eMedicine Specialties > Pediatrics: General Medicine > Parasitology

Fascioliasis: Treatment & Medication

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

Treatment

Medical Care

  • Bithionol continues to be the drug of choice (DOC) in fascioliasis,4 although it is available in the United States only under an investigational protocol from the Centers for Disease Control and Prevention (CDC).
  • A new fasciolicide, triclabendazole, cured 31 of 40 infected Egyptian children with 1 day of therapy.5 A second day of treatment cured the remaining 9 children. Further studies of the safety and efficacy of triclabendazole are pending. This agent is not currently available in the United States.
  • Praziquantel is safe, although it may not be effective against Fasciola hepatica (Fh). Praziquantel administration is recommended only if bithionol or triclabendazole is unavailable.
  • Medications previously used but no longer recommended because of toxicity or unproven efficacy include emetine, dehydroemetine, chloroquine, albendazole, and mebendazole.
  • Fascioliasis complicated by ascending cholangitis requires treatment with appropriate antibacterial antibiotics.

Surgical Care

  • Patients with ascending cholangitis may require surgery.
  • Although one study promoted endoscopic flushing of the gallbladder with povidone-iodine for patients in whom oral fasciolicides proved ineffective,6 this technique has had no further validation.

Consultations

  • An infectious diseases specialist and gastroenterologist should be consulted in patients with suspected fascioliasis.
  • A surgeon may be consulted. 
  • Patients with an ectopic infection or a visceral larva migrans–like illness may require additional consultations for specific manifestations of the condition.
  • Consult the CDC Drug Service (404-639-3670) to obtain bithionol.

Medication

New fasciolicides are being used in small numbers of children with encouraging results and minimal toxicities. The best studied agent, bithionol, is available from the CDC Drug Service (see CDC Drug Service: Bithionol). Despite limited data on their use and safety in US children, these new fasciolicides are the DOC because of the poorer efficacy and greater toxicities of older, more familiar agents. The Medical Letter (2000 Edition) and many experts recommend triclabendazole, a veterinary drug not approved for human use in the United States, as the DOC.7

Anthelmintics

Parasite biochemical pathways are different from the human host; thus, toxicity is directed to the parasite, egg, or larvae. The mechanism of action varies within the drug class. Antiparasitic actions may include the following:

  • Inhibition of microtubules causes irreversible block of glucose uptake
  • Tubulin polymerization inhibition
  • Depolarizing neuromuscular blockade
  • Cholinesterase inhibition
  • Increased cell membrane permeability, resulting in intracellular calcium loss
  • Vacuolization of the schistosome tegument
  • Increased cell membrane permeability to chloride ions via chloride channels alteration

Bithionol (Lorothidol, Bitin)

Inhibits oxidative phosphorylation in the parasite, leading to blockade of ATP synthesis. DOC because of its safety and effectiveness for Fh and Fg. Most supporting data are from developing countries. It is a phenolic compound structurally related to hexachlorophene. Available from the CDC.

Adult

30-50 mg/kg on alternate days PO divided tid for 5-15 treatment days; some patients may require repeat treatment courses

Pediatric

Administer as in adults

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

May cause anorexia, nausea, vomiting, diarrhea, abdominal pain, hypotension, dizziness, headache, photosensitivity, or pruritus


Triclabendazole (Fasinex)

Recent reports suggest this veterinary drug is safe, well tolerated, and effective in adults and children. It remains the second DOC until further data accumulate, supporting its preferential use. Binds selectively to fluke tubulin, disrupting microtubule formation and function. As of 2009, is unavailable in the United States.

Adult

10-20 mg/kg/d PO pc divided q12-24h for 1 dose

Pediatric

Administer as in adults

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

May cause transient dizziness and headache


Praziquantel (Biltricide)

Although generally safe and effective for other trematode infections, praziquantel appears much less efficacious against Fh and Fg. Because it is readily available and more familiar than triclabendazole (Fasinex), it is the third DOC. Reserve use for situations in which the first and second DOC are unobtainable. Praziquantel increases permeability of the trematode tegument to calcium, causing contraction of the parasite muscle.

Adult

25 mg/kg/dose PO q8h for 1 d

Pediatric

Administer as in adults

Hydantoins may reduce serum praziquantel concentrations, possibly leading to treatment failures

Documented hypersensitivity; ocular cysticercosis

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Destruction of parasite within eyes can cause irreparable lesions (ocular cysticercosis should not be treated with praziquantel); caution while driving or performing other tasks requiring alertness on day of and day following treatment; minimal increases in liver enzyme levels reported; when fluke infection associated with cerebral cysticercosis, hospitalize patient for duration of treatment

Corticosteroids

Corticosteroids may ameliorate the treatment course in children with severe acute phase infection.


Prednisolone (Pediapred, Delta-Cortef, Econopred)

A short course that is given for 2 d preceding fasciolicidal therapy in children with severe acute phase infection is reported anecdotally to ameliorate the course of the illness and to decrease fever, pain, pruritus, and toxicity.

Adult

2 mg/kg/d PO divided q12-24h; not to exceed 60 mg/d

Pediatric

Administer as in adults

Decreases effects of salicylates and toxoids (for immunizations); phenytoin, carbamazepine, barbiturates, and rifampin decrease effects

Documented hypersensitivity; viral, fungal or tubercular skin lesions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in hyperthyroidism, osteoporosis, cirrhosis, nonspecific ulcerative colitis, peptic ulcer, diabetes, and myasthenia gravis; mood changes, seizures, hyperglycemia, diarrhea, nausea, abdominal distension, and GI bleeding are unusual with short courses of therapy

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.