The Brief Case: What a Fluke! A Case of Fascioliasis with Pulmonary Involvement in a Peace Corps Volunteer

Abstract

A 25-year-old Caucasian American woman without significant medical history presented to the travel clinic with a 1-week history of worsening diarrhea and bloating. She had recently returned from an 8-month trip to Ethiopia, where she worked as a Peace Corps volunteer. While in Ethiopia, she resided with a local host family, ate the local cuisine, and drank untreated water. During her 8-month tour, she was diagnosed with and treated locally for intestinal Entamoeba histolytica amebiasis and giardiasis with tinidazole. Five weeks after leaving Ethiopia, she took praziquantel as preemptive therapy for schistosomiasis. Upon initial evaluation, she reported significant fatigue, nighttime urticaria, and nonproductive cough. She did not report right upper quadrant pain, jaundice, or fever. Physical examination was unremarkable. A complete blood count revealed eosinophilia of 46% (reference range, 1 to 3%) and an absolute eosinophil count of 12.28 ϫ 10 9 /liter (Table 1). Liver function tests were within the reference range. A stool enzyme immunoassay for Cryptosporidium spp. was positive, and a stool parasite exam reported Blastocystis hominis, Endolimax nana, Entamoeba coli, Entamoeba hartmanni, and Dientamoeba fragilis. A gastrointestinal (GI) pathogen PCR panel (BioFire Diagnostics, Salt Lake City, UT) was positive for enteroaggregative Escherichia coli and enterotoxigenic E. coli. A fourth-generation HIV-1/2 antigen/antibody test and an interferon gamma release assay were negative. Tests for Entamoeba histolytica serum IgG antibody (R-Biopharm AG, Darmstadt, Germany), Toxocara serum IgG antibody (Gold Standard Diagnostics, Davis, CA), Echinococcus serum IgG antibody (R-Biopharm AG, Darmstadt, Germany), Schistosoma serum IgG antibody (NovaTec Immundiagnostica GmbH, Dietzenbach, Germany), and Strongyloides serum IgG antibody (Bordier Affinity Products SA, Crissier, Switzerland) and Strongyloides stercoralis stool culture were negative. A Knott's concentration test for filariae was also negative. A computed tomography (CT) scan of the chest and abdomen/pelvis revealed patchy airspace infiltrates in the left lower lobe and areas of ill-defined low attenuation in the liver. Upper gastrointestinal endoscopy with biopsy was unremarkable, and small bowel aspirate revealed no organisms. She was empirically started on tinidazole for suspected amebic liver abscess. Three weeks later, she was admitted to the hospital due to worsening dyspnea. A repeated CT of the chest and abdomen/pelvis revealed multifocal areas of consolidation in both lungs and persistent ill-defined liver hypodensities (Fig. 1). Bronchoalveolar lavage revealed an eosinophil count of 73%, but no parasite eggs or larvae were noted. Peripheral bacterial and fungal blood cultures were negative. Magnetic resonance imaging of the abdomen revealed ill-defined hepatic enhancement in the right and left hepatic lobes associated with mild intrahepatic biliary ductal dilation. An ultrasoundguided biopsy of the left lobe lesion was performed. Histologic examination demon