Fever and eosinophilia in a returned traveller

A previously healthy 37-year-old Frenchman was admitted to hospital because of fever and asthenia. He had returned 6 weeks previously from a 15-day trip to rural areas in the south of Madagascar (eastern and western coasts). He took chloroquine prophylaxis for malaria. He reported having, during his travels, inflammatory skin lesions on his right foot, which resolved within a few days, and 2 days of diarrhoea without any fever. Asthenia and fever appeared 1 month later, associated with myalgia. On admission to hospital, 10 days later, his temperature was 38°C. He complained of asthenia, myalgia, abdominal pain and, more recently, an unproductive cough without dyspnoea. Physical examination was normal. The patient’s white blood cell count was 8200 cells/mm3 with 45% neutrophils, 20% lymphocytes, 8% monocytes and 27% eosinophils (2210 eosinophils/mm3). His liver profile showed raised alkaline phosphatase activity (161 U/l; normal <130 U/l) and γ-glutamyltranspeptidase activity (172 U/l; normal <60 U/l), normal aspartate aminotransferase activity (29 U/l; normal <50 U/l) and alanine aminotransferase activity (59 U/l; normal <60 U/l). Repeated blood smears disclosed no parasites. Stool and urine examinations were also negative for parasites …