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.
A 73-year-old man, farmer from Gorgan, a city in the north of Iran, who came because of fever and icterus since 1 week before presentation. He had no obvious symptoms since 1 week before admission when he developed progressive jaundice and episodic right upper quadrant pain especially after meal but unrelated to position or respiration. He also reported mild fever, anorexia, and generalized body pain during this period. To analyze his problem, abdominal sonography was performed in outpatient setting, which showed an increased liver echogenesity without the dilation of bile ducts and gall stone. Based oh the abovementioned symptoms, his primary care physician made a diagnosis of viral hepatitis, but the patient eventually developed constant high-grade fever and right upper quadrant pain. Therefore, he was referred to our hospital and was admitted. At the time of hospitalization, the temperature was 39.5°C, the pulse was 90 beats/min, and the respiratory rate was 18 breaths/min. The blood pressure was 110/65 mm Hg. On physical examination, the patient did not appear to be in severe pain, and there was mild jaundice. The lungs and heart sounds were normal. The abdomen was flat, and the bowel sounds were present. There was tenderness in the right upper and quadrant, with mild guarding but without rebound tenderness. No mass or hernia was detected. The arms and legs were well perfused. No abnormalities were found on rectal examination. His sonography at admission revealed minimal intrahepatic and mild extrahepatic biliary dilation, while other organs were normal and no stones were observed. Blood tests revealed mild normocytic normochromic anemia, while white blood cell and absolute eosinophil count were normal in the patient. The erythrocyte sedimentation rates were high (90 mm/h) and serum chemical analysis revealed the following values: albumin, 3.4 g/dl; alkaline phosphatase, 170 U/l (normal range, 53–128); alanine aminotransferase, 73 U/l (normal range, 10–35); aspartate aminotransferase, 54 U/l (normal range, 14–50); and total bilirubin, 8.9 mg/dl (normal range 0.3–1.2), with a direct bilirubin level of 5.7 mg/dl (normal,< 0.2). The white-cell count was 11 400/mm3, with 84% neutrophils and 1% eosinophils. The urine was orange and was positive for bile (++), protein (+), and urobilinogen (+). Because of the endemicity of leptospirosis, serologic test (indirect hemagglutination test) was done, which revealed negative result. A urine culture and multiple blood cultures were negative. Assays for the presence of hepatitis B antigen and antibody, hepatitis C antibody, and antimitochondrial antibodies were negative. Chest radiographs showed no abnormalities. Endoscopic retrograde cholangiopancreatography (ERCP) demonstrated extrahepatic biliary dilatation; the common bile ducts (CBDs) were about 12–15 mm in diameter, with a small filling defect in the distal part [].\nSerologic test for showed high titer against that (positive titer 1/80), and the detection of ova in stool documented infestation with this liver fluke. After diagnosis, triclabendazole was administered at a dose of 10–12 mg/kg for 1 or 2 days, after which the symptoms disappeared and biochemical values soon returned to normal, and the patient was discharged with good condition. During the follow-up, her jaundice subsided, and ultrasonography revealed an almost normal CBD in our patient.