16 September 2020: Articles
Atypical Presentation of a Rare Parasitic Infection with A Multidisciplinary Case Report
Unusual clinical course, Challenging differential diagnosis, Unusual or unexpected effect of treatment, Diagnostic / therapeutic accidents
Luca Rinaldi1ABCDE*, Veronica Folliero2EF, Luciano Restivo3ABD, Francesco Foglia2EG, Gianluigi Franci4DEF, Annalisa Chianese2E, Natalina Iuliano5BD, Serena De Luca6DEF, Barbara Guerrera1BD, Luca Del Viscovo7D, Luigi Elio Adinolfi1ADDOI: 10.12659/AJCR.924704
Am J Case Rep 2020; 21:e924704
Abstract
BACKGROUND: Fascioliasis is a zoonotic disease caused by Fasciola hepatica (F. hepatica). This infection is associated with a broad spectrum of clinical symptoms such as fever, eosinophilia, and gastrointestinal symptoms.
CASE REPORT: We report a case of F. hepatica abdominal mass in the peri-pancreatic region in a 58-year-old man, returned from Venezuela. The patient developed abdominal pain, nausea, anorexia, and weakness. Radiological investigations showed hepatomegaly, as well as mild intra-hepatic and extrahepatic ductal dilatation. The increase in eosinophilia, elevated total IgE titer, and anamnestic data suggested the hypothesis of parasitic infection. The diagnosis was established by high serological titer against F. hepatica.
CONCLUSIONS: The development of abdominal mass, with jaundice and dilation of the biliary tract, does not always suggest the presence of heteroplasia. Systemic parasitosis represents a not negligible event, especially considering the personal history of life in endemic areas.
Keywords: Fasciola hepatica, Parasitic Diseases, Ultrasonography, Abdominal Pain, Eosinophilia, fascioliasis, Fever
Background
Human fascioliasis is a zoonosis caused by the trematode
Case Report
We describe the case of a 58-year-old Italian man who has been living in Venezuela for more than 20 years. He returned to southern Italy in September 2014. During this period, he developed diffuse abdominal pain, cold night sweats, nausea, anorexia, weight loss (about 8 kg in 1 month), and weakness. He underwent routine laboratory tests: WBC count of 13 300 cells/mm3 with 70% neutrophils, 12.3% lymphocytes, 7.2% monocytes, and 8% eosinophils; hematocrit level 34.5%; aspartate aminotransferase (AST) 22 IU/L (normal range, 0–37 IU/L); ala-nine aminotransferase (ALT) 43 IU/L (normal range, 0–40 IU/L); total bilirubin 0.52 mg/mL (normal range, 0–1.3 mg/mL); albumin 3.3 g/dL, and G-globulins 3.07 g/dL. TORCH serology, copro-culture, and stools analyses for parasites were negative. After 2 weeks, the patient showed worsening jaundice and was referred to our hospital. On the first day, we performed an abdominal ultrasound (US), which showed hepatomegaly, mild intra-hepatic and extrahepatic ductal dilatation (especially in the left lobe) in absence of the focal lesions, and splenomegaly (15 cm). The pancreas was homogeneous, without Wirsung duct dilatation. In the peri-pancreatic region, we detected a swollen hypoechoic mass of 10×7 cm (aggregate of lymph nodes), contiguous with the left hepatic lobe, showing inner anechoic components associated with enlarged lymph nodes (max 16 mm) in para-aortic and mesenteric regions (Figure 1). Laboratory tests showed an increase of serum levels of AST (142 IU/L), ALT (314 IU/L), total (5.6 mg/mL) and direct (3.7 mg/dl) bilirubin, GGT 663 U/L (11–43), ALP 2183 IU/L (80–300), and Ca19.9 131 U/ml (<33). AFP, CEA, and PSA serum levels were negative. His WBC count was 8700 cells/mm3 with 55% neutrophils and a significant increase of eosinophils (19%). A magnetic resonance imaging (MRI) scan of the upper abdomen integrated with cholangio-pancreatography (MRCP) demonstrated a peri-pancreatic, polycyclic, and inhomogeneous mass, defined as “likely due to lymphoma”, close to the head of the pancreas, enveloping the mesenteric vessels, without signs of macroscopic vascular invasion. It also confirmed severe bile duct ectasia without evidence of focal lesions (Figures 2, 3). Chest radiograph, colonoscopy, and esophagogastroduodenoscopy were negative for malignancies. Contrast-enhanced ultrasonography (CEUS) did not show any hypoechoic liver areas in the late phase and no pathologic contrast enhancement of lymph nodes was detected. The increased eosinophilia in the absence of malignancies and the subsequent detection of a high titer of total IgE (PRIST) >1000 IU/mL (normal range, 0–100) suggested the hypothesis of parasitic disease. The patient’s anamnestic data revealed he had been living in South America and eating poorly cooked mutton and unsafe vegetables, so a stool analyses for parasites was repeated and a serologic test for
Discussion
Infection with the liver fluke
Conclusions
Presence of an abdominal mass, with jaundice and dilatation of biliary tract, suggests, in most of cases, the presence of heteroplasia. However, we must not overlook the existence of non-oncological diseases, which, although rare, can mimic the procession of symptoms and seriously delay diagnosis. In particular, systemic parasitosis is important, especially when there is a history of living in endemic areas. A diagnostic hypothesis based on teamwork by clinicians, radiologists and pathologists allows exclusion of the principal differential diagnoses (including hydatic cyst disease, amoebic and pyogenic liver abscess) and to establish a correct diagnosis and rapid interventional therapeutic approach that can be life-saving. The pivotal role of US was remarkable in all stages of the disease. The interpretation of the sonograms enabled us to identify lymph node lesions in the early phase, to exclude secondary liver lesions by CEUS, and to evaluate the effectiveness of the therapy during follow-up.
Figures
Figure 1.. Nodal peri-pancreatic aggregate, adjacent to the left-lobe liver, indicated by the arrows. Figure 2.. MRI: retroperitoneal, polycyclic, and inhomogeneous mass, defined as “likely attributable to lymphoma”. The arrow indicates the main lymph node aggregates. Figure 3.. Cholangiographic sequences: dilatation of the bile ducts in the absence of solid lesions. The arrow indicates the point of greatest dilatation of the main bile duct. Figure 4.. The concentric wall thickening, with a visibility of the residual lumen of the common bile duct indicated by the arrow. Figure 5.. Sites of granulomatous inflammation with presence of several eggs stained in light purple, indicated by the arrow. Figure 6.. The endoprosthesis in the common bile duct indicated by the arrow.References:
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