Fasciola hepatica infestation as a very rare cause of extrahepatic cholestasis

Fasciola hepatica, an endemic parasite in Turkey, is still a very rare cause of cholestasis worldwide. Through ingestion of contaminated water plants like watercress, humans can become the definitive host of this parasite. Cholestatic symptoms may be sudden but in some cases they may be preceded by a long period of fever, eosinophilia and vague gastrointestinal symptoms. We report a woman with cholangitis symptoms of sudden onset which was proved to be due to Fasciola hepatica infestation by an endoscopic retrograde cholangiography.     

Fasciola hepatica infection: clinical and computerized tomographic findings of ten patients.

BACKGROUND/AIMS: Fasciola hepatica is the cause of liver infection, fascioliasis. Although rare, it is still a problem even in developed countries. In this study, the clinical and computerized tomographic findings of 10 patients diagnosed with fascioliasis are summarized. METHODS: The medical records of the patients with fascioliasis were retrospectively examined. Clinical, laboratory findings and computerized tomographic results were recorded. RESULTS: Abdominal pain, fever, eosinophilia and abnormal liver function tests were the most commonly encountered symptoms and signs. One patient was human immunodeficiency virus -positive with active tuberculosis. Serologic test for fasciola hepatica was positive in all patients. Nodular masses without prominent enhancement, and branching low-attenuated tubular lesions were the most commonly seen tomographic findings and were supportive for the diagnosis. All except the HIV-positive patient received bithionol therapy; six patients responded well, two lost contact with the clinic and one patient who was unresponsive to bithionol therapy received triclabendazole. During follow-up of the six patients who responded, all the clinical and radiological findings regressed. CONCLUSION: In any patient with peripheral eosinophilia, abdominal pain and elevated liver enzymes, especially when CT reveals tubular and nodular hypodense lesions particularly in subcapsular area, F. hepatica infection should be considered. Either triclabendazole or bithionol can be used effectively for the treatment.     

Ectopic fascioliasis mimicking a colon tumor

Fasciola hepatica, a leaf shaped trematode that is common in cattle, sheep and goats, is acquired by eating raw water plants like watercress or drinking water infected with the encysted form of the parasite. The varied clinical presentations of fascioliasis still make a high index of suspicion mandatory. Besides having a wide spectrum of hepatobiliary symptoms like obstructive jaundice, cholangitis and liver cirrhosis, the parasitic infection also has extrabiliary manifestations. Until recently, extrahepatic fascioliasis has been reported in the subcutaneous tissue, brain, lungs, epididymis, inguinal lymph nodes, stomach and the cecum. In this report, a strange manifestation of the fasciola infection in a site other than the liver, a colonic fascioliasis, is presented.     

Primary pulmonary coccidioidomycosis in China

Coccidioidomycosis is a fungal infection endemic to south‐west USA, north Mexico and parts of Central and South America. We report here a case of primary pulmonary coccidioidomycosis in a previously healthy 14‐year‐old boy in China, which is considered a non‐endemic country. The patient had non‐specific symptoms of pulmonary infection, including fever, non‐productive cough and night sweats. Both spherules and endospores of Coccidioides immitis were seen histologically following transbronchial biopsy of a cavitary lesion. The patient was treated with amphotericin B and fluconazole. Follow up 6 months post discharge found that the patient made a good recovery.     

Plasmodium vivax malaria with clinical presentation mimicking acute type idiopathic thrombocytopenic purpura

Causes of thrombocytopenia are diverse, and infection with plasmodia often brings about thrombocytopenia. Japan is not an endemic area of malaria infection at present and most cases are travelers to endemic areas. In some cases, initial clinical diagnoses may not be correct because of a variety of symptoms, physical findings and laboratory abnormalities. A 67-year-old female, who had traveled to South American countries 2 months before the onset of the disease, presented with a case of vivax malaria. Because of the patient's high fever, profound thrombocytopenia (1.5 x 10(4)/microl), and elevated platelet-associated IgG on admission, our initial diagnosis was acute type idiopathic thrombocytopenic purpura (ITP). However, we recognized her tertian fever and plasmodial vivax in erythrocytes 4 days later. She responded promptly to anti-parasitic therapy after diagnosis of malaria and her laboratory data also improved. Travel history is indicative of malaria infection in some cases with thrombocytopenia mimicking acute ITP.     

Spontaneous splenic rupture complicating acute Q fever.

Q fever is usually a self-limited febrile illness that involves the lungs and the liver. Acute complications are rare. We present the case of a 30-yr-old patient with spontaneous splenic rupture during the course of acute Q fever infection. He was admitted to the hospital with high temperature and the radiological signs of an atypical pneumonia. Forty-eight hours after admission, he developed shock. Because of free intraabdominal liquid, a laparatomy was performed that revealed a tear in the enlarged spleen. A splenectomy was performed. The diagnosis of Q fever was established by a significant titer increase in complement fixation test and IgM-ELISA. Serological investigations into the patient's surroundings revealed evidence of Q fever infection in 10 additional persons. Q fever should be taken into account as a possible differential diagnosis in patients with unexplained febrile illness and symptoms of pneumonia. The acute course of Q fever infection can be complicated by splenic rupture. The diagnosis of an acute infection with Coxiella burnetii often requires serologic testing of a second serum sample obtained at least 10 days after the onset of symptoms. Q fever should be ruled out in cases of unexplained splenic rupture particularly in Q fever endemic areas.     

Evolution of Fascioliasis after Eating Wild Watercress

Abstract: Evolution of fascioliasis after eating wild watercress. J. Croese, G. Chapman and N. D. Gallagher. Aust. HZ. J. Med., 1982, 12 , pp. 525–527.
Fascioliasis is rarely reported in humans although it is endemic in sheep and cattle. We describe the illness of a 60-year-old widow who ate wild watercress which is the usual source of infestation. Laparotomy for suspected liver abscesses revealed necrotic tracts on the surface of the liver left by the invasion of numerous flukes. Diagnosis was made during the latent phase by the detection of serum antibody to fasciola hepatica antigen obtained from a sheep. Symptoms returned during the cholestatic phase. Mature flukes were then present in the large bile ducts and ova appeared in the stools. Symptoms resolved twelve weeks after presentation.     

Risk of gallstone disease in advanced chronic phase of fascioliasis: an experimental study in a rat model

In Wistar rats experimentally infected with Fasciola hepatica, the association between time of infection, number of flukes, rat weight, and serum lipid levels and the risk of developing pigment stones in the main bile duct was examined using data obtained at 100, 200, 300, 400, and 500 days postinfection. Gallstone presence increased with infection time. The relative risk of gallstone disease increased when the number of flukes per rat and rat weight increased. The presence of gallstones was associated with serum high-density lipoproteins and triglyceride levels. In a multivariate analysis, the association between gallstones and rat weight disappeared after adjustment for serum lipids. The absence of an effect of rat weight independent from serum lipids suggests that serum lipids are more closely linked to gallstone pathogenesis than is overweight. The presence of gallstones was strongly associated with the number of flukes located in the bile duct. A high risk of developing gallstones may be expected in human subjects inhabiting areas where F. hepatica is highly endemic and where high egg outputs detected in humans suggest that liver fluke burdens may also be very high.     

Investigation of antibody to severe fever with thrombocytopenia syndrome virus (SFTSV) in blood samples donated in a SFTS‐endemic area in Japan

The risk of transfusion‐transmitted infection (TTI) for severe fever with thrombocytopenia syndrome virus (SFTSV) is a concern because person‐to‐person transmission resulting from contact with SFTSV‐contaminated blood has been reported. To obtain information regarding the risk of TTI‐SFTSV, antibody testing was performed for blood samples donated in an severe fever with thrombocytopenia syndrome‐endemic area in Japan. No antibody‐positive samples were detected among 3990 samples. This finding suggested that there were few cases of SFTSV infection among donors and that the risk of TTI‐SFTSV was also estimated low in Japan.     

Identification and characterization of a major Schistosoma mansoni glycoprotein antigen cross-reactive with Fasciola hepatica

A major surface antigen of Schistosoma mansoni has been identified and characterized as a glycoprotein of 66,000 molecular weight (Mr) and isoelectric point of 6.2-6.1 (SM66-GP) by use of a monoclonal antibody. The antigen was expressed by schistosome eggs, cercariae, larvae, and adults, and was recognized by sera of schistosome infected hosts. Direct immunofluorescence microscopy showed the antigen was distributed in a uniform pattern on the entire worm surface. Indirect immunofluorescence microscopy revealed that it was present in the parenchymal tissue of immature and mature Fasciola hepatica, in the gut of the mature fluke, and in embryonated fasciola eggs. The cross-reactive F. hepatica epitope recognized was expressed on a polypeptide of Mr 220,000.     

Hyperendemic fascioliasis associated with schistosomiasis in villages in the Nile Delta of Egypt

Coprologic surveys were carried out in villages of the Behera Governorate in the Nile Delta region of Egypt to characterize the epidemiologic features of human fascioliasis caused by Fasciola hepatica and F. gigantica in this lowland endemic area by comparison with fascioliasis caused by only F. hepatica in areas hyperendemic for human disease in the Andean highlands of South America. The fascioliasis prevalences detected (range = 5.2-19.0%, mean = 12.8%) are the highest obtained in Egypt. The comparison with previous results suggests that in the Nile Delta, fascioliasis is spreading from an original situation of sporadic human cases in well-known endemic foci for animal disease to an endemic distribution in humans, which may be characterized as a mesoendemic region that includes several hyperendemic areas for human disease. As in Andean countries, a relationship with sex was found, although in Egypt prevalences, but not intensities, appeared to be significantly higher in females. All ages appear to be susceptible to liver fluke infection, with prevalences and intensities being lower before and after school age, a situation that is consistent with that detected in Andean countries, although the peak in the 9-11-year-old age group appears less pronounced in Egypt. The intensities were very high when compared with those found in subjects sporadically infected in areas endemic for animal disease, but relatively low for a hyperendemic situation, although the intensities may not be conclusive because of the transmission seasonality of fascioliasis in the Nile Delta. The marked similarities in the qualitative and quantitative spectrums of protozoans and helminths, multiparasitisms, and associations between liver flukes and other parasitic species suggest physiographic-hydrographic and behavioral-social characteristics similar in all areas hyperendemic for human fascioliasis, which are independent of other factors such as climate, altitude, and cultural or religious features. The significant positive association between liver fluke infection and schistosomiasis mansoni detected in one locality has never been described elsewhere, and must be considered relevant from clinical, pathologic, diagnostic, and therapeutic points of view. Interestingly, the relationships of schistosomiasis prevalences and intensities with sex and age follow patterns similar to those found in fascioliasis.     

„Emerging Infectious Diseases“

Some emerging infectious diseases have recently become endemic in Germany. Others remain confined to specific regions in the world. Physicians notice them only when travelers after infection in endemic areas present themselves with symptoms. Several of these emerging infections will be explained. HIV is an example for an imported pathogen which has become endemic in Germany. SARS and avian influenza are zoonoses with the potential to spread from person to person. Avian influenza in humans provides a possibility for the reassortment of a potential new pandemic strain. Outbreaks of dengue fever in endemic areas are reflected in increased infections in travelers returning from these areas. Currently, West-Nile-virus infections are only imported into Germany. The timely implementation of diagnostic, therapeutic and infection control measures requires physicians to include these diseases in their differential diagnosis. To achieve this goal, good cooperation between physicians, laboratories and the public health service is essential.     

Fascioliasis imported to Norway

We report 3 cases of fascioliasis imported to Norway: a 24-y-old male Vietnamese immigrant and a 51-y-old female Vietnamese immigrant with acute fascioliasis, and a 2-y-old male Ethiopian adoptee with chronic fascioliasis. Diagnosis was confirmed by detection of specific antibodies to Fasciola hepatica in the 2 first cases and by demonstration of Fasciola hepatica eggs in stool samples in the latter case. Treatment with oral triclabendazole led to prompt cure in all 3 patients. Imported fascioliasis is rarely reported but should be suspected in patients with a travel history to endemic areas, abdominal symptoms and hypereosinophilia of the blood.     

Clinical manifestations of Q fever in adults and children

Q fever is a common zoonosis with almost a worldwide distribution caused by Coxiella burnetii. Farm animals and pets are the main reservoirs of infection and transmission to humans is usually via inhalation of contaminated aerosols, which may be carried by the wind far from the original source of infection. Occupational groups with close association with farm or wild animals are most at risk, however travellers occasionally become infected. The disease is associated with a wide spectrum of clinical manifestations and symptoms, ranging from asymptomatic infection to fatal disease. Awareness of the disease and newer diagnostic methods led to increase of recognition and detection in cases with various or multiple symptoms in adults and children. However, children seem to be less frequently symptomatic and may have milder disease. This review of Q fever cases examines clinical manifestations and symptoms of Q fever in both adults and children and shows that certain symptoms and their severity have altered presentation in children with acute and chronic Q fever when compared to adults.     

Massive infection with fasciola hepatica in man

The six year clinical course of a patient who acquired a massive infection with the liver fluke, Fasciola hepatica, is described. A peripheral blood eosinophilia was an almost constant finding throughout the illness. The patient may well have been infected with a multiple of 40 adult flukes as his fecal ova count (1,000/g) was 40 times greater than that of a subject with an asymptomatic infection. During the illness, cholecystectomy was carried out. The surface of the liver was studded with greyish white hard nodules. Microscopy of the gallbladder revealed a nonspecific chronic cholecystitis; a liver biopsy disclosed florid changes of large duct biliary obstruction, granulomas, patchy periductular fibrosis and an ovum morphologically similar to an ovum of Fasciola hepatica surrounded by a granuloma. Three exacerbations of symptoms were associated with severe microcytic hypochromic anemia, possibly due to blood loss into the biliary tract. A course of bithionol was associated with rapid amelioration of symptoms and disappearance of ova from feces. No evidence of recurrence of infection occurred during the following two and a half years. The infection was probably acquired by eating wild watercress (Nasturtium officinale) containing encysted metacercariae at a campsite frequented by the patient in the Lake District of England. At this site, a habitat suitable for the life cycle of F. hepatica was found, including snails of the genus Limnaea truncatula, which were shown to contain cercariae. The site is in a region with a high rainfall, a factor known to favor the life cycle of F. hepatica. Infection with this parasite should be considered whenever a clinical picture suggestive of biliary tract disease is associated with an eosinophilia.     

3 dengue fever cases,infected during a group tour to the Philippines

We report three dengue fever cases, infected during a group tour to the Philippines. A 58-year old male experienced sudden onset of high fever 5 days after returning to Japan, followed by rash and thrombocytopenia. The other 2 cases experienced similar symptoms. Clinically suspected from the travel history, incubation time and the state of dengue fever epidemic in the Philippines, dengue virus infection was confirmed by the laboratory tests. The incidence and geographical distribution of dengue virus infection have greatly increased in recent years. There have been reports of Japanese travelers who visited dengue endemic countries, infected and developed symptoms after returning home. Dengue virus infection should be included in the differential diagnosis of the patients who develop high fever and rash after returning from tropical areas.     

Evaluation of Fas2-ELISA for the serological detection of Fasciola hepatica infection in humans

The performance of Fas2-ELISA for the diagnosis of Fasciola hepatica infection in children living in areas of high endemicity for fascioliasis in the Peruvian Andes is analyzed. Fas2-ELISA is based on the detection of circulating IgG antibodies elicited in infected individuals against a F. hepatica antigen termed Fas2. The study was conducted in three Andean localities, Huertas-Julcan in Junin, Asillo in Puno, and Cajamarca, with a total population of 634 children in an age range 1 to 16 years old. Child fascioliasis prevalence was 21.1% in Huertas-Julcan, 25.4% in Asillo, and 24% in Cajamarca, estimated by coprological inspection. The seroprevalence of F. hepatica infection, determined by Fas2-ELISA, was 27.8% in Huertas-Julcan, 44.6% in Asillo, and 29.1% in Cajamarca. The overall sensitivity of Fas2-ELISA was 92.4%, the specificity 83.6%, and the negative predictive value 97.2%. No association between OD(450) Fas2-ELISA and infection intensity measured by egg counting was observed. Results show that Fas2-ELISA is a highly sensitive immunodiagnostic test for the detection of F. hepatica infection in children living in human fascioliasis endemic areas.     

Imported Fasciola hepatica infection in the United States and treatment with triclabendazole.

Infection with Fasciola hepatica, a liver trematode, is not frequently reported in the United States. We describe 2 patients, both originally from Cape Verde, who illustrate the spectrum of clinical presentations of F. hepatica as well as the means of treating infection with this parasite. Patient 1 had extensive disease and underwent multiple diagnostic procedures before the correct diagnosis was reached. Patient 2, who had few symptoms, had fascioliasis diagnosed by a noninvasive evaluation. Both patients were treated with triclabendazole without experiencing significant side effects. Fascioliasis that has been imported to the United States may elude prompt or accurate diagnosis. Obtaining a detailed travel history and recognizing the clinical presentation early in the course of infection may permit timely and noninvasive identification of infection. Triclabendazole is now the recommended drug for treating for fascioliasis because of its efficacy, safety, and ease of use.     

河南省小动物宿主肝毛细线虫病流行病学调查

目的调查分析河南省小动物宿主感染肝毛细线虫病流行现状。方法根据地理方位和地理特征选择7个县为调查点，在户外捕捉鼠类等动物，鉴定种类，解剖取鼠肝用直接压片法镜检肝毛细线虫感染情况。结果共捕获各种鼠类和其他动物15种1188只，其中啮齿目动物11种，1169只。优势鼠种为褐家鼠、大仓鼠、黄胸鼠、小家鼠和黑线姬鼠。6种鼠157只检出肝毛细线虫感染，平均感染率为13．62％。感染率最高的为家栖鼠类，其中褐家鼠25．83％，黄胸鼠12．90％，小家鼠10．00％。地区分布以汝南县鼠感染率最高，为23．83％；郑州市惠济区1．76％。环境分布以村周鼠感染率最高，为30．34％；村内19．49％，田地17．24％。结论河南省鼠肝毛细线虫分布十分广泛，部分地区鼠类感染较为严重。开展人肝毛细线虫流行病学调查和防治十分必要。     

Human fascioliasis successfully treated with triclabendazole

Fascioliasis, caused by the common liver fluke Fusciolu hepatica , is an endemic infection in sheep and cattle in many parts of Australia. Infections in humans in Australia have been reported infrequently and the most appropriate therapy for human fascioliasis remains to be determined. This case report describes a patient with the infection unsuccessfully treated with multiple high doses of praziquantel, mebendazole or albendazole. The infection was successfully eliminated by the administration of triclabendazole in two single doses of 900 mg (12 mg/kg) two days apart. No side effects were observed after the treatment. Based on our experience and that recently reported in the literature, triclabendazole may be regarded as the drug of choice for the treatment of human fascioliasis. (Aust NZ J Med 1992; 22: 45–47.)