eMedicine Specialties > Pediatrics: General Medicine > Parasitology

Fascioliasis

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

Introduction

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, and Fasciola gigantica (Fg); these flukes cause similar illnesses in patients who become infected by ingesting contaminated watercress or water. 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.

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.

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.

International

An estimated 2 million cases of fascioliasis have been reported worldwide, and incidence has apparently increased since 1980.1

Fh typically occurs worldwide in temperate regions, except Oceania. Fg causes outbreaks in tropical areas of Southern Asia, 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%).1 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.

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.

Clinical

History

  • Approximately 50% of infections are subclinical.
  • The most common symptoms are fever, hepatomegaly, and abdominal pain.
  • Symptoms of fascioliasis (derived from a large series, primarily involving adult patients) include the following:
    • Abdominal pain, generalized or involving the right hypochondrium or right upper quadrant - 65%
    • Intermittent fever - 60%
    • Malaise and weight loss - 35%
    • Hives - 20%
    • Cough, shortness of breath, and/or chest pain - 15%
    • Change in bowel habits, nausea, anorexia, vomiting, diarrhea, and/or jaundice - less frequent
  • Generally, patients with chronic infection are asymptomatic, with the following exceptions:
    • Symptoms of biliary colic may be present because of ascending cholangitis (eg, fever, jaundice, abdominal pain).
    • Symptoms of pancreatitis occur, particularly in children.
  • Fever of unknown origin or without an obvious source may occur, with or without eosinophilia.
  • Fever and abdominal pain occur more frequently in children than in adults.
  • Sweating, dizziness, and hives may occur.
  • Patients may present with painful or pruritic subcutaneous nodules, although this condition is rare.
  • Halzoun/marrerra manifests with severe pharyngitis, dysphagia, foreign body sensation, and/or airway obstruction.

Physical

  • Physical examination typically reveals no specific signs of infection.
  • Abdominal tenderness may be general or may be localized to the right hypochondrium, right upper quadrant, gall bladder, mid epigastrium, or left upper quadrant.
  • Tender or nontender hepatomegaly may occur.
  • Patients often have fever, pallor, and/or evidence of weight loss.
  • Less often, patients present with urticaria, wheezing, subcutaneous nodules as large as 6 cm in diameter, or other manifestations of ectopic larval migration to the skin, lungs, heart, brain, eye, intestine, and genitourinary tract.
  • Patients with halzoun/marrerra may have severe pharyngitis and/or laryngeal edema.

Causes

  • The major risk factor is consumption of contaminated water plants or water. Many patients report consuming watercress.2
  • Consumption of raw liver from infected sheep, goats, or cows is also a reported cause.

More on Fascioliasis

Overview: Fascioliasis
Differential Diagnoses & Workup: Fascioliasis
Treatment & Medication: Fascioliasis
Follow-up: Fascioliasis
Multimedia: Fascioliasis
References
[ CLOSE WINDOW ]

References

  1. Haseeb AN, el-Shazly AM, Arafa MA, Morsy AT. A review on fascioliasis in Egypt. J Egypt Soc Parasitol. Apr 2002;32(1):317-54. [Medline].

  2. Dreyfuss G, Vignoles P, Rondelaud D. Fasciola hepatica: epidemiological surveillance of natural watercress beds in central France. Parasitol Res. Mar 2005;95(4):278-82. [Medline].

  3. el-Shabrawi M, el-Karaksy H, Okasha S, el-Hennawy A. Human fascioliasis: clinical features and diagnostic difficulties in Egyptian children. J Trop Pediatr. Jun 1997;43(3):162-6. [Medline].

  4. Bacq Y, Besnier JM, Duong TH, et al. Successful treatment of acute fascioliasis with bithionol. Hepatology. Dec 1991;14(6):1066-9. [Medline].

  5. el-Karaksy H, Hassanein B, Okasha S, Behairy B, Gadallah I. Human fascioliasis in Egyptian children: successful treatment with triclabendazole. J Trop Pediatr. Jun 1999;45(3):135-8. [Medline].

  6. Dowidar N, El Sayad M, Osman M, Salem A. Endoscopic therapy of fascioliasis resistant to oral therapy. Gastrointest Endosc. Sep 1999;50(3):345-51. [Medline].

  7. Apt W, Aguilera X, Vega F, et al. Treatment of human chronic fascioliasis with triclabendazole: drug efficacy and serologic response. Am J Trop Med Hyg. Jun 1995;52(6):532-5. [Medline].

  8. Arauco R, Zetola NM, Calderon F, Seas C. Human fascioliasis: a case of hyperinfection and an update for clinicians. Foodborne Pathog Dis. 2007;4(3):305-12. [Medline].

  9. Arjona R, Riancho JA, Aguado JM, Salesa R, Gonzalez-Macias J. Fascioliasis in developed countries: a review of classic and aberrant forms of the disease. Medicine (Baltimore). Jan 1995;74(1):13-23. [Medline].

  10. Ashrafi K, Valero MA, Massoud J, et al. Plant-borne human contamination by fascioliasis. Am J Trop Med Hyg. Aug 2006;75(2):295-302. [Medline].

  11. Bunnag D, Bunnag T, Goldsmith R. Liver fluke infections. In: Hunter's Tropical Medicine. 1991:818-27.

  12. Cheng AC, Zakhidov BO, Babadjonova LJ, Rogers NK, McCollum CJ, Hillyer GV. A 6-year-old boy with facial swelling and monocular blindness. Clin Infect Dis. Nov 1 2007;45(9):1207, 1238-9. [Medline].

  13. Clark BM, Lloyd BA, Christopher GW, Foody WF. A young man from Peru with fever and abdominal pain. Clin Infect Dis. Mar 15 2005;40(6):842-3, 879-80. [Medline].

  14. Diaz E, Mondragon J, Ramirez E, Bernal R. Epidemiology and control of intestinal parasites with nitazoxanide in children in Mexico. Am J Trop Med Hyg. Apr 2003;68(4):384-5. [Medline]. [Full Text].

  15. Dreyfuss G, Rondelaud D. Biodiversity of flukes. Parasite. Sep 2008;15(3):282-5. [Medline].

  16. Espinoza JR, Maco V, Marcos L, Saez S, Neyra V, Terashima A. Evaluation of Fas2-ELISA for the serological detection of Fasciola hepatica infection in humans. Am J Trop Med Hyg. May 2007;76(5):977-82. [Medline].

  17. Fox LM, Saravolatz LD. Nitazoxanide: a new thiazolide antiparasitic agent. Clin Infect Dis. Apr 15 2005;40(8):1173-80. [Medline].

  18. Garcia HH, Moro PL, Schantz PM. Zoonotic helminth infections of humans: echinococcosis, cysticercosis and fascioliasis. Curr Opin Infect Dis. Oct 2007;20(5):489-94. [Medline].

  19. Graham CS, Brodie SB, Weller PF. Imported Fasciola hepatica Infection in the United States and Treatment with Triclabendazole. Clin Infect Dis. Jul 1 2001;33(1):1-5. [Medline].

  20. Hien TT, Truong NT, Minh NH, et al. A randomized controlled pilot study of artesunate versus triclabendazole for human fascioliasis in central Vietnam. Am J Trop Med Hyg. Mar 2008;78(3):388-92. [Medline].

  21. Kabaalioglu A, Apaydin A, Sindel T, Luleci E. US-guided gallbladder aspiration: a new diagnostic method for biliary fascioliasis. Eur Radiol. 1999;9(5):880-2. [Medline].

  22. Kaewpitoon N, Kaewpitoon SJ, Pengsaa P, Pilasri C. Knowledge, attitude and practice related to liver fluke infection in northeast Thailand. World J Gastroenterol. Mar 28 2007;13(12):1837-40. [Medline].

  23. Katz M, Despommier DD, Gwadz RW. Fasciola hepatica. In: Parasitic Diseases. 1989:112-6.

  24. Keiser J, Utzinger J. Chemotherapy for major food-borne trematodes: a review. Expert Opin Pharmacother. Aug 2004;5(8):1711-26. [Medline].

  25. Le TH, De NV, Agatsuma T, Blair D, Vercruysse J, Dorny P. Molecular confirmation that Fasciola gigantica can undertake aberrant migrations in human hosts. J Clin Microbiol. Feb 2007;45(2):648-50. [Medline].

  26. Lim JH, Kim SY, Park CM. Parasitic diseases of the biliary tract. AJR Am J Roentgenol. Jun 2007;188(6):1596-603. [Medline].

  27. Lim JH, Mairiang E, Ahn GH. Biliary parasitic diseases including clonorchiasis, opisthorchiasis and fascioliasis. Abdom Imaging. Mar-Apr 2008;33(2):157-65. [Medline].

  28. Liu LX, Harinasuta KT. Liver and intestinal flukes. Gastroenterol Clin North Am. Sep 1996;25(3):627-36. [Medline].

  29. Lopez-Velez R, Dominguez-Castellano A, Garron C. Successful treatment of human fascioliasis with triclabendazole. Eur J Clin Microbiol Infect Dis. Jul 1999;18(7):525-6. [Medline].

  30. MacLean JD, Cross J, Mahanty S. Liver, lung, and intestinal fluke infections. In: Tropical Infectious Diseases: Principles, Pathogens, & Practice. 1999:1039-57.

  31. Makay O, Gurcu B, Caliskan C, Nart D, Tuncyurek M, Korkut M. Ectopic fascioliasis mimicking a colon tumor. World J Gastroenterol. May 14 2007;13(18):2633-5. [Medline].

  32. Mannstadt M, Sing A, Leitritz L, Brenner-Maucher K, Bogner J. Conservative management of biliary obstruction due to Fasciola hepatica. Clin Infect Dis. Nov 2000;31(5):1301-3. [Medline].

  33. Mansour-Ghanaei F, Shafaghi A, Fallah MS. The effect of metronidazole in treating human fascioliasis. Med Sci Monit. Oct 2003;9(10):PI127-30. [Medline].

  34. Marcos L, Maco V, Samalvides F. Risk factors for Fasciola hepatica infection in children: a case-control study. Trans R Soc Trop Med Hyg. Feb 2006;100(2):158-66. [Medline].

  35. Marcos LA, Tagle M, Terashima A, et al. Natural history, clinicoradiologic correlates, and response to triclabendazole in acute massive fascioliasis. Am J Trop Med Hyg. Feb 2008;78(2):222-7. [Medline].

  36. Marcos LA, Terashima A, Gotuzzo E. Update on hepatobiliary flukes: fascioliasis, opisthorchiasis and clonorchiasis. Curr Opin Infect Dis. Oct 2008;21(5):523-30. [Medline].

  37. McManus DP, Dalton JP. Vaccines against the zoonotic trematodes Schistosoma japonicum, Fasciola hepatica and Fasciola gigantica. Parasitology. 2006;133 Suppl:S43-61. [Medline].

  38. Nawa Y, Hatz C, Blum J. Sushi delights and parasites: the risk of fishborne and foodborne parasitic zoonoses in Asia. Clin Infect Dis. Nov 1 2005;41(9):1297-303. [Medline].

  39. Noyer CM, Coyle CM, Werner C, et al. Hypereosinophilia and liver mass in an immigrant. Am J Trop Med Hyg. Jun 2002;66(6):774-6. [Medline]. [Full Text].

  40. Pearson RD. Nitazoxanide As Treatment of Intestinal Parasites in Children. Curr Infect Dis Rep. Feb 2004;6(1):25-26. [Medline].

  41. Pearson RD, Weller PF, Guerrant. Chemotherapy of parasitic diseases. In: Tropical Infectious Diseases: Principles, Pathogens, & Practice. 1999:215-37.

  42. Price TA, Tuazon CU, Simon GL. Fascioliasis: case reports and review. Clin Infect Dis. Sep 1993;17(3):426-30. [Medline].

  43. Rana SS, Bhasin DK, Nanda M, Singh K. Parasitic infestations of the biliary tract. Curr Gastroenterol Rep. Apr 2007;9(2):156-64. [Medline].

  44. Richter J, Knipper M, Gobels K. Fascioliasis. Curr Treatment Options Infect Dis. 2002;4:313-7.

  45. Robertson J, Shilkofski N. Drug doses. In: The Harriet Lane Handbook: A Manual for Pediatric House Officers. Philadelphia, Pa: Mosby; 2005:679-1009.

  46. Sripa B, Kaewkes S, Sithithaworn P, Mairiang E, Laha T, Smout M. Liver fluke induces cholangiocarcinoma. PLoS Med. Jul 2007;4(7):e201. [Medline].

  47. Tantrawatpan C, Maleewong W, Wongkham C, et al. Serodiagnosis of human fascioliasis by a cystatin capture enzyme-linked immunosorbent assay with recombinant Fasciola gigantica cathepsin L antigen. Am J Trop Med Hyg. Jan 2005;72(1):82-6. [Medline]. [Full Text].

  48. Turner JA. Trematodes. In: Textbook of Pediatric Infectious Diseases. 2004:2817-25.

  49. Valero MA, Santana M, Morales M, et al. Risk of gallstone disease in advanced chronic phase of fascioliasis: an experimental study in a rat model. J Infect Dis. Sep 1 2003;188(5):787-93. [Medline].

  50. Walker SM, McKinstry B, Boray JC, et al. Response of two isolates of Fasciola hepatica to treatment with triclabendazole in vivo and in vitro. Parasitol Res. Dec 2004;94(6):427-38. [Medline].

  51. Xuan le T, Hung NT, Waikagul J. Cutaneous fascioliasis: a case report in Vietnam. Am J Trop Med Hyg. May 2005;72(5):508-9. [Medline]. [Full Text].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

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

[ CLOSE WINDOW ]

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

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.