eMedicine Specialties > Pediatrics: General Medicine > Parasitology

Fascioliasis: Differential Diagnoses & Workup

Author: Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine
Contributor Information and Disclosures

Updated: Jan 22, 2009

Differential Diagnoses

Amebiasis
Fever Without a Focus
Ancylostoma Infection
Filariasis
Anemia, Chronic
Giardiasis
Ascariasis
Gnathostomiasis
Bancroftian Filariasis
Hepatitis A
Biliary Atresia
Hepatitis B
Catscratch Disease
Hepatitis C
Cholecystitis
Hookworm Infection
Cholelithiasis
Hymenolepiasis
Cholestasis
Hypereosinophilic Syndrome
Cutaneous Larva Migrans
Intestinal Protozoal Diseases
Cysticercosis
Leptospirosis
Dirofilariasis
Schistosomiasis
Dracunculiasis
Taenia Infection
Echinococcosis

Other Problems to Be Considered

Ascending cholangitis
Familial Mediterranean fever
Fever of unknown origin

Workup

Laboratory Studies

The following studies are indicated in fascioliasis:

  • CBC count
    • Leukocytosis may occur.
    • Severe anemia may occur, especially in children.
    • Eosinophilia occurs in 95% of acute stage infections.
    • Eosinophilia may wax and wane during the chronic stage of infection.
    • Among Egyptian children with acute fascioliasis, 14-82% had peripheral eosinophilia.3
  • Erythrocyte sedimentation rate: About one half of affected patients have an elevated erythrocyte sedimentation rate.
  • Serology
    • Serologic modalities include complement fixation, immunofluorescence, indirect hemagglutination, counterimmunoelectrophoresis, and enzyme-linked immunosorbent assay (ELISA).
    • The Falcon screening test-ELISA is the most reliable diagnostic study and is the test of choice because of its routine availability, cost, sensitivity, and specificity.
    • A serum ELISA test result may become positive months before stool examination for ova because flukes do not produce eggs until the chronic stage (ie, 4 mo after infection [range, 3-18 mo]).
  • Immunoglobulin levels: These may be elevated, particularly immunoglobulins G and E.
  • Liver function tests
    • Elevated levels of gamma-glutamyl transpeptidase, alkaline phosphatase, and bilirubin may suggest cholestatic liver injury.
    • Although rare, elevated transaminase levels suggest hepatocellular injury.
  • Stool examination for ova and parasites
    • The small number of eggs in stool requires multiple specimens. The eggs measure 130-150 X 60-90 μm and can be confused with Fasciolopsis buski eggs.
    • ELISA may be performed on stool specimens.
    • Flukes that measure 30 X 15 mm almost never appear in stool; the rare exceptions follow successful treatment.

Imaging Studies

  • Chest radiography
    • In patients with pulmonary symptoms, parenchymal infiltrates are rarely visible.
    • A right-sided pleural effusion is also rare.
  • Ultrasonography
    • Ultrasonography may reveal hypodense/hypoechoic lesions in the liver that correspond to the burrow tracks of the larvae.
    • Ultrasonography may reveal the adult fluke in a bile duct or the gallbladder.
    • Ultrasonography rarely reveals scant ascites.
  • CT scanning
    • CT scanning may reveal multiple lesions that measure 1-10 mm or tunnels in the liver parenchyma.
    • A radiating pattern of tunnels is diagnostic.
    • CT scanning may also reveal an adult fluke in a bile duct or the gallbladder.
  • MRI: MRI may suggest granulomata of the liver parenchyma and may provide findings similar to CT scanning.
  • Cholangiography: This may reveal a fluke in the biliary tree.
  • US-guided gallbladder aspiration: This can reveal eggs in the bile, even when stool examination test results are negative.
  • Technetium-99 scanning: This imaging study reveals multiple intrahepatic defects in approximately 50% of cases.

Other Tests

  • Bone marrow aspiration, performed only as part of the diagnostic evaluation for other conditions, can reveal increased bone marrow eosinophils.

Procedures

  • Duodenal aspiration may reveal eggs.
  • Liver biopsy findings include the following:
    • Liver biopsy can reveal microabscesses and tunnels of parenchymal necrosis, surrounded by inflammatory infiltrates containing abundant eosinophils.
    • Older lesions may be fibrotic.
  • Laparoscopy often reveals multiple gray-white and yellow nodules, 2-20 mm in diameter, and short vermiform cords on the liver surface. Rarely, these nodules may occur throughout the peritoneal cavity and intestine wall.
  • Exploratory laparotomy may reveal identical findings as laparoscopy; flukes are often present in the bile duct or gallbladder.
  • Upper GI endoscopy is associated with the following:
    • Endoscopy can reveal a filling defect in the bile duct.
    • Endoscopic removal of the fluke is possible.
    • Administration of intravenous cholecystokinin can promote egg release, which can be sampled endoscopically for diagnosis.
  • Thoracentesis for pleural effusion may reveal increased eosinophils in pleural fluid.

Histologic Findings

  • Flukes can be found during autopsy or in surgical specimens. Multiple subcapsular cavities (5-10 mm in diameter) may be present, filled with necrotic material from which necrotic tracks radiate and surrounded by inflammatory infiltrates that contain large numbers of eosinophils.
  • Fibrosis may characterize older lesions. Tissues taken from ectopic sites of larval migration may demonstrate granulomatous nodules or small abscesses.

More on Fascioliasis

Overview: Fascioliasis
Differential Diagnoses & Workup: Fascioliasis
Treatment & Medication: Fascioliasis
Follow-up: Fascioliasis
Multimedia: Fascioliasis
References
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Further Reading

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Keywords

fascioliasis, abdominal pain, airway obstruction, ascending cholangitis, biliary colic, cattle, dysphagia, Fasciola gigantica, F gigantica, Fg, Fasciola hepatica, F hepatica, Fh, foreign body sensation, halzoun (Lebanese), hepatomegaly, jaundice, liver fluke, marrerra (Sudanese), pancreatitis, parasitic infection, pharyngitis, sashimi, severe anemia, sheep liver fluke, sheep liver fluke disease, subcutaneous nodules

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Contributor Information and Disclosures

Author

Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine
Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility
Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Consulting; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; Novartis Honoraria Speaking and teaching; sanofi pasteur Grant/research funds Unrestricted research grant; sanofi pasteur  Consulting; sanofi pasteur Honoraria Speaking and teaching; Tap Honoraria Speaking and teaching; Baxter Healthcare Honoraria Speaking and teaching

Medical Editor

Glenn J Fennelly, MD, MPH, Director, Division of Pediatric Infectious Diseases, Jacobi Medical Center; Associate Professor, Department of Pediatrics, Albert Einstein College of Medicine
Glenn J Fennelly, MD, MPH is a member of the following medical societies: Pediatric Infectious Diseases Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Martin Weisse, MD, Program Director, Associate Professor, Department of Pediatrics, West Virginia University
Martin Weisse, MD is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Pediatric Infectious Diseases Society
Disclosure: Nothing to disclose.

CME Editor

Daniel Rauch, MD, FAAP, Director, Pediatric Hospitalist Program, Associate Professor, Department of Pediatrics, New York University School of Medicine
Daniel Rauch, MD, FAAP is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Society of Hospital Medicine
Disclosure: Baxter Honoraria Consulting; Pfizer Honoraria Consulting

Chief Editor

Russell W Steele, MD, Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine
Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association
Disclosure: None None None

 
 
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