Painless Jaundice Caused by Clonorchis sinensis Infection: A Case Report.

A man with only yellowing of the skin and eye sclera was diagnosed with clonorchiasis, which rarely manifested jaundice as the initial symptom. However, because of a lack of evidence for a diagnostic gold standard, the time until definitive diagnosis was more than a week. The diagnostic process relied on inquiring about the patient's history, including the place of residence, dietary habits, and symptoms, as well as on serological findings, an imaging examination, and pathological findings. MRCP and CT results showed mild dilatation of intrahepatic ducts and increased periductal echogenicity. The eggs were ultimately found in stool by water sedimentation method after the negative report through direct smear. DNA sequencing of PCR production of the eggs demonstrated 98-100% homology with ITS2 of Clonorchis sinensis. After anti-parasite medical treatment, the patient's symptoms were gradually relieved. Throughout the diagnostic procedure, besides routine examinations, the sedimentation method or concentration method could be used as a sensitive way for both light and heavy C. sinensis infection in the definite diagnosis.

Rare cause of jaundice in a post liver transplant patient.

A hepatitis B virus carrier suffering from acute flare of chronic hepatitis B infection underwent deceased-donor liver transplantation. He was put on the immunosuppressive agent tacrolimus. On routine follow-up, he was found to have abnormal liver function. Computed tomography scan of the abdomen did not show any dilatation of the biliary system. Liver biopsy showed scattered microabscesses, and a microgranuloma was detected. Endoscopic retrograde cholangiography was performed and a biliary anastomotic stricture (BAS) was noted. In addition, the Chinese liver fluke, Clonorchis sinensis, was discovered. Balloon dilatation and stenting were performed. The patient was given a course of praziquantel. His liver function improved and normalized. We present the case of a liver transplant recipient with cholangitis caused by C. sinensis infestation and infection and biliary obstruction resulting from BAS.

Hepatobiliary complications of alveolar echinococcosis: A long-term follow-up study.

AIM: To determine the long-term hepatobiliary complications of alveolar echinococcosis (AE) and treatment options using interventional methods. METHODS: Included in the study were 35 patients with AE enrolled in the Echinococcus Multilocularis Data Bank of the University Hospital of Ulm. Patients underwent endoscopic intervention for treatment of hepatobiliary complications between 1979 and 2012. Patients' epidemiologic data, clinical symptoms, and indications for the intervention, the type of intervention and any additional procedures, hepatic laboratory parameters (pre- and post-intervention), medication and surgical treatment (pre- and post-intervention), as well as complications associated with the intervention and patients' subsequent clinical courses were analyzed. In order to compare patients with AE with and without history of intervention, data from an additional 322 patients with AE who had not experienced hepatobiliary complications and had not undergone endoscopic intervention were retrieved and analyzed. RESULTS: Included in the study were 22 male and 13 female patients whose average age at first diagnosis was 48.1 years and 52.7 years at the time of intervention. The average time elapsed between first diagnosis and onset of hepatobiliary complications was 3.7 years. The most common symptoms were jaundice, abdominal pains, and weight loss. The number of interventions per patient ranged from one to ten. Endoscopic retrograde cholangiopancreatography (ERCP) was most frequently performed in combination with stent placement (82.9%), followed by percutaneous transhepatic cholangiodrainage (31.4%) and ERCP without stent placement (22.9%). In 14.3% of cases, magnetic resonance cholangiopancreatography was performed. A total of eight patients received a biliary stent. A comparison of biochemical hepatic function parameters at first diagnosis between patients who had or had not undergone intervention revealed that these were significantly elevated in six patients who had undergone intervention. Complications (cholangitis, pancreatitis) occurred in six patients during and in 12 patients following the intervention. The average survival following onset of hepatobiliary complications was 8.8 years. CONCLUSION: Hepatobiliary complications occur in about 10% of patients. A significant increase in hepatic transaminase concentrations facilitates the diagnosis. Interventional methods represent viable management options.

[A man in his thirties with icterus and itching]. / En mann i 30-årene med icterus og kløe.

BACKGROUND: We present a patient from South-East Asia who has been living in Norway for five years. He was referred to our department with jaundice caused by opisthorchiasis/clonorchiasis. This reason for jaundice is highly unusual in Europe. Worldwide, however about 35,000,000 people are infected. CASE PRESENTATION: A male in his thirties, originally from South-East Asia, experienced diffuse itching for five weeks and painless jaundice for two weeks. Blood samples showed increasing cholestasis. Abdominal ultrasound, MRCP and computed tomography showed no sign of bile duct obstruction or liver tumour. Serological tests and liver biopsy revealed no infectious or autoimmune liver disease. ERCP showed normal bile ducts, but large quantities of typical hookworms in the duodenum. Stool samples showed at least one egg typical of Opisthorchis/Clonorchis and a large quantity of hookworm eggs. We interpreted these findings as parasite-induced obstruction of some of the small bile ducts. The patient recovered completely after treatment with Praziquantel. INTERPRETATION: Jaundice due to bile duct obstruction by opisthorchiasis/clonorchiasis is a well-known problem in South-East Asia. It may become more common in Europe as well as a result of increasing migration. Treatment with Praziquantel is simple and effective.

A cross-sectional study for algorithm in diagnosing simple uncomplicated malaria in children in health facilities without laboratory backup in Nigeria.

AIMS AND OBJECTIVES: The objective of this study was to determine an algorithm for malaria diagnosis using presenting signs and symptoms of children (aged 0-13 years) with uncomplicated malaria in Gwagwalada Area Council of Abuja, Nigeria. MATERIALS AND METHODS: A validated questionnaire was used to obtain relevant data from 400 children diagnosed presumptively of simple malaria by clinicians and 400 other children of similar sex and age considered as not having malaria. Giemsa-stained thick blood films were used to determine parasitaemia. Data obtained was analysed using Epi-Info version 3.3.2. RESULTS: Thirty-eight per cent of children with presumptive diagnosis of malaria had parasitaemia. Fever, rigor, vomiting, jaundice, pallor and spleen enlargement had significant statistical relationship with parasitaemia on bivariate analysis, but only fever (p=0.00), rigor (p=0.00), vomiting (p=0.00), and pallor (p=0.00) maintained the relationship when subjected to logistic regression analysis. But these symptoms individually had low sensitivity and/or specificity. Candidate algorithms (combinations of symptoms) were then successively subjected to bivariate, logistic and validity analyses. Fever with vomiting gave the highest sensitivity (56.2%), specificity (76.4%) and PPV (60.0%) and were therefore adopted as the algorithm of choice. CONCLUSION AND RECOMMENDATIONS: Children presenting with fever and vomiting without any other obvious cause in health facilities without laboratory support in the research area should receive antimalarial treatment, to help reduce the malaria scourge. This algorithm should be field-tested and if found reliable should be adopted to ease the problem of malaria diagnosis in peripheral health facilities.

Fasciola hepatica as a cause of jaundice after chewing khat: a case report.

Fasciola hepatica is a worldwide distributed zoonotic trematode incidentally infecting humans. Although often symptomatic, fascioliasis can cause a wide spectrum of disease. The diagnosis can be established by stool examination detecting ova of the parasite, although serological testing has a higher sensitivity and specificity in the acute phase of disease. This case presents a 24-year-old Somalian man admitted with jaundice and abdominal discomfort due to fascioliasis after chewing khat. The patient was treated successfully with a single dose of triclabendazole.

Abnormal findings on dipstick urinalysis of out-patients with malaria in Abakaliki, Nigeria.

BACKGROUND & OBJECTIVES: Malaria, one of the major health challenges of the tropics affecting about 500 million people, particularly the children and pregnant women have been associated with changes in urine compositions. The present study was undertaken to document the urinary abnormalities in malaria patients based on malaria species and the level of malaria parasitaemia. METHODS: Febrile patients (n = 365) with positive Giemsa - stained blood films for malaria recruited from Outpatient Department of Ebonyi State University Teaching Hospital, Abakaliki participated in the study. Patients were classified into two categories (+ and ++) based on parasite density. Apparently healthy individuals (n = 81), without malaria parasite on both thick and thin films of comparable age and gender acted as control group. Urine sample (10 ml) was collected from each participant and analysed using standard laboratory methods and techniques. RESULTS: Seventy - four (20.3%) of the patients had Plasmodium falciparum malaria. Although all the urine parameters were higher in the malarial patients in comparison to the control, only bilirubinuria and urobilinogenuria were statistically significant (p <0.05). Also, bilirubinuria, urobilinogenuria, haematuria and proteinuria were significantly (p < 0.05) higher in P. falciparum infection than in infections with other malaria species, but only in P. falciparum infection, bilirubinuria and urobilinogenuria were significantly (p < 0.05) higher at higher parasitaemia. CONCLUSION: Even though positive blood film for malaria parasite remains the gold standard for the diagnosis of malaria, urinary abnormalities, such as bilirubinuria, urobilinogenuria, proteinuria and haematuria may aid in identifying patients with severe malaria parasitaemia, especially the falciparum malaria.

A case of transplacental transmission of Theileria equi in a foal in Trinidad.

Equine piroplasmosis due to Theileria equi and Babesia caballi is endemic in Trinidad. A case of equine piroplasmosis due to T. equi was diagnosed in a thoroughbred foal at 10h post-partum. A high parasitaemia (63%) of piroplasms was observed in a Wright-Giemsa(®) stained thin blood smear from the foal. In addition, the 18S rRNA gene for Babesia/Theileria was amplified from DNA extracted from the blood of the foal and the mare. Amplified products were subjected to a reverse line blot hybridization assay (RLB), which confirmed the presence of T. equi DNA in the foal. The mare was negative by RLB but was positive for T. equi using a nested PCR and sequence analysis. In areas where equine piroplasmosis is endemic, severe jaundice in a post-partum foal may be easily misdiagnosed as neonatal isoerythrolysis. Foals with post-partum jaundice should be screened for equine piroplasmosis, which may be confirmed using molecular methods if available.

Ursodeoxycholic acid and artesunate in the treatment of severe falciparum malaria patients with jaundice.

BACKGROUND AND AIMS: Plasmodium falciparum (PF) infection can lead to severe complications. Ursodeoxycholic acid (UDCA) is increasingly used for the treatment of cholestatic liver diseases. The present study aims to determine the effects of combined UDCA and artesunate compared to placebo and artesunate on the improvement of liver tests in severe PF jaundiced patients. METHODS: All severe PF jaundiced patients, aged > or = 15 years and diagnosed as having severe malaria according to WHO 2000 criteria, were enrolled. Patients with evidence of biliary obstruction, other cholestatic liver diseases and those who were pregnant were excluded. Patients were randomized to receive either oral UDCA or placebo for 2 weeks in additional to artesunate. All patients were admitted for at least 14 days to monitor the result of the treatment. RESULTS: Seventy-four severe PF malaria patients with jaundice were enrolled. Both groups had similar demographic and laboratory tests, with the exception being more males in the UDCA group than in the placebo group (P = 0.04). The median of percentage change of total bilirubin and aminotransferase levels at the end of weeks 1, 2, 3 and 4 showed no difference between the two groups. Only the median of percentage change of alkaline phosphatase at the end of week one compared with the baseline values showed less increment in the UDCA group than in the placebo group (P = 0.04). No serious adverse events were seen during the 4 weeks of follow up. CONCLUSIONS: In severe PF malaria patients with jaundice, combined therapy with UDCA and artesunate is safe, but does not significantly improve liver tests compared to placebo and artesunate.

Jaundice with hepatic dysfunction in P. falciparum malaria.

UNLABELLED: To evaluate the frequency and severity of jaundice with hepatic dysfunction in Plasmodium (P.) falciparum malaria in adult patients admitted in the hospital. STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: The Infectious Diseases Unit and Medical Wards at Rashid Hospital, Dubai, United Arab Emirates, from January 2005 to December 2007. METHODOLOGY: This study included 105 adult patients who fulfilled the inclusion criteria. The diagnosis of P.falciparum malaria was confirmed by examination of thin and thick film stained with Leishman's stain. Other laboratory investigations included full blood count, liver function tests, blood urea, electrolytes, serum creatinine, reticulocyte count, blood sugar, viral hepatitis serology and coagulation profile. Patient with significant clinical/biochemical hepatic dysfunction were also subjected to ultrasonic examination of abdomen. RESULTS: On clinical examination, 23% patients were found to be jaundiced. Serum alanine amino transferase (ALT) level was above the reference range in 67.6%, but in only 11.4%, ALT was more than 3 times of normal level. Serum bilirubin was found to be higher than normal level in 81%, however, only in 23% of the patients, Serum bilirubin was >3mg/dl. Predominantly conjugated hyperbilirubinemia was observed in patients with high ALT. There was no significant change in serum albumin and prothrombin time. In comparison to normal bilirubin level, the patient with bilirubin >3mg/dl had high frequency of raised ALT 87.5% vs. 45% (p<.0001), thrombocytopenia 91.6% vs. 65% (p<.01), anemia 70.8% vs. 25% (p<.05) and renal impairment 50% vs. 20% (p>.05). Overall, 5 (4.7%) patients died and mortality rate was high among the patients with bilirubin level>3mg/dl than with normal bilirubin level 4 (16.6%) vs 1 (5%). CONCLUSION: Hepatic dysfunction in acute P.falciparum malaria ranged from mild elevation of liver enzymes to acute hepatitis (ALT>10 times of normal level). It indicates severe illness with high frequency of complication and mortality rates.

Malarial hepatopathy in falciparum malaria.

OBJECTIVE: To evaluate the clinical, biochemical and sonographic changes in patients with falciparum malaria and jaundice. STUDY DESIGN: A case series. PLACE AND DURATION OF STUDY: This study was conducted at Medical Unit-I (Ward 5), Jinnah Postgraduate Medical Centre, Karachi, from January 2006 to November 2007. METHODOLOGY: A total of 62 adult patients, regardless of age and gender, with peripheral blood film evidence of falciparum malaria, who had jaundice, were included. Any patient with evidence of infection with Plasmodium vivax or other causes of liver disease (e.g. viral hepatitis, cirrhosis, portal hypertension, amoebic liver abscess, unexplained hepatomegaly, ascites, history of alcoholism, taking hepatotoxic drugs, past history of jaundice) was excluded on the basis of history, relevant clinical examination and investigations. RESULTS: Age of the patients ranged from 13-48 years (mean 26.04+/-8.33). All patients were febrile and icteric, with pallor in 67.7%, hepatomegaly in 30.6%, splenomegaly in 70.9% and impaired consciousness in 20%. Serum bilirubin levels ranged from 3 to 24 mg%. Thirty two (51.6%) had serum bilirubin 3-6 mg%, 20 (32.2%) had 6-10 mg% and 10 (16.1%) had >10 mg%. ALT levels ranged from 20-870 IU/L and AST levels 24-1210 IU/L respectively. INR ranged from 1-1.3. Twenty eight patients (45%) had predominantly conjugated or mixed hyperbilirubinemia and serum transaminases were more than three times normal. Ultrasonography revealed hepatomegaly with decreased echogenicity in 22 (35.4%), splenomegaly in 48 (77.4%) and both hepatomegaly and splenomegaly in 16 (25.8%). Gallbladder wall thickness was increased in 5 (8.06%) patients. There was no evidence of biliary dilatation. CONCLUSION: A significant percentage of patients having falciparum malaria with jaundice fulfill the criteria for malarial hepatopathy. It should be considered in patients presenting with acute febrile illness with jaundice so that specific treatment can be given.

Hepatic changes in fatal malaria: an emerging problem.

Over the last few years there has been a rise in the incidence of fatal malaria in urban areas of India, and this worrying trend is a major cause of concern for the national health authorities. The spectrum of histopathological changes that occur in the livers of Indian subjects with fatal malaria has recently been investigated, in a retrospective autopsy-based study. This investigation involved the 151 fatal cases of malaria seen at a tertiary-care hospital in Mumbai between January 2001 and December 2007. The diagnosis of malaria was made on the basis of the examination of a smear of peripheral blood (81 cases) or a histopathological examination (70 cases). For each subject of the present study, at least two blocks were prepared, using routine histological methods, from a liver sample collected at autopsy. The sections produced from these blocks were stained with various compounds, including Prussian Blue (which was used to distinguish malarial pigment from non-malarial). The pattern of liver necrosis seen in the malaria cases was compared with that seen in 11 cases of acute viral hepatitis, and with the liver histology seen in 50 control subjects, who had died of causes other than malaria or liver disease. The most common clinical presentation of the subjects who died of malaria was fever (85%), followed by jaundice (68%). The presence of jaundice often led to an initial misdiagnosis of acute viral hepatitis. In the livers of the fatal malaria cases, Kupffer-cell hyperplasia and the retention of haemozoin pigment were the two most common histological features. Necrosis was seen in 63 (41%) of these cases, with predominant centrilobular haemorrhagic necrosis in 16 (10%). The inflammation in the sections of liver from the malaria cases with hepatic necrosis was sparse compared with that in the corresponding sections from patients with acute viral hepatitis, although mixed portal inflammation was frequently noted in the malaria cases. None of the liver sections from the 50 control subjects showed evidence of pigment, necrosis or any other pathology. In conclusion, jaundice was one of the commonest clinical presentations of the fatal cases of malaria and could mimic viral hepatitis on clinical examination. The characteristic histopathological features of the livers of those with fatal malaria were Kupffer-cell hyperplasia, malarial pigment within the Kupffer cells, and liver-cell necrosis, with portal inflammation, steatosis and cholestasis also observed.

Severe Plasmodium vivax malaria: a report on serial cases from Bikaner in northwestern India.

Epidemiologic studies and clinical description of severe Plasmodium vivax malaria in adults living in malaria-endemic areas are rare and more attention is needed to understand the dynamics and its interaction with the immune system. This observational study included 1,091 adult patients admitted to medical wards of S. P. Medical College and associated group of hospitals in Bikaner, India from September 2003 through December 2005. The diagnosis of P. vivax malaria was established by peripheral blood film (PBF), rapid diagnostic test (RDT), and polymerase chain reaction (PCR), and severe malaria was categorized as per World Health Organization guidelines. Of 1,091 patients with malaria, 635 had P. falciparum malaria and 456 had P. vivax malaria. Among patients with severe manifestations, 40 had evidence of monoinfection of P. vivax malaria diagnosed by PBF, RDT, and PCR. Complications observed were hepatic dysfunction and jaundice in 23 (57.5%) patients, renal failure in 18 (45%) patients, severe anemia in 13 (32.5%) patients, cerebral malaria in 5 patients (12.5%), acute respiratory distress syndrome in 4 patients (10%), shock in 3 patients (7.5%), and hypoglycemia in 1 (2.5%) patient. Thrombocytopenia was observed in 5 (12.5%) patients, and multi-organ dysfunction was detected in 19 (47.5%) patients. Further large-scale multicentric epidemiologic studies are needed to define the basic pathology of this less known entity.

Jaundice in falciparum malaria; changing trends in clinical presentation--a need for awareness.

OBJECTIVES: To describe the clinical characteristics, laboratory parameters and prognostic factors in patients with falciparum malaria (FM) with jaundice. METHODS: A cross-sectional comparative study was conducted at the Department of Medicine, medical unit II, Jinnah Postgraduate Medical Centre, Karachi. Adult patients with jaundice and smear positive plasmodium falciparum infection, who fulfilled the inclusion criteria were selected for the study from amongst all cases of FM who presented during the study period. Patients were divided in to two groups on the basis of rising bilirubin and adverse outcome. The data was analyzed on SPSS ver 12. Results were expressed as, percentages, mean and standard deviations. P-value < 0.05 was taken as significant. RESULTS: Among 76 patients of FM, 35 (46.05%) developed jaundice. Fifteen (42.86%) patients had bilirubin 3-10 mg/dl while 20 (57.14%) had bilirubin > 10 mg/dl. Comparative analysis of the groups showed that elevation of ALT and AST was modest in comparison with conjugated hyperbilirubinaemia while prolonged duration of illnes impaired consciousness, hepatomegaly, acute renal failure with deranged renal parameters, low platelet counts and high parasite density were significantly associated with rising bilirubin and adverse outcome. Twenty-one (60%) patients recovered completely while 14(40%) succumbed to the disease. CONCLUSION: FM is one of the causes of severe jaundice in adults in this part of the world. This presentation of complicated FM needs to be recognized globally in order to institute prompt and specific therapy. Delayed diagnosis and inappropriate treatment is the leading cause of complications and increased mortality in FM.

Malaria por Plasmodium falciparum en el servicio de medicina del Hospital San Camilo de San Felipe / Malaria by Plasmodium falciparum in the medicine service of San Camilo Hospital of San Felipe

Paciente de 36 años (camionero), sin antecedentes mórbidos de importancia, que luego de un viaje por Brasil, inicia cuadro de malestar general, poliartralgia y gran decaimiento. Consultando a la semana por sensación febril e ictericia en el Hospital de los Andes. Se constata fiebre, compromiso del estado general, ictericia, destacando en los exámenes de laboratorio: elevación de las transaminasas, fosfatasas alcalinas, hiperbilirrubinemia y disminución de hematocrito y plaquetas. Se lo hospitaliza con el diagnóstico de Síndrome Febril Ictérico Obs: Hepatitis viral, malaria o fiebre amarilla. Evoluciona con caída de su hematocrito y plaquetas, manteniéndose las pruebas hepáticas alteradas. Se realizan exámenes directos e indirectos para diagnóstico de Malaria, confirmándose con la visualización de trofozoítos de Plasmodium falciparum e indirectamente por detección en sangre de pLDH mediante optiMAL IT kit. Se inicia terapia con Cloroquina, con buena respuesta sintomática, con recuperación de plaquetas, mantención del Hematocrito y normalización de las pruebas hepáticas. La malaria por P. falciparum se describe como aquella que ocasiona las formas más graves y con compromiso hepático. Se destaca que ante la facilidad de transporte de personas de áreas endémicas, se hace más factible la aparición de casos en áreas no endémicas como en este servicio. Debido al riesgo, se debe estar preparado para la toma de muestras adecuadas que permitan la certificación en centros que como en éste, llegan pacientes extranjeros. El diagnóstico del paciente se hizo de forma expedita debido a una buena anamnesis, la que orientó claramente al diagnóstico de certeza.