A case of ectopic parasitism: Fasciola hepatica larvae burrow through a human brain and mimic cerebral aneurysm

Highlights of human ectopic fascioliasis: a systematic review

Fascioliasis is a tropical zoonotic disease caused by the Fasciola parasite. The adult parasite usually resides in the liver and biliary ducts; however, several cases of ectopic fascioliasis (EF) have been reported. This study is a highlight on EF according to the confirmed case reports. In a setting of systematic review, we found 25 eligible articles containing 26 confirmed cases of EF (any date until 30 November 2018), including abdominal and intestinal EF in six cases, skin and subcutaneous tissues in five cases, eye in four cases, brain and pancreas in three cases, neck and lymph node in two cases, and lung, dorsal spine, and peritoneal cavity in one case, respectively. The result indicates that fascioliasis can have diverse ectopic forms and should be more attended in the endemic regions of fascioliasis in order to distinguish from other endemic diseases.

Numerous Fasciola plasminogen-binding proteins may underlie blood-brain barrier leakage and explain neurological disorder complexity and heterogeneity in the acute and chronic phases of human fascioliasis

Human fascioliasis is a worldwide, pathogenic food-borne trematodiasis. Impressive clinical pictures comprising puzzling polymorphisms, manifestation multifocality, disease evolution changes, sequelae and mortality, have been reported in patients presenting with neurological, meningeal, neuropsychic and ocular disorders caused at distance by flukes infecting the liver. Proteomic and mass spectrometry analyses of the Fasciola hepatica excretome/secretome identified numerous, several new, plasminogen-binding proteins enhancing plasmin generation. This may underlie blood-brain barrier leakage whether by many simultaneously migrating, small-sized juvenile flukes in the acute phase, or by breakage of encapsulating formations triggered by single worm tracks in the chronic phase. Blood-brain barrier leakages may subsequently occur due to a fibrinolytic system-dependent mechanism involving plasmin-dependent generation of the proinflammatory peptide bradykinin and activation of bradykinin B2 receptors, after different plasminogen-binding protein agglomeration waves. Interactions between diverse parasitic situations and non-imbalancing fibrinolysis system alterations are for the first time proposed that explain the complexity, heterogeneity and timely variations of neurological disorders. Additionally, inflammation and dilation of blood vessels may be due to contact system-dependent generation bradykinin. This baseline allows for search of indicators to detect neurological risk in fascioliasis patients and experimental work on antifibrinolytic treatments or B2 receptor antagonists for preventing blood-brain barrier leakage.

Controversial aspects of the life cycle of Fasciola hepatica

Fasciola hepatica is a well-known helminth parasite, with significant economic and public health importance all over the world. It has been known since more than 630 years ago and a considerable research work has been carried out on the life cycle of this important parasite. In the hepatic phase of the life cycle of F. hepatica, it is assumed that the young flukes, after about 6-7 weeks of migration in the liver parenchyma, enter into the bile ducts of the definitive hosts and become sexually mature. Even though the secretion of cysteine peptidases including cathepsin L and B proteases by F. hepatica may justify this opinion, because of several scientific reasons and based on the experimental studies conducted in different animals (reviewed in this article), the entry of parasites into the bile ducts, after their migration in the liver parenchyma seems to be doubtful. However, considering all the facts relating to the hepatic and biliary phases of the life cycle of F. hepatica, two alternative ideas are suggested: 1) some of the migrating juvenile flukes may enter into the bile ducts immediately after reaching the liver parenchyma while they are still very small, or 2) when newly excysted juvenile flukes are penetrating into the intestinal wall to reach the liver through the abdominal cavity, a number of these flukes may enter into the choleduct and reach the hepatic bile ducts, where they mature. According to the previously performed natural and experimental studies in different animals and human beings, the supporting and opposing evidences for the current opinion as well as the evidences that might justify the two new ideas are reviewed and discussed briefly. In conclusion, our present knowledge about the time and quality of the entry of F. hepaticas into the bile ducts, seems to be insufficient, therefore, there are still some dark corners and unknown aspects in this field that should be clarified.

Neurological and ocular fascioliasis in humans

Fascioliasis is a food-borne parasitic disease caused by the trematode species Fasciola hepatica, distributed worldwide, and Fasciola gigantica, restricted to given regions of Africa and Asia. This disease in humans shows an increasing importance, which relies on its recent widespread emergence related to climate and global changes and also on its pathogenicity in the invasive, biliary, and advanced chronic phases in the human endemic areas, mainly of developing countries. In spite of the large neurological affection capacity of Fasciola, this important pathogenic aspect of the disease has been pronouncedly overlooked in the past decades and has not even appear within the numerous reviews on the parasitic diseases of the central nervous system. The aim of this wide retrospective review is an in-depth analysis of the characteristics of neurological and ocular fascioliasis caused by these two fasciolid species. The terms of neurofascioliasis and ophthalmofascioliasis are restricted to cases in which the direct affection of the central nervous system or the eye by a migrant ectopic fasciolid fluke is demonstrated by an aetiological diagnosis of recovered flukes after surgery or spontaneous moving-out of the fluke through the orbit. Cases in which the ectopic fluke is not recovered and the symptoms cannot be explained by an indirect affection at distance may also be included in these terms. Neurofascioliasis and ophthalmofascioliasis cases are reviewed and discussed. With regard to fascioliasis infection giving an indirect rise to neurological affection, the distribution and frequency of cases are analysed according to geography, sex, and age. Minor symptoms and major manifestations are discussed. Three main types of cases are distinguished depending on the characteristics of their manifestations: genuine neurological, meningeal, and psychiatric or neuropsychic. The impressive symptoms and signs appearing in each type of these cases are included. Brain examination techniques and neuroimaging useful for the diagnosis of neurological cases are exposed. Within fascioliasis infection indirectly causing ocular manifestations, case distribution and frequency are similarly analysed. A short analysis is devoted to clarify the first reports of a human eye infection. The affection of related and close organs is discussed by differentiating between cases of the dorsal spine, pulmonary manifestations, heart and vessel affection, findings in blood vessels, skin and dermatologic reactions, cases of ectopic mature flukes, and upper body locations. The clinical complexity of the puzzling polymorphisms, the disconcerting multifocality of the manifestations, and their changes along the evolution of the disease in the same patient, as well as the differences between the clinical pictures shown by different patients, are highlighted. The many syndromes involved are enumerated. The pathogenic and physiological mechanisms underlying neurofascioliasis and ophthalmofascioliasis caused by ectopic flukes and the physiopathogenic processes indirectly affecting the central nervous system and causing genuine neurological, meningeal, psychiatric, and ocular manifestations are discussed. The diagnosis of neurological and ophthalmologic fascioliasis is analysed in depth, including clinical and paraclinical diagnosis, eosinophilia in the blood and cerebrospinal fluid, differential diagnosis from other parasitic infections such as helminthiases and myiases, an update of human fascioliasis diagnosis, and fluke and/or fluke egg recovery by surgery. Diagnostic analyses with faecal and blood samples for fascioliasis patients are updated. Therapy for patients with major neurological manifestations includes both antiparasitic treatments and anti-inflammatory therapeutics. Prognosis in fascioliasis patients with neurological manifestations is discussed, with emphasis on sequelae and fatal cases, and the care of patients with ophthalmologic manifestations is added. Conclusions indicate that neurological cases are overlooked in human fascioliasis endemic areas and also in developing countries in general. In remote zones, rural health centres and small hospitals in or near the human endemic areas do not dispose of the appropriate equipments for neurological analyses. Moreover, physicians may not be aware about the potential relationship between liver fluke infection and neurological implications, and such cases may therefore remain misdiagnosed, even in developed countries. Priority should henceforth be given to the consideration of neurological and ocular affection in human endemic areas, and efforts should be implemented to assess their characteristics and frequency. Their impact should also be considered when estimating the global burden of fascioliasis.

Peritoneal manifestations of fascioliasis on CT images: a new observation

PURPOSE

To describe peritoneal manifestations of fascioliasis on CT.

MATERIALS AND METHODS

We reviewed CT images in 31 patients with fascioliasis confirmed by enzyme-linked immunosorbent assay (ELISA) (n = 24) or surgery (n = 7). Image analyses were performed to identify hepatic, biliary, and peritoneal abnormalities.

RESULTS

Hepatic abnormalities were seen in 28 (90.3 %) of the 31 patients. The most common finding was caves sign, which was present in 25 (80.1 %) patients. Three patients (9.7 %) presented with biliary abnormalities exhibiting dilatation and enhancing wall thickening of the bile duct, wall thickening of the gallbladder, and elongated structures in the bile duct or gallbladder. Peritoneal abnormalities were seen in 14 (45.2 %) of the 31 patients. The most common peritoneal abnormality was mesenteric or omental infiltration, which was seen in 9 (29.0 %) patients. Other peritoneal findings included lymph node enlargement (n = 7), ascites (n = 7), thickening of ligamentum teres (n = 2), and peritoneal mass (n = 2).

CONCLUSION

Peritoneal manifestations of fascioliasis are relatively common, and CT findings include mesenteric or omental infiltration, lymph node enlargement, ascites, thickening of the ligamentum teres, and peritoneal masses.

Assessment of a 27-kDa antigen in enzyme-linked immunosorbent assay for the diagnosis of fasciolosis in Vietnamese patients

Fasciolosis has emerged as an important zoonotic disease in many parts of the world. In recent years, an increasing number of human cases were reported in Vietnam. In this study, the 27-kDa component protein from the excretory/secretory production of adult Fasciola gigantica, purified by high performance liquid chromatography, was assessed in an enzyme-linked immunosorbent assay (ELISA) to detect antibodies against Fasciola spp. for diagnosis of human fasciolosis. The ELISA showed a high sensitivity (100%) and specificity (97.67%) when tested on patients with fasciolosis, other parasitic infections, cholangiocarcinoma and on healthy controls. The assay was applied for diagnosis on 143 patients in the Viet Duc-Hanoi hospital who presented with clinical signs of liver disease and lesions in their livers as shown by imaging techniques. Antibodies were found in 37 (25.9%) of these patients, of whom only 3 shed Fasciola eggs in their stools (2.1%). The excellent response to triclabendazole treatment of 37 sero-positive patients confirmed the diagnosis of fasciolosis. This study demonstrated the diagnostic potential for human fasciolosis of the 27-kDa antigen ELISA. Fasciolosis should be considered in the differential diagnosis of hepatic disease in Vietnam.