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Fascioliasis mimicking malignancy in humans

1.Medical Director, Infection Prevention Department, Forrest General Hospital, Hattiesburg, MS, USA2.Laboratorio de Parasitología, Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Perú.

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Artículo Original/Original Article

Citation: Marcos LA, Terashima A. Fascioliasis mimicking malignancy in humans. Peruv j parasitol. 2013;21(1):e14-e19.

Open access peer-reviewed scientific journal published by the Asociación de Parasitólogos del Perú. Copyright ® 2013. All rights reserved.

Abstract

Key words:

Palabras clave:

Fascioliasis has become a re-emergent infectious disease in the Andean Region. Microscopic pathological findings have been mostly described in animals but not in humans. We describe histopathological findings of three liver and one cutaneous biopsy (neck) from human cases with Fasciola hepatica infection that were initially diagnosed as possible cancer, mass, metastases or tumour. The pathological patterns included liver fibrosis, eosinophilic necrosis with multiple hepatic abscesses, track-like lesions with eosinophils that corresponds to the migration of the juvenile parasite through the liver, and immature parasite in the peritoneum mimicking peritoneal carcinomatosis. The present study adds more information in the human histopathology in fascioliasis during the acute infection of F. hepatica.

Fasciola hepatica |Histology | Pathology | Biopsy | Peru (Source: BIREME: Decs).

Resumen

Fasciolosis se ha convertido en una enfermedad infecciosa re-emergente en la región Andina. Los hallazgos patológicos por microscopia han sido en su mayoría descritos en animales pero no en humanos. Describimos los hallazgos patológicos de tres biopsias de hígado y una biopsia de cuello de casos humanos por la infección de F. hepatica quienes fueron inicialmente diagnosticados con un posible cáncer, masa, metástasis o tumor. Los patrones histológicos encontrados en estos cases incluyen fibrosis del hígado, necrosis eosinofilica con múltiple abscesos hepáticos, lesiones tipo rastro con eosinofilos que corresponden a la migración del parasito juvenil a través del hígado, presencia del parasito inmaduro en el peritoneo remediando una carcinomatosis peritoneal. El presente estudio agrega mas información en la patología humana de fasciolosis y sugerimos reconocer estos patrones histológicos para sospechar en la infección por F. hepatica especialmente en los estadios iniciales de la enfermedad.

Fasciola hepatica |Histología Patología|Biopsia|Perú. (Fuente: BIREME:

Fasciolosis remediando cáncer en humanos

1,2 2Luis A. Marcos , Angélica Terashima

Peruvian journal

of parasitologyVolumen 21- Número 1 - Año 2013ISSN 2311-4533 (Electronic version)

JP

P

Peruvian journal of parasitology

Volumen 21- Número 1 - Año 2013ISSN 2311-4533 (Electronic version)

15

Original Article Marcos LA, Terashima A. Fascioliasis mimicking malignancy in humans

Introduction consequent liver fibrosis. In an animal study in Peru, 50% of livers infected by F. hepatica from

ascioliasis is a parasitic disease caused by cattle collected in a slaughterhouse had liver (15)two flukes, Fasciola hepatica (F. hepatica) cirrhosis by histological examination. For F. gigantica. Cases of human fascioliasis

(1) We hypothesize that besides the well-known can be present in all continents, and it affects histopathological characteristics described in approximately 17 million people around the

(2) animals, we can include novel histological clues world. The Andean Region of South America in human fascioliasis along with a clinical seems to be one of the more affected regions picture which might increase the suspicion on worldwide. In Peru, 1,684 cases have been

(3) fascioliasis in the clinical practice especially reported between 1963 and 2004. Recent data when a diagnosis of malignancy is entertained. indicated that another 1,000 human cases with

fascioliasis may have been reported after 2004 (Terashima, personal communication).

Patients. Between 2000 to 2005, 4 cases, 3 with Prevalence rates in the range between 8 to 72% a liver biopsy and 1 with an extrahepatic biopsy in Peru, and up to 60% in Bolivia have been

(4,5) (before a confirmed diagnosis of F. hepatica reported. For all these reasons, fascioliasis is infection) were identified at the Hospital a major concern in public health in South Nacional Cayetano Heredia and Instituto America. Especializado de Salud del Nino in Lima, Peru.

F. hepatica infection has two clinical phases, (2) Confirmed case. A liver biopsy in a patient with acute and chronic. The acute phase, up to 4

acute fascioliasis (fever, hepatomegaly, months of duration, is characterized by the eosinophilia, CT-determined liver lesions) migration of larvae from the duodenum confirmed by a positive serological test (Fas2 through the intestinal wall, peritoneal cavity, ELISA or Western blot) and finding of the across Glisson's capsule entering the liver parasite in the tissue; or with chronic fascioliasis parenchyma and reaching the biliary ducts. confirmed by detecting eggs in stools and Fasciola may produce subcapsular hemorrhages, detecting the parasite or eggs in the biopsy. hepatic degeneration, eosinophils infiltration,

lymphocytes and macrophages, fibrosis, venous Tissue Examination. The paraffin-embedded thrombosis, appearance of necrotic cords with tissues and slides were collected from the giant cells and granulation tissue and hospitals above mentioned. The tissue samples

(2)granuloma-containing parasite egg. In were examined under light microscope (H&E humans, subcapsular hemorrhages, multiple and Trichrome stains). Permission from both hepatic abscesses, hepatic necrosis, liver institutions were obtained prior to chart review. calcifications and severe anemia have been Exemption of the requirement for written

(6-8)reported. informed consent was obtained from each

institution. The chronic phase occurs months to up to 13.5 (9,10)

years after infection. In theory, it begins when adult parasites deposit eggs in the biliary

(2) Description of patients enrolled. Four cases (1 ducts. The chronic infection may present with male and 3 female) with a mean age of 44.5 biliary obstruction, gallstones, bacterobilia or

(11-13) years ± 15.9 (range 12 to 63 years) were hepatic dysfunction. In addition, F. hepatica included. Symptoms persisted on average 7.7 ± infection may be associated with bile duct

(14) 6.7 weeks until presentation (range: 0.5 to 12 hyperplasia and possible cirrhosis of the liver. weeks). The source of infection was possible Furthermore, the number of parasites seems to watercress in three patients and lettuce in one. be critical in the hepatic damage and

Material and Methods

Results

Peruv. j. parasitol 2013; 21 (1)

Acceso gratuito en línea a texto completo.



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Clinical manifestations were mainly right upper common findings were the track-like lesion in the liver parenchyma (n=2/4), eosinophilic quadrant pain, fever ≥ 38ºC malaise, anorexia, scattered infiltration (n=2/4), necrosis and weight loss >10 kg, nausea and vomiting. All small haemorrhages in the liver (n=1/4). No cases were suspected to have a biliary parasite was found in liver biopsies. A juvenile malignancy or metastases by imaging or parasite was noted in a peritoneum biopsy clinically prior biopsy. mimicking metastases. Laparoscopic or

Pathological findings. Three cases had a liver percutaneous CT guided biopsies performed in biopsy. The fourth case of extra-hepatic Fasciola 3 patients yielded a fluke only in one of them

(16)has been reported elsewhere. The most (Figures 1-5).

Figure 1. Juvenile parasite migrating in the peritoneal cavity causing destruction and haemorrhages in case (haematoxylin and eosin stain, magnification x100; Bar 500 um). The biopsy in the peritoneum was performed due to clinical suspicion of metastases (Picture obtained with permission from: Marcos LA, Terashima A, Gotuzzo E. Update on hepatobiliary flukes: fascioliasis, opisthorchiasis and clonorchiasis. 2008 Oct;21(5):523-30)*

Curr Opin Infect Dis.

Figure 2. Area of necrosis caused by the juvenile parasite during its migration through the liver parenchyma (track-like lesion), characteristic of acute fascioliasis. There are scattered eosinophils surroundings (haematoxylin and eosin, magnification x100; Bar 500 u.

Figure 3. Necrotic abscess with fibrosis (trichrome stain, magnification x100; Bar 500 um).

Figure 4. Severe chronic inflammatory process, portal fibrosis and fibrosis moderate to severe (trichrome stain, magnification x100; Bar 500 um).




http://www.ncbi.nlm.nih.gov/pubmed/18725803



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Discussion observation of eggs or the parasite in the lesion (23)

by microscopy. The present study describes the pathological

In human livers, the migration is accompanied findings of four cases of human fascioliasis by an intense inflammatory reaction with either in the liver or as extrahepatic location, prominent eosinophils as seen in Figure 2. A showing that, in massive acute infection it may large serie of 16 human cases with F. hepatica present like metastases in the liver by imaging or

(25)infection were reported in 1979, the liver was clinically. involved in 13 cases, the gallbladder in 9 cases

The human cases reported in the literature with and the stomach in 2 cases. The lesions fascioliasis along with histological findings are containing parasitic remnants or fluke eggs seldom. For instance, two cases of hepatic were rarely seen and the most common fascioliasis due to F. hepatica were retrieved from characteristic lesions seen were surface scarring 1969 to 2005 in a Thailand Hospital. The adult of the liver, scar tracks and granuloma in the parasite was detected in a large cystic lesion in a organs. lobectomized liver specimen in one case, and of

In our serie, all biopsies were ordered to rule out deposited eggs in the large liver specimen (16) metastases. The biopsies did not yield any obtained from open biopsy in another case.

malignant cells or any adult parasites, but they Aberrant or ectopic sites of infection –by the did reveal a juvenile parasite migrating through immature larvae- are much less common and the peritoneum (Figure 1) and a tunnel-like include subcutaneous tissue (the most common tract lesion which eventually might be a major site) or tissues of the intestine walls, lungs, criterion for the diagnosis of fascioliasis (Figure

(17-20)heart, eyes or brain. Ectopic cases are even 2). This finding are in agreement with other

(25,26)more uncommon and the diagnosis is made in cases reported. The lesions of the liver the histological examination of the tissue. caused by F. hepatica are diverse since most of Histological diagnosis has been made in ectopic the times the parasite or eggs are not seen, cases such as the dorsal spine and pancreatitis. making the suspicion a challenge for the (21,22)

Currently, the diagnosis of ectopic cases clinician. relies on serological detection or direct

Figure 5. Numerous eosinophils with lymphocytic infiltration in portal spaces (haematoxylin and eosin, magnification x100; Bar 500 um).




18 Peruv. j. parasitol 2013; 21 (1)




We conclude that the present study adds more Peru; for his help in the pictures; and Dr. Juan information in the human histopathology in Carlos Ferrufino (deceased) from HNCH; and fascioliasis during the acute infection. the Pediatric group of INSN for providing

information about some of these cases. We appreciate the great

The authors have no help and collaboration of Mr. Roy Andrade, Faculty of Veterinary and Zootechnia, conflicts of interest concerning the work Universidad Peruana Cayetano Heredia, Lima, reported in this paper.

Acknowledgments:Conflict of interest:

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12. Valero MA, Navarro M, Garcia-Bodelon MA, 2. Mas-Coma S, Bargues MD, Esteban JG. Human Marcilla A, Morales M, Hernandez JL, et al. High

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3. Marcos LA, Terashima A, Leguia G, Canales M, 13. Blancas G, Terashima A, Maguiña C, Vera L, Alvarez Espinoza JR, Gotuzzo E. La Infección por Fasciola H, Tello, R. Fasciolosis humana y compromiso hepatica en el Peru: Una enfermedad Emergente?. gastrointestinal: Estudio de 277 pacientes en el Rev Gastroenterol Peru. 2007;27:389-96. Hospital Nacional Cayetano Heredia. 1970-2002.

Rev Gastroenterol Peru. 2004;24, 143-57.4. Parkinson M, O'neill SM, Dalton JP. Endemic human

fasciolosis in the Bolivian Altiplano. Epidemiol Infect. 14. Marcos LA, Terashima A, Yi P, Andrade R, Cubero 2007;135:669-74. FJ, Albanis E, et al. Mechanisms of liver fibrosis

associated with experimental Fasciola hepatica 5. Marcos L, Maco V, Florencio L, Terashima A,

infection: Roles of Fas2 Proteinase and hepatic Samalvides F, Miranda E, et al. Altas tasas de

stellate cell activation. J Parasitol. 2011, 97: 82-7.prevalencia de Fasciolosis humana en el Perú: Una enfermedad emergente. Rev Per Enf Infec Trop. 2005; 15. Marcos LA, Yi P, Machicado A, Andrade R, 3:8-13. Samalvides F, Sánchez J, et al. Hepatic fibrosis and

Fasciola hepatica infection in cattle. J Helminth. 2007, 6. Loja, D., Alvizuri, J., Vilca, M., Aviles, R., Sanchez, M.

25:1-6. Hepatic subcapsular hematoma caused by fascioliasis. Rev Gastroenterol Peru. 2003;23:142-8. 16. Marcos LA, Legua P, Sánchez J, Espinoza JR, Yi P,

Tantaleán M. Cervical tumor caused by the sexually 7. Marcos LA, Yi P, Machicado A, Andrade R,

mature stage of Fasciola hepatica. Trans R Soc Trop Samalvides F, Sánchez J, et al. Hepatic Fibrosis and

Med Hyg. 2009;103:318-20. Fasciola hepatica infection in cattle. J Helminth. 2007;81:381-6. 17. Aroonroch R, Worawichawong S, Nitiyanant P,

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Correspondence: Luis A. Marcos, MD, MPH. Forrest General Hospital, Hattiesburg, MS. Email: [email protected]


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