Fasciola hepatica: a cause of obstructive jaundice in an elderly man from Iran

Characteristics of Hepatobiliary Fascioliasis and the Role of Endoscopic Retrograde Cholangiopancreatography in Management: A Single Center Experience

Background

Hepatobiliary fascioliasis has two phases, each requiring specific management approaches. Triclabendazole has been widely effective in treating the two phases of clinical fascioliasis and endoscopic retrograde cholangiopancreatography (ERCP) in the biliary phase. We aimed to characterize presentations of hepatobiliary fascioliasis and highlight the role of ERCP in management.

Subjects and methods

This retrospective cohort includes patients diagnosed with clinical hepatobiliary fascioliasis between January 2013 and December 2022. Demographic data, clinical presentation, laboratory and radiological investigations, treatment, and endoscopy reports were collected from the records of 62 participants. Patients were divided into two groups: acute hepatic and chronic biliary phases.

Results

Thirty-six patients were in the biliary phase, and 26 were in the hepatic phase. All patients were from rural areas, and females were predominant (76%). Hypereosinophilia was detected in 92% of acute cases and 58% of chronic biliary cases. In chronic biliary cases, the levels of liver biochemicals, including alanine transaminase (ALT), aspartate aminotransferase (AST), gamma-glutamyltransferase (GGT), and bilirubin, were higher at levels of 189 ± 76, 127 ± 47, 268 ± 77, and 2.4 ± 0.7 respectively, compared to acute hepatic cases, 35.6 ± 8.2, 32.7 ± 4.3, 69.2 ± 45.45, and 0.58 ± 0.01. The corresponding P-values were 0.003, 0.001, <0.001, and <0.001, respectively. Triclabendazole effectively cured 93.5% of patients and was used in combination with ERCP in biliary-phase cases where the fluke was extracted from the biliary system in 34 patients (94.4%). Three patients (8.8%) were diagnosed with post-ERCP pancreatitis. None of the patients experienced bleeding, perforation, or required biliary stenting.

Conclusion

Clinical fascioliasis could manifest in acute hepatic or chronic biliary phases. Hypereosinophilia was more evident in the hepatic phases, while ALT, AST, GGT, and bilirubin were higher in the biliary phase. Triclabendazole is effective in the hepatic phase and when combined with ERCP in the biliary phase. ERCP is highly effective for relieving obstruction and treating biliary fascioliasis.

A common presentation of uncommon disease - Biliary Fasciola Hepatica

Hepatobiliary fascioliasis is one of the rare but important parasitic infection in endemic areas such as Pakistan. Clinical manifestations overlap with common clinical conditions such as hepatitis and biliary stones causing common bile duct obstruction. Fascioliasis is a zoonotic infection caused by a leaf-shaped organism known as Fasciola Hepatica. Humans are accidentally infected by consuming contaminated water or food, especially undercooked cattle and sheep liver or raw green vegetables. We report three cases with similar clinical manifestations presenting in two different cities in Pakistan. After detailed clinical evaluation and laboratory investigations, the diagnosis was established by abdominal ultrasound and diagnostic and therapeutic cholangiography. Patients were followed till complete resolution of their symptoms and normalisation of liver function tests.

Fascioliasis associated with chronic cholecystitis in a woman from Sistan and Baluchestan province, a non-endemic region in Southeastern Iran

BACKGROUND

Fascioliasis, caused by Fasciola hepatica, is a neglected zoonotic food-borne trematodiasis. The Caspian littoral in northern Iran is endemic for the disease, and human fascioliasis is well-known in that region. In the present study, we report the diagnosis, identification, and clinical management of a human case of fascioliasis associated with common bile duct (CBD) obstruction from a non-endemic remote area in southeastern Iran.

CASE PRESENTATION

A 42-year-old female was admitted to Afzalipour Medical Center hepatobiliary surgery ward in Kerman with abdominal pain for the past three months. Dilated biliary tract and an ill-defined mass in CBD were reported in abdominal ultrasonography and magnetic resonance cholangiopancreatography, respectively. During distal CBD operation, nine leaf-like motile flatworms were isolated. A morphological study confirmed all the isolates as Fasciola, and further molecular investigations, identified the flukes as F. hepatica using both pepck multiplex PCR and cox1 sequencing.

CONCLUSION

Molecular and morphological findings of the study indicated the presence of human fascioliasis in the southeastern province of Sistan and Baluchestan in Iran. Fascioliasis is among the etiologies of chronic cholecystitis, and physicians should consider chronic cholecystitis associated with fascioliasis in the differential diagnosis. In the present report, endoscopic ultrasound was usefully applied for the accurate diagnosis of biliary fasciolosis.

Checklist of digenean trematodes of Iran

Digeneans are an important class of trematodes which infect variety of animals ranging from vertebrates (mainly final hosts) to invertebrates (mainly as intermediate hosts). Additionally, some of these parasites are zoonotic and one health importance. Diversity of digeneans in Iran and reports of several zoonotic cases show the importance of these parasites in this country. This is the checklist of digenean parasites reported from Iran representing a total of 118 species, from 105 genera, 43 families, 21 subfamilies, and 3 orders that are reported from 139 species of different hosts including humans. Some of the most important final number of families, genera, and species reported in Iran fauna include: Fasciolidae, Genus: Fasciola, Fasciola gigantica, Fasciola hepatica, Family: Dicrocoeliidae, Genus: Dicrocoelium, Dicrocoelium dendriticum, Family: Diplostomidae, Genus: Diplostomum, Diplostomum spathaceum, Family: Heterophyidae, Genus: Haplorchis, Haplorchis taichui, Family: Notocotylidae, Genus: Notocotylu, Notocotylus aegyptiacus, Family: Bucephalidae, Genus: Rhipidocotyle, Rhipidocotyle illense.

A 53-Year-Old Man with Intermittent Colicky Abdominal Pain due to Fasciola Incarceration in Common Bile Duct: A Case Report

Fascioliasis is a zoonotic disease caused by liver flukes of the genus Fasciola, as F. hepatica, and F. gigantica, mainly affecting the liver and biliary system during the chronic phase. These trematodes migrate through biliary ducts results in mild inflammation, when it is difficult to distinguish from obstructive lesions. Here we describe a 53-yr-old man from Golpayegan, a city in Isfahan Province, Iran, in year 2015, with occasional fever and chills, and also frequent colicky abdominal pain mainly on the right upper quadrant, with tenderness at that part. There was no jaundice and elevated bilirubin, but increased alkaline phosphatase was detected. Dilated common bile duct on abdominal sonography, without any visible lesion at its end and also dilated intra- and extrahepatic biliary ducts on abdominal CT-scan were seen. Endoscopic Retrograde Cholangiopancreatography (ERCP) detected incarceration of parasites behind Oddi's sphincter and also in common bile duct and serologic test (ELISA) confirmed fascioliasis. However, Iran is one of the most affected countries by Fasciola, being aware of rare symptoms and presentations of this disease can aid the physicians to make timely and accurate diagnosis and therefore reduce the consequent morbidities.

Comparison between in-house indirect ELISA and Dot-ELISA for the diagnosis of Fasciola gigantica in cattle

This survey was done to investigate the efficacy of the in-house indirect ELISA (iELISA) and Dot-ELISA methods Prepared from excretion-secretory (ES Ag) and Crude (Cr Ag) antigens of Fasciola for sero-diagnosis of Fasciola gigantica in cattle. The liver specimens of slaughtered cattle were collected and their liver examined macroscopically and microscopically for infestation to fasciolosis. Sera from two groups of cattle, one infected with fasciolosis (n = 60) and the other non-infected with fasciolosis (n = 60), were used in the iELISA and Dot-ELISA test; grouping based on histopathology results. Except specificity, other parameters such as, sensitivity, accuracy, positive and negative predictive values of both Dot-ELISA and iELISA done with ES Ag were better than those of tests performed with Cr Ag. Interestingly, the reliability of two methods was very good similar to one another.

The Status of Human and Animal Fascioliasis in Iran: A Narrative Review Article

BACKGROUND

The public health importance of human fascioliasis has increased during last few decades due to the appearance of new emerging and re-emerging foci in many countries. Iran, as the most important focus of human disease in Asia, has been included among six countries known to have a serious problem with fascioliasis by WHO. Various aspects of the disease in Iran are discussed in this review.

METHODS

This narrative review covers all information about human and animal fascioliasis in Iran, which has been published in local and international journals from 1960 to 2014 using various databases including PubMed, SID, Google Scholar, Scopus, Science Direct.

RESULTS

During the period of the study the infection rates of 0.1% to 91.4% was noted in various livestock. Despite the higher infection rates of livestock in southern areas in past decades, human disease has been mostly encountered in northern Provinces especially in Guilan. Recent studies indicate noticeable decrease in prevalence rates of veterinary fascioliasis in Iran, however the prevalence rates of fascioliasis in livestock in northern Provinces of Guilan and Mazandaran seem to remain at a higher level in comparison to other parts. New foci of the disease have also been reported recently.

CONCLUSION

While the prevalence of animal fascioliasis has decreased during last decades, human fascioliasis emerged as a public health problem in the country. The validity of new foci of human fascioliasis needs complementary standard studies.

Finding of biliary fascioliasis by endoscopic ultrasonography in a patient with eosinophilic liver abscess

Fascioliasis is an endemic zoonotic disease in Iran. It occurs mainly in sheep-rearing areas of temperate climates, but sporadic cases have been reported from many other parts of the world. The usual definitive host is the sheep. Humans are accidental hosts in the life cycle of Fasciola. Typical symptoms may be associated with fascioliasis, but in some cases diagnosis and treatment may be preceded by a long period of abdominal pain and vague gastrointestinal symptoms. We report a case with epigastric and upper quadrant abdominal pain for the last 6 months, with imaging suggesting liver abscess and normal biliary ducts. The patient had no eosinophilia with negative stool examinations, so she was initially treated with antibiotics for liver abscess. Her clinical condition as well as follow-up imagings showed appropriate response after antibiotic therapy. Finally, endoscopic ultrasonography revealed Fasciola hepatica, which was then extracted with endoscopic retrograde cholangiopancreatography.

Dengue haemorrhagic fever presenting with cholestatic hepatitis: two case reports and a review of literature

Background

Dengue fever is a common mosquito borne viral fever in South Asia, which causes significant morbidity and mortality. Dengue fever is well known to involve the liver, especially in dengue hemorrhagic fever. The hepatic involvement is usually that of a mild hepatitis with transaminase derangement without jaundice. In cases of dengue hemorrhagic fever where shock has ensued, a severe hepatitis with gross derangements of transaminases and bilirubin may occur. These are two rare cases of adult patients with dengue hemorrhagic fever presenting with a cholestatic type of jaundice.

Case presentation

This case report describes two female patients aged 30 and 46 years who presented with fever, icterus and biochemical analysis revealed cholestatic jaundice. Evolution of the clinical picture and dropping platelets prompted serological investigations in the form of dengue non-structural protein 1 antigen and dengue immunoglobulin M which confirmed acute dengue infection.

Conclusion

These cases highlight the importance of considering dengue fever as a differential diagnosis even in the presence of a cholestatic jaundice, especially in countries where dengue fever is endemic, and in travelers returning from dengue endemic countries. The early diagnosis of dengue fever and timely institution of supportive fluid management is essential to prevent morbidity and mortality.

Immune responses to polyethylenimine-mannose-delivered plasmid DNA encoding a Fasciola gigantica fatty acid binding protein in mice

Fasciola gigantica fatty acid binding protein (FABP) was evaluated for evoking an immune response in mice, by delivering the gene coding for this protein with mannosylated-polyethylenimine (PEI) to peritoneal cells. Mice were immunized with 50 microg recombinant plasmid DNA (Group I) or DNA-PEI-mannose (a 22 kDa linear cationic polymer with mannose ligand) (Group II) via the intraperitoneal route. Antibody studies showed no significant humoral immune response evoked to this DNA immunization with either PEI-mannose-delivered or naked DNA. However, on protein boosting of these DNA-primed mice there was a significant enhancement of antibody titre. Flow cytometric bead array was used to measure quantities of interleukin (IL)-2, IL-4, IL-5, interferon-gamma (IFN-gamma) and tumour necrosis factor (TNF) cytokines. Overexpression of T-helper 1 (Th1) cytokines such as IFN-gamma and TNF, with a lower but significant expression of the T-helper 2 (Th2) cytokine IL-5 was detected. Gene delivery using polyethylenimine-mannose ligand showed significant expression of IFN-gamma and TNF (P < 0.05), but no significant difference in IL-2, IL-4 and IL-5 (P>0.05) cytokine expression was observed between naked-DNA- and mannosylated PEI-DNA-delivered mice. Naked- or PEI-delivered-DNA immunization produced insignificant levels of IL-2 and IL-4 (P>0.05) cytokines in both groups of mice.

Molecular cloning and characterization of a glutathione S-transferase in the tropical liver fluke, Fasciola gigantica

Glutathione S-transferase from an Indian isolate of Fasciola gigantica of buffalo origin was isolated and characterized. Total RNA was transcribed to cDNA by reverse transcription and an amplicon of 657 bp glutathione S-transferase gene was obtained by polymerase chain reaction (PCR). The present isolate showed 99.1% sequence homology with the published sequence of the F. giganticaGST gene of cattle origin, with six nucleotide changes causing an overall change of four amino acids. Glutathione S-transferase protein was expressed in Escherichia coli using a prokaryotic expression vector pPROEXHTb. The recombinant protein was purified under non-denaturing and denaturing conditions by nickel nitrilotriacetic acid (Ni-NTA) affinity chromatography. Recombinant GST protein detected F. gigantica infection in naturally infected buffaloes by dot-ELISA.