Massive infestation by Ascaris lumbricoides of the biliary tract: report of a successfully treated case

Andrade Júnior, Dahir Ramos de; Karam, José Abi; Warth, Maria do Patrocínio Tenório Nunes; Marca, Alexandre Frederico de; Jukemura, José; Machado, Marcel Cerqueira Cesar; Rocha, Antonino dos Santos

doi:10.1590/S0036-46651992000100012

Abstracts

This is a report of a 25 years old black woman from the city of São Paulo, Brazil, who developed acute obstructive cholangitis of Ascaris lumbricoides with septicemia and multiple hepatic abscesses. The patient had sickle cell trait and normal delivery 3 months ago. Massive infestation of the biliary tract by Ascaris lumbricoides was diagnosed by abdominal ultrasonography and endoscopic retrograde cholangiography. Sixty worms were removed from the common bile duct and hepatic abscesses were drained by surgery. The infectious process was polymicrobial. The patient's recovery was complete after a long evolution with a wide spectrum antibiotic therapy. New surgeries were needed to remove residual worms in the biliary tract. The diagnostic methods, clinical-biochemical features and also the clinical and surgical management are presented. The biliary ascariasis pathophysiology is commented.

Biliary ascariasis; massive infestation; cholangitis

Descrito caso de mulher de 25 anos, negra, procedente da cidade de São Paulo - Brasil, que desenvolveu quadro agudo de colangite obstrutiva por Ascaris lumbricoides, com septicemia e múltiplos abscessos hepáticos. Era portadora de traço falciforme e tinha tido um parto normal há 3 meses. Foi estabelecido o diagnóstico de infestação maciça por Ascaris lumbricoides em vias biliares com ultrasonografia abdominal e colangiografia retrógrada endoscópica. Sessenta vermes foram retirados do colédoco e drenados os abscessos hepáticos por cirurgia. O quadro infeccioso era polimicrobiano. Houve recuperação total da paciente após longa evolução, com antibioticoterapia de amplo espectro e novas cirurgias com extração de vermes residuais. Os autores apresentam os métodos diagnósticos empregados, o quadro clínico-bioquímico e a abordagem terapêutica. A fisiopatologia da ascaridíase biliar é discutida.

CASE REPORT

Massive infestation by Ascaris lumbricoides of the biliary tract: report of a successfully treated case

Infestação maciça por Ascaris lumbricoides nas vias biliares: relato de um caso tratado com sucesso

Dahir Ramos de Andrade Júnior^I; José Abi Karam^I; Maria do Patrocínio Tenório Nunes Warth^I; Alexandre Frederico de Marca^I; José Jukemura^II; Marcel Cerqueira Cesar Machado^II; Antonino dos Santos Rocha^I

^IDiscipline of General Clinic and Propedeutics at the Medical Clinic Department of the Clinic Hospital of São Paulo University, in São Paulo city, Brazil

^IIDiscipline of the Digestive System Surgery at the Gastroenterology Department. Biliary Tract and Pancreas Surgery Service of the Clinic Hospital of São Paulo University, in São Paulo city, Brazil

^{Address for correspondence} Address for correspondence: Dr. Dahir Ramos de Andrade Júnior Faculdade de Medicina da USP - Laboratório de Pesquisa Básica - LIM/12 Av. Dr. Arnaldo, 455, 2º andar, sala 117 CEP 01246 - São Paulo. Brasil

SUMMARY

This is a report of a 25 years old black woman from the city of São Paulo, Brazil, who developed acute obstructive cholangitis of Ascaris lumbricoides with septicemia and multiple hepatic abscesses. The patient had sickle cell trait and normal delivery 3 months ago. Massive infestation of the biliary tract by Ascaris lumbricoides was diagnosed by abdominal ultrasonography and endoscopic retrograde cholangiography. Sixty worms were removed from the common bile duct and hepatic abscesses were drained by surgery. The infectious process was polymicrobial. The patient's recovery was complete after a long evolution with a wide spectrum antibiotic therapy. New surgeries were needed to remove residual worms in the biliary tract. The diagnostic methods, clinical-biochemical features and also the clinical and surgical management are presented. The biliary ascariasis pathophysiology is commented.

Key words: Biliary ascariasis, massive infestation, cholangitis.

RESUMO

Descrito caso de mulher de 25 anos, negra, procedente da cidade de São Paulo - Brasil, que desenvolveu quadro agudo de colangite obstrutiva por Ascaris lumbricoides, com septicemia e múltiplos abscessos hepáticos. Era portadora de traço falciforme e tinha tido um parto normal há 3 meses. Foi estabelecido o diagnóstico de infestação maciça por Ascaris lumbricoides em vias biliares com ultrasonografia abdominal e colangiografia retrógrada endoscópica. Sessenta vermes foram retirados do colédoco e drenados os abscessos hepáticos por cirurgia. O quadro infeccioso era polimicrobiano. Houve recuperação total da paciente após longa evolução, com antibioticoterapia de amplo espectro e novas cirurgias com extração de vermes residuais. Os autores apresentam os métodos diagnósticos empregados, o quadro clínico-bioquímico e a abordagem terapêutica. A fisiopatologia da ascaridíase biliar é discutida.

Full text available only in PDF format.

Texto completo disponível apenas em PDF.

ACKNOWLEDGEMENTS

We thank Maria José Machado Mendes for immunological tests and Dr. Lauro Kawakami of the Radiology Service of the Clinical Hospital of São Paulo University for the valuable methods of image.

Recebido para publicação em 6/6/1991.

Aceito para publicação em 24/10/1991.

1. CERRI, G.G.; LEITE, G.J.; SIMŐES, J.B.; DA ROCHA, D.J.C.; ALBUQUERQUE, F.P.; MACHADO, M.C.C. & MAGALHĂES, A. - Ultrasonographic evaluation of Ascaris in the biliary tract. Radiology, 146: 753-754, 1983.
2. CHIN-CHE, C. & CHEN-TEH, H. - Biliary ascariasis in childhood. A clinical analysis of 788 cases. Chin. med. J., 85: 167-171, 1966.
3. DOHERTY, P.S.; La CRUZ, F.J.; BARRANGÁN, E.G.; REYNOSO, S.G. & LARIS, C.R. - Parasitosis de vias biliares: Ascaris lumbricoides. Rev. Invest. clin., 38: 297-302, 1986.
4. EFEM, S.E.E. - Ascaris lumbricoides and intestinal perforation. Brit. J. Surg., 74: 643-644, 1987.
5. JESSEN, K.; AL MOFLEH, I. & AL MOFARREH, M. - Endoscopic treatment of ascariasis causing acute obstructive cholangitis. Hepato-Gastroent., 33: 275-277, 1986.
6. KEYSTONE, J.S. - Ascariasis. In: GOLDSMITH, R. & HEYNEMAN, D. ed. - Tropical medicine and parasitology. Norwalk, Appleton & Lange, 1989. p. 350-355.
7. KHUROO, M.S. & ZARGAR, S.A. - Ascariasis biliary. A common cause of biliary and pancreatic disease in an endemic area. Gastroenterology, 88: 418-423, 1985.
8. LIFSCHITZ, O.; TIU, J.; SUMERUK, R.A. & WEISS, A. - Biliary ascariasis. A case report. S. Afr. med. J., 71: 329-330, 1987.
9. LOUW, J.H. - Abdominal complications of Ascaris lumbricoides infestation in children. Brit. J. Surg., 53: 510-521, 1966.
10. MAKIDONO, J. - Observations on ascaris during fluoroscopy. Amer. J. trop. Med. Hyg., 5: 699-702, 1956.
11. NGUYEN, D.Q.; SCHMAUSS, A.K. & NGUYEN, X.T. - Ascaridiasis der Gallenwege beim Kind Bericht Uber 127 Beobachtungen vom 1.1.1961-30.12.1961. Trop. Dis. Bull., 60: 244-245, 1963 (Abstract).
12. PAUL, M. - The movement of the adult Ascaris lumbricoides. Brit. J. Surg., 59: 437-442, 1972.
13. PESSÔA, S.B. & MARTINS, A.V. - Parasitologia médica. 9Ş ed. Rio de Janeiro, Guanabara Koogan, 1974. p. 669-690.
14. PIGGOTT, J.; HANSBARGER Jr., E.A. & NEAFIE, R.C. - Human ascariasis. Amer. J. clin. Path., 53: 223-234, 1970.
15. PRÓSPERO, J.D. - Ascaridiose Hepática. Anatomia patológica classificaçăo e patogenia. Arq. Hosp. Sta. Casa S. Paulo, 6: 1-16, 1960.
16. SAPUNAR, J. - Ascariasis múltiple del colédoco. Bol. chil. Parasit., 28: 34-36, 1973.
17. SAPUNAR, J.; POMÉS, J.; SAPUNAR (hijo), J. & ARROYO, A. - Ascariasis coledociana postoperatoria. Extracción endoscópica del parasito. Bol. chil. Parasit., 41: 72-78, 1986.
18. SAUL, C.; PIAS, V.M.; JANNKE, H.A. & BRAGA, N.H.M. - Endoscopic removal of Ascaris lumbricoides from the common bile duct. Amer. J. Gastroent., 79: 725-727, 1984.
19. SCHULMAN, A. - Biliary ascariasis presenting in the United States. Amer. J. Gastroent., 68: 167-170, 1977.
20. SCHULMAN, A. - Non-western patterns of biliary stones and the role of ascariasis. Radiology, 162: 425-430, 1987.
21. STREET, N.E. & MOSMANN, T.R. - Functional diversity of T lymphocytes due to secretion of different cytokine patterns. FASEB J., 5: 171-177, 1991.
22. WELLER, P.F. - Seminars in Medicine of the Beth Israel Hospital, Boston: The immunobiology of Eosinophils. N. Engl. J. med., 324: 1110-1118, 1991.
23. WINTERS Jr. C.; CHOBANIAN, S.J.; BENJAMIN, S.B.; FERGUSON, R.K. & CATTAN Jr., E.L. - Endoscopic documentation of Ascaris induced acute pancreatitis. Gastroint. Endosc., 30: 83-84, 1984.
24. YELLIN, A.E. & DONOVAN, A.J. - Biliary lithiasis and helmintiasis. Amer. J. Surg., 142: 128-136, 1981.

Address for correspondence:

Dr. Dahir Ramos de Andrade Júnior

Faculdade de Medicina da USP - Laboratório de Pesquisa Básica - LIM/12

Av. Dr. Arnaldo, 455, 2º andar, sala 117

CEP 01246 - São Paulo. Brasil

Publication Dates

Publication in this collection
06 Sept 2006
Date of issue
Feb 1992

History

Accepted
24 Oct 1991
Received
06 June 1991

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

[1] 1. CERRI, G.G.; LEITE, G.J.; SIMŐES, J.B.; DA ROCHA, D.J.C.; ALBUQUERQUE, F.P.; MACHADO, M.C.C. & MAGALHĂES, A. - Ultrasonographic evaluation of Ascaris in the biliary tract. Radiology, 146: 753-754, 1983.

[2] 2. CHIN-CHE, C. & CHEN-TEH, H. - Biliary ascariasis in childhood. A clinical analysis of 788 cases. Chin. med. J., 85: 167-171, 1966.

[3] 3. DOHERTY, P.S.; La CRUZ, F.J.; BARRANGÁN, E.G.; REYNOSO, S.G. & LARIS, C.R. - Parasitosis de vias biliares: Ascaris lumbricoides. Rev. Invest. clin., 38: 297-302, 1986.

[4] 4. EFEM, S.E.E. - Ascaris lumbricoides and intestinal perforation. Brit. J. Surg., 74: 643-644, 1987.

[5] 5. JESSEN, K.; AL MOFLEH, I. & AL MOFARREH, M. - Endoscopic treatment of ascariasis causing acute obstructive cholangitis. Hepato-Gastroent., 33: 275-277, 1986.

[6] 6. KEYSTONE, J.S. - Ascariasis. In: GOLDSMITH, R. & HEYNEMAN, D. ed. - Tropical medicine and parasitology. Norwalk, Appleton & Lange, 1989. p. 350-355.

[7] 7. KHUROO, M.S. & ZARGAR, S.A. - Ascariasis biliary. A common cause of biliary and pancreatic disease in an endemic area. Gastroenterology, 88: 418-423, 1985.

[8] 8. LIFSCHITZ, O.; TIU, J.; SUMERUK, R.A. & WEISS, A. - Biliary ascariasis. A case report. S. Afr. med. J., 71: 329-330, 1987.

[9] 9. LOUW, J.H. - Abdominal complications of Ascaris lumbricoides infestation in children. Brit. J. Surg., 53: 510-521, 1966.

[10] 10. MAKIDONO, J. - Observations on ascaris during fluoroscopy. Amer. J. trop. Med. Hyg., 5: 699-702, 1956.

[11] 11. NGUYEN, D.Q.; SCHMAUSS, A.K. & NGUYEN, X.T. - Ascaridiasis der Gallenwege beim Kind Bericht Uber 127 Beobachtungen vom 1.1.1961-30.12.1961. Trop. Dis. Bull., 60: 244-245, 1963 (Abstract).

[12] 12. PAUL, M. - The movement of the adult Ascaris lumbricoides. Brit. J. Surg., 59: 437-442, 1972.

[13] 13. PESSÔA, S.B. & MARTINS, A.V. - Parasitologia médica. 9Ş ed. Rio de Janeiro, Guanabara Koogan, 1974. p. 669-690.

[14] 14. PIGGOTT, J.; HANSBARGER Jr., E.A. & NEAFIE, R.C. - Human ascariasis. Amer. J. clin. Path., 53: 223-234, 1970.

[15] 15. PRÓSPERO, J.D. - Ascaridiose Hepática. Anatomia patológica classificaçăo e patogenia. Arq. Hosp. Sta. Casa S. Paulo, 6: 1-16, 1960.

[16] 16. SAPUNAR, J. - Ascariasis múltiple del colédoco. Bol. chil. Parasit., 28: 34-36, 1973.

[17] 17. SAPUNAR, J.; POMÉS, J.; SAPUNAR (hijo), J. & ARROYO, A. - Ascariasis coledociana postoperatoria. Extracción endoscópica del parasito. Bol. chil. Parasit., 41: 72-78, 1986.

[18] 18. SAUL, C.; PIAS, V.M.; JANNKE, H.A. & BRAGA, N.H.M. - Endoscopic removal of Ascaris lumbricoides from the common bile duct. Amer. J. Gastroent., 79: 725-727, 1984.

[19] 19. SCHULMAN, A. - Biliary ascariasis presenting in the United States. Amer. J. Gastroent., 68: 167-170, 1977.

[20] 20. SCHULMAN, A. - Non-western patterns of biliary stones and the role of ascariasis. Radiology, 162: 425-430, 1987.

[21] 21. STREET, N.E. & MOSMANN, T.R. - Functional diversity of T lymphocytes due to secretion of different cytokine patterns. FASEB J., 5: 171-177, 1991.

[22] 22. WELLER, P.F. - Seminars in Medicine of the Beth Israel Hospital, Boston: The immunobiology of Eosinophils. N. Engl. J. med., 324: 1110-1118, 1991.

[23] 23. WINTERS Jr. C.; CHOBANIAN, S.J.; BENJAMIN, S.B.; FERGUSON, R.K. & CATTAN Jr., E.L. - Endoscopic documentation of Ascaris induced acute pancreatitis. Gastroint. Endosc., 30: 83-84, 1984.

[24] 24. YELLIN, A.E. & DONOVAN, A.J. - Biliary lithiasis and helmintiasis. Amer. J. Surg., 142: 128-136, 1981.

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