Massive biliary ascariasis: an unusual cause of acute cholangitis

Gallbladder perforation due to biliary ascariasis: A case report

INTRODUCTION

Biliary ascariasis is a rare complication of Ascaris lumbricoides infestation, often leading to biliary obstruction and cholangitis. Gallbladder perforation secondary to biliary ascariasis is exceedingly uncommon.

CASE PRESENTATION

A 28-year-old female farmer from a rural area presented with a one-year history of intermittent right upper quadrant pain, worsened by fatty meals. Her symptoms progressed a week before presentation to include fever, jaundice, dark urine, and pruritus. Examination revealed a positive Murphy sign and jaundice, with laboratory results showing leukocytosis and elevated bilirubin. Imaging confirmed biliary ascariasis with choledocholithiasis and ascending cholangitis. Intraoperatively, a sealed perforation of the gallbladder was found alongside a dead Ascaris and multiple stones in the common bile duct (CBD). Surgical intervention included removal of the worms and stones, cholecystectomy and CBD irrigation. Postoperative recovery was uneventful, and the patient was discharged with antihelminthic therapy.

DISCUSSION

Biliary ascariasis is an infrequent cause of biliary obstruction but can lead to severe complications such as cholangitis and gallbladder perforation. Diagnosis is often clinical, supported by ultrasound and CT imaging. Management involves both medical and surgical approaches, including antibiotics and surgical removal of worms and stones. This case represents a type II gallbladder perforation, as per the Neimeier classification, where an abscess is contained by adhesions.

CONCLUSION

This case highlights the importance of recognizing parasitic infections as a potential cause of severe biliary complications, particularly in endemic regions.

The COVID-19 Mirage: A Young Biologist With an Atypical Presentation of a Zoonotic Disease During the COVID-19 Pandemic

COVID-19 has become one of the main causes of febrile illness among emergency department patients and is always a differential diagnosis to keep in mind. Nonetheless, some patients with a history of exposure, persistent fever, and suspicion of COVID-19 end up having entirely different etiologies. Here, we present the case of a 29-year-old male biologist with an uncommon presentation of a zoonotic disease, characterized by unspecific signs and symptoms, which led to a delayed diagnosis, causing significant emotional distress in the patient. We also coin the term “COVID-19 Mirage," to serve as a constant reminder for clinicians of the effect that COVID-19 has caused on the differential diagnosis of fever of unknown etiology.