Fascioliasis 

  • Author: Robert W Tolan Jr, MD; Chief Editor: Russell W Steele, MD   more...
 
Updated: Jan 9, 2012
 

Background

Fascioliasis is an infection caused by flukes of the class Trematoda, most often characterized by fever, eosinophilia, and abdominal pain, although as many as one half of patients may be asymptomatic. Humans are incidental hosts for Fasciola hepatica (Fh), commonly known as the sheep liver fluke (see the image below), and Fasciola gigantica (Fg); these flukes cause similar illnesses in patients who become infected by ingesting contaminated watercress or water.

Life cycle of Fasciola hepatica. Life cycle of Fasciola hepatica.

The illness occurs worldwide, particularly in regions with intensive sheep or cattle production. Incidence of human infection has apparently increased over the past 20 years.[1]

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Pathophysiology

When pathogen eggs in mammalian stool are deposited in tepid water (22-26°C) miracidia appear, develop, and hatch in 9-14 days. These miracidia then invade many species of freshwater snails, in which they multiply as sporozoites and redia for 4-7 weeks. They leave as free-swimming cercaria that subsequently attach to watercress, water lettuce, mint, parsley, or khat. Free-swimming cercaria may remain suspended in the water and encyst over a few hours.

When humans consume contaminated plants or water, the larvae excyst in the duodenum, migrate through the bowel wall and peritoneal cavity, and penetrate the Glisson capsule, actions that initiate the acute larval, hepatic, and invasive stages of human infection. Larvae sometimes also travel to ectopic body sites. This stage may last 3-4 months, during which the larvae mature and migrate through the liver into the large hepatic and common bile ducts. Mature flukes consume hepatocytes and duct epithelium and reside for years in the hepatic and common bile ducts and occasionally in the gall bladder; this is the chronic adult biliary stage of infection. Adult fluke worms produce eggs about 4 months (with a range of 3-18 mo) after infection; these eggs traverse the sphincter of Oddi and intestine and then continue the cycle of infection. Acute and chronic stages can overlap, particularly in a high-level infection.

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Epidemiology

Frequency

United States

Fascioliasis is exceptionally rare in the United States, especially among children. Travelers to and immigrants from regions of high endemicity are most frequently affected.[2]

International

An estimated 2 million cases of fascioliasis have been reported worldwide, and incidence has apparently increased since 1980.[3]

Fh typically occurs worldwide in temperate regions, except Oceania. Fg causes outbreaks in tropical areas of Southern Asia,[4] Southeast Asia, and Africa. Infection is most prevalent in regions with intensive sheep and cattle production. Miracidia require temperate water to develop and hatch.

Disease prevalence is particularly high in specific regions of Bolivia (65-92%), Ecuador (24-53%), Egypt (2-17%), and Peru (10%).[3] As many as 68% of Bolivian children in hyperendemic areas have evidence of infection, as do 11% of Ethiopians who emigrated to Israel.

In a study of approximately 3000 Egyptian children, 3% were infected. Many were severely anemic. Among individuals who presented with fever of unknown origin to an Egyptian hospital, 4% had Fh. Fh-caused disease that formerly occurred in scattered endemic foci along the Nile river in Egypt has now spread throughout the Nile valley.

Travelers to and immigrants from regions of high endemicity are most frequently affected, as illustrated by a survey of imported cases in the United Kingdom.[5]

A distinct syndrome of fascioliasis, termed halzoun in Lebanon and marrerra in the Sudan, can result from consuming raw livers of infected sheep, goats, or cows. The living fluke adheres to the posterior pharyngeal wall, causing severe pharyngitis and laryngeal edema. Similarly, disease can follow consumption of sashimi of bovine liver served in "Yakitori" bars in Japan, if the liver is contaminated with juvenile worms.

Mortality/Morbidity

Because of the large numbers of people infected worldwide, fascioliasis causes considerable morbidity. In children, fascioliasis is often associated with severe anemia, although it is seldom fatal.

Race

Fascioliasis infection has no apparent racial predilection.

Sex

Approximately 60% of infections occur in males, which may reflect occupational, dietary, or recreational exposures.

Age

Although most reported patients are adults, fascioliasis appears to equally affect people of all ages. Some geographic difference is observed in the age-related incidence of the disease; for example, it is rarely reported in children in Turkey.

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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: Novartis Honoraria Speaking and teaching

Specialty Editor Board

Glenn Fennelly, MD, MPH  Director, Division of Infectious Diseases, Lewis M Fraad Department of Pediatrics, Jacobi Medical Center; Clinical Associate Professor of Pediatrics, Albert Einstein College of Medicine

Glenn Fennelly, MD, MPH is a member of the following medical societies: Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

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.

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

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: Nothing to disclose.

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Life cycle of Fasciola hepatica.
 
 
 
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