A Diagnostic Dilemma: Hepatic Fascioliasis in a Child Presenting as Multifocal Liver Abscesses mimicking Malignancy: A case report

Technical Summary: Hepatic Fascioliasis in a Child Mimicking Malignancy

Problem Statement
Fascioliasis, a zoonotic infection caused by the trematode Fasciola hepatica, typically affects the hepatobiliary system. While common in developing regions with livestock exposure, it remains underreported in Africa, particularly regarding pediatric cases. The primary clinical challenge lies in the infection's nonspecific presentation, which frequently mimics bacterial pyogenic liver abscesses or hepatic malignancies (such as hepatoblastoma). This diagnostic overlap often leads to misdiagnosis, prolonged empirical antibiotic therapy without clinical improvement, and unnecessary invasive interventions. In pediatric patients, the differentiation between infectious, inflammatory, and neoplastic hepatic lesions is particularly critical yet difficult, as radiological findings can be ambiguous.

Methodology
This study presents a single case report of a 7-year-old female patient from Ethiopia. The methodology involved a retrospective analysis of the patient's clinical course, laboratory evaluations, imaging studies, and histopathological findings.

• Clinical Presentation: The patient presented with a three-week history of right upper quadrant (RUQ) and epigastric pain, vomiting, and tachycardia.
• Initial Workup: Initial contrast-enhanced CT at an external facility diagnosed pyogenic liver abscess, leading to 18 days of broad-spectrum intravenous antibiotics (ceftriaxone, vancomycin, metronidazole) with no improvement.
• Re-evaluation: Upon admission to the authors' institution, the patient exhibited stable vitals but persistent RUQ tenderness. Laboratory results showed elevated inflammatory markers (CRP 42) and mild eosinophilia (5.5%).
• Imaging: Abdominal ultrasound revealed multiple hyperechoic solid and thick-walled cystic focal liver lesions, raising suspicion for a liver mass or abscess. Serum AFP and stool examinations were normal.
• Definitive Diagnosis: Due to the lack of response to antibiotics and the suspicion of malignancy or refractory abscess, a core needle liver biopsy was performed. Histopathological analysis revealed multifocal dense mixed inflammatory infiltrates dominated by eosinophils, palisading epithelioid granulomas, and scattered Charcot–Leyden crystals. No ova or parasites were visualized in the tissue, but the histologic pattern was deemed suggestive of Fasciola hepatica.
• Intervention: Based on the histopathological findings and clinical context, the patient was treated with triclabendazole.

Key Results

• Diagnostic Confirmation: The diagnosis of hepatic fascioliasis was established primarily through histopathology (eosinophil-rich granulomatous inflammation with Charcot–Leyden crystals) rather than serology or direct visualization of the parasite, which was unavailable or not observed in the sample.
• Therapeutic Outcome: Following the initiation of triclabendazole, the patient demonstrated significant clinical improvement, resolving the symptoms that had persisted despite 18 days of broad-spectrum antibiotics.
• Clinical Course: The case highlighted that the patient was in the acute hepatic migratory phase of the infection, characterized by parenchymal invasion, rather than the more commonly diagnosed chronic biliary phase.

Key Contributions

• Diagnostic Pathway: This report details a less common diagnostic pathway where histopathological evaluation of liver tissue was decisive in establishing a diagnosis of fascioliasis during the hepatic phase, particularly in a setting where serological testing was not available.
• Pediatric Presentation: It documents a pediatric case where multifocal hepatic lesions mimicked malignancy, emphasizing the difficulty in distinguishing parasitic infections from neoplastic conditions in children.
• Histopathological Markers: The study reinforces the utility of identifying Charcot–Leyden crystals and eosinophil-rich granulomas as key indicators of parasitic infection when direct parasite visualization is absent.

Significance and Claims
The authors claim that this case underscores the necessity of including fascioliasis in the differential diagnosis for children presenting with persistent hepatic lesions, eosinophilia, and a poor response to conventional antibiotic therapy, especially in endemic regions.

• Avoidance of Harm: Early recognition and appropriate treatment with triclabendazole can prevent unnecessary surgical interventions, prolonged antibiotic exposure, and complications such as biliary obstruction or cholangitis.
• Clinical Vigilance: The paper argues that in endemic settings, the combination of persistent hepatic lesions and eosinophilia should trigger a consideration of parasitic etiologies even when imaging suggests abscess or tumor.
• Treatment Efficacy: The case confirms that triclabendazole remains highly effective against both immature and adult flukes, leading to favorable outcomes when the diagnosis is made early.

The paper concludes that while fascioliasis is a diagnostic dilemma, a multidisciplinary approach correlating radiologic, laboratory, and histopathologic findings is essential for accurate diagnosis and timely management in pediatric patients.