Post-partum pyogenic abscess containing Ascaris lumbricoides.

We report an unusual case of multiple pyogenic liver abscesses containing Ascariasis lumbricoides in a 35-year-old post-partum female who had delivered 1 month back. Open drainage of liver abscess along with liver worm was done. Patient did well post-operatively.

Biliary ascariasis is common in certain geographical areas of the world. In India, it is common in Kashmir valley.[1] Usual habitat of Ascariasis lumbricoides is the small intestines. Biliary ascariasis result when worm migrates through papilla. The worm may remain in the bile duct or gall bladder. Some worms may travel up and colonize in the parenchyma forming liver abscess.[2] Post-partum pyogenic liver abscess has been described in literature.[3] The three major forms of liver abscess, classified by etiology, are as follows: Pyogenic abscess, which is most often polymicrobial, Amebic abscess due to Entamoeba histolytica and fungal abscess, most often due to Candida species. We report a case of 35-year-old female who had delivered 28 days back, presented with multiple pyogenic liver abscess. On open exploration one of the liver abscess cavities contained live A. lumbricoides.

THE CASE

A 35-year-old female, 28 days post-partum (Lower Segment Cesarian Section LSCS done) presented to our department with history of fever for 7 days. Fever was high-grade and was associated with rigors and chills. General physical examination revealed tempreture 101.5°F, pallor was present. Abdominal examination revealed tenderness in right hypochondrium. LSCS scar was healthy. Complete blood count showed Hemoglobin: 7.1 mg/dl, Total leukocyte count – 21,000 (N = 87%, M = 2%, E = 1%, L = 10%). Platelet count – 250,000, Kindey Function Tests KFT-Normal, Liver Function Tests – [Bilirubin: 2.15 mg/dl, Alanine Transaminase ALT: 50, Aspartate Transaminase AST: 42, Alkaline Phosphatase ALP: 350, Coagulogram – Prothombin Time Index PTI: 90%, International Normalised Ratio INR: 1.3, Prothrombin Time PT: 17 s]. X-ray chest: Normal, X-ray abdomen; Elevated right hemidiaphargm. Ultrasonography (USG) abdomen revealed multiple liver abscesses in the right lobe of liver. A note of presence of liver hyperechoic structure was made in one of the abscess cavities in segment VII. Contrast enhanced computed tomography (CECT) abdomen revealed multiple liver abscesses in the right lobe of liver, size varying from 3 cm to 18 cm in segment VII and VIII [Figure 1]. Intravenous antibiotics were started. A conservative trial of 2 days was given but patient did not respond and continued to have abdominal pain and fever. Decision to explore the patient was made. On exploration, the liver was enlarged; adherent with lateral thoracic wall and diaphragm contained multiple abscesses. On evaluation of one of the abscess cavities, live Ascaris was seen protruding from the abscess, which was located in segment VII of the liver. The worm was extruded with a forcep and abscess cavity drained [Figures 2 and 3]. Gall bladder and common bile duct was normal. Patient was kept on Intravenous antibiotics for 1 week post-operatively and discharged on oral antibiotics and anthelminthic treatment. Patient is doing well. USG abdomen 6 weeks post-surgery is normal.

Figure 1

Computed tomography liver showing a hyperdens shadow in abscess cavity

Figure 2

Intra-operative photograph live worm being extruded from abscess cavity with foreceps

Figure 3

Intra-operative photograph live worm completely removed from abscess cavity with forceps

CONCLUSIONS

Biliary ascariasis is reported from highly endemic regions like Indian subcontinent, Far-east, Latin America, parts of Middle East and Africa.[2] Symptoms results when worm migrates across the papilla and may result in cholangitis, biliary stricture, calculi, cholecystitis and pancreatitis.[3] Worm may also result in formation of a liver abscess.[4] Biliary ascariasis is more common in women than men. Khuroo et al., in their study reported a similar observation.[5] Predisposing factors include, cholecystectomy, sphincterotomy, previous biliary tract surgery[567] although, the present case had no such history. As our patient had recently delivered and the pregnancy being a high hormone level state (increased estrogens and increased progesterone levels) could be a predisposing factor for biliary ascariasis. As described earlier also the disease is common in middle aged females as described in the literature.[5678] It is possible that in these young females the hormone progesterone may lead to relaxation of smooth muscles of sphincter of oddi, allowing the worm to penetrate into the biliary tract. Progesterone is known to increase gall bladder volume and decreases its emptying.[9] It is clear from the above discussion that pregnancy might be a predisposing factor for biliary ascariasis in our case also. As mentioned in the case, a live worm was extruded from one of the abscess cavities of the liver. Lloyd in one of his study described massive hepatobiliary ascaris in childhood and has also mentioned presence of the Ascaris in liver abscess cavity of a child.[4] In our case, the presence of this solitary liver worm could not have been a cause of the liver abscess per se but the worm could have intruded the abscess cavity during its development as our report being the first of its instance in the literature.

In post-partum ladies and pregnant patient biliary ascariasis being a common condition the possibility of this case should also be kept in mind while evaluating post-partum fever. This particular case highlights the endemic nature of Ascaris which can even survive in a walled off abscess cavity.