Unanticipated discovery: incidental encounter with fasciola hepatica during ERCP - a case report.

Introduction and Importance: Fasciola hepatica (FH) is a rare parasitic infection in humans. Its incidental detection during endoscopic retrograde cholangiopancreatography (ERCP) is exceptionally uncommon. This case underscores the importance of considering parasitic infections, even in low-endemicity regions, and the potential implications of dietary and environmental factors in disease transmission. Case Presentation: The authors present a case of a 31-year-old female from Dhading, Nepal, who underwent ERCP for suspected biliary stone. The patient had been experiencing recurring, nonradiating, burning epigastric pain for 5 to 7 years, which had recently intensified. Previous evaluations, including abdominal ultrasonography, CT, and MRI, revealed a dilation within the common bile duct and an obstruction in the biliary system. Clinical Discussion: During ERCP, cholangiography revealed mildly dilated extra and intrahepatic bile ducts with irregular filling defects in the common hepatic duct. Sphincterotomy was performed, followed by the extraction of multiple FH worms. A 7 Fr 7 cm double pigtail plastic stent was placed with a good flow of bile. However, the patient experienced anaphylaxis during the procedure, necessitating swift and tailored administration of appropriate medications to ensure effective management and stabilization. The patient was closely monitored in the ICU postprocedure. Conclusion: After careful monitoring and treatment, the patient fully recovered. The unexpected discovery of FH during ERCP is extremely rare. Early recognition and appropriate management of such incidental findings are crucial to ensuring optimal patient outcomes.

Simultaneous analysis of the of levamisole with triclabendazole in pharmaceuticals through developing TLC and HPLC-PDA chromatographic techniques and their greenness assessment using GAPI and AGREE methods.

Two simple and rapid chromatographic methods were developed and validated for the analysis of levamisole and triclabendazole simultaneously in pure and pharmaceutical products. The first method is thin-layer chromatography (TLC) with densitometry, and the second method is high-performance liquid chromatography with PDA detection (HPLC-PDA). A Hypersil BDS C18 column with dimensions of 4.6 × 150 mm and a particle size of 5 µm was used in the HPLC-PDA method. An isocratic condition was used to carry out the separation, and the mobile phase was made up of acetonitrile and a 0.03 M potassium dihydrogen phosphate buffer in double-distilled water. The ratio of the mobile phase preparation was 70:30 (v/v), and the flow rate was 1 mL/min. A wavelength of 215 nm was employed for analyte detection. Precoated silica gel 60 F254 aluminium plates were used for the TLC method's separation. Mobile phase was made of ethyl acetate, hexane, methanol, and ammonia (69:15:15:1) for the separation. The detection wavelength selected was 215 nm. According to the International Council for Harmonization (ICH) guidelines, the proposed methods were validated and it was found that the two chromatographic methods are accurate, precise, and linear for both compounds in the range of 3.75-37.5 and 6-60 mg/L for the HPLC method for levamisole and triclabendazole, respectively and in the range of 2-14 µg/spot for the TLC method. The developed methods greenness profile was assessed using AGREE and ComplexGAPI tools.

Challenges in Diagnosis and Treatment of Fasciola hepatica Infection.

A 57-year-old female patient presented with fever, nausea, vomiting, loss of appetite, and weight loss within the last two months. Ceftriaxone and metronidazole therapy was started upon discovery of a liver abscess but provided no benefit. Following the of abscess biopsy, the patient developed fever, itching, anemia, acute renal failure, hyperbilirubinemia, and eosinophilia that required intensive care unit (ICU) admission. The Fasciola hepatica antibodies were detected by enzyme-linked immunosorbent assay (ELISA). Triclabendazole was started, after which the symptoms and magnetic resonance imaging (MRI) findings regressed. Even without eosinophilia, F. hepatica should be considered in cases with a liver abscess that does not respond to antibiotics.

Triclabendazole Induces Pyroptosis by Activating Caspase-3 to Cleave GSDME in Breast Cancer Cells.

Pyroptosis is a form of programmed cell death, in which gasdermin E (GSDME) plays an important role in cancer cells, which can be induced by activated caspase-3 on apoptotic stimulation. Triclabendazole is a new type of imidazole in fluke resistance and has been approved by the FDA for the treatment of fascioliasis and its functions partially acting through apoptosis-related mechanisms. However, it remains unclear whether triclabendazole has obvious anti-cancer effects on breast cancer cells. In this study, to test the function of triclabendazole on breast cancer, we treated breast cancer cells with triclabendazole and found that triclabendazole induced lytic cell death in MCF-7 and MDA-MB-231, and the dying cells became swollen with evident large bubbles, a typical sign of pyroptosis. Triclabendazole activates apoptosis by regulating the apoptoic protein levels including Bax, Bcl-2, and enhanced cleavage of caspase-8/9/3/7 and PARP. In addition, enhanced cleavage of GSDME was also observed, which indicates the secondary necrosis/pyroptosis is further induced by active caspase-3. Consistent with this, triclabendazole-induced GSDME-N-terminal fragment cleavage and pyroptosis were reduced by caspase-3-specific inhibitor (Ac-DEVD-CHO) treatment. Moreover, triclabendazole induced reactive oxygen species (ROS) elevation and increased JNK phosphorylation and lytic cell death, which could be rescued by the ROS scavenger (NAC), suggesting that triclabendazole-induced GSDME-dependent pyroptosis is related to the ROS/JNK/Bax-mitochondrial apoptotic pathway. Besides, we showed that triclabendazole significantly reduced the tumor volume by promoting the cleavage of caspase-3, PARP, and GSDME in the xenograft model. Altogether, our results revealed that triclabendazole induces GSDME-dependent pyroptosis by caspase-3 activation at least partly through augmenting the ROS/JNK/Bax-mitochondrial apoptotic pathway, providing insights into this on-the-market drug in its potential new application in cancer treatment.

Zinc supplementation augments the suppressive effects of repurposed NF-κB inhibitors on ACE2 expression in human lung cell lines.

AIMS: Angiotensin-converting enzyme 2 (ACE2) is a key negative regulator of the renin-angiotensin system and also a major receptor for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Here, we reveal a role for NF-κB in human lung cell expression of ACE2, and we further explore the potential utility of repurposing NF-κB inhibitors to downregulate ACE2. MAIN METHODS: Expression of ACE2 was assessed by Western blotting and RT-qPCR in multiple human lung cell lines with or without NF-κB inhibitor treatment. Surface ACE2 expression and intracellular reactive oxygen species (ROS) levels were measured with flow cytometry. p50 was knocked down with siRNA. Cytotoxicity was monitored by PARP cleavage and MTS assay. KEY FINDINGS: Pyrrolidine dithiocarbamate (PDTC), an NF-κB inhibitor, suppressed endogenous ACE2 mRNA and protein expression in H322M and Calu-3 cells. The ROS level in H322M cells was increased after PDTC treatment, and pretreatment with N-acetyl-cysteine (NAC) reversed PDTC-induced ACE2 suppression. Meanwhile, treatment with hydrogen peroxide augmented ACE2 suppression in H322M cells with p50 knockdown. Two repurposed NF-κB inhibitors, the anthelmintic drug triclabendazole and the antiprotozoal drug emetine, also reduced ACE2 mRNA and protein levels. Moreover, zinc supplementation augmented the suppressive effects of triclabendazole and emetine on ACE2 expression in H322M and Calu-3 cells. SIGNIFICANCE: These results suggest that ACE2 expression is modulated by ROS and NF-κB signaling in human lung cells, and the combination of zinc with triclabendazole or emetine shows promise for clinical treatment of ACE2-related disease.

Fasciola Hepatica Induced Hepatic Abscess Treated with Triclabendazole.

Fascioliasis is a zoonotic disease caused by Fasciola hepatica that infects mainly cattle, sheep, and goats. Humans can be infected by water or aquatic plants contaminated with metacercariae. The authors encountered two cases of F. hepatica infection. One patient reported abdominal discomfort with marked eosinophilia. The other patient had chest discomfort with marked eosinophilia. The abdominal CT images revealed hypodense lesions in the liver. The ultrasonography-guided liver biopsy findings in both patients were indicative of parasitic infections. Serological tests confirmed the definite diagnoses. Both patients were treated with a single dose of triclabendazole, which is the treatment of choice for fascioliasis. These findings suggest that a diagnosis of fascioliasis, particularly in the acute phase, should be considered in patients with abdominal pain, marked eosinophilia, and hypodense hepatic lesions on CT.

Paragonimiasis pulmonar. Reporte de caso pediátrico / Pulmonary paragonimiasis. Pediatric case report

La paragonimiasis es una parasitosis provocada por varias especies de Paragonimus, un trematodo que se transmite a través del consumo de cangrejos poco cocidos o crudos y que se ha encontrado en áreas tropicales y subtropicales de América, Asia y África. Esta infección afecta, principalmente, los pulmones y provoca manifestaciones clínicas y radiológicas muy similares a la tuberculosis pulmonar, por lo cual siempre debe incluirse dentro del diagnóstico diferencial. Se presenta el caso de una niña escolar de 7 años de edad, hospitalizada con el diagnóstico de paragonimiasis pulmonar, quien presentó evolución favorable luego de recibir tratamiento con triclabendazol.

Paragonimiasis is a parasite infection caused by several species of Paragonimus, a trematode that is transmitted through the consumption of raw or undercooked crabs and that has been found in the subtropical areas of America, Asia and Africa. This infection mainly affects the lungs, causing clinical and radiological manifestations very similar to pulmonary tuberculosis, so it should always be included in the differential diagnosis. We present the case of a 7-year-old school patient, hospitalized with the diagnosis of pulmonary paragonimiasis, who had a favorable evolution after receiving treatment with triclabendazole.

Immature Fasciola gigantica: Time-dependent ultrastructural changes following in vivo treatment with triclabendazole.

An in vivo study was carried out to investigate the ultrastructural effects of triclabendazole (TCBZ) on immature Fasciola gigantica in a goat model. Five goats were infected with an oral gavage of 150 metacercarial cysts of F. gigantica and anthelmintic treatment occurred at 4 weeks post infection with an oral dose of 10 mg/kg. They were euthanized at 0 (untreated), 24, 48, 72 and 96 h post treatment (h pt). Juvenile flukes were recovered from each of the goat's liver and processed for transmission electron microscopy (TEM). The untreated control flukes showed normal ultrastructure and no apparent changes were observed at 24 h pt. At 48 h pt, moderate levels of disruption were observed to the tegument and minor changes to the sub-tegument which included widespread blebbing and disruption of apical tegumental membrane, swollen mitochondria, reduced number of secretory bodies, swelling of basal infolds leading to severe vacuolation, and relatively mild disruption to the subtegumental muscle fibres, parenchyma and tegumental cells, whereas the gastrodermal cells appeared less affected. By 72 h pt, sloughing of the tegumental syncytium was evident leading to the exposure of the basal lamina and the disruption was severe in the subtegument too. At 96 h pt, the flukes were totally devoid of tegument and the disruption was extremely severe, distorting the ultrastructure of the entire fluke's body. The results of the present study revealed that the flukes showed time-dependent progressive disruption to the internal tissues which became increasingly severe over time pt. This is the first study to detail the time-scale and impacts on ultrastructural morphology of the in vivo TCBZ treatment of the immature tropical liver fluke, Fasciola gigantica.

Fracaso de dosis única de triclabendazole para el tratamiento de fasciolosis humana / Failure of single-dose triclabendazole in the therapy of human fasciolasis

La fasciolosis humana es prevalente en zonas ganaderas del Perú. La única droga efectiva para tratar a la infección por Fasciola hepatica en la práctica clínica es el triclabendazole (TCBZ). Sin embargo, se ha reportado recientemente resistencia de la F. hepatica al TCBZ en Perú tanto en humanos como en animales. Este problema ya se sospechaba anteriormente en vista que una dosis única de triclabendazole no curaba (eliminación de huevos de Fasciola en heces) en algunos pacientes. Aquí reportamos 11 de 12 casos humanos infectados por F. hepatica que no respondieron a dosis única de TCBZ 10 mg/kg vía oral. En vista de estos resultados observados en la práctica clínica, recomendamos considerar por lo menos dos dosis de TCBZ para los infectados. Creemos que el tratamiento de fasciolosis se ha convertido en un problema emergente desde el punto de vista farmacológico. Se necesitan nuevos regímenes de terapia o drogas contra F. hepática

Human fascioliasis is prevalent in cattle raising areas in Peru. The only effective drug against Fasciola hepatica infections in clinical practice is triclabendazole (TCBZ). However, the occurrence of TCBZ-resistant F. hepatica both in humans and animals has recently been reported in Peru. This issue was previously suspected, due to treatment failure (presence of Fasciola eggs after treatment) in some patients receiving a single dose of TCBZ. Here, we report 11 of 12 human cases infected by F. hepatica who did not respond to TCBZ administered in a single 10 mg/Kg oral dose. Given these results observed in clinical practice, we recommend the use of at least two doses of TCBZ for human fascioliasis. Nowadays, the treatment for fascioliasis has become an emergent problem from the pharmacological point of view. New therapies against Fasciola are urgently needed

DIAGNOSIS AND THERAPY OF LIVER FLUKE (FASCIOLOIDES MAGNA) INFECTION IN FALLOW DEER (DAMA DAMA) IN SERBIA.

Giant liver fluke ( Fascioloides magna ) infection is an important health problem of cervids in southeastern Europe. We measured the prevalence and intensity of infection with F. magna in a fenced area near the Danube River in the South Backa District of Serbia. Parasitologic, pathomorphologic, and histopathologic examinations were conducted from November 2007 to February 2008, beginning with a population of 127 adult fallow deer ( Dama dama ). After a positive diagnosis, therapy with triclabendazole-medicated corn was applied. Deer were treated at four baiting stations, using medicated feed providing triclabendazole at an estimated dose of 10-14 mg/kg of body weight per deer. Treatment lasted for 7 d in early February 2008 and an additional 7 d 2 wk later. For the complete success of pharmacotherapy it was necessary to prevent any contact of deer with the snail intermediate host ( Galba truncatula ). Intervention in the habitat, removing grass and low vegetation, and draining ponds reduces the possibility of contact. Six months after the treatment, livers of hunted deer were reddish, with fibrous tracks; pigmentation and cysts in the parenchyma were surrounded by a fibrous capsule and their fecal samples contained no eggs of F. magna . Over the following years, livers of hunted deer were negative, and the last control cull in March 2015 confirmed complete absence of infection. We reconfirmed the presence of giant liver flukes in fallow deer in Serbia, apparently the result of natural spread across the Danube from Hungary and Croatia. We also report that the treatment of deer with triclabendazole-medicated corn is an effective method for administration of therapeutic doses of drug in semicaptive deer. Interventions in the environment are necessary to prevent recontact of deer with habitats used by the snail intermediate host, and enable the success of the therapy.

Discovery of novel polyamine analogs with anti-protozoal activity by computer guided drug repositioning.

Chagas disease is a parasitic infection caused by the protozoa Trypanosoma cruzi that affects about 6 million people in Latin America. Despite its sanitary importance, there are currently only two drugs available for treatment: benznidazole and nifurtimox, both exhibiting serious adverse effects and limited efficacy in the chronic stage of the disease. Polyamines are ubiquitous to all living organisms where they participate in multiple basic functions such as biosynthesis of nucleic acids and proteins, proliferation and cell differentiation. T. cruzi is auxotroph for polyamines, which are taken up from the extracellular medium by efficient transporters and, to a large extent, incorporated into trypanothione (bis-glutathionylspermidine), the major redox cosubstrate of trypanosomatids. From a 268-compound database containing polyamine analogs with and without inhibitory effect on T. cruzi we have inferred classificatory models that were later applied in a virtual screening campaign to identify anti-trypanosomal compounds among drugs already used for other therapeutic indications (i.e. computer-guided drug repositioning) compiled in the DrugBank and Sweetlead databases. Five of the candidates identified with this strategy were evaluated in cellular models from different pathogenic trypanosomatids (T. cruzi wt, T. cruzi PAT12, T. brucei and Leishmania infantum), and in vitro models of aminoacid/polyamine transport assays and trypanothione synthetase inhibition assay. Triclabendazole, sertaconazole and paroxetine displayed inhibitory effects on the proliferation of T. cruzi (epimastigotes) and the uptake of putrescine by the parasite. They also interfered with the uptake of others aminoacids and the proliferation of infective T. brucei and L. infantum (promastigotes). Trypanothione synthetase was ruled out as molecular target for the anti-parasitic activity of these compounds.

Evaluation of activity of triclabendazole against Taenia solium metacestode in naturally infected pigs.

OBJECTIVE: To assess the efficacy of triclabendazole (TCBZ) in porcine cysticercosis. METHODS: Eighteen naturally infected cysticercosis pigs were divided into 3 groups of 6 individuals each. The first group was treated orally with TCBZ at a single dose of 30 mg/kg of body weight, the second group was treated orally with oxfendazole at a single dose of 30 mg/kg of body weight and the third group received a placebo (control group). All animals were kept under the same management conditions. The pigs were euthanized 17 wk post-treatment and the number of surviving cysts in muscles was assessed and compared between groups. RESULTS: All pigs treated with oxfendazole had only degenerated cysts in their carcasses. In contrast, TCBZ had very little effect against the parasitic cysts. Cysts from pigs in the TCBZ group looked apparently normal after treatment. However, histological evaluation showed a mild to moderate degree of inflammation. CONCLUSIONS: TCBZ is not an efficacious drug against Taenia solium cysticercosis in swine using a single dose.

Fascioliasis hepática humana: resistencia al tratamiento con triclabendazol / Resistant human fasciolasis: Report of four patients

Human fascioliasis is a parasitic zoonosis that affects the liver of human and herbivorous animals. In chronic cases, its diagnosis is confirmed by direct visualization of parasitic eggs in stool examination, by positive testing for Fasciola hepatica antigens in stools, or by direct observation of parasites by endoscopic retrograde cholangiography or surgery. In acute cases, serological reactions as immunoblothing or detection of parasite antigens in the blood are useful. The treatment of choice is triclabendazole. However, parasite resistance in animals, as well as in man, has been reported to this drug. We report four patients in whom the parasitic infection persisted despite a course of treatment with triclabendazole.

Effects of triclabendazole on secretion of danofloxacin and moxidectin into the milk of sheep: role of triclabendazole metabolites as inhibitors of the ruminant ABCG2 transporter.

ATP-binding cassette transporter G2/breast cancer resistance protein (ABCG2/BCRP) mediates drug-drug interactions that affect the secretion of drugs into milk. The aims of this study were: (1) to determine whether the major plasma metabolites of the flukicide triclabendazole (TCBZ), triclabendazole sulfoxide (TCBZSO) and triclabendazole sulfone (TCBZSO2), inhibit ovine and bovine ABCG2 and its Y581S variant in vitro, and (2) to examine whether coadministration of TCBZ with the ABCG2 substrates danofloxacin (a fluoroquinolone) and moxidectin (a milbemycin) affects the secretion of these drugs into the milk of sheep. TCBZSO and TCBZSO2 inhibited ruminant ABCG2 in vitro by reversing the reduced mitoxantrone accumulation and reducing basal to apical transport of nitrofurantoin in cells transduced with bovine variants (S581 and Y581) and the ovine variant of ABCG2. Coadministration of TCBZ with moxidectin or danofloxacin to sheep resulted in significantly reduced levels of moxidectin, but not danofloxacin, in the milk of TCBZ-treated sheep compared to sheep administered moxidectin or danofloxacin alone. The milk area under concentration time curve (AUC 0-48 h) was 2.99±1.41 µg h/mL in the group treated with TCBZ and moxidectin, and 7.75±3.58 µg h/mL in the group treated with moxidectin alone. The AUC (0-48 h) milk/plasma ratio was 37% lower in the group treated with TCBZ and moxidectin (7.34±1.51) than in the group treated with moxidectin alone (11.68±3.61). TCBZ metabolites appear to inhibit ruminant ABCG2 and affect the secretion of ABCG2 substrates into milk of sheep.

Comportamiento clínico-terapéutico de Fasciola hepatica en una serie de 87 pacientes / Clinical and therapeutic behaviour of Fasciola hepatica in a series of 87 patients

Introducción: la fasciolosis, por Fasciola hepatica, muestra a escala mundial un incremento en la incidencia de enfermos en los últimos años. Cuba se encuentra entre aquellos países donde se reportan casos esporádicos y algunos brotes epidémicos. Objetivo: describir el comportamiento clínico-terapéutico de esta trematodiosis de trasmisión digestiva en una serie de 87 pacientes ingresados en el Instituto de Medicina Tropical "Pedro Kourí" desde enero de 1996 a diciembre de 2005. Método: los pacientes se dividieron en 2 grupos atendiendo al fármaco prescrito, dihidroemetina o triclabendazol. Se recogieron las variables clínicas al inicio del diagnóstico y 90 d después del tratamiento; se hallaron las medias y la desviación estándar. Resultados: el sexo masculino predominó discretamente con 54 por ciento en nuestra serie de pacientes ingresados en el servicio de medicina tropical del instituto. La ingestión de berro (Nasturtium officinale) estuvo presente en casi la mitad de los pacientes. El dolor abdominal, fiebre y astenia resultaron los síntomas de mayor frecuencia. El triclabendazol y la dihidroemetina fueron útiles en el tratamiento. Conclusiones: se comprobó la utilidad de los exámenes de laboratorio en el diagnóstico y seguimiento de los enfermos. Los antiparasitarios dihidroemetina y triclabendazol resultaron efectivos a las dosis utilizadas con efectos adversos menores.

Introduction: in the last few years, the Incidence rate of fascioliosis caused by Fasciola hepatica has increased worldwide. Cuba is one of the countries that have reported sporadic cases and also some outbreaks of fasciolosis. Objective: to describe clinical and therapeutic features of this trematodiasis of digestive transmission found in 87 patients, who had been admitted to "Pedro Kourí" Institute of Tropical Medicine from January 1996 to December 2005. Methods: patients were divided into 2 groups according to the prescribed drug, that is, triclabendazole and dihydroemetine. The clinical variables were collected at the time of diagnosis and 90 days after treatment; the means and the standard deviation were estimated. Results: males was slightly predominant (54) in our series of patients admitted to the institute service. Consumption of watercress (Nasturtium officinale) was found in almost half of the patients. Abdominal pain, fever and malaise were the most frequent symptoms. Both drugs were useful to treat F. hepatica. Conclusions: this study showed the usefulness of lab tests for diagnosis and follow-up of patients after treatment. The anti-parasitic drugs dihydroemetine and triclabendazole proved to be effective at the prescribed doses in this research with minor adverse effects.

A paragonimiasis patient with allergic reaction to praziquantel and resistance to triclabendazole: successful treatment after desensitization to praziquantel.

Paragonimiasis is an infectious disease caused by trematodes of the genus Paragonimus. This trematode can be treated successfully with praziquantel in more than 90% of the cases. Although praziquantel is generally well tolerated, anaphylactic reactions to this drug have been reported in a few cases. We report here a 46-year-old Korean female with paragonimiasis, presumed to be due to Paragonimus westermani, who displayed an allergic reaction to praziquantel and resistance to triclabendazole treatment. The patient was successfully treated with praziquantel following a rapid desensitization procedure. Desensitization to praziquantel could be considered when no alternative drugs are available.