Fasciola Infection Unexpectedly Found During Cholecystectomy: Review on How to Avoid Increasing Surgery Interventions in Non-human Endemic Areas

Abstract

Purpose: Fascioliasis is caused by Fasciola hepatica of almost worldwide distribution and F. gigantica in wide regions of Asia and Africa. Their adult stage develops in the biliary canals and gallbladder. Infection follows an initial, 3-4 month long invasive, migratory or acute phase, and a several year-long biliary, chronic or obstructive phase.

Methods: The unexpected finding of a fasciolid inside the gallbladder during a cholecystectomy for obstructive lithiasis suspicion in a patient is reported from an area of Iran where human infection had been never reported before and studies on fascioliasis in livestock are absent.

Results: The fluke obtained was phenotypically classified as F. hepatica by morphometry and genotypically as F. gigantica by mtDNA cox1 fragment sequencing, although with F. hepatica scattered mutations in species-differing nucleotide positions. The clinical, radiological, and biological signs observed at the acute and chronic phases often lead to some misdiagnosis. Serological methods may be useful in cases of negative coprology. Diagnostic techniques with insufficient resolution leading to unnecessary invasive interventions are analyzed. The way to avoid unnecessary surgery is described, including analyses to be made, diagnostic tools to be used, and aspects to be considered.

Conclusion: Reaching a correct diagnosis in the confusing presentations avoids procedure delays and unnecessary surgery. A correct drug treatment may be sufficient. Except in extreme pathological presentations, lesions decrease in number and size and finally disappear or calcify after a successful treatment. Finally, the need to increase awareness of physicians about fascioliasis is highlighted, mainly in non-human endemic areas.

Keywords: Avoiding unnecessary surgery; Cholecystectomy; Eastern Iran; Fasciola hybrid; Human fascioliasis; Misdiagnosing presentations.

Fig. 1

Map showing the locality of Birjand, capital of South Khorasan Province, in eastern Iran, where the infected surgically intervened patient came from. Note: location close to Afghanistan and Pakistan where intermediate fasciolid forms are known; western areas of Iran where human infection has been reported (shaded areas); northeastern provinces of Northern Khorasan and Razavi Khorasan where fascioliasis has been reported in livestock; province of Fars where the only previous Iranian report of an intermediate fasciolid has been reported in animals; and Turkish locality of Elazig where a similar mtDNA cox1 sequence has been found

Fig. 2

Fasciolid specimen surgically found inside the gallbladder of the patient from Birjand during cholecystectomy: A whole specimen in ventral view (note cephalic cone, shoulders, and dark-reddish gravid uterine area below the ventral sucker); B anterior extremity showing the two suckers and the evaginated cirrus; C egg