36.5℃, pulse rate 60 beats per minute, and respiratory rate,16 per minute. He was not in acute distress and in good nutritional status. Skin examination was normal. Physical examinations were unremarkable and there was  no abdominal tenderness or organomegaly.      Complete blood counting at admission revealed hematocrit 40.6% and WBC 20,790/μl with 68% eosinophilia. Liver function tests revealed total bilirubin 0.4 mg/dL, aminotransferase 46 IU/L, and alkaline phosphatase 390 IU/L. Stool examination for parasites were repeatedly negative. Computed tomography (CT) disclosed multiple tumors of low densities at the segment 3 (2 cm in diameter), segment 4 (2 cm), and segment 6 and 7 (4 cm). Portal veins were patent.      Pathology of the liver biopsy specimens showed prominent eosinophilic infiltration and mild lymphocyte infiltration in portal area and sinusoids. Bone marrow biopsy showed an interstitial infiltration of eosinophils accounting for about 10% of the mononuclear cells. To obtain bile for parasitic examination, endoscopic retrograde cholangiopancreatography （ERCP）was performed to yield 15 ml bile. A few ova of Clonorchis sinensis was identified. He was given praziquantel at a daily dose of 75 mg/kg for one day. Subsequent follow-up revealed resolving eosinophilia. The liver CT would be followed 3-6 month later on an outpatient basis. 繼續教育考題 1. (D) 下列哪些疾病，容易引起嗜伊性球過多症？ A 對phenytoin過敏 B 類風濕性關節炎 C Hodgkin's disease D 以上皆是 2. (D) 吸蟲類（trematodes），包括腸道（intestinal flukes）、肝（liver flukes）、肺（lung flukes）和血吸蟲（blood flukes），以下敘述何者為非？ A 第一中間宿主都是snail B 治療首選藥物（除了牛羊肝吸蟲外），都是praziquantel C 肝吸蟲幼蟲生活史，包括miracidium、sporocyst、redia、cercaria和metacercaria D 大陸地區盛行的血吸蟲是Schistosoma haematobium 3. (B) 下列吸蟲類感染，成蟲寄生部位配對何者為非？ A 中華肝吸蟲（Clonorchis sinensis）－膽道 B 日本血吸蟲（Schistosoma japonicum）－腸道 C 衛氏肺吸蟲（Paragonimus westermani）－肺臟 D 薑片蟲（Fasciolopsis buski）－腸道 4. (D) 下列吸蟲感染，感染源和吸蟲的配對何者為是？ A 中華肝吸蟲－淡水魚 B 薑片蟲－荸薺 C 衛氏肺吸蟲－毛蟹 D 以上皆是 5. (A) 下列哪些寄生蟲感染可能誘發癌症發生？ A 中華肝吸蟲－膽道癌 B 日本血吸蟲－膀胱癌 C 衛氏肺吸蟲－肺癌 D 以上皆是 6. (D) 下列何寄生蟲感染途徑配對何者為是？ A Necator americanus－經皮感染 B Strongyloides stercoralis－經皮感染 C Brugia malayi－蚊子叮咬 D 以上皆是 7. (B) 下列何種寄生蟲感染不會或鮮少引起eosinophilia？ A Toxocara spp. B Entamoeba histolytica C Trichnella spiralis D Clonorchis sinensis 8. (D) 下列寄生蟲感染與其治療藥物配對，何者為是？ A Clonorchis sinensis－praziquantel B Hookworm－mebendazole C Enterobius vermicularis－pyrantel pamoate D 以上皆是 9. (C) 下列寄生蟲感染的檢驗，最合適的檢體配對，何者為非？ A Paragonimus westermani－sputum B Clonorchis sinensis－bile C Trichnella spiralis－stool D Enterobius vermicularis－perianal "Scotch tape" test檢體 10. (D) 下列哪些寄生蟲會發生幼蟲移行，造成皮膚病徵和eosinophilia？ A Ascaris lumbricoides B Hookworm C Strongyloides stercoralis D 以上皆是