Liver Abscess Secondary to Ascaris Lumbricoides: Case Report

Background: Ascaris lumbricoides is one of the most frequent human helminthiasis, but the complication with liver abscess is very rare and severe, being a challenge for the correct and timely diagnosis. Case: A male of 62-years-old was brought to emergency room of a rural hospital referring one week of evolution with abdominal pain in right upper quadrant and epigastrium, with fever about 39oC the last three days, anorexia, asthenia, adinamia, diarrhea, and mental status deterioration the last 24 hours. At physical exam with Glasgow 11, dehydrated, with tachycardia or tachypnea, abdominal pain in right upper quadrant and epigastrium, without rebound, and with normal bowel sounds. Laboratories report leucocytes 29300 cell/mm3, neutrophils 80%, eosinophils 8%, Hemoglobin 9.5 mg/dL, Glucose 144mg/dL, Creatinine 2, total bilirubin 2.3, indirect bilirubin 1.9, ast 124 alt 112 ggt 193. A hepatic amebian abscess is suspected and empirical management with liquids, ceftriaxone and metronidazole was started. Patient continue with fever and disturbed mental status for the next two days. Ultrasound reports hepatomegaly related with liver abscess located in left lobe, with heterogeneous echogenicity secondary to hypoechoic images, rounded, well-defi ned, displacing hepatic vessels with tubular images inside. Albendazol was added to management and after two days, by the continued bad evolution CT scan was requested and report multiple liver abscesses in left lobe, segment II and III, the biggest of 68x60mm, with 16 Hounsfi eld units. An exploratory laparotomy was performed fi nding multiple encapsulated abscesses with the presence of Ascaris lumbricoides inside that were drain and after washing an open drain was placed. Patient presents signifi cant improvement with continued medical management and was discharged 7 days after surgery. Conclusion: This is a very uncommon complication of Ascaris lumbricoides infection but must be suspected and treated promptly by the severe consequences associated, with poor outcomes although correct management. Case Report Liver Abscess Secondary to Ascaris Lumbricoides: Case Report Luis Angel Medina Andrade1*, Lizette Blanco Aguilar2, Eduardo Vidrio Duarte3, Carlos Eduardo Rodríguez Rodríguez3, Adriana Paz Mendoza3, Ilse Liliana Martinez Elvira3, Daniel Flores Rodríguez4, José Daen Jonathan Cabañas Gomez5, Nestor Apaez Araujo5, Stephanie Serrano Collazos5, Oscar Rodrigo Rocha Erazo6 and Rene Cano Rodríguez6 1General Surgery Department, General Zone Hospital #30, Mexican Social Security Institute, Mexico City, México. 2Autonomous University of Chiapas, Tuxtla Gutierrez, México. 3General Surgery Department, Hospital Angeles Metropolitano, México City, México 4General Surgery Department, Veracruz High Specialty Regional Hospital ISSSTE, Veracruz, México. 5General Surgery Department, Ecatepec General Hospital, México State, México. 6General Surgery Department, Central Military Hospital, México City, México Dates: Received: 03 December, 2016; Accepted: 27 December, 2016; Published: 30 December, 2016 *Corresponding author: Luis Angel Medina Andrade, General Surgery Department, General Zone Hospital #30, Mexican Social Security Institute, Mexico City, México, E-mail:


Introduction
There are 1.5 billion people infected with Ascaris lumbricoides around the world, especially in tropical and sub-tropical areas like México, representing a source of high morbidity and mortality [1].
Liver abscess is classically related with Entamoeba histolytica, followed by pyogenic bacteria and sometimes caused by Mycobacterium tuberculosis [2]. The liver abscess caused by Ascaris lumbricoides is extremely rare, especially in adults, with no distinctive clinical features that guide us to differential diagnosis against other causes of liver abscess, constituting only 3.8% of all hepatobiliary complications associated with this parasite [3]. requested. Abdominal ultrasound reports hepatomegaly related with liver abscess located in the left lobe, with heterogeneous echogenicity secondary to hypoechoic images, rounded, welldefi ned, displacing hepatic vessels with tubular images inside. Albendazol was added to management and after two days, by the continued bad evolution, a CT scan was requested and report multiple liver abscesses in left lobe, segment II and III, the biggest of 68x60mm, with 16 Hounsfi eld units (Fig. 1). Feces exam reports Ascaris lumbricoides eggs. An exploratory laparotomy was performed fi nding multiple encapsulated abscesses with the presence of an adult Ascaris lumbricoides inside, and Ascaris eggs in the purulent liquid that were drained (Fig. 2), and after washing, an open drain was placed. Septic shock was resolved with medical management, for the next 7 days, with renal failure recovery and discharge after that uneventfully.

Discussion
Ascaris lumbricoides is one of the most frequent parasites around the world, with a prevalence near 25-30%, especially in developing countries, constituting an important source of morbidity and mortality. It is a soil-transmitted helminth; its eggs hatch larvae in the duodenum and enter the circulation to the liver and lungs by sixth or eighth day. The alveolar membrane is damaged, and worms are expectorated and reenter the intestinal tract by day eighth or tenth, where they mature into adults with subsequent oral, nasal, or anal passage. People with poor socioeconomic environment, education, sanitization, poor hygienic habits or lack of water supply are more proper to acquire and re-acquire this parasite although proper treatment [1,4].
Complications associated with Ascaris lumbricoides includes intestinal obstruction, volvulus, pancreatitis, cholangitis, cholecystitis, and liver abscess, the last of this the less frequent (<1%) but one very severe in some cases [5,6]. The tendency of Ascaris to enter all orifi ces allow it to carry gut fl ora along with it in the biliary three, and people with massive worm infestation in duodenum are more prone to get it. The association with bacterial fl ora, especially E. Coli leads to cholangitis, and it can invade the hepatic parenchyma leading to local infl ammation, necrosis and abscess formation, in some cases favored by death worms in the parenchyma [2,7].
Symptoms use to be very unspecifi c, including right upper quadrant pain, tenderness and fever, this last the more common presented. Clinical history or symptoms are indistinguishable from pyogenic abscess and for this reason the etiological diagnosis is very diffi cult, sometimes only achieved after initial medical treatment failure, imaging studies that observe an adult worm directly in the abscess or at surgery. Ultrasound is the preferred method for this purpose and could see adult worms when intentionally searched up to 84% of cases [5]. CT scan is another option for diagnosis with sensitivity of 95% for unique abscess or 100% when multiple abscesses, and sometimes used to perform a surgical plan. Initially medical treatment is recommended with Albendazol 400mg per day for three days, and in some cases guided punction and drain of abscess is performed with limited success. In the present case it is contraindicated for being multiple abscesses and location in the left lobe. Surgery remains the standard of treatment for liver abscess secondary to Ascaris lumbricoides, especially when they are multiple or biliary three is obstructed because medical treatment would fail in this cases, secondary to adult parasite die inside the liver, giving rise to necrotic focus [7]. During surgery adult worms or eggs could be found in the abscess or necrotic tissue, associated with an intense infl ammatory reaction and Charcot-Leyden crystals [6].
Charcot-Leyden crystals are structures eosinophil and basophil derivatives. Their presence indicates an infl ammatory process, usually allergic or by hypersensitivity, with degranulation of eosinophils, basophils or both of them, being characteristic of parasitic diseases. After surgical abscess drainage medical treatment must be continued until drain removal, with image studies like CT scan confi rming abscess absence.
Hepatic abscess secondary to Ascaris lumbricoides is an extremely rare complication of this parasite infection, with severe consequences in cases of diagnosis and treatment delay that is very common secondary to the unspecifi c signs and symptoms, with progression to multi-organic failure and dead