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| CASE REPORT |
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| Year : 2012 | Volume
: 58
| Issue : 2 | Page : 150-152 |
Cases of human fascioliasis in India: Tip of the iceberg
J Ramachandran1, SSR Ajjampur1, A Chandramohan2, GM Varghese3
1 Department of Gastrointestinal Sciences, Christian Medical College, Vellore, India
2 Department of Radiodiagnosis, Christian Medical College, Vellore, India
3 Department of Medicine and Infectious Diseases, Christian Medical College, Vellore, India
| Date of Submission | 07-Aug-2011 |
| Date of Decision | 17-Oct-2011 |
| Date of Acceptance | 23-Nov-2011 |
| Date of Web Publication | 14-Jun-2012 |
Correspondence Address:
G M Varghese
Department of Medicine and Infectious Diseases, Christian Medical College, Vellore
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0022-3859.97180
This report presents two cases of human fascioliasis from different states in India. Although only few cases of human fascioliasis have been reported from India previously, both these cases were encountered within a span of three months at this tertiary care centre. Case 1 had significant symptoms with episodes of fever, abdominal pain and eosiniphilia and underwent multiple diagnostic procedures before the correct diagnosis was reached. Case 2, who had few symptoms, had fascioliasis diagnosed with minimal evaluation. These different presentations seen at two ends of the clinical spectrum of disease along with findings of peripheral eosinophilia, and radiological findings led to a presumptive diagnosis that was then confirmed by microscopic examination of bile. Morphometric analysis of ova from these cases was suggestive of infestation with F. gigantica or a F. gigantica-like hybrid. Both patients were treated with triclabendazole which was imported from Geneva. The need to be aware of the possibility of occurrence of this disease and the inclusion of drugs used for treating the disease, in the Indian drug list, should be emphasized.
Keywords: Fasciola, liver, trematode, triclabendazole
How to cite this article:
Ramachandran J, Ajjampur S, Chandramohan A, Varghese G M. Cases of human fascioliasis in India: Tip of the iceberg. J Postgrad Med 2012;58:150-2 |
| :: Introduction | |  |
Human fascioliasis, a trematodal zoonotic infestation, most often is characterized by fever, eosinophilia, and abdominal pain, although as many as one half of patients may be asymptomatic. Although fascioliasis is distributed worldwide, [1] it is infrequently reported from India. [2],[3],[4],[5],[6],[7] Humans become incidental hosts for the closely related species of liver flukes Fasciola hepatica and Fasciola gigantica by ingesting contaminated watercress or water. We describe two patients, one from Arunachal Pradesh and the other from West Bengal, who illustrate the spectrum of clinical presentations of human fascioliasis. We also discuss the treatment considerations for this parasite.
| :: Case Report | | |
Case 1
A 55-year-old lady from Arunachal Pradesh with a past history of laparoscopic cholecystectomy five years ago, presented with complaints of intermittent right upper quadrant abdominal pain and short febrile episodes for three years in November 2010. On examination the patient was afebrile and the liver was palpable 7 cm below the right costal margin. She had a peripheral white blood cell count of 11500 cells/cumm (15% neutrophils, 25% lymphocytes, 5% monocytes, and 55% eosinophils) (absolute eosinophil count 6325/cu mm); bilirubin (total) -0.4 mg/dl and direct- 0.2 mg/dl; total protein- 8.7 g/dl; albumin- 3.4 g/dl; SGOT- 101 U/L; SGPT- 118 U/L and alkaline phosphatase- 209 U/L. Ultrasonogram [Figure 1]a - b revealed multiple hypo-echoic irregular sup-capsular focal lesions with no color flow within indicating a necrotic area, and intrahepatic biliary radicle dilatation with echogenic non-shadowing cast within the dilated system. CT scan revealed peripheral intrahepatic biliary radicle dilatation and irregular necrotic area in the right hemi liver [Figure 1]d - f. Ultrasound-guided biopsy of liver lesion showed necrotizing granulomatous inflammation with marked eosinophilia and Charcot-Leyden crystals. Stool examination for ova was negative. Endoscopically aspirated bile showed numerous yellowish brown, ellipsoidal, unembryonated ova [Figure 2]a with a small operculum measuring ~170 x 95 μ [Figure 2]b consistent with Fasciola ova were seen. The patient was treated with a single dose of triclabendazole (10 mg/kg). A month later at review the patient had gained 4.3 kg body weight, and there was total disappearance of abdominal pain, and regression of hepatomegaly. The absolute eosinophil count improved and liver function tests normalized. When the bile aspirate was examined on follow-up in January 2011, no ova were seen. | Figure 1: (a-c) Ultrasonogram of the liver shows multiple irregular hypoechoic focal lesions, echogenic worm casts within the dilated thickened intrahepatic bile ducts. (d-f) Contrast-enhanced computed tomography images in liver window setting shows capsular enhancement, subcapsular serpigenous tracts, liver abscesses, intrahepatic bile duct dilatation and thickened wall of the intrahepatic bile ducts
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 | Figure 2: Fasciola ova in bile aspirate a) Case 1: numerous ova at 100x magnification and b) Case 1: ova at 400x magnification c) Case 2: ova at 400x magnification
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Case 2
A 54-year-old lady from West Bengal presented with a one-year history of dyspeptic symptoms and occasional dull aching upper abdominal pain in February 2011. Her physical examination was unremarkable. Investigations done previously suggested eosinophilia (absolute eosinophil count ranging from 2100 to 9360) and multiple irregular lesions in both lobes of the liver with necrotic centre. Evaluation at our hospital showed an absolute eosinophil count of 800, near normal liver function tests with an alkaline phosphatase of 150 U/L and two hypoechoic lesions in the right lobe of the liver on ultrasonography [Figure 1]c. Examination of aspirated bile revealed Fasciola ova [Figure 2]c. She was treated with single-dose triclabendazole (10 mg/kg). On follow-up in April 2011, bile aspirated was found to be free of trematode ova.
Morphometric analysis: Since Fasciola hepatica and F. gigantica ova are similar in appearance and the geographical distribution of species is not clearly documented for this region, more detailed measurement of size was carried out. For the first case, length and width of 30 ova were measured by two independent observers, and a mean size of 168.5 × 94.5 μ was observed. The second case had fewer ova and the mean size of three ova measured by two independent observers was 182.9 × 97.5 μ. Applying size ranges for differentiation of species suggested by Valero et al.,[8] the egg length and width of the first case is suggestive of either F. gigantica or a F. gigantica-like hybrid while that of the second case is suggestive of F. gigantica.
| :: Discussion | | |
Till date, human fascioliasis in India has been limited to a few case reports and incidental findings on imaging or endoscopy mainly from north and northeastern India including Assam, Uttar Pradesh and Bihar [2],[3],[4] with more recent reports from Mumbai. [5] Most of these reports have documented the presence of flukes in the bile duct [2],[3],[5] and spine [4] and only one report, the presence of ova in stool. [2] None of the other reports documented ova in aspirated bile. Although triclabendazole is recommended by the World Health Organization (WHO) as the treatment for human fascioliasis, none of the previous reports have documented using this drug. Triclabendazole for treatment of these two cases had to be imported from WHO, Geneva. Non-availability of triclabendazole is a significant issue considering the possible emergence of this zoonotic parasitosis in India.
On reviewing the available literature, no epidemiological data on the prevalence or endemicity of this zoonotic parasitosis in India was available. The available reports from animal studies indicate that F. gigantica is more prevalent in India than F. hepatica. [9] In regions with a geographical overlap of the two species, "hybrid' species have been reported to exist. [1] Based on a comparison of ova measurements in human and animal samples from Bolivia, Peru and Egypt, Valero et al.,[8] have proposed size ranges to determine species in areas with only F. hepatica and regions with both F. hepatica and F. gigantica in circulation. The north and northeastern regions of India where both these cases are from probably have an overlap of the two species based on animal studies and so the corresponding size range was applied and the results suggest infection with F. gigantica or hybrids.
Radiological features in endemic regions are helpful for diagnosis. Liver lesions correspond to necrotizing granulomatous lesions rich in eosinophils. [10] Biliary wall thickening, echogenic worm casts and intrahepatic biliary radicle dilatation are seen in the biliary phase. Both hepatic and biliary phases may often coexist as in our case. Serology, especially enzyme-linked immunosorbent assay (ELISA) based, has good sensitivity and specificity. Serologic tests usually become positive during the early phase of migration through the liver, and therefore are useful in faster diagnosis prior to the appearance of eggs in the feces. A recent study using sandwich ELISA showed a sensitivity and specificity of 96% and 98.2% in stool while in serum 94% and 94.6% respectively. [11]
In conclusion, although not well-documented in India, a high index of suspicion for fascioliasis is warranted in patients presenting with abdominal symptoms, peripheral eosinophilia and irregular focal lesions in the liver. The occurrence of this disease in India may be greater than previously reported because of lack of healthcare workers' familiarity with the diagnosis and the difficulty in identification of cases. Fascioliasis is eminently treatable with a single dose of triclabendazole and inclusion of this drug in the Indian drug list is warranted.
| :: Acknowledgments | | |
Prof. S. Mas Coma, Departament de Parasitologia, Facultad de Farmacia, Universidad de Valencia, Spain for confirming the identity of the ova and suggesting the morphometric analysis, Mrs. Sheela Roy and Mrs. Selvi Laxmanan for morphometric measurements, Dr. T. Jacob John for connecting us with WHO, New Delhi and Dr. Albis Francesco Gabrielli, Department of Control of Neglected Tropical Diseases, WHO, Geneva for supplying triclabendazole for treating these patients.
| :: References | | |
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| 2. | Narain K, Biswas D, Rajguru SK, Mahanta J. Human distomatosis due to Fasciola hepatica infection in Assam, India. J Commun Dis 1997; 29:161-5.
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| 3. | Elhence V, Mehta B, Gupta RK. Fascioliasis: A case fom central Uttar Pradesh. Indian J Gastroenterol 2001;20:164.
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| 4. | Vatsal DK, Kapoor S, Venkatesh V, Vatsal P, Husain N. Ectopic fascioliasis in the dorsal spine: Case report. Neurosurgery 2006;59:E706-7; discussion E- 706-7.
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| 5. | Gandhi V, Jain P, Rathod V, Nagral S. Endoscopic ultrasound in biliary fasciolosis. Indian J Gastroenterol 2010;29:128.
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| 8. | Valero MA, Perez-Crespo I, Periago MV, Khoubbane M, Mas-Coma S. Fluke egg characteristics for the diagnosis of human and animal fascioliasis by Fasciola hepatica and F. gigantica. Acta Trop 2009;111:150-9.
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| 9. | Garg R, Yadav CL, Kumar RR, Banerjee PS, Vatsya S, Godara R. The epidemiology of fasciolosis in ruminants in different geo-climatic regions of north India. Trop Anim Health Prod 2009;41:1695-700.
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| 10. | Ceken K, Alimoglu E, Saba R, Cubuk M, Arslan G, et al. Hepatobiliary fascioliasis: Sonographic and CT findings in 87 patients during the initial phase and long-term follow-up. AJR Am J Roentgenol 2007;189:824-8.
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