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Images in medicine
Fascioliasis: a rare cause of liver abscess INTRODUCTION Fascioliasis, a liver fluke infection caused by Fasciola hepatica, is one of the rarer causes of liver abscesses1. Differentiating these infections from the more common pyogenic and amoebic liver abscesses can be difficult. Diagnosis can be confirmed by demonstrating live parasites or eggs in the bile or feces2. We present the radiograph images and a short video which demonstrate a liver fluke being removed from the bile duct at endoscopic retrograde cholangio-pancreatography (ERCP) in a lady who presented with a liver abscess.
THE CASE A 65-year-old retired teacher presented with a 3-months’ history of upper abdominal discomfort and nausea. Over the past 2 years she had travelled extensively and visited countries including Cuba and Morocco. On examination she had mild tenderness in the upper abdomen. Blood tests showed a leucocytosis with marked eosinoplia. An ultrasound scan followed by computed tomogram of the abdomen showed an abscess in the right lobe of liver. She was treated with antibiotics for 6 weeks. Following treatment her symptoms improved. Post-treatment MR scan showed a partial resolution of the abscess but the common bile duct was dilated at 13 mm with a filling defect (figure 1). ERCP and a sphincterotomy were performed. A cholangiogram (figure 2) and endoscopic video (online supplementary video) were obtained. The video shows a liver fluke, which had appeared as a filling defect in the bile duct, after it was trawled out of the bile duct using an endoscopic balloon. Following ERCP she had a complete serology screen. The serology for Fasciola was positive, which makes this likely to be a ‘Cuban’ liver fluke. She was treated with Praziquantel 2.5 g stat dose and Nitazoxanide 500 mg twice a day for 7 days. On follow-up, she was asymptomatic, and a MR scan done 9 months after her initial presentation showed complete resolution of the abscess and no filling defects in the bile ducts.
DISCUSSION The clinical course of fascioliasis consists of two phases. In the initial, acute, hepatic phase, the immature larvae penetrate the
Figure 2 Cholangiogram image obtained during ERCP showing a filling defect (arrow) with in the bile duct.
liver capsule and lodge in the parenchyma and can clinically manifest as a liver abscess3. Symptoms in the acute phase can be non-specific and atypical of a pyogenic liver abscess. During the latter, ductal phase, the larvae enter the bile ducts where they can stay for months (figure 1) and can be either asymptomatic or manifest with symptoms of biliary colic, obstructive jaundice or rarely cholangitis3. The above described case and images demonstrate both phases corresponding to the migratory pathway of the larvae through the liver. It can be challenging to diagnose fascioliasis at initial presentation, but a high index of suspicion in patients with an appropriate history, clinical findings, imaging and serology may help in a prompt diagnosis and treatment. Shridhar S Dronamraju,1 Bryon C Jaques,1 Matthias Schmid,2 Julie R Samuel,3 Richard M Charnley1 1
Department of Hepatobiliary Pancreatic and Transplant Surgery, Freeman Hospital, Newcastle Upon Tyne, Tyne and Wear, UK 2 Department of Infection and Tropical Medicine, Royal Victoria Infirmary, Newcastle upon Tyne, Tyne and Wear, UK 3 Department of Microbiology, Royal Victoria Infirmary, Newcastle Upon Tyne, Tyne and Wear, UK Correspondence to Dr Shridhar Sanjeevarao Dronamraju, Department of Hepatobiliary Pancreatic and Transplant Surgery, Freeman Hospital, Newcastle Upon Tyne, Tyne and Wear NE7 7DN, UK; [email protected] ▸ Additional material is published online only. To view please visit the journal online (http://dx.doi.org/10.1136/postgradmedj-2013-131942). Contributors SSD: collection of data, editing of images and video and preparing the manuscript. RMC: conceived the idea, performed the endoscopic procedure, recorded the video of the procedure and revision of the manuscript. MS, JRS, and BCJ helped with providing the data and revision of the manuscript. Competing interests None. Patient consent Obtained. Provenance and peer review Not commissioned; externally peer reviewed.
Figure 1 Magnetic resonance scan image showing a filling defect (arrow) with in the bile duct. Dronamraju SS, et al. Postgrad Med J March 2014 Vol 90 No 1061
179
Downloaded from http://pmj.bmj.com/ on December 14, 2014 - Published by group.bmj.com
Images in medicine To cite Dronamraju SS, Jaques BC, Schmid M, et al. Postgrad Med J 2014;90:179–180. Received 11 March 2013 Revised 22 October 2013 Accepted 2 December 2013 Published Online First 2 January 2014 Postgrad Med J 2014;90:179–180. doi:10.1136/postgradmedj-2013-131942
180
REFERENCES 1 2
3
Jha AK, Goenka MK, Goenka U, et al. Hepatobiliary fascioliasis in non-endemic zones: a surprise diagnosis. Arab J Gastroenterol 2013;14:29–30. Kaya M, Beştaş R, Çetin S. Clinical presentation and management of Fasciola hepatica infection: single-center experience. World J Gastroenterol 2011;17:4899–904. Dusak A, Onur MR, Cicek M, et al. Radiological imaging features of fasciola hepatica infection—a pictorial review. J Clin Imaging Sci 2012;2:2.
Dronamraju SS, et al. Postgrad Med J March 2014 Vol 90 No 1061
Downloaded from http://pmj.bmj.com/ on December 14, 2014 - Published by group.bmj.com
Fascioliasis: a rare cause of liver abscess Shridhar S Dronamraju, Bryon C Jaques, Matthias Schmid, Julie R Samuel and Richard M Charnley Postgrad Med J 2014 90: 179-180 originally published online January 2, 2014
doi: 10.1136/postgradmedj-2013-131942 Updated information and services can be found at: http://pmj.bmj.com/content/90/1061/179
Supplementary Material
Supplementary material can be found at: http://pmj.bmj.com/content/suppl/2014/01/02/postgradmedj-2013-131 942.DC1.html These include:
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Articles on similar topics can be found in the following collections Pancreas and biliary tract (58) Liver disease (67) Radiology (361) Radiology (diagnostics) (255) Ethics (108) Drugs: infectious diseases (192) General surgery (148) Journalology (62) Pain (neurology) (194) Surgical diagnostic tests (144)
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
Images in medicine
Fascioliasis: a rare cause of liver abscess INTRODUCTION Fascioliasis, a liver fluke infection caused by Fasciola hepatica, is one of the rarer causes of liver abscesses1. Differentiating these infections from the more common pyogenic and amoebic liver abscesses can be difficult. Diagnosis can be confirmed by demonstrating live parasites or eggs in the bile or feces2. We present the radiograph images and a short video which demonstrate a liver fluke being removed from the bile duct at endoscopic retrograde cholangio-pancreatography (ERCP) in a lady who presented with a liver abscess.
THE CASE A 65-year-old retired teacher presented with a 3-months’ history of upper abdominal discomfort and nausea. Over the past 2 years she had travelled extensively and visited countries including Cuba and Morocco. On examination she had mild tenderness in the upper abdomen. Blood tests showed a leucocytosis with marked eosinoplia. An ultrasound scan followed by computed tomogram of the abdomen showed an abscess in the right lobe of liver. She was treated with antibiotics for 6 weeks. Following treatment her symptoms improved. Post-treatment MR scan showed a partial resolution of the abscess but the common bile duct was dilated at 13 mm with a filling defect (figure 1). ERCP and a sphincterotomy were performed. A cholangiogram (figure 2) and endoscopic video (online supplementary video) were obtained. The video shows a liver fluke, which had appeared as a filling defect in the bile duct, after it was trawled out of the bile duct using an endoscopic balloon. Following ERCP she had a complete serology screen. The serology for Fasciola was positive, which makes this likely to be a ‘Cuban’ liver fluke. She was treated with Praziquantel 2.5 g stat dose and Nitazoxanide 500 mg twice a day for 7 days. On follow-up, she was asymptomatic, and a MR scan done 9 months after her initial presentation showed complete resolution of the abscess and no filling defects in the bile ducts.
DISCUSSION The clinical course of fascioliasis consists of two phases. In the initial, acute, hepatic phase, the immature larvae penetrate the
Figure 2 Cholangiogram image obtained during ERCP showing a filling defect (arrow) with in the bile duct.
liver capsule and lodge in the parenchyma and can clinically manifest as a liver abscess3. Symptoms in the acute phase can be non-specific and atypical of a pyogenic liver abscess. During the latter, ductal phase, the larvae enter the bile ducts where they can stay for months (figure 1) and can be either asymptomatic or manifest with symptoms of biliary colic, obstructive jaundice or rarely cholangitis3. The above described case and images demonstrate both phases corresponding to the migratory pathway of the larvae through the liver. It can be challenging to diagnose fascioliasis at initial presentation, but a high index of suspicion in patients with an appropriate history, clinical findings, imaging and serology may help in a prompt diagnosis and treatment. Shridhar S Dronamraju,1 Bryon C Jaques,1 Matthias Schmid,2 Julie R Samuel,3 Richard M Charnley1 1
Department of Hepatobiliary Pancreatic and Transplant Surgery, Freeman Hospital, Newcastle Upon Tyne, Tyne and Wear, UK 2 Department of Infection and Tropical Medicine, Royal Victoria Infirmary, Newcastle upon Tyne, Tyne and Wear, UK 3 Department of Microbiology, Royal Victoria Infirmary, Newcastle Upon Tyne, Tyne and Wear, UK Correspondence to Dr Shridhar Sanjeevarao Dronamraju, Department of Hepatobiliary Pancreatic and Transplant Surgery, Freeman Hospital, Newcastle Upon Tyne, Tyne and Wear NE7 7DN, UK; [email protected] ▸ Additional material is published online only. To view please visit the journal online (http://dx.doi.org/10.1136/postgradmedj-2013-131942). Contributors SSD: collection of data, editing of images and video and preparing the manuscript. RMC: conceived the idea, performed the endoscopic procedure, recorded the video of the procedure and revision of the manuscript. MS, JRS, and BCJ helped with providing the data and revision of the manuscript. Competing interests None. Patient consent Obtained. Provenance and peer review Not commissioned; externally peer reviewed.
Figure 1 Magnetic resonance scan image showing a filling defect (arrow) with in the bile duct. Dronamraju SS, et al. Postgrad Med J March 2014 Vol 90 No 1061
179
Downloaded from http://pmj.bmj.com/ on December 14, 2014 - Published by group.bmj.com
Images in medicine To cite Dronamraju SS, Jaques BC, Schmid M, et al. Postgrad Med J 2014;90:179–180. Received 11 March 2013 Revised 22 October 2013 Accepted 2 December 2013 Published Online First 2 January 2014 Postgrad Med J 2014;90:179–180. doi:10.1136/postgradmedj-2013-131942
180
REFERENCES 1 2
3
Jha AK, Goenka MK, Goenka U, et al. Hepatobiliary fascioliasis in non-endemic zones: a surprise diagnosis. Arab J Gastroenterol 2013;14:29–30. Kaya M, Beştaş R, Çetin S. Clinical presentation and management of Fasciola hepatica infection: single-center experience. World J Gastroenterol 2011;17:4899–904. Dusak A, Onur MR, Cicek M, et al. Radiological imaging features of fasciola hepatica infection—a pictorial review. J Clin Imaging Sci 2012;2:2.
Dronamraju SS, et al. Postgrad Med J March 2014 Vol 90 No 1061
Downloaded from http://pmj.bmj.com/ on December 14, 2014 - Published by group.bmj.com
Fascioliasis: a rare cause of liver abscess Shridhar S Dronamraju, Bryon C Jaques, Matthias Schmid, Julie R Samuel and Richard M Charnley Postgrad Med J 2014 90: 179-180 originally published online January 2, 2014
doi: 10.1136/postgradmedj-2013-131942 Updated information and services can be found at: http://pmj.bmj.com/content/90/1061/179
Supplementary Material
Supplementary material can be found at: http://pmj.bmj.com/content/suppl/2014/01/02/postgradmedj-2013-131 942.DC1.html These include:
References Email alerting service
Topic Collections
This article cites 3 articles, 0 of which you can access for free at: http://pmj.bmj.com/content/90/1061/179#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Articles on similar topics can be found in the following collections Pancreas and biliary tract (58) Liver disease (67) Radiology (361) Radiology (diagnostics) (255) Ethics (108) Drugs: infectious diseases (192) General surgery (148) Journalology (62) Pain (neurology) (194) Surgical diagnostic tests (144)
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
