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A Worm Hole: Liver Abscess in Ascariasis

(A) Ultrasonography demonstrated a linear hypoechoic structure (arrows) in an area of tissue breakdown in the left lobe of the liver. (B) Magnetic resonance imaging (MRI) showed a hypointense, coiled structure (arrows) in an abscess in the liver’s left lobe. (C) MRI disclosed a linear hypointense structure—a worm, which is denoted by the arrow—in the abscess in the liver parenchyma. (D) MRI with contrast identified the liver abscess (asterisk) and the nonenhancing, hypointense worm (arrow).

A patient with an infection that is often asymptomatic developed an uncommon complication. The 60-year-old woman presented with fever and pain in the epigastrium and right hypochondrium, symptoms that had existed for the previous 5 days. On touch, she was clearly febrile. Her temperature was 38.6°C (101.5°F). Her blood pressure and pulse rate were within normal limits.

Assessment

Physical examination identified evidence of epigastric tenderness and hepatomegaly. The patient’s respiratory rate was 14 breaths/min, and her pulse rate was 82 beats/min. Her laboratory reports revealed an increased white blood cell count of 14,000 cells/µL. Her hemogram and coagulation profile were within normal limits.

Ultrasonography of the abdomen disclosed an area of altered echogenicity associated with breakdown of tissue in the liver’s left lobe. This region contained a coiled, mobile, hypoechoic, tubular structure (Supplementary Video 1, available online).

Diagnosis

The patient, according to our preliminary diagnosis, had a liver abscess inhabited by a worm, specifically, Ascaris lumbricoides. This was confirmed by magnetic resonance imaging, which displayed Ascaris within a liver abscess in the left lobe (Figure 1).

Liver abscess secondary to biliary ascariasis is a rare complication of Ascaris infestation. It may result when adult worms or eggs are in the biliary channels or liver parenchyma, and in some cases, when worms in the larval stages enter the hepatic parenchyma.1

Management

The standard treatment for multifocal abscesses due to ascariasis is surgery followed by a regimen of albendazole or mebendazole; for patients with a single abscess, treatment consists of ultrasonography-guided drainage with subsequent antihelminthic therapy.2

Our patient’s liver abscess was aspirated under ultrasonographic guidance, and the worm was removed through a 16F (5.33 mm) pigtail catheter (Figure 2). She then received albendazole, 100 mg twice per day, for 3 days. On follow-up, she was free of symptoms .

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-Mohd Ilyas, MD, Mohd Yaqoob Wani, MD, Kifayat Hussain Ganaie, MD, Gh. Mohammad Wani, DNB, Musaib Ahmad Dar, MD

This article originally appeared in the August issue  of The American Journal of Medicine.

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