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Clonorchiasis/Opisthorchiasis in Malaysians

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Clonorchiasis/Opisthorchiasis in Malaysians CASE REPORTS The clinical course of CPM is not invariably fatal. in practice the corrected sodium level may be more Asymptomatic cases and cases with clinical and difficult to predict. Hence, there is no substitute for radiological resolution have been documented. more frequent estimation of serum sodium level in the Magnetic resonance imaging is superior to management of hyponatraemic patients. computerized tomography in detecting CPM. The rate of rise in the correction of hyponatraemia can Acknowlegdemernt theoretically be measured by calculating the deficit and We thank Kamaruzzaman from UPp, UKM for the correcting it over time by hypertonic saline. However, photographs. 1. Areft AI, Llach P, Massry SG. Neurologic manifestation and 3. Sterns RH, Riggs JE, Schochet SS. Osmotic demyelination morbidity of hyponatreamia: correlation with brain water and syndrome following correction of hyponatraemia. N Engl J electrolyte. Medicine (Baltimore) 1976;55 : 121-9. Med 1986;314 : 1535-42. 2. Stein RH. Severe symptomatic hyponatraemia: Treatment and outcome. Ann Intern Med 1987;107 : 656-64. Clonorchiasis/O pisthorchiasis in Malaysians -- Case Repo rts and Review K Chandra Shekhar, PhD* A R Nazarina; MPath** S H Lee, FRCS*** R Pathmanathan, FRCPA ** * Depariment of Parasitology * * Department of Pathology * * * Department of Surgery faculty of Medicine, University of Malaya, 59100 Kuala Lumpur 182 Med J Malaysia Vol 50 No 2 June 1995 CASE REPORTS Introduction A CT scan done shdwed stones in the common bile duct. At cholecystectomy, two large stones were Liver fluke disease, caused by Clonorchis sinensis, removed from the common bile duct. There was no Opisthorchis viverrini and 0. felineus is endemic in obvious hepatomegaly and a percutaneous transhepatic parts of Asia and Europe. While C. sinensis is the cholangiogram revealed dilatation of intrahepatic bile important fluke infecting man in China, Japan, Korea ducts. Laboratory findings included a slight rise in and countries of Southeast Asia, 0. viverrini more serum bilirubin and abnormal liver function tests. frequently occurs in man in Southeast Asia especially in the Mekong Valley area and northeast Thailand. The Grossly, the gall bladder appeared as a small cystic prevalence rate of opisthorchiasis ranges from between structure measuring 2.5 cm x 2.5 cm and the wall 3.5-50 million and the rate is increasing was 3 mm thick and fibrotic. Histological sections proportionately due to large number of immigrants or showed mucosal ulceration, thickening and fibrosis of refugees migrating from endemic areas and the the wall. The wall was infiltrated by acute and chronic consumption of fish imported from endemic areas. inflammatory cells consisting of plasma cells and Infection is acquire.d by consuming fresh water, fish lymphocytes as well as polymorphs. Rokitansky Aschoff containing the infective metacercariae. sinuses were present and dilated with inspissated bile. A pronounced granulomatous reaction to numerous Whether either of these conditions is endemic in parasitic ova was noted with numerous multinucleated Malaysia is controversial. The first documented case giant cells (Figure 1). The ova were operculated and of imported clonorchiasis was reported by Kuntz and contained miracidia while some were engulfed by giant Wells! in Sabah. Bisseru andLim found 11 cases of cells. The mean size of the ova measured 25 !lID x 17 opisthochiasis in .a survey of 97 medical students and' !lID. Postoperatively, a single adult Clonorchis sinensis 13 relatives2• The authors showed that four cases were worm was isolated from the patient's draining T-tube. indigenous and the rest had acquired infection overseas. The adult worm measured 26mm by 5mm (Figure 2). The same group of workers confirmed that the Subsequent stool examination by the formal-ether intermediate hosts for the parasite - the grass carp technique confirmed ova of Clonorchis sinensis and cysts Ctenopharyngodon idellus (Cuvier and Valenciennes) and of Entamo.eba histolytica. The identified fluke eggs the snail vectors - are present locally. The local cases measured 27-34 !lID x 12.5-19 !lID. The patient was reported have been diagnosed from general and district treated with antibiotics, metronidazole (500 mg three hospitals and are based on either findings on stool times daily for 5 days) and praziquantel (3 x 25 mg/ examination or histopathology. The present report documents another two cases of clonorchiasis and one case of opisthorchiasis in Malaysians. Case Presentations Case 1 A 64-year-old male Chinese newspaper vendor from Seremban, Negeri Sembilan was referred by a GP'to the University Hospital, Kuala Lumpur. He presented with a 3-week history of obstructive jaundice and right hypochondrial pain. Epidemiological investigations carried out revealed that he had been to Hong Kong, Singapore, Thailand and Europe and had consumed raw fish often in the company of friends. He had, Fig. 1, Foreign body grai'luioma with however, not been abroad after 1983. He had numerous giant cens (G) some of which complained of repeated attacks of fever for more than contain ova ( arrow ) x 200. H &. E a month. stain Med J Malaysia Vol 50 No 2 June 1995 183 CASE REPORTS kg body weight on each of 2 successive days). Stool bouts of diarrhoea for two weeks. A physical examination a month later failed to reveal the presence examination was essentially negative. Stool of ova. examination was positive for E. histolytica cysts and numerous eggs of C. sinensis. Eggs were ovoid, flask shaped and Llcasured from 26-35 /-lm x 12-21f1m. The shell was yellowish brown and had pronounced shoulders at the rim of the operculum. A spine was found at the broader opercular end of the egg. The patient admitted that he had travelled to Japan and Thailand and had on many occasions consumed raw fish dishes. The particular fish dish that he recollected eating in Thailand was mashed, raw fish seasoned with garlic, lemon juice, chillies and sauce, with glutinous rice and vegetables. The blood chemistry profile and liver function tests were essentially within normal limits. The patient refused a cholangiogram and studies to exclude pancreatitis and a gall bladder series were not carried. The patient was treated with metronidazole (500mg three times daily for 5 days) and praziquantel (20mg/kg body weight x 3 days) and discharged on the 6th hospital day.. Case :3 An asymptomatic 54-year-old female Chinese housewife had her stools analysed as part of a health clinic checkup. The stool was examined by the formol-ether sedimentation technique and numerous eggs measuring 22-32 f1m x 11-21 f1m were detected. The patient was a Malaysian and denied living anywhere except for a tour of Taiwan and Thailand during the last three months. She had stayed in Chiang Mai, Thailand for over a month. During the visits she had consumed raw fish delicacies on several occasions. On direct questioning, she did complain of mild epigastric pain Fig. 2: Adult Clonorchis sinensis recovered unrelated to food and occasional intermittent fever. As from Case 1. x 100. [os ::: oral sucker; the eggs were smaller than Clonorchis eggs and based vs ::: ventral sucker; ce ;:,:: cecum; ut ::: on her travel history and endemicity of the disease in uterus; ov = ovary; te :::: testes; eb :::: that region of Thailand, she probably was infected with excretory bladder1 Opisthorchis viverrini. She was treated with a similar dose of praziquantel. Two months later her stools were Case :2 negative for eggs. Co incidently, a friend of Case 1 described above was admitted to the same surgical ward for suspected Discussion amoebiasis. He was a 54-year-old Chinese fish dealer who imports large quantities of fresh water fish from Both Clonorchis sinensis and Opisthorchis viverrini have Thailand. He had complained of mild right upper similar life cycles, and clinical and pathologic features. quadrant pain, acholic stools, decreased appetite and The parasitic trematodes are widely prevalent in many 184 Med J Malaysia Vol 50 No 2 June 1995 CASE REPORTS parts of Asia and Europe. The mode of infestation is imported i.e. patients acquired the infection while through the gastrointestinal tract. The clinical travelling abroad. It is also interesting to note that all symptoms depend on the degree of infection and the 23 cases of clonorchiasis and opisthorchiasis correlates with worm burden, frequency, duration of reported in this country were restricted to the people infection and the condition of the host. of Chinese origin, and this is accounted for by the predilection of Chinese for raw fish. These liver flukes predispose to biliary stasis and calculi formation. The calculi are usually darkly pigmented, Of the i2 opisthorchiasis cases described initially by soft, friable and irregular in shape and often found in Bisseru et af2., 4 were considered indigenous as the the intrahepatic bile ducts. A parasite may act as a affected individuals claimed never to have left Malaysia. nidus for stone formation or provoke local The fact that the fish and snail intermediate hosts are inflammation in the bile ducts. In opisthorchiasis, the found in Malaysia might seem to support this notion. gall bladder is invariably parasitized in heavy infections However, one cannot dismiss the fact that of the many and may contain hundreds of flukes. field' surveys conducted in Malaysia, using detection methods that would almost certainly have detected Other complications of the infection include these eggs, none has yielded Opisthorchis or Clonorchis cholangitis (which may be acute suppurative or eggs in the general population4• Additionally, if these recurrent pyogenic), biliary calculi, acalculous diseases were truly endemic, since the initial reporting cholecystitis, cholangiohepatitis, acute pancreatitis, of cases in the late 60s, the incidence of the disease choledocho-bronchial fistula and rarely obstruction of would be expected to increase, a trend that has not the common bile duct or pancreatic duct. The developed. Malaysia imports large quantities of fresh association of clonorchiasis and opisthorchiasis with water fish from Thailand and Taiwan, where the cholangiocarcinoma is well established3 .
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