Development of an Anti-Elicitin Antibody-Based Immunohistochemical Assay for Diagnosis of Pythiosis.

Pythiosis is an emerging and life-threatening infectious disease of humans and animals living in tropical and subtropical countries and is caused by the fungus-like organism Pythium insidiosum. Antifungals are ineffective against this pathogen. Most patients undergo surgical removal of the infected organ, and many die from advanced infections. Early and accurate diagnosis leads to prompt management and promotes better prognosis for affected patients. Immunohistochemical assays (IHCs) have been developed using rabbit antibodies raised against P. insidiosum crude extract, i.e., culture filtrate antigen (CFA), for the histodiagnosis of pythiosis, but cross-reactivity with pathogenic fungi compromises the diagnostic performance of the IHC. Therefore, there is a need to improve detection specificity. Recently, the elicitin protein, ELI025, was identified in P. insidiosum, but it was not identified in other human pathogens, including true fungi. The ELI025-encoding gene was successfully cloned and expressed as a recombinant protein in Escherichia coli. This study aims to develop a new IHC using the rabbit anti-ELI025 antibody (anti-ELI) and to compare its performance with the previously reported anti-CFA-based IHC. Thirty-eight P. insidiosum histological sections stained positive by anti-ELI-based and anti-CFA-based IHCs indicating 100% detection sensitivity for the two assays. The anti-ELI antibody stained negative for all 49 negative-control sections indicating 100% detection specificity. In contrast, the anti-CFA antibody stained positive for one of the 49 negative controls (a slide prepared from Fusarium-infected tissue) indicating 98% detection specificity. In conclusion, the anti-ELI based IHC is sensitive and specific for the histodiagnosis of pythiosis and is an improvement over the anti-CFA-based assay.

Ultrasound predictors of thyroid cancer.

OBJECTIVE: To identify ultrasound (US) features associated with cancer in thyroid nodules. MATERIAL AND METHOD: During a two and a half-year period, medical charts, US images, and pathological findings in 629 consecutive patients with thyroid nodules who underwent US examination as well as fine needle aspiration biopsy (FNAB) or surgical excision or both were retrospectively reviewed. Clinical and US findings associated with thyroid cancer were identified using statistical models. RESULTS: Unequivocal cytological or pathological findings were available for 578 patients. Forty-eight patients (8%) had thyroid cancer. Independent clinical and US features associated with thyroid cancer included younger age, symptoms other than palpable mass, solid nodules, fewer number of nodules, presence of calcifications, and enlarged cervical lymph nodes. The combination of all these features was most specific for the diagnosis of thyroid cancer. The absence of all these features could rule out all thyroid cancers. CONCLUSION: The risk of the thyroid cancer in patients with thyroid nodules could be estimated by using relevant clinical and US features.

Fine needle aspiration of thyroid: a cyto-histopathological correlation in Ramathibodi Hospital.

OBJECTIVE: To evaluate the accuracy of fine needle aspiration cytology (FNAC) of thyroid lesions in Ramathibodi patients. MATERIAL AND METHOD: A retrospective review is performed on 469 cases of thyroid surgical pathology specimens with previous FNAC reports; during January 2005 to January 2008. All histopathology reports are compared to the latest previous cytopathology results which are categorized as unsatisfactory, benign, inconclusive, borderline and malignancy RESULTS: The cytopathology results showed 74 cases (15.7%) of unsatisfactory specimens, 243 cases (51.8%) of benign lesions, 33 cases (7%) of inconclusive lesions, 15 cases (3.2%) of borderline lesions and 104 cases (22%) of malignant lesions. The histopathology results for benign lesions reveal multinodular and nodular goiter of 236 cases and other diagnosis of 54 cases. The histopathology results for malignant lesions were papillary carcinoma of 147 cases, follicular carcinoma of 24 cases and other malignancy of 8 cases. Among 243 cases of benign from FNAC; 23 cases turn out to be malignancy while 104 cases of malignancy from FNAC show no false positive. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of FNAC are 81.9%, 100%, 100%, 90.4% and 93.4% respectively. CONCLUSION: FNAC is a minimally invasive, highly accurate and cost-effective procedure. In our setting the FNAC enable the clinician to "rule-in" malignant lesions with confidence.

Coexisting vulvar Paget's disease and mucinous carcinoma of the breast: a case report and review of the literature.

Vulvar Paget 'disease is the most common site of extramammary Paget's disease (EMPD). The disease frequently associated with the underlying invasive skin adnexal carcinoma or representing the migration of underlying internal malignancy, especially anorectal and genitourinary cancer, but the coexisting with primary breast cancer is rare. Herein, the authors report a case of a 46-year-old Thai woman who had vulvar Paget's disease with subsequent development of mucinous carcinoma of the breast. Interestingly, the overexpression of HER-2/neu in vulvar Paget's disease raises the additional option of anti-HER-2/neu antibody therapy in highly aggressive or recurrent disease. In conclusion, primary breast cancer should be of concern in patients with vulva Paget's disease, even though it is an uncommon association.

Germline RB1 Mutation in Retinoblastoma Patients: Detection Methods and Implication in Tumor Focality.

Purpose: The study aimed to generate a stepwise method to reduce the workload of full-scale RB1 sequencing for germline mutation screening in retinoblastoma (RB) patients. The implication of germline mutation in tumor focality was also determined in this study. Methods: A stepwise method was created on the basis of "hotspot" exons analyzed using data on germline RB1 mutation in the RB1-Leiden Open Variation Database and then tested for mutation screening in the blood DNA of 42 patients with RB. The method was compared with the clinical next-generation sequencing (NGS) panel in terms of sequencing outcomes. The germline RB1 mutation was examined in association with multifocality in RB. Results: Germline RB1 mutation was identified in 61% of all bilateral cases in the first step of the 3 stepwise method and in 78% and 89% for the two and three steps combined, respectively. NGS detected a mosaic variant of RB1 that was not detected by the first two steps and increased the sensitivity from 78% to 83%. Analysis of the relationship between mutation status and tumor focality indicated that multifocality in RB was dependent on germline RB1 mutation, confirming a higher tendency to have a germline RB1 mutation in patients with multifocal RB. Conclusions: A 3 stepwise method reduces the workload needed for sequencing of the RB1 for bilateral cases. NGS outweighs conventional sequencing in terms of the identification of germline mosaic variants. Multifocal tumors in RB may be used to presume germline mutation. Translational Relevance: The presence of "hotspot" exons of germline RB1 mutation in bilateral cases facilitates a mutation screening. However, when genetic testing is not available, multifocality in RB regardless of tumor laterality is predictive of germline RB1 mutation.

Infection-associated hemophagocytic syndrome among patients with dengue shock syndrome and invasive aspergillosis: a case series and review of the literature.

The authors report four autopsy cases of previously healthy children with dengue shock syndrome complicated with infection-associated hemophagocytosis and invasive aspergillosis. Hemophagocytosis is confirmed by histopathology of autopsied reticuloendothelial organs. All four children were identified to have invasive aspergillosis by histopathology and three cases were positive on fungal culture for Aspergillus spp. Regarding the cause of death among the four children without pre-existing underlying disease, three cases were directly ascribable to invasive aspergillosis and the remaining case was ascribed to dengue shock syndrome. The transmigration of preexisting fungi from the respiratory mucosa damaged by the dengue shock process is postulated as the pathogenesis of invasive aspergillosis. The main predisposing factor was found to be prolonged dengue shock syndrome. We reviewed the clinicopathologic features and therapeutic management of infection-associated hemophagocytic syndrome in patients with dengue shock syndrome and invasive aspergillosis.

Adrenal histoplasmosis: a case series and review of the literature.

Adrenal histoplasmosis is an uncommon mycotic disease typically caused by Histoplasma capsulatum. The objective was to determine the clinicopathological findings in adrenal histoplasmosis. Pathological records were searched from the database at the Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University from 1993 to 2008 for cases of adrenal histoplasmosis. The keywords were "histoplasmosis" and "adrenal gland". Adrenal histoplasmosis was diagnosed by histopathology and Gomori-Grocott methenamine silver staining. Histoplasma capsulatum was confirmed by tissue culture and/or serology. The authors report seven cases of adrenal histoplasmosis in immunocompetent patients. The mean age at diagnosis was 67 years. All patients presented as chronic fatigue syndrome. The onset of symptoms ranged from one to three months. Addison's disease was found in adrenal histoplasmosis in one case (14.3%). The computed tomography revealed adrenal nodules measuring 1.2 to 7.8 cm in diameter. The histopathology showed granulomatous inflammation with caseous necrosis. Culture of adrenal tissue from two patients revealed Histoplasma capsulatum. Serum Histoplasma antibodies were positive in four cases. A cure was accomplished in 6 out of 7 cases (85.7%). The patients were followed up for 2.5 to 16.5 years.

Deep Neck Infection: Atypical Presentation of Papillary Thyroid Cancer.

Deep neck infection is defined as an infectious process in the potential spaces and fascial plane of the neck which may result in a fatal complication. Prompt drainage and broad-spectrum antibiotics are the mainstays of treatment. Deep neck infection as the initial presentation of primary head and neck cancer is not common. Nevertheless, head and neck squamous cell carcinoma is the most common primary head and neck cancer, which could present with cervical metastasis and subsequently becomes infected. Papillary thyroid cancer has a naturally indolent course, and most patients present with a thyroid nodule. However, deep neck infection could be an uncommon presentation of papillary thyroid cancer which may obscure the diagnosis of underlying malignancy. This case report aims to present a rare presentation of papillary thyroid cancer which needs meticulous evaluation. Moreover, the pathological examination should be performed in all cases of deep neck infection for early detection and management of underlying papillary thyroid cancer.

Predisposing Factors, Clinical Presentations, and Outcomes of Contact Lens-Related Pythium Keratitis.

PURPOSE: To describe predisposing factors, clinical presentations, and treatment outcomes of contact lens (CL)-related Pythium keratitis. METHODS: This was an 11-year retrospective study of CL-related Pythium keratitis conducted from 2009 to 2019. Six eyes of 6 patients were identified. Demographics, predisposing factors, CL history, clinical presentation, diagnostic tests, treatments, and outcomes were reviewed. RESULTS: Mean age of the patients was 34 years (SD 16.3 years) with equal proportion between male and female patients. Five of 6 patients (83.3%) used soft CL, whereas 1 patient used rigid gas permeable lens. All patients had a history of water contamination (tap water and water from river and sea). Mean duration from the onset was 7.8 days (range 4-14 days). Mean size of the corneal lesion was 3.33 mm (SD 1.31 mm) in width. The typical feature of tentacle-like lesions radiating in a reticular pattern was observed in all patients. Feathery edge (1 eye), satellite lesions (2 eyes), and radial keratoneuritis (2 eyes) were also found. Every patient received therapeutic penetrating keratoplasty because of failed medical treatments. One patient subsequently underwent enucleation. Globe salvage was achieved in 5 patients (83.33%). CONCLUSIONS: Awareness of the history of water contamination, recognition of specific clinical features of Pythium keratitis, and performing surgical treatment are key for achieving globe salvage in patients with CL-related Pythium keratitis.

Double check up of malignancy biopsy specimens for patient safety.

BACKGROUND: The diagnostic of malignancy in biopsy specimens is very important because it guides to selected treatment option and prognostic prediction. However biopsy specimens usually have small pieces leading to variations of the interpretation by anatomical pathologists. OBJECTIVE: To detect and correct the errors or the significant discrepancies in the diagnosis of biopsy specimens before sign-out and to determine the frequency of anatomic pathology significant discrepancies. DESIGN: The application of the mutually agreed work instructions (record) for the detection of errors or the significant discrepancies and their process of sign-out. The record of biopsy specimen that received a secondary check (1959 cases, 2005-2007) was analyzed. RESULTS: After a secondary check, 53 cases of non-malignancy for any reason by a second pathologist were included. However when using our definition on significant discrepancies, only 37 cases were considered. Another seven cases with the opinions with malignancy that were of different cell types that do harm to the patients were added. Therefore, 44 cases (2.25%) had truly significant discrepancies. CONCLUSION: The truly significant discrepancy frequency was 2.25% during the process of pre-sign-out secondary check of malignancy of biopsy specimens. The project has been applied as a routine daily work. It can be an innovative safety program for patient in Thailand.

Duodenal mature teratoma causing partial intestinal obstruction: A first case report in an adult.

BACKGROUND: A teratoma is a germ cell tumor that is composed of tissue derived from two or three germ layers. Duodenal teratomas are extremely rare and have been exclusively reported in neonates and children. This is the third case of a teratoma primarily arising in the duodenum and the first case that occurred in an adult. CASE SUMMARY: A 31-year-old male presented with clinical partial gut obstruction (epigastric pain, nausea, and vomiting). The physical examination showed a palpable ill-defined mass on the left side of the abdomen. The computed tomography scan revealed a multiseptated cystic tumor at the retroperitoneal area. First, he underwent gastrojejunostomy to relieve the symptoms and was referred to a tertiary-care hospital. The second operation revealed a 10-cm solid-cystic mass originating from the third part of the duodenum and adhering to the abdominal aorta and pancreas. Segmental duodenectomy was performed. The pathological diagnosis was a mature cystic teratoma. The patient was asymptomatic at 5 mo after the operation. CONCLUSION: Duodenal teratomas are extremely rare but should be included in the differential diagnosis in patients who present with intestinal obstruction. Radiological imaging is helpful to reach the preoperative diagnosis. Multidisciplinary team planning is essential to avoid injury to the adjacent organ in duodenal operation.

Clinical Presentations and Outcomes of Retinoblastoma Patients in relation to the Advent of New Multimodal Treatments: A 12-Year Report from Single Tertiary Referral Institute in Thailand.

PURPOSE: To investigate the clinical presentations and outcomes of retinoblastoma in relation to the advent of new multimodal treatments in Thailand. Patients and Methods. Retrospective case series. We evaluated the clinical presentation, staging, details of treatment, and treatment outcomes of retinoblastoma patients who were treated at Ramathibodi Hospital, Bangkok, Thailand, between January 1, 2007, and December 31, 2018. The log-rank test was used to explore clinical characteristics and treatment modalities that affected globe salvage and survival curves. RESULTS: This study included 124 eyes of 81 patients with retinoblastoma. Forty-three patients (53.1%) had bilateral retinoblastoma. The median age at diagnosis was 8 months (range, 1-48 months). Of 124 eyes, 9 eyes (7.3%) had extraocular retinoblastoma and 115 eyes (92.7%) had intraocular retinoblastoma, which were classified by the International Classification of Retinoblastoma (ICRB) as group A, 4 eyes (3.5%); group B, 19 eyes (16.5%); group C, 6 eyes (5.2%); group D, 31 eyes (27%); and group E, 56 eyes (47.8%). Treatment included systemic chemotherapy, intra-arterial chemotherapy, ruthenium-106 plaque brachytherapy, external beam radiation therapy, cryotherapy, transpupillary thermotherapy, subtenon chemotherapy, and intravitreal chemotherapy. At the median follow-up period of 38.4 months (range, 0.2-148.2 months), the overall globe salvage rate of intraocular retinoblastoma was 51.7%. For unilateral retinoblastoma, globe salvage rate was 37.5% (group B, 100%; group C, 100%; group D, 50%; and group E, 18.8%). For bilateral intraocular retinoblastoma, the globe salvage rate was 57.8% (group A, 100 %; group B, 94.4%; group C, 100%; group D, 64.7%; and group E, 28.2%). The overall survival rate was 93.8%. CONCLUSIONS: Recent advanced treatment modalities have improved the probability of globe salvage. However, enucleation remains an important life-saving intervention in many advanced cases.

Silencing of the Long Noncoding RNA MYCNOS1 Suppresses Activity of MYCN-Amplified Retinoblastoma Without RB1 Mutation.

Purpose: MYCNOS (MYCN opposite strand) is co-amplified with MYCN in pediatric cancers, including retinoblastoma. MYCNOS encodes several RNA variants whose functions have not been elucidated in retinoblastoma. Thus, we attempted to identify MYCNOS variants in retinoblastoma and aimed to decipher the role of MYCNOS variant 1 (MYCNOS1) on the activity of MYCN-amplified retinoblastoma. Methods: The profiles of MYCNOS variants and MYCN status were determined in 17 retinoblastoma tissues, cell lines, retinas, and retinal organoids. A functional study of MYCNOS1 expression was conducted in patient-derived tumor cells and in retinoblastoma cell lines via short hairpin RNA-mediated gene silencing. We carried out MYCN expression, cell viability, cell cycle, apoptosis, soft agar colony formation, and transwell assays to examine the role of MYCNOS1 in MYCN and cell behaviors. We analyzed a transcriptome of MYCN-amplified retinoblastoma cells deficient for MYCNOS1 and, finally, tested the responses of these cells to chemotherapeutic agents. Results: Expression of MYCNOS1 was associated with the expression and copy number of MYCN. Knockdown of MYCNOS1 caused instability of the MYCN protein, leading to cell cycle arrest and impaired proliferation and chemotaxis-directed migration in MYCN-amplified retinoblastoma cells in which RB1 was intact. MYCNOS1 expression was associated with gene signatures of photoreceptor cells and epithelial-mesenchymal transition. MYCNOS1 silencing enhanced the response of retinoblastoma cells to topotecan but not carboplatin. Conclusions: MYCNOS1 supports progression of retinoblastoma. Inhibition of MYCNOS1 expression may be necessary to suppress MYCN activity when treating MYCN-amplified cancers without RB1 mutation.

Evaluation of an in-house immunoperoxidase staining assay for histodiagnosis of human pythiosis.

Pythiosis, a life-threatening infectious disease of humans and animals in tropical and subtropical countries, is caused by the fungus-like organism Pythium insidiosum. As diagnosis of pythiosis is difficult, delayed diagnosis of pythiosis leads to poor prognosis. We developed an immunoperoxidase staining assay using rabbit anti-P. insidiosum antibodies to detect P. insidiosum directly in infected tissues of 19 patients with vascular (n = 11), ocular (n = 7) or cutaneous (n = 1) pythiosis. Tissue sections from 31 patients with various fungal infections were included as controls. Tissue sections from all pythiosis patients and 2 patients with Fusarium infections were stained positive, whereas the other 29 control sections were stained negative. Sensitivity and specificity of the assay was 100% and 94%, respectively. Based on the prevalence of human pythiosis (2%), calculated positive predictive value and negative predictive value was 24% and 100%, respectively. Thus, the diagnostic value of this assay is for ruling out pythiosis. The assay requires routine laboratory equipments and can easily be performed by pathologists in rural hospitals where the disease is more prevalent.

Lacrimal myoepithelial carcinoma ex recurrent pleomorphic adenoma: A clinicopathological report and review of the literature.

Myoepithelial carcinoma is an uncommon malignant tumor of the lacrimal gland, composed of neoplastic myoepithelial cells with an infiltrative growth. The present study describes a unique case of progressive proptosis and blindness of the right eye in a 68-year-old woman following total tumor removal for lacrimal pleomorphic adenoma. Clinical study, surgical exploration, and pathology revealed lacrimal myoepithelial carcinoma ex recurrent pleomorphic adenoma, T2N0M0. In addition, 18 cases of lacrimal myoepithelial tumor that have been previously described in the literature are reviewed. The application of clinical, radiological, histopathologic, and immunohistochemical investigations may help to reach the definite diagnosis. Criteria for malignancy of lacrimal myoepithelial tumor should be the same as salivary myoepithelial tumor diagnosis, until long-term outcome data for a larger number of patients with lacrimal myoepithelial carcinoma become available.

A three-dimensional organoid model recapitulates tumorigenic aspects and drug responses of advanced human retinoblastoma.

Persistent or recurrent retinoblastoma (RB) is associated with the presence of vitreous or/and subretinal seeds in advanced RB and represents a major cause of therapeutic failure. This necessitates the development of novel therapies and thus requires a model of advanced RB for testing candidate therapeutics. To this aim, we established and characterized a three-dimensional, self-organizing organoid model derived from chemotherapy-naïve tumors. The responses of organoids to drugs were determined and compared to relate organoid model to advanced RB, in terms of drug sensitivities. We found that organoids had histological features resembling retinal tumors and seeds and retained DNA copy-number alterations as well as gene and protein expression of the parental tissue. Cone signal circuitry (M/L+ cells) and glial tumor microenvironment (GFAP+ cells) were primarily present in organoids. Topotecan alone or the combined drug regimen of topotecan and melphalan effectively targeted proliferative tumor cones (RXRγ+ Ki67+) in organoids after 24-h drug exposure, blocking mitotic entry. In contrast, methotrexate showed the least efficacy against tumor cells. The drug responses of organoids were consistent with those of tumor cells in advanced disease. Patient-derived organoids enable the creation of a faithful model to use in examining novel therapeutics for RB.

Invasive fungal infection in Ramathibodi Hospital: a ten-year autopsy review.

OBJECTIVE: Determine the clinicopathological findings in autopsy cases with invasive fungal infection. MATERIAL AND METHOD: The autopsy and medical records with invasive fungal infection in Ramathibodi Hospital between January 1997 and December 2006 were analyzed. The criterions for the diagnosis of invasive fungal infection were the evidence of fungal elements from histopathological section. The age, gender underlying predisposing risk factors for the disease, clinical manifestations, extent of systemic organ involvement documented morphologically at autopsy, and fungal culture were analyzed RESULTS: There were 155 autopsy cases (73 male, 82 female; mean age 45.3 years, range 3 months to 87 years) with the diagnosis of invasive fungal infection. The common clinical presentations were fever (55.5%), and dyspnea (26.5%). The invasive fungal infection was associated with hematologic malignancy in 31%. The common mycoses were aspergillosis and candidiasis, which were observed in 88 and 80 cases, respectively. There were 32 cases (20.6%) of mixed fungal infection. Cultures from autopsy materials were positive for fungus in 80 cases out of 99 cases (80.8%). The most frequent site of fungal infection was in the lungs (74.8%), followed by gastrointestinal tract (28.4%), and brain (26.5%). Invasive fungal infection was diagnosed intravitally in 63.9% of total cases. CONCLUSION: A diagnosis of invasive fungal infection requires a high index of suspicion, especially in immunocompromised patients who presented with prolonged fever Clinical specimens must be sent for histopathology and fungal culture for a definite diagnosis and an appropriate management. Therefore, the physician should inform the laboratory if invasive fungal infection is suspected because special media are necessary for the best recovery of fungi. In addition, the present study underscores the significance of autopsy as a diagnostic method and means of medical quality control.

Bisphosphonate-related osteonecrosis of jaws in advanced stage breast cancer was detected from bone scan: a case report.

Bisphosphonates (BPs) are indicated to treat skeletal-related events (SREs) for cancer patients with bone metastasis. We report a 79-year-old woman with advanced stage breast cancer with bone metastasis who was prescribed BPs (zoledronate), then developed osteonecrosis of jaw. We provide a brief review of the pathogenesis, diagnosis and treatment of this complication.

A Novel PRKAR1A Mutation Identified in a Patient with Isolated Primary Pigmented Nodular Adrenocortical Disease.

Primary pigmented nodular adrenocortical disease (PPNAD) is a rare cause of Cushing syndrome, especially the isolated form without Carney complex, associated with germline mutations in PRKAR1A, the protein kinase A regulatory subunit type 1 alpha gene. We report a 31-year-old female who presented with secondary amenorrhea, cushingoid appearance, and hypertension without Carney complex. Biochemical laboratory examinations confirmed the ACTH-independent adrenal Cushing syndrome with negative Liddle test. A small right adrenal adenoma of 0.8 cm was shown on computed tomography while magnetic resonance imaging revealed nodularity of both adrenal glands. The histological report confirmed PPNAD using laparoscopic right adrenalectomy, and subsequent left adrenalectomy was performed 6 months later. She had inherited heterozygosity of a novel germline mutation of the PRKAR1A gene (g.114213T≥G or c.709-5T≥G). This splice site mutation results in exon 8 skipping. Her father carrying the same mutation had no clinical features of either PPNAD or Carney complex. This novel PRKAR1A gene mutation, c.709-5T≥G, is reported here for the first time manifesting as an incomplete clinical expression of the isolated form of PPNAD and being inherited with low penetrance unlike other inherited mutations of the Carney complex which have a penetrance of almost 100%.

Hepatic fascioliasis due to Fasciola hepatica: a two-case report.

Two cases of hepatic fascioliasis due to Fasciola hepatica were retrieved from our surgical-pathology file since the hospital's foundation in 1969 up to 2005. The diagnosis of hepatic fascioliasis was based on detection of one live fluke in a large cystic lesion in the lobectomized liver specimen in one case and of deposited eggs in the large liver specimen obtained from open biopsy in the other Hepatic fascioliasis is rather rare and almost worldwide in distribution including Thailand. The diagnosis should be considered in the patient from endemic areas consisting of the northern, northeastern and upper-central regions of the country, with a history of ingesting fresh water plants or drinking untreated water and having fever right-upper-quadrant pain or intrahepatic cystic lesion(s) together with absolute peripheral blood eosinophilia.