Saudi Journal of Gastroenterology
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CASE REPORT Table of Contents   
Year : 2001  |  Volume : 7  |  Issue : 3  |  Page : 113-115
Large liver abscess: Unusual presentation of fascioliasis: Case report and literature review


Department of General Surgery, Guilan University of Medical Sciences, Razi Hospital, Rasht, Iran

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Date of Submission20-Jul-2000
Date of Acceptance23-May-2001
 

How to cite this article:
Riazi H. Large liver abscess: Unusual presentation of fascioliasis: Case report and literature review. Saudi J Gastroenterol 2001;7:113-5

How to cite this URL:
Riazi H. Large liver abscess: Unusual presentation of fascioliasis: Case report and literature review. Saudi J Gastroenterol [serial online] 2001 [cited 2020 Nov 24];7:113-5. Available from: https://www.saudijgastro.com/text.asp?2001/7/3/113/33422



   Introduction Top


Infection with the liver fluke, fasciola hepatica, is a cosmopolitan zoonosis throughout the sheep­raising areas of the world. Human fascioliasis has been reported, particularly from south America, Europe, Africa, China, and Australia. In a collective review of 2594 persons with fascioliasis, more than half was reported from France, Portugal, Spain, Great Britain, and Tadjikistan. Other reports came from Cuba, Peru, Algeria, Egypt, and Australia [1]. Infection is contracted by ingestion of the encysted forms of the fluke attached to edible aquatic plants such as watercress. The larvae exist in the duodenum, migrate through the intestinal wall, pass into the peritoneal cavity, penetrate the liver capsule and finally reach the bile ducts, where the mature [2],[3],[4] Occasionally larvae may migrate to and mature in ectopic locations including subcutaneous tissue, chest cavity, and brain [1],[2],[3],[4] . Guilan province in northern Iran has suffered two outbreaks in 1989 and 1999 during the recent years [5] . We report a case of fascioliasis presenting as a large liver abscess.


   Case Report Top


A 50-year old female patient from Guilan province in northern Iran was admitted to surgical ward with right upper quadrant pain of two months duration, which had gradually increased in intensity. There was no history of any other accompanied symptoms. Physical examination was unremarkable, except for mild tenderness in right upper quadrant. In laboratory investigations, a white blood cell count of 11400/ mm3 with a 37% predominance of eosinophils was detected. Liver function tests were normal.

On ultrasonography, a liver abscess of 7-8cm in diameter was found in right lobe. Abdominal computed tomography scan showed a large liver abscess in right lobe [Figure - 1]. Indirect hemagglutination test (IHAT) for amebiasis was negative.

During surgical exploration, a 7-8 liver abscess with intact wall and smooth contour was found. Aspiration of the abscess revealed thick brown fluid. Resection of the abscess wall was performed and the remnant cavity was filled with omentum.

Histological examination revealed fibrin deposit and infiltration of polymorphs and eosinophils. Later on, IHAT for fasciola hepatica was carried out, which was positive with a titre of 1/1024. We diagnosed this case as a fasciola hepatica liver abscess because of the following reasons: (1) Epidemic outbreak of fascioliasis in the region at the time of onset, (2) histological findings suggestive of fascioliasis and (3) Positive IHAT for fasciola hepatica. Supportive medical treatment with a single oral dose of triclabendazole was given and the patient's sign and symptom subsided gradually. During a 16 months follow-up after surgical and medical treatment, the patient was free of symptom. At this time, IHAT for fasciola hepatica was negative with a titre of 1/16.


   Discussion Top


Many human fasciola infections are asymptomatic, but symptomatic, fascioliasis can be divided into two phases; larval migratory or acute phase, and adult or chronic phase [6] . Two weeks after infection, during attack on Glisson's capsule by several metacercariae, subcapsular hematoma and hemoperitoneum may occur, in severe infestation this results in hemorrhagic shock requiring emergency laparotomy. During this acute phase, the patient complains of headache, anorexia, nausea and vomiting, pruritus, right hypochondrial pain, and high fever with tender hepatomegaly, urticaria, and marked eosinophilia. This may persist for three or four months [1],[6],[7],[8] .

In the chronic phase, because of the size of the adult fluke in relation to the bile ducts, even mild infection may sometimes cause transient biliary colic. At this stage the patient presents with right upper quadrant pain and obstructive jaundice, fever, and chills , with tender hepatomegaly, eosinophilia, and abnormal liver function tests. In this phase, anemia is evident, and the erythrocyte sedimentation rate is commonly elevated [1],[4],[6],[7].

During the acute invasive phase, some metacercariae fail to reach the liver. Ectopic fascioliasis frequently manifests as painful migratory subcutaneous nodules, which may be mistaken for infected sebaceous cysts. Such lesions have been found in the stomach, cecum, appendix, pancreas, spleen, orbit, brain, heart, lungs, pleura, and the epididymis [1],[5],[7],[9] .

Diagnosis is suspected by finding the clinical picture of biliary tract disease with eosinophilia. It is confirmed by finding ova in the feces [4],[6],[7],[8] .

Most cases may be diagnosed by serologic methods and the reference to serologic tests is of remarkable value in many cases. Specific immunofluorescent antibodies show an increase in titre [4],[6],[8],[10] . In one study, diagnosis was based on antibody detection by IHAT in egg- negative patients [11].

Radiology may play a role in diagnosis. Computed tomography scan show peripheral filling defects, sometimes crescentic, and tortuous linear tracks in the liver due to the migratory fluke [7],[8] .

Recently a report concerning magnetic resonance (MR) in human fascioliasis, stated that there are findings that suggest various changes associated with traumatic hepatitis caused by migration of the worm in the liver and that these changes can be helpful in diagnosing fascioliasis [12]. Liver biopsy shows infiltration of the portal zone with histiocytes, eosinophils, and polymorphs. Hepatic granulmas and ova in the liver may occasionally be seen [6],[8]. Bithional at 30-50 mg/kg on alternate days for 10 to 15 doses is the treatment of choice [4],[7] .

Triclabendazole is an effective treatment against fasciola hepatica and is becoming the drug of choice. A single oral dose of 10mg/kg eliminates the infestations in about 75% of the cases. Two separately administered doses of this drug almost totally eliminate the parasites [8],[14],[15],[16],[17] .

Our enthusiastic search in medical texts, medline archive, and other medical literatures could not find similar case. Necrotic granuloma of the liver has been reported by Kim-KA and et al [13] .

We report a case of large liver abscess due to human fascioliasis. Our diagnosis was based on ultrasonography and computed tomography scan findings, a positive IHAT for fasciola hepatica, and compatible histological findings for fascioliasis. Treatment of the patient with surgical resection and triclabendazole was successful and IHAT for fasciola hepatica became negative.

It is concluded that due to high prevalence in northern Iran (Guilan), fascioliasis should be considered in the differential diagnosis of the large liver abscesses.

 
   References Top

1.Oluwatope A. Mabogunje, Christopher Grant, and A.S Dear. Biliary and intestinal trematodes. In : Peter J. Morris and Ronald A. Malt; Oxford textbook of SURGERY 1994:2573.  Back to cited text no. 1    
2.Hardman EW, Jones RLH, Davis AH. Fascioliasis a large outbreak. BMJ 1970;3:502.  Back to cited text no. 2    
3.Osman MM. Evaluation of fasciola antigenic fractions in the diagnosis of human fascioliasis. Ph. D. Thesis. Alexandria University, Egypt 1991.  Back to cited text no. 3    
4.Adel A. F. Mahmoud: Trematodes (schistosomiasis) and other flukes. In: Mandell G., et al (Eds); Principles and practice of INFECTIOUS DISEASES. Fourth edition 1995:2542.  Back to cited text no. 4    
5.M. Aghajanzadeh, A. Sarshad, R. Ebrahimian. Pneumothorax a rarity in fascioliasis. Archives of Iranian Medicine 1999, 2: 213.  Back to cited text no. 5    
6.Tranakchit Harinasuta, Danai Bunnag; Liver; Lung, and Intestinal Trematodiasis. In: Kenneth S. Warren, Adel A. F. Mahmoud; Tropical and geographical medicine. Second edition 1990 :478.  Back to cited text no. 6    
7.Theodore E.Nash. Schistosomiasis and other trematode infections. In: Fauci, et al (Eds); Harrison's principles of INTERNAL MEDICINE. 14 th edition 1998:1223.  Back to cited text no. 7    
8.Choi BI, Kim HJ, Han MC, et al; liver flukes. In :Sheila Sherlock and James Dooley (Eds); Diseases of the liver and biliary system. Ninth edition 1993:496.  Back to cited text no. 8    
9.Flores M, Merino Angula J., Aguirre Errastic. Pulmonary infiltrates as first sign of infection by fasciola hepatica, Eur J Respir Dis 1982; 63:231-3.  Back to cited text no. 9    
10.Hillyer GV, De Weil NS. Serodiagnosis of fascioliasis by immunorecipitation tests. Int J Parasitol 1981; 11:71-8.  Back to cited text no. 10    
11.El Shabrawi M, El Karaksy H, Okasha S, El Hennawy A. Human fascioliasis: clinical features and diagnostic difficulties in Egyptian children. J Trop Pediatr 1997; 43:162-6.  Back to cited text no. 11    
12.Han JK, Han D, Choi Bi, Han MC. MR findings in human fascioliasis. Trop Med Int Health 1996; 1:367-72.  Back to cited text no. 12    
13.Kim KA, Lim HK, Kim SH, Lee WJ, Lim JH. Necrotic granuloma of the liver by human fascioliasis: Imaging findings. Abdominal Imaging 1999; 24:462-4.  Back to cited text no. 13    
14.Lopez Velez R, Dominguez Castellano A, Garron C. Successful treatment of human fascioliasis with triclabendazole.Eur J Clin Microbiol Infect Dis 1999;18:525-6.  Back to cited text no. 14    
15.El Karaksy H, Hassanein B, Okasha S, Behairy B, Gadallah I. Human fascioliasis in Egyptian children successful treatment with triclabendazole. J Trop Pediatr 1999:45: 135-8.  Back to cited text no. 15    
16.Yilmaz H, Oner AF, Akdeniz H, Arsalan S. The effect of Triclabendazole (Fasinex) in children with fascioliasis. J Egypt Soc Parasitol 1998; 28:497-502.  Back to cited text no. 16    
17.Apt W, Aguilera X, Vega I, et al. Treatment of human chronic fascioliasis with triclabendazole: drug efficacy and serologic response. Am J Trop Med Hyg 1995; 52:532-5.  Back to cited text no. 17    

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Correspondence Address:
Hedayat Riazi
Department of General Surgery, Razi Hospital, P. 0. Box 41448, Rasht
Iran
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Source of Support: None, Conflict of Interest: None


PMID: 19861779

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