A 64-year-old female with epigastric and right upper quadrant pain was referred to Taleghani Hospital in Tehran, Iran. She complained of intermittent pain attacks radiating to the back, exacerbated after eating. There had been 3–4 episodes of pain on most days, lasting about 1 h and then decreasing gradually for at least 6 month before presentation.\nShe also stated weight loss of about 3 kg (from 66 to 63 kg) within 6 months without fever, icterus or any change in bowel habit. In her past medical history, there were no important medical problems.\nHer previous laboratory evaluation revealed an increased erythrocyte sedimentation rate (64 mm/h), while total bilirubin was 3.2 mg/dl (normal <2 mg/dl), aspartate aminotransferase 31 IU/l (normal <30 IU/l), alanine aminotransferase 37 IU/l (normal <30 IU/l), alkaline phosphatase 473 IU/l (normal <306 IU/l) and γ-glutamyltranspeptidase 82 IU/l (normal <60 IU/l). Complete blood count showed hemoglobin 12.1 g/dl, platelets 190,000/mm3 (normal 100,000–450,000/mm3) and white blood cells 4,030/mm3 (normal 4,000–10,000/mm3) with 12% eosinophils (484/mm3) on peripheral smear. Blood chemistry tests were in the normal range. Hydatid antibody titer was requested and was within normal limits. The results of stool examinations at three different times for detecting ova and parasites as well as occult blood were normal.\nAfter admission, ultrasonography and abdominopelvic computed tomography (CT) scan showed normal intrahepatic bile ducts, but an ill-defined large heterogeneous mass lesion which contained multiple hypodense portions in the right and caudate lobes of the liver was noted (fig. ). There were no other remarkable findings on ultrasonography and CT imaging. After that, the patient underwent evaluation to rule out possible malignant and non-malignant etiologies as follows: Endoscopy and colonoscopy were performed to rule out probable sources of liver metastasis, which were both unremarkable. The patient also underwent CT-guided core needle biopsy for pathologic and microbiological evaluation, which showed predominant eosinophil infiltration of liver sections with microabscess (eosinophilic abscess) formation without neoplastic or granulomatous process. Microbiological cultures of aspiration fluid of the liver mass showed no growth after 72 h.\nEmpirically, initial treatment with intravenous ceftriaxone and metronidazole was initiated, followed by oral ciprofloxacin and metronidazole. Following antibiotic therapy, the patient's symptoms alleviated gradually, and erythrocyte sedimentation rate decreased to 10 mm/h within 3 weeks. The patient was discharged from hospital and on follow-up visits mentioned improvement in her general condition. Ultrasonography performed 2 months after discharge showed resolution of the liver mass with normal intra- and extrahepatic biliary ducts, but second follow-up ultrasonography revealed a small (8 × 10 mm) cystic lesion in the right lobe of the liver with dilation of the common bile duct (CBD) (9 mm) that was confirmed by magnetic resonance imaging (fig. ). Magnetic resonance cholangiopancreatography showed a slightly dilated CBD (9.5 mm) and normal intrahepatic bile ducts, with irregularity of the wall of the distal third of the CBD with suspicious filling defect (fig. ). Finally, EUS with a linear echoendoscope showed a 10 mm CBD with long, linear, hyperechogenic structures, moving freely in the lower third of the CBD, in favor of F. hepatica (fig. ). After diagnosis of F. hepatica by EUS, ERCP was performed, and after sphincterotomy, an extraction balloon was passed and removed a live Fasciola (fig. ).
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.