A 41-year-old man presented with right-upper-quadrant abdominal pain and a febrile sensation for 3 days. He had no specific medical history. He was employed as a butcher and used to eat raw liver. Physical examination revealed diffuse abdominal tenderness. Laboratory findings demonstrated a white blood cell count of 12,370/mm3 (normal range, 4,500 to 11,000) with an eosinophil count of 2,860/µL (<450/µL), total bilirubin level of 4.2 mg/dL (normal range, 0.2 to 1.2), aspartate aminotransferase of 213 IU/L (normal range, 5 to 40), alanine aminotransferase level of 192 IU/L (normal range, 0 to 40), alkaline phosphatase level of 298 IU/L (normal range, 44 to 119), and gamma glutamyl transpeptidase level of 473 IU/L (normal range, 12 to 73). Transabdominal ultrasonography and computed tomography revealed mild bile duct dilation with no definite cause. Magnetic resonance cholangiopancreatography (MRCP) also revealed no specific findings for acute cholangitis (). ERCP was performed for the diagnosis and treatment of the highly suspected choledocholithiasis. A cholangiogram did not reveal any findings specific for acute cholangitis (). IDUS was performed to evaluate occult bile duct diseases, such as small stones or sludge. A 2.0-mm-diameter IDUS probe with a frequency of 20 MHz (UM-G20-29R; Olympus, Tokyo, Japan) was inserted into the bile duct over a guidewire. The bile duct was examined while withdrawing the probe from the right intrahepatic duct into the papilla. At the beginning of the IDUS scan, crescent-layered wall thickening was apparent in the right main hepatic duct (). However, after a while, the thickened wall-like tubular structure detached from the ductal wall, and was then noted as an actively motile, hyperechoic tubular structure in the bile duct (, Supplementary Video 1 [available online at ]). We performed an endoscopic extraction of this “lesion.” A flat, leaf-shaped motile parasite was extracted from the bile duct using a balloon catheter after endoscopic biliary sphincterotomy. The worm was gently removed from the patient after capturing with grasping forceps (Olympus) (, Supplementary Video 2 [available online at ]). The leaf-shaped worm was identified macroscopically as F. hepatica (). The patient’s symptoms resolved rapidly following the extraction of the parasitic worm.
A 67-year-old woman was presented to our center at Namazi Hospital (Shiraz University of Medical Sciences, Iran) with abdominal pain, icter, nausea, and anorexia beginning two weeks prior to evaluation. Symptoms became worst progressively. She lived in the Zagros mountain area (southern Iran) consuming unsafe water and contaminated vegetables. Her past medical history was unremarkable except for a controlled hypertension with captopril. On physical examination, she was ill and icteric with right upper quadrant tenderness.\nAccording to the laboratory values upon admission, she had mild leukocytosis with prominent neutrophil without any evidence of eosinophilia. Liver biochemical tests were abnormal. Serum levels of amylase and lipase were normal. Her work up for virology markers (HAV, HBV and HCV) was negative. shows the patient’s initial laboratory results.\nIn abdominal ultrasonography, three small cysts and a dilated common bile duct were seen. Abdominal computed tomography scan showed three small cysts (<1 cm) and a dilated common bile duct, but liver parenchyma and intrahepatic bile ducts were normal ().\nERCP was performed because of the diagnosis of cholangitis. In ERCP, dilatation of common bile duct with multiple filling defects was seen, but gallbladder and intrahepatic bile ducts were normal ().\nOur primary impression for filling defects was common bile duct stones or sludge. Therefore, after sphincterotomy, we used a basket for removing the suspected stones, but surprisingly three living F. hepatica were removed by 3 times use of the basket. The F. hepaticas were alive and crawling in the basket.\nThe fluke’s samples were sent for pathology evaluation and confirmed as F. hepatica. Stool examination for detection of F. hepatica eggs was negative. In addition to antibiotics for acute cholangitis (metronidazole 500 mg/IV/q6h and ceftazidim 200 mg/IV/q8h), triclabendazole (10 mg/kg single dose) was started for therapy. After the first week, oral ciprofloxacin was replaced for IV antibiotics and continued for another week.\nClinical and laboratory condition of the patient improved after 4 weeks; leukocytosis and liver biochemical tests were completely normalized (). The patient showed no clinical and laboratory problems in favor of the liver disease after 12 months follow up.