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A unique case of ascending cholangitis

      Highlights

      • Ascariasis is one of the most common helminthic human infections worldwide.
      • Most infections are asymptomatic, and its diagnosis requires a high index of suspicion.
      • Biliary migration may cause biliary colic, obstructive jaundice, or ascending cholangitis.

      1. Indication

      A 64-year-old Asian female was admitted with a 3-day history of subjective fever, abdominal pain, nausea, and vomiting. On admission, the patient was febrile with mild abdominal tenderness on exam. Her lab values were significant for leukocytosis and abnormal liver function tests suggestive of a cholestatic pattern. Initial ultrasound showed a dilated common bile duct measuring 9 mm and no evidence of gallstones, choledocholithiasis, or pancreatitis. The patient was admitted to the hospital with a diagnosis of systemic inflammatory response syndrome and started on intravenous antibiotics. The blood cultures grew pan sensitive Escherichia coli. The patient responded well to the initial treatment but continued to have intermittent abdominal pain and nausea. Computerized tomography scan of the abdomen with contrast showed tubular filling defects in the small bowel (Fig. 1). What's the diagnosis?
      Fig. 1
      Fig. 1Sagittal and coronal view showing filling defects

      2. Diagnosis

      Ascaris lumbricoides is an intestinal nematode that infects the human gastrointestinal (GI) tract [
      • Dold C.
      • Holland C.V.
      Ascaris and ascariasis.
      ]. The roundworms are actively motile and may be found anywhere in the GI tract but mostly resides in the jejunum. The symptoms usually occur during the migration of larvae and adult worms. Most cases are asymptomatic. Signs and symptoms of GI ascariasis vary depending on the worm load and its location. They include nonspecific intestinal symptoms, intestinal obstruction, and perforation. The intestinal obstruction most commonly occurs at the ileocecal valve. The migration of the adult worms into the biliary tree can cause biliary colic, obstructive jaundice, ascending cholangitis, acalculous cholecystits, and acute pancreatitis [
      • Rana S.S.
      • Bhasin D.K.
      • Nanda M.
      • Singh K.
      Parasitic infestations of the biliary tract.
      ]. The diagnosis requires a high index of suspicion and is usually established via stool microscopy and imaging [
      • Das C.J.
      • Kumar J.
      • Debnath J.
      • Chaudhry A.
      • et al.
      Imaging of ascariasis.
      ]. Endoscopic retrograde cholangiopancreatography is the most useful tool in management of biliary ascariasis.
      Our patient was suspected to have cholangitis secondary to transient obstruction of the bile duct. Stool ova and parasite examination confirmed the presence of A. lumbricoides and was subsequently treated successfully with antihelmintic therapy.

      Conflict of interests

      The authors state that they have no conflicts of interest.

      References

        • Dold C.
        • Holland C.V.
        Ascaris and ascariasis.
        Microbes Infect. 2011 Jul; 13: 632-637
        • Rana S.S.
        • Bhasin D.K.
        • Nanda M.
        • Singh K.
        Parasitic infestations of the biliary tract.
        Curr Gastroenterol Rep. 2007 Apr; 9: 156-164
        • Das C.J.
        • Kumar J.
        • Debnath J.
        • Chaudhry A.
        • et al.
        Imaging of ascariasis.
        Australas Radiol. 2007 Dec; 51: 500-506