33 Fasciola hepatica as a cause of jaundice after chewing khat
Bree, L.C.J. de, Bodelier, A.G.L, Verburg, G.P.
Locatie(s): Zaal 0.2/0.3
Categorie(ën): Parallelsessie
Case: A 24-year old Somalian immigrant was admitted because of jaundice and abdominal discomfort. He was known for a panuveitis caused by tuberculosis for which he had completed tuberculostatic treatment. His last visit to Somalia was 4 years ago. Physical examination revealed jaundice and right hypogastric tenderness. Laboratory findings revealed eosinophilia, hyperbilirubinemia and elevated liver enzymes. Abdominal ultrasound was completely normal. Serological tests for hepatitis A, B and C, EBV, CMV, HIV, strongyloides and schistosoma infection and auto-immune hepatitis markers were all negative. MRCP showed a dilated common bile duct. Fas2 ELISA, detecting fasciola hepatica IgG-antibodies was positive. Ova were detected in stool examination. Patient admitted to chew khat leafs which was most likely the source of infection. He was treated successfully with triclabendazole.
Discussion: Fascioliasis is a zoonotic foodborne disease caused by the trematode fasciola hepatica. This parasite incidentally infect human after ingestion of contaminated water or food. Fasciola hepatica has a worldwide distribution including Europe. Highest prevalences are reported in Andean countries, Northern Africa and the Middle East.
After ingestion, metacercariae migrate through the intestinal wall and Glisson’s capsule to the liver, were they cause parenchymatous destruction and migrate to the biliary ducts. Matured parasites release eggs via the biliary system into the duodenum. The eggs become embryonated and upon reaching water they release miracidiae, which invade freshwater snails as their intermediate hosts. Subsequently cercercariae are released and transformed to metacercariae on aquatic vegetation.
Although usually mild, the acute hepatic phase is sometimes accompanied by fever, abdominal pain and hepatomegaly. Biliary colics and jaundice can be seen in the chronic biliary phase, which can last for years. Complications like cholangitis, pancreatitis and cirrhosis can occur. Eosinophilia is the most common laboratory finding.
Stool examination is considered to be the gold standard, although eggs are often undetectable in the acute phase. The diagnosis can also be established serologically by Fas2 ELISA, which detects IgG-antibodies against Fas2 antigen as early as 10 days after infection.
Characteristic findings on imaging studies are subcapsular nodular of branching lesions in the liver and bile duct dilatation, gallbladder or bile duct edema in the chronic phase.
Successful treatment can be achieved with a single dose of triclabendazole.
Conclusion: As illustrated, diagnosing fascioliasis can be challenging in non-highly endemic countries. However, fasciola hepatica infection should be considered in patients with abdominal pain, jaundice and eosinophilia. Special attention should be given to food, drugs and travel history.