Case No.

7
A patient with a history of eating raw or undercooked freshwater fish was hospitalized
with acute shock caused by severe abdominal pain. Physical examination suggested
acute abdomen with severe abdominal pain and rigidity. Stool Examination reveals no
ova or parasite found. Computed tomography (CT) detection indicated acute biliary
obstruction. After cholecystectomy, several liver flukes were found in the drainage tube.
Further tests have been conducted with this case and indicated the presence of an oval
shaped egg with convex operculum with a small knob protrusion on the opposite side.

Based on the presented case study, the patient likely has an infection with a liver fluke

known as Clonorchis sinensis.

Here are the details:

(1)

​ Species: Clonorchis sinensis, commonly known as the Chinese liver fluke.

​ Symptoms:
● Acute abdominal pain.
● Shock.
● Acute biliary obstruction.
● Possible fever and chills.
● Jaundice (in severe cases).
​ Diagnosis:
● Stool examination may not always reveal the presence of eggs.
● Imaging studies like CT scans may show signs of biliary obstruction.
● Identification of the fluke or its eggs in bile or tissue samples obtained
during cholecystectomy.
​ Treatment:
● Cholecystectomy (removal of the gallbladder) to eliminate adult flukes
residing in the bile ducts.
● Praziquantel is the drug of choice for treating liver fluke infections. It kills
both adult flukes and eggs.
● Supportive therapy for managing symptoms like pain and fever.
​ Alternative treatments:
 ● Triclabendazole is another anthelmintic drug used to treat liver fluke
infections, but it may not be as effective as praziquantel against
Clonorchis sinensis.
● Albendazole and mebendazole are alternative drugs, but their efficacy
against liver flukes is limited compared to praziquantel.
​ Prevention:
● Educating people about the risks of consuming raw or undercooked
freshwater fish, especially in endemic areas.
● Proper cooking of fish can prevent transmission of the parasite.
● Public health measures to control the spread of the parasite in endemic
regions.

Prompt diagnosis and treatment are crucial to prevent complications and long-term

health issues associated with Clonorchis sinensis infection, such as

cholangiocarcinoma (bile duct cancer).

(2)

The patient's presentation, history of consuming raw or undercooked freshwater fish,

and subsequent diagnosis of acute biliary obstruction with the discovery of liver flukes

post-cholecystectomy strongly suggest a case of clonorchiasis.

Clonorchiasis is caused by the liver fluke Clonorchis sinensis, which infects humans

through the consumption of raw or undercooked freshwater fish containing the

parasite's encysted larvae. The oval-shaped egg described, with a convex operculum

and a small knob protrusion on the opposite side, is characteristic of Clonorchis

sinensis eggs.

The acute abdominal pain and rigidity observed in the patient are consistent with the

inflammatory response caused by the migration of the flukes within the biliary tree,

leading to obstruction and subsequent symptoms.

Treatment typically involves the administration of praziquantel to eradicate the parasite.

Additionally, cholecystectomy may be necessary in cases of severe biliary obstruction

or complications such as cholangiocarcinoma, which can arise from chronic

clonorchiasis infection. Preventative measures include cooking freshwater fish

thoroughly before consumption and avoiding the ingestion of raw or undercooked fish

from endemic areas.

HISTORY OF PRESENTING ILLNESS

- Most infected persons have no symptoms. In mild cases, symptoms may include

indigestion, abdominal pain, diarrhea, or constipation. Most signs and symptoms

are related to inflammation and intermittent obstruction of the bile ducts. In

severe cases, abdominal pain, nausea, and diarrhea can occur.

PARASITIC LIFE CYCLE

Clonorchis sinensis eggs are discharged in the biliary ducts and in the stool in an

embryonated state image .

Eggs are ingested by a suitable snail intermediate host image.

Eggs release miracidia image, which go through several developmental stages

(sporocysts image , rediae image , and cercariae image ).

The cercariae are released from the snail and, after a short period of free-swimming

time in water, they come in contact and penetrate the flesh of freshwater fish, where

they encyst as metacercariae image.

Infection of humans occurs by ingestion of undercooked, salted, pickled, or smoked

freshwater fish image . After ingestion, the metacercariae excyst in the duodenum

image

and ascend the biliary tract through the ampulla of Vater image.

Maturation takes approximately one month. The adult flukes (measuring 10 to 25 mm

by 3 to 5 mm) reside in small and medium sized biliary ducts.

PATHOPHYSIOLOGY SIDES NOTES

➢ Mechanisms of parasitic infection

1. Ingestion of raw or undercooked freshwater fish containing larvae of liver flukes (C.
sinensis - Metacercaria).

.
➢ Host-parasitic infection
2. Upon ingestion, the larvae migrate to the liver and enter biliary capillaries
3. The presence of liver flukes in the bile ducts leads to mechanical obstruction, causing
acute biliary obstruction.
4. Obstruction of the bile ducts results in impaired bile flow, leading to symptoms such
as severe abdominal pain and rigidity.
5. The acute obstruction can also lead to inflammation and injury to the surrounding
tissues, contributing to the presentation of acute abdomen because local accumulation
of worms results in bile stasis favoring bacterial growth, inflammation, and
subsequently, recurrent cholangitis. Toxic effects of excretory-secretory products
(ESPs) released by the parasite also result in inflammation.

➢ Immunological response
Proteins excreted by the juvenile stages (encysted-metacercariae and metacercariae)
trigger type 1 immune response which is pro-inflammatory with the production of
cytokines such as IL-1β, IL-6, and TNF-α by macrophages, and IL-12, IFN-γ and IgG2b,
IgG2c by T cells and B cells, respectively. This pro-inflammatory reaction is supposed to
lead to the expulsion of the parasite and biliary injuries.

Adult parasites secrete compounds that lead to the production of type 2 immune
response that allows them to escape the host immune response.
COMPLICATIONS:

● Hepatitis is a medical term that refers to inflammation of the liver.

● Pancreatitis is a condition characterized by inflammation of the pancreas.
● Hepatocellular carcinoma is the most common type of primary liver cancer. It
usually develops in individuals with underlying liver disease, such as chronic
hepatitis B or C infection, cirrhosis (scarring of the liver), or non-alcoholic fatty
liver disease.
● Cholecystitis is a medical term that refers to inflammation of the gallbladder.
● Acute suppurative cholangitis characterized by inflammation and infection of the
bile ducts within the liver. It occurs when there is a blockage in the bile ducts,
which leads to the buildup of bile and subsequent bacterial infection.
● Recurrent pyogenic cholangitis, also known as Oriental cholangiohepatitis or
Asian cholangitis, is a chronic inflammatory condition that affects the bile ducts
within the liver. [symptoms such as abdominal pain, fever, jaundice and
sometimes chills.]
● Cholangiocarcinoma is a type of cancer that originates in the bile ducts. It is also
sometimes referred to as bile duct cancer.
● Calculi is the plural form of the term calculus, which refers to a small, hard,
mineralized deposit that forms within a body structure. [Calculi in kidneys (kidney
stones), the gallbladder (gallstones), the salivary glands (salivary stones or
sialoliths), and the urinary bladder (bladder stones)].

Different Diagnosis Considered

Differential diagnosis for Clonorchis sinensis infection includes other liver flukes such
as Fasciola hepatica, which cause obstruction of the bile duct and dilatation of the
biliary tract. It is also similar to Opisthorchis viverini, which also causes mechanical
obstruction and inflammation of the bile duct.