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 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.