An interesting case of Fasciola gigantica in Ho Chi Minh City, Viet nam
LE THI XUAN, NGUYEN THIEN HUNG,
TRAN VINH HIEN, DINH THI THI, NGUYEN THANH LIEM,
NGUYEN QUANG VINH, CHAU VAN CON, PHAN THANH HAI
ABSTRACT:
A case of double parasitism, both hepatic and cutaneous lesions, produced by Fasciola gigantica is described in a 40 year-old woman who have stayed for several years in Gialai, Kontum. An infiltrating lesion with many microabscesses was seen in the left lobe of the liver. The cutaneous manifestation is a dark serpentine line protruding at right upper quadrant similar to the cutaneous lesion in the syndrome of cutaneous larva migrans.
INTRODUCTION:
The pathogenic flukes in men are Fasciola hepatica and Fasciola gigantica. In European countries, especially in French, there are several hundred thousands of cases infected by F. hepatica, meanwhile only some dozens of cases infected by Fasciola gigantica were reported in Hawaii, Africa and Asia.
In Vietnam, long times ago, sickness due to Fasciola hepatica in men was very rare. Nguyen Xuan Huyen met a case infected with two hundreds of Fasciola and patient finally died. Dang van Ngu and Do Duong Thai (1959) described a case of ectopic Fasciola which sliped out from an abscess in a patient leg. But till now, there has not been any published report about men infected by Fasciola gigantica in Vietnam.
Early years, Tran Vinh Hien and collaborates (12,13) detected many cases of fascioliasis in the liver based on clinics, imaging technics (CT-scan and ultrasound) and serology, all of them were Fasciola hepatica. Imaging diagnosic authors in Vietnam gave some reports in which they described imaging findings of CT-scan and ultrasound on Vietnamese patients having fascioliasis (6,8,9).Till now there is only one case of fascioliasis with lesions in liver and in the subcutaneous layer and intradermic layer of the abdominal wall.
In this report we describe a case infected by giant fluke which had hepatic lesions and cutaneous manifestation that is similar with larva migrans syndrome and we caught a Fasciola at the end of the serpentine line protruding on the skin. The morphologic and size characters confirmed Fasciola gigantica.
CASE REPORT
On the 24th of June, 2000 a 40 year -old female patient who earned her living in the farm of Gialai province arrived Medic Medical Centre, HCMC for burning pain at her RUQ where there was a dark red serpentine protruding line. She was feeding cows, dogs and cats and sometimes she took some raw watercress.
According to her, one month ago, she got anorexia, asthenia, dizziness, epigastric pain which irridiated to RUQ region but no fever. After that it appeared a red solid and painless mass at the epigastric region and moved up the thoracic wall some days later. The conclusion of the local paraclinic are hepatic abscess and myositis of intercostal muscles. She were in local hospital on the 2nd of June, 2000 and were given antibiotics, steroids and analgesic and tonic drugs. After 2 weeks the mass disappeared but some days later it reappeared firts a small bubble, in size of a peanut, then the bubble were getting a serpentine, angulated and protruding line on the skin. This line lengthened more and more, 3-4cm more longer per day. She felt a burning pain along this protruding line. An ultrasound examination at Gialai on the 16th of June, 2000 described a echo poor structure 31x52.3mm in the left lobe of liver which were thought hepatic abscess, but not exclusing cysts of fluke. She decided to enter Medic Medical Centre in Ho Chi Minh City at last.
This patient were sent to Department of Parasitology from Medic Medical Centre being suspected cutaneous manifestation and hepatic lesions of larva migrans on the 24th of June, 2000. Ultrasound findings in Medic of left hepatic lesions were some small cystic structure measuring 73 by 51mm and of cutaneous lesions in the RUQ are echo free, tubular structure and edema of surrounding subcutaneous tissue with hyperechogenic appearance. The blood film: RBC 3,980,000/mm3, WBC 7,100/mm3 (neutro 76%, eosino 02% (2 times), lymph 22%). Serologic diagnosis of Fasciola sp was 1/6,400. There was no egg of Fasciola sp in stool (2 times at the interval of 3 days).
At the RUQ we saw a dark red protruding andserpentine line 23.6cm in length, and a shadow at the end of the line (Fig 1, 2, 3, 5). We used an aseptic gauze to pierce at the end of the line, some light red brown fluid passed out. After that this protruding line was flatten, the skin over this line was getting wrinkled, easily torn. This line was 4.5mm in width with red pots in the pink base and no bleed. At the beginning of the line, there were 2 concave holes, 2mm in diameter, at 5mm distant from each other, and no bloody. In cleaning the wound we found out a light brown living Fasciola at the end of this line.
DESCRIPTIONS of THE FLUKE
The fluke, in living, was 10mm in length and 5mm in width (Fig 4, 4b), with protruding head and shoulder not seen. After staining, size of the parasite was 21x5mm, thin and long in form, size of the widthest was at the middle of the body, and nearby the caudate there was a knot. The head was round, and small, no shoulder. The tail was round, one side was concave which was damaged by manoeuver. Abdominal cupping was bigger than mouth cupping. The esophagus is shorter than the pharynx. The cecum has 2 branches which lenghthened to the end of the caudate, give many branches inside and outside. The ovary was a round mass, at 1/3 anterior of the body, between 2 cecums, uterus was a serpentine tubule and opened above abdominal cupping, no egg in the uterus. There were 2 testicules which were very thin, distributed one anterior, one posterior of the ovary.
DISCUSSIONS
This was a young giant fluke which was ectopic in the cutaneous layer of RUQ region. There were 2 concave holes that were the sites of going in and out and maybe it went in and out 2 times at least because these holes were at the beginning of the line.
Fasciola hepatica and Fasciola gigantica look the same in the morphologic, structural and size characters.
Table of comparison of characters of Fasciola hepatica and Fasciola gigantica
|
Characters |
Fasciola hepatica |
Fasciola gigantica |
|
Length of body |
3m |
5cm |
|
Length/Width |
2-3/1 |
5/1 |
|
The widest at |
anterior part of body |
in the middle of body |
|
Shoulder |
well seen |
not seen |
In comparison with above characters the caught specimen had morphologic characters of Fasciola gigantica.
There were 2 factors which emphasize our conclusions: geographic distribution and infectious ratio in animal in Vietnam.
1.About geographic distribution, Fasciola gigantica are popular in men and animals in southeast of Asia, Africa, Hawaii, Pakistan and Thailand, meanwhile Fasciola hepatica are common in Europe, southeast of Africa, United States of America, Australia and Japan.
2. About infectious ratio in animal in Vietnam: According to many reports of vietnamese authors, herbivorous animals in Vietnam, especially cattle, are contagious by Fasciola in high degree and most of them by Fasciola gigantica.
Many cases of fascioliasis in men were detected in the world and in Vietnam, nowsaday there were over 500 cases in the southern provinces of Vietnam. Hepatic involvements are most common. But, sometimes parasites can penetrate some ectopic sites: wall of bowell, abdominal wall, lung, heart, brain, subcutaneous layer of the skin. There are cases which the parasites were located in both liver and subcutaneous layer of the skin.
Our case had both lesions in the liver and in subcutaneous layer and intradermic layer of the skin.
Results of ultrasound examination 2 times at the interval of 1 week showed the hepatic lesion getting larger ( on the16th day, left lobe of the liver had hypoechogenic structure 31x52.3mm in size and on the 24th day, it turned into cystic structures with many small cysts measuring 73 by 51mm).
Stool exams 2 times at the interval of 3 days showed no egg of the parasite. But, in cases of Fascioliasis usually the probability of having egg is low.
Eosinophils are increased in fascioliasis, high or moderate, but in this case, eosinophils were not increased (02%). According to patient, with the onset of semiology for one month, it seems to be due to using steroids or due to be in the early stage of the incubation.
In some reported cases of ectopic larva migrating in Vietnam and the world, the lesion was a nodule in the subcutaneous layer of the skin, but in our case, it was a line of the skin, protruding and serpentine, getting more longer 3-4cm/day. These characters are the same as larva migrans syndromes of Toxocara canis and Toxocara catis or of Spirurina suborder in men. We found no data about cutaneous manifestation of Fasciola sp like that and in the cause of larva migrans syndrome, there was no name of Fasciola sp.
So maybe this is a new clinical manifestation of Fasciola sp. And this make us thinking that Fasciola sp can go anywhere when it enters human body.
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