Spontaneous hepatic hemorrhage in fascioliasis: Imaging and diagnostic challenges in a rare case series from East Africa

Abstract

Fascioliasis is a zoonotic infection caused by the hepatic trematodes Fasciola hepatica and Fasciola gigantica. It presents with nonspecific symptoms, which can occasionally be complicated by rare but severe manifestations such as spontaneous hepatic hemorrhage. This study describes 3 cases of fascioliasis in female patients aged 35-56 years, who presented with right upper quadrant pain and nonspecific symptoms, including anorexia, nausea, and weakness. Laboratory investigations revealed hypereosinophilia and elevated liver enzymes. Imaging showed massive subcapsular and intrahepatic hematomas, along with multiple linear hypodense liver lesions. Given the lack of availability of immunological testing locally, empirical treatment with triclabendazole was initiated. The diagnosis in all cases was later confirmed through serological tests sent abroad. All patients showed significant clinical improvement with resolution of the eosinophilia and reduction of hepatic hemorrhage upon follow-up. These cases emphasize the importance of considering fascioliasis in patients presenting with hepatic hemorrhage and eosinophilia, and highlight the role of imaging and fine-needle aspiration cytology (FNAC) in guiding early empirical treatment when definitive serological testing is unavailable.

Keywords: Eosinophilia; Fasciola hepatica; Fascioliasis; Hepatic hemorrhage; Subcapsular Hematoma.

Fig. 1

Subcapsular hematoma in a 35-year-old female with fasciola hepatica. Precontrast CT (A) demonstrates a subcapsular hyperdense collection (arrowhead) suggesting hematoma. Postcontrast images (B-D) reveal a focal, ill-defined lesion adjacent to the subcapsular area in the posterior segments of the right hepatic lobe. The lesion is better visualized on the portal venous phase (arrow in C) and exhibits delayed iso-enhancement (arrow in D).

Fig. 2

Same patient as in Figure 1. Ultrasound performed at 1-month follow-up. The image, taken in the intercostal space, demonstrates the previously identified massive subcapsular hematoma (open arrow), which has now organized and developed multiple internal septations. The focal hepatic lesion (bold arrow) which was initially hypoechoic now appears iso- to relatively hyper-echoic.

Fig. 3

Forty-nine years old female with subcapsular hematoma and fasciola hepatica. Multiphasic CT scan of a 49 years old female patient shows massive subcapsular hematoma (arrow in A). There are multiple linear and rounded hepatic lesions more on the left lobe (arrows in B and C). This patient also had pelvic peritoneal hematoma (not shown here).

Fig. 4

Fifty-six years old female with hepatic fascioliasis. Axial CT scan images at different levels (A to D) demonstrate a massive subcapsular and intra-parenchymal hemorrhage in a patient with Fasciola hepatica infection. Panels (A and B) show large subcapsular and intra-parenchymal collections with densities consistent with hematoma (arrows). Panels (C and D) reveal linear hypodense lesions within the hepatic parenchyma, extending from the subcapsular area of the liver (indicated by arrows).