An 80–years–old Korean man with a history of liver fluke infection treated 26 years ago presented with 2 weeks history of fever and abdominal pain Pt had a non diagnostic CT scan of abdomen 2 weeks prior to this hospitalization. During the hospitalization the patient was treated empirically with intravenous piperacillin/tazobactam. Fever persisted, and a repeat CT scan of the abdomen revealed interval development of multiple liver abscesses. This was confirmed on MRI and characterized by thick walled heterogeneous hepatic masses. They were not amenable to percutaneous drainage. Because of continued abdominal pain and fever, antibiotic coverage was broadened to imipenem. Initial stool studies for ova and parasite were negative, however repeat studies revealed Clonorchis sinenses. Pt was successfully treated with praziquantel 1800 mg po every 8 hours for 3 doses. A follow up repeat CT abdomen revealed complete resolution of the hepatic abscesses.
Clonorchis sinenses is a widespread trematode parasite found in Southeast Asia that infects the biliary passage in humans. Humans are infected by eating raw or partially cooked freshwater fish or dried, salted, or pickled fish infected with the metacercariae stage of the worm. The ingested cyst is digested in the duodenum and an immature larva is released. The larva enters the biliary duct, where it develops and matures into an adult worm. The adult worm feeds on the mucosal secretions and begins to lay fully embryonated operculated eggs, which are excreted in the feces. The worm then progesses through a complex life cycle until it is encysted in the scale or muscle of a fish, waiting to be ingested by an unsuspecting human. Majority of people infected with Clonorchis sinensis are asymptomatic, however during acute infection or chronic infections, symptoms may occur. Acutely patients can present with abdominal pain, fever, myalgias, athralgias, urticaria, malaise and anorexia. Chronic symptoms and complications include cholangitis, cholangiocarcinoma and cholangiohepatitis. Patients with very severe disease may also develop pyogenic hepatic abscesses, recurrent cholangitis, obstructive jaundice and gallstones. The drug of choice for treatment is praziquantel. The fascinating aspect of this case is that this may have been a case of chronic quiescent infection extending over 26 years, then becoming an acute febrile illness with pyogenic liver abscess leading to diagnosis and treatment.
This case underscores the importance of diagnosing chronic liver fluke infestation. This condition can lead to recurrent pyogenic liver abscess, cholangitis, obstructive jaundice and cholangiocarcinoma. Recognizing the patient population at risk for chronic infestation is essential. Patients at risk who presented with liver abscess, obstructive jaundice or cholangitis without any other cause, must be evaluated for chronic infestation by Clonorchis sinenses or other liver flukes.