A Curious Case of Walking Cholangitis in a Nonendemic Region: Hepatobiliary Fascioliasis

CASE REPORT A 35-year-old woman presented with fever and right upper quadrant pain without jaundice for 3 months. Clinical examination revealed tachycardia and tender hepatomegaly. Laboratory investigations revealed anemia (hemoglobin 8.88 g/dL), normal bilirubin, and elevated gamma-glutamyl transferase (204 U/L; normal<54 U/L). Ultrasonography showed multiple evolving abscesses in both lobes of the liver. She was treated with parenteral antibiotics for suspected amoebiasis for 2 weeks after which she was discharged in an afebrile state subsequently. One month later, she again presented with high grade fever and jaundice (bilirubin 4.2 mg/dL). Computed tomography of the abdomen showed hepatomegaly with multiple small, oval to round, clustered hypodense lesions in both lobes with mildly dilated common bile duct (CBD) with hyperdense content in CBD (Figure 1). Endoscopic retrograde cholangiopancreatography (ERCP) showed dilated CBD with filling defect (Figure 1). Balloon sweeps extracted multiple fluke-like organisms (flatworm) and were microbiologically identified as Fasciola hepatica, and CBD stenting was performed in view of cholangitic abscess (Figure 2). She was successfully treated with parenteral antibiotics and oral nitazoxanide. Repeat computed tomography of the abdomen at 3 months showed resolving abscess with clinical and radiological improvement (Figure 2). Repeat ERCP was performed twice on follow-up with plastic stent exchanges and thereafter removed after 7 months of index presentation with near-complete resolution of abscesses.1Figure 1.: (A) Contrast-enhanced computed tomography of the abdomen showed hepatomegaly with multiple small, oval to round, clustered hypodense lesions in both lobes with mildly dilated CBD with hyperdense content in CBD; (B) cholangiogram taken during endoscopic retrograde cholangiopancreatography showed dilated CBD, mild intrahepatic biliary ductal dilatation with a filling defect. CBD, common bile duct.Figure 2.: (A, B) Multiple large, flat, leaf-like organisms (flukes) with a pointed anterior end (Fasciola hepatica) extracted after balloon sweep during endoscopic retrograde cholangiopancreatography in the duodenum; (C) repeat contrast-enhanced computed tomography of the abdomen at the 3-month follow-up showed plastic stent in common bile duct with resolving liver abscess.Fasciolosis is an important zoonosis, and approximately 50% of human infections are asymptomatic. Extrahepatic cholestasis is an extremely uncommon manifestation of fasciolosis, and diagnosis can be performed with high index of suspicion. Medical treatment is the mainstay of treatment; however, mechanical extraction with ERCP may be required in case of extrahepatic biliary obstruction or cholangitis.2,3 DISCLOSURES Author contributions: AK Singh: patient management, first draft of the article, acquisition, analysis and interpretation of data, final approval of the manuscript; J. Dhar: acquisition of data, analysis and interpretation of data, critical revision of the manuscript, final approval of the manuscript; SK Sinha: acquisition of data, analysis and interpretation of data, critical revision of the manuscript, final approval of the manuscript; J. Samanta: conception and design, patient management, acquisition of data, analysis and interpretation of data, critical revision of the manuscript, final approval of the manuscript, and is the is the article guarantor. All author agree and approve the final version of the manuscript. Financial disclosure: None to report. Informed consent was obtained for this case report.