In the case of cancer-type liver lesions, infectious causes, including parasitic infections, should also be considered in addition to neoplastic causes. This is what Markus Zachäus, a doctor at Helios Park-Klinikum in Leipzig, and his colleagues recommend. The reason is the clinical history of a 50-year-old man, described in a specialized journal of internal medicine.
The patient and his story
According to the authors, the 50-year-old man turned to the Leipzig clinic because of severe pain in the lower abdomen.The history revealed arterial hypertension, type 2 diabetes, chronic obstructive pulmonary disease (COPD) and an inguinal hernia operated years earlier.
The results
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Pain following pressure in the lower abdomen.
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Leukocytes below normal and slightly elevated CRP.
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Abdominal ultrasound: irregular structure limited at the level of the sigmoid colon with surrounding fluid lamellae and lymphadenopathy; several round liver foci.
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Ultrasound with contrast medium: mild marginal arterial hyperperfusion, central recess and venous wash-out, with suspicion of malignancy.
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Computed tomography: suspicion of neoplasm with metastases to the liver; According to the authors, a distant thrombosis from the lateral branch of the left paracolic inferior mesenteric vein with surrounding inflammatory reaction was evident.
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Colonoscopy: extensive infestation with Enterobius vermicularis in all segments of the colon; no tumor; in sigmoid «several small submucosal masses with raised edematous mucosa and dotted depressions» (histologically pronounced eosinophilic inflammatory reaction without evidence of malignancy).
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Microscopic examination of two removed superficial «metastatic formations»: pronounced necrosis surrounded by a strong eosinophilic inflammatory infiltrate; in necrosis, evidence of a female parasite of the type Enterobius vermicularis swollen and full of tapeworm eggs.
Pain following pressure in the lower abdomen.
Leukocytes below normal and slightly elevated CRP.
Abdominal ultrasound: irregular structure limited at the level of the sigmoid colon with surrounding fluid lamellae and lymphadenopathy; several round liver foci.
Ultrasound with contrast medium: mild marginal arterial hyperperfusion, central recess and venous wash-out, with suspicion of malignancy.
Computed tomography: suspicion of neoplasm with metastases to the liver; According to the authors, a distant thrombosis from the lateral branch of the left paracolic inferior mesenteric vein with surrounding inflammatory reaction was evident.
Colonoscopy: extensive infestation with Enterobius vermicularis in all segments of the colon; no tumor; in sigmoid «several small submucosal masses with raised edematous mucosa and dotted depressions» (histologically pronounced eosinophilic inflammatory reaction without evidence of malignancy).
Microscopic examination of two removed superficial «metastatic formations»: pronounced necrosis surrounded by a strong eosinophilic inflammatory infiltrate; in necrosis, evidence of a female parasite of the type Enterobius vermicularis swollen and full of tapeworm eggs.
Diagnosis, treatment and course
For doctors in Leipzig the diagnosis was enterobiosis of the colon with hepatic involvement.The man was then treated with albendazole (100 mg o.w. 3 times at 14-day intervals as a single dose). After two months, the authors report that no pinworms were detected by the SCOTCH test . Ultrasound monitoring showed no evidence of persistent hepatic manifestations of worms or thrombosis.
Discussion
Enterobius vermicularis (EV) is one of the most common parasites in the world and has a unique life cycle, explains Eva Schadelbauer from the Department of Dermatology and Venereology at the Medical University of Graz. «After oral or nasal ingestion of eggs, the larvae hatch in the proximal part of the small intestine. On their way to the large intestine, the larvae molt twice, become adult worms and multiply.» The male worm can live up to 50 days and dies after mating. Female specimens can live up to 100 days.Only the pregnant worm, which can produce up to 11,000 eggs, migrates to the perianal and perineal region to lay oval, asymmetrical eggs.
The typical clinical symptom is nocturnal (peri)itching, which can lead to incessant scratching and bacterial superinfection, explains the dermatologist. EV is transmitted through contact with contaminated food, clothing, bedding and other objects, or through direct skin contact and sexual activity.
According to Markus Zachäus and his colleagues, systemic extraintestinal enterobiosis with multi-organ infestation is rare. The active substances approved for the treatment of enterobiosis are mebendazole, pyrantelembonate and pyrvinium embonate. Application is limited to enteric infestations. For extraintestinal infestations, albendazole and ivermectin are considered very effective as «off-label therapy». However, only the benzimidazole derivative albendazole is adulticidal and ovicida.
It is necessary that all people living in a family and also the sexual partners of patients are examined, tested and, if necessary, treated, emphasizes Eva Schadelbauer.Even after effective therapy, however, relapses may occur.
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