Le Infezioni in Medicina, n. 2, 115-116, 2009 Casi clinici Dicrocoelium dendriticum: a true infection? Case reports Dicrocoelium dendriticum: una vera infezione?

Barbara Magi1, Elena Frati2, Laura Bernini1, Anna Sansoni1, Giacomo Zanelli1 1Infectious Diseases Clinic, Department of Molecular Biology, Siena University; 2Clinic of Rheumatology, Department of Clinical Medicine and Immunology, University of Siena, Italy

n INTRODUCTION eosinophilia (9.7%) and slightly elevated biliru- bin (1.5 mg/dl). Other laboratory results were icrocoelium dendriticum is the most wide- within the normal range. Abdominal ultra- spread liver fluke in cattle and sheep in sonography was negative for liver and biliary D Italy [1]. Adult forms live in the gall blad- abnormalities. Total IgE count was normal and der and bile ducts of their final hosts (ruminants). there was no history of allergy. Microscopical Eggs are passed in faeces and ingested by land s- examinations of three stool specimens after nails which excrete cercaria in mucous balls, concentration revealed Dicrocoelium dendriticum which are eaten by ants. Infestation usually oc- eggs (Figures 1, 2). She denied liver consump- curs by ingestion of ants that carry metacercariae tion, travel or animal contact within the past by animals and occasionally humans [2]. Here we weeks. She did not complain of abdominal dis- describe a rare case of asymptomatic human di- comfort except for a long history of constipa- crocoeliasis. tion. She was treated with albendazole (400 mg twice a day for 7 days) and 4 weeks later para- sitological examination was negative and blood n CASE REPORT parameters had returned to normal.

A 55-year-old Italian woman was admitted to the Rheumatology unit (Siena University Hos- n DISCUSSION pital, Italy) in June 2007 with a chronic history of cervical and lumbar pain and was diagnosed Despite the widespread nature of the liver fluke with osteoarthritis. Blood tests showed mild Dicrocoelium dendriticum, dicrocoeliasis is rarely

Figures 1, 2 - Dicrocoelium dendriticum: two small (40 mm X 20 mm), thick-walled, yellowish-brown opercula- te eggs containing miracidium (40X).

115 2009 encountered in clinical practice [2]. Infections Re-examination of stools after three days of liv- occur by ingestion of the second intermediate er-free diet is generally conclusive [6]. In the host (ants) contaminating raw fruit and vegeta- present case, there was no history of liver con- bles. sumption. Although the patient was symptom- Metacercariae migrate into the bile system free, eosinophilia and elevated bilirubin (either causing chronic irritation of the liver and bile reported in dicrocoeliasis) that returned to nor- ducts [2]. Symptoms associated with human in- mal after antiparasitic therapy, suggest true in- fection include chronic constipation or diar- fection with initial involvement of the bile rhoea, hepatomegaly, bile duct obstruction, hy- ducts. pereosinophilia and possibly urticaria [2-5]. Imidazole therapy was effective in eradicating Asymptomatic infection has been documented the parasite as reported in a prior study [2]. In in animals. our opinion, the present was a rare case of Detection of parasite eggs in human stools is asymptomatic dicrocoeliasis and to our knowl- not always associated with real infection, but edge there has been no prior report from Italy. may indicate “spurious infection” or pseudoparasitism due to ingestion of raw or Key words: dicrocoeliasis, human infection, liver undercooked infected liver [2, 4]. fluke.

SUMMARY

Dicrocoelium dendriticum is a liver parasite of ru- old woman who presented with eosinophilia and minants. Humans are occasionally infected by in- elevated bilirubin. Therapy with albendazole gestion of intermediate hosts. eradicated the parasite and normalized blood pa- We report a rare case of dicrocoeliasis in a 55-year- rameters.

RIASSUNTO

Dicrocoelium dendriticum è un parassita epatico dei ru- croceliasi in una donna di 55 anni che ha presentato eo- minanti. sinofilia ed aumento della bilirubina. Il trattamento con L’uomo si infetta occasionalmente attraverso l’ingestio- albendazolo ha eradicato il parassita con normalizzazio- ne di ospiti intermedi. Descriviamo un raro caso di di- ne dei parametri laboratoristici.

n REFERENCES [3] Rack J., Adusu E., Jelinek T. Humane infektion mit Dicrocoelium dendriticum. Dtsch. Med. Wochen- [1] Cringoli G., Rinaldi L., Veneziano V., Capelli G., schr. 129, 2538-2540, 2004. Malone JB. A cross-sectional coprological survey of [4] Sing A., Tybus K., Facler I. Acute urticaria asso- liver flukes in cattle and sheep from an area of the ciated with Dicrocoelium dendriticum infestation. In- southern Italian Apennines. Veterinary Parasitology dian J. Med. Microbiol. 26, 96-98, 2008. 108, 137-143, 2002. [5] El-Shiekh Mohamed A.R., Mummery V. Human [2] Karadag B., Bilici A., Doventas A., Kantarci F., dicrocoeliasis. Report on 208 cases from Saudi Ara- Selcuk D., Dincer N., Oner Y.A., Erdincler D.S. An bia. Trop. Geogr. Med. 42, 1-7, 1990. unusual case of biliary obstruction caused by Dicro- [6] Helmy M.M., Al-Mathal E.M. Human infection coelium dendriticum. Scand. J. Infect. Dis. 37, 385-388, with Dicrocoelium dendriticum in Riyadh district (Sau- 2005. di Arabia). J. Egypt Soc. Parasitol. 33, 139-144, 2003.

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