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Case Report: Surgical Intervention for Fasciolopsis Buski Infection: a Literature Review

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Case Report: Surgical Intervention for Fasciolopsis Buski Infection: a Literature Review Am. J. Trop. Med. Hyg., 103(6), 2020, pp. 2282–2287 doi:10.4269/ajtmh.20-0572 Copyright © 2020 by The American Society of Tropical Medicine and Hygiene Case Report: Surgical Intervention for Fasciolopsis buski Infection: A Literature Review Xinglang Wu, Weimin Wang, Qujin Li, Qiang Xue, Yue Li, and Shengwei Li* Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China Abstract. Fasciolopsis buski, also called the giant intestinal fluke, is the largest intestinal fluke of the zoonotic trem- atode parasites and found mainly in Southeast Asian countries, including China. Fasciolopsis buski infection was formerly a common health problem in many countries, but it is now rare. Typically, it can be cured by oral drugs, but some infected patients need surgical intervention because of the severity of their condition or because of an unclear diagnosis or even misdiagnosis. Here, we report a case of a 15-year-old girl from Guizhou Province, China, presenting with recurrent upper- middle abdominal pain that was misdiagnosed as a choledochal cyst. Through laparotomy combined with postoperative histopathological examination, the source of the pain was proven to be mechanical biliary obstruction caused by F. buski infection. In the past, mechanical obstruction, especially biliary obstruction, caused by F. buski infection leading to surgery was not uncommon, but it is very rare in modern society. Moreover, delayed treatment and misdiagnosis of parasitic infection can lead to severe consequences. Therefore, we reviewed the previous literature on F. buski infection treated by surgical operation and summarized the characteristics and therapeutic strategies of these cases to raise clinicians’ awareness of this rare infection. INTRODUCTION strategies for F. buski infection are also summarized in the present study. Fasciolopsis buski, commonly known as the giant intestinal fluke, is a trematode of the Fasciolidae family and was first discovered in the duodenum of an Indian sailor by George CASE PRESENTATION Busk in 1843.1 It is now known to be a common intestinal A 15-year-old Han Chinese girl from Guizhou Province was parasite of humans and pigs in Asia, including southern and admitted with a history of recurrent upper-middle abdominal central China, and India.2,3 Infection with F. buski occurs pain for 10 years that had intensified for 4 days. The abdominal through the consumption of raw or improperly cooked aquatic pain started 10 years previously with no obvious predisposing plants (water chestnut, water caltrop, water bamboo, etc.) causes, lasted for approximately a few minutes, and went contaminated with metacercariae, especially when peeling off away on its own. Her parents took her to the local hospital the outer layers of the plant with human teeth.4–6 In addition, several times, and she was suspected of having cholangitis F. buski can also occur as a coinfection with other soil- due to intrahepatic stones. However, the condition did not transmitted helminths when the infected host is immuno- improve during the course of the treatment. After admission, compromised.7 Mild infection of F. buski is asymptomatic, but the doctor took a careful history, and the girl denied a history of in heavy infection, the common symptoms are abdominal parasites, viral hepatitis, travel, and direct contact with live pain, diarrhea, low-grade fever, toxemia, allergic symptoms, animals or poultry. On physical examination, she was mildly anemia, ascites, generalized edema, and intestinal obstruc- anemic and malnourished, and the abdominal examination tion, sometimes even leading to death.8,9 In general, the di- showed light tenderness in the upper-middle abdominal re- agnosis of F. buski is based on the detection of eggs in stool, gion. Routine blood examination revealed a hemoglobin level but a definitive diagnosis requires the observation of adult of 116 g/L, neutrophils 71.1%, and eosinophils 8.0%. In ad- worms.10 Oral praziquantel is effective in the vast majority of dition, liver function tests showed an alkaline phosphatase diagnosed patients, but some patients cannot be diagnosed (ALP) level of 152 U/L, and bilirubin was normal. Routine stool or have severe symptoms and may require surgical treatment and occult blood tests showed no abnormal changes, in- first. cluding parasitic eggs. Ultrasonography and MRCP showed In clinical practice, a rare kind of mechanical biliary ob- dilatation of the common bile duct and a right intrahepatic struction caused by F. buski infection could sometimes stone (Figure 1A and B). The gastroduodenoscopy only be misdiagnosed and treated as other biliary diseases. Here, revealed superficial gastrosinusitis. Combined with the we report a 15-year-old girl presenting with recurrent aforementioned clinical symptoms and examination results, upper-middle abdominal pain for 10 years. In addition, choledochal cysts and right intrahepatic stones with chol- ultrasonography (USG) and magnetic resonance chol- angitis were suspected. Symptomatic therapy was adminis- angiopancreatography (MRCP) suggested dilatation of the tered by using antibiotics, analgesic drugs, and stomach- and common bile duct. Finally, her illness was confirmed through liver-protective drugs. The patient achieved remission after exploratory laparotomy due to F. buski infection. To increase treatment but still felt unbearable irregular pain, and the di- clinicians’ awareness about these kinds of cases, we reviewed agnosis was still unclear. Because of economic and personal the previous literature on F. buski infection treated by surgery reasons, her parents decided on exploratory laparotomy (Table 1). Moreover, the characteristics and therapeutic rather than laparoscopy. Except for slight edema of the gall- bladder and a slight thickening of the common bile duct and its wall, no tumor or other abnormalities were found in the ab- * Address correspondence to Shengwei Li, Department of Hepato- biliary Surgery, The Second Affiliated Hospital of Chongqing Medical dominal cavity. Therefore, only common bile duct exploration University, No. 74 Linjiang Road, Yuzhong District, Chongqing, China was performed (the gallbladder was preserved). After opening 400010. E-mail: [email protected] the common bile duct, surprisingly, the stone forceps 2282 TABLE 1 Important characteristics of patients with F. buski infection treated by surgery History Post- of raw Presurgery surgery Age Epidemic aquatic stool Endoscopic F. buski Eosinophil Worm Surgical Worm stool Post-surgery First author Year Country Gender (years) area plants examination examination Imaging examination diagnosed increase Symptoms location Coinfection forms load examination treatment Outcome Jin and Si40 1972 China F 46 Yes Yes N/A No Venous cholangiography No N/A Abdominal Duodenum Ascaris Laparotomy 3 Ova (−) Areca Recovered pain and and the lumbricoides decoction distension, CBD chills, fever SURGICAL INTERVENTION FOR 1973 China M 66 Yes Yes Ova (+) No N/A Yes N/A Upper CBD Ascaris Emergency 2 N/A Okra fried Recovered abdominal lumbricoides laparotomy and pepper pain and decompression and areca jaundice of the biliary decoction tract 1974 China M 41 Yes Yes Ova (+) No N/A Yes N/A Upper-middle CBD Ascaris Emergency 8 N/A Pepper, areca Recovered abdominal lumbricoides, laparotomy and decoction, colic, fever, hookworm decompression and chill, and of the biliary buphenine jaundice tract Zhou33 2002 China F 24 Yes Yes Undone No USG No N/A Right upper CBD No Open 3 Ova (+) Oral Recovered quadrant cholecystectomy praziquantel dull pain, and common abdominal bile duct distension, exploration FASCIOLOPSIS BUSKI and fever Wang 2004 China F 46 Yes Yes N/A No X-ray No N/A Constipation, Jejunum and No Emergency 153 N/A N/A Recovered et al.41 abdominal ileum laparotomy pain, and distension Bhattacharjee 2009 India M 10 Yes N/A N/A No X-ray No Yes Central Ileum No Emergency More Ova (+) Oral N/A et al.42 abdominal laparotomy and than praziquantel pain and ileostomy 25 abdominal distension fever INFECTION Singh et al.30 2011 India F 22 Yes N/A N/A No X-ray No Yes Constipation, Jejunum and No Emergency Heavy Ova (−) Oral Recovered abdominal ileum laparotomy, loads praziquantel distension, ileostomy, and fever, and end-to-end vomiting anastomosis Ma and 2017 China F 32 Yes Yes N/A No Magnetic resonance imaging No Yes Right upper Left hepatic No Laparotomy and 2 Ova (−) Oral Recovered Yang43 quadrant duct and biliary tract praziquantel pain the CBD exploration Wu et al. 2020 China F 15 Yes Yes Ova (−) Yes USG and magnetic No Yes Recurrent CBD No Laparotomy and 1 Ova (−) Oral Recovered resonance upper- biliary tract praziquantel cholangiopancreatography middle exploration abdominal pain CBD = common bile duct; F = female; F. buski = Fasciolopsis buski; M = male; N/A = not applicable; USG = ultrasonography. 2283 2284 WU AND OTHERS FIGURE 1. (A and B) Ultrasonography and magnetic resonance cholangiopancreatography showing dilatation of the common bile duct. This figure appears in color at www.ajtmh.org. removed a flat foreign body from the middle of the duct, length and eggs measure 130–140/80–85 mm.15 The worms measuring 1.6 × 1.0 × 0.1 cm, with a sucker at the front and a inhabit the duodenum and jejunum, and can also be found in tail-like object at the back (Figure 2A). Careful observation much of the intestinal tract, including the stomach, in mod- showed that the object could move and was considered as a erate and heavy infections.16 Then, immature eggs are re- biliary
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