fasciolid trematodes , such as fasciola hepatica and fasciola gigantica , are primarily the liver flukes of herbivorous mammals , i.e. , sheep , cattle , and goats . this trematode infection , i.e. , fascioliasis , is widely distributed throughout the world . in particular , many cases have been reported from south america , northern africa , iran , and western europe [ 1 - 3 ] . recently , although several human cases have been sporadically reported in the republic of korea , endemic areas have not been known yet [ 7 - 11 ] . in human fascioliasis however , they are sometimes detected in ectopic foci , i.e. , cecum , ascending colon , brain , eye , spinal cord , subcutaneous tissues , and lymph nodes [ 7 - 9,12 - 16 ] . intestinal perforation was seen in dead rabbits experimentally infected with f. hepatica , and fascioliasis could be fatal due to various complications . ectopic fascioliasis in various organs such as the pancreas , cecum , eye , and subcutaneous tissues have been reported in korea [ 7,19 - 21 ] . the histopathologic findings in ectopic fascioliasis are characterized by eosinophilic infiltration and granulomatous lesions formed around eggs and/or worms . we report a case of human ectopic fascioliasis in which an adult fluke and eggs were found in the mesocolon in a surgically resected specimen . mesocolon abscess by ectopic fascioliasis should be given a thought in the differential diagnosis of patients exposed to fresh water plants . a 56-year - old female was admitted to a local hospital with discomfort and pain in the left lower quadrant of the abdomen for 10 days . the patient had a surgical history of appendectomy 4 years ago . she was admitted after the symptom onset 10 days later ( 21 october 2011 ) ; an abscess was found in the left lower paracolic gutter by abdominal ct and the patient was treated with oral antibiotics . twenty days after the first ct , on a follow - up ct , 2 additional abscesses were found at the splenic flexure in the left upper quadrant area and the pelvic cavity . crp was 7.41 mg / dl , and serum electrolytes and liver enzymes were within normal range . an abdominal ct showed 3 abscesses in the left upper quadrant , mesentery , and pelvic cavity . on the 11th hospital day after transfer ( 21 november 2011 ) two abscesses were found in the anterior aspect of the distal transverse colon ( 4 cm ) and the interbowel space of the left mid abdomen ( 3.5 cm ) ( fig . small bowel series and colonoscopy showed no remarkable findings except a diverticulum at the duodenal third portion . routine parasitic elisa test ( architect i2000sr , abbott diagnostics , abott park , illinois , usa ) was requested , and the result was positive for cysticercus cellulosae and sparganum . on the 18th hospital day after transfer ( 28 november 2011 ) , the patient underwent transverse and left colectomy and anterior resection under the impression of cysticercosis . surgical exploration showed abscess pockets in the mesocolon of the sigmoid colon and distal one third of the transverse colon ( fig . the leaf - like worm was found in the abscess pocket of the mesocolon of the left colon . the leaflet - like worm was diagnosed as an adult fluke of f. hepatica ( fig . the adult fluke of f. hepatica measured 1.3 cm in body length and 0.4 cm in body width . the worm had 2 suckers ( oral and ventral ) and a characteristic conical projection . histologically , numerous eggs of f. hepatica were noted with acute and chronic granulomatous inflammations in the subserosa and pericolic adipose tissues of the sigmoid colon and descending colon . eosinophils showed diffuse infiltrations in the subserosa , and scattered eosinophils were noted in the submucosa with edematous changes ( fig . a year later , she did not complain of any symptoms related to the disease , and an abdominal ct finding was normal except the left hemicolectomy ( fig . in extrabiliary fascioliasis , juvenile or larval worms are found in most cases but adult flukes are rarely detected . in the present study , it is interesting that eggs and adult flukes were found at the same time in the extrabiliary mesocolon . we think that the metacercariae of f. hepatica are stuck to the lotus , and raw lotus extract could infect humans . after a few days , f. hepatica penetrates the capsule of the liver . through the liver parenchyma , the juvenile fluke reaches the bile duct , where it matures into an adult and eggs are passed . the adult fluke in this case the usual forms of human fascioliasis are masses or abscesses in the liver parenchyma , or masses in the bile duct . related clinical manifestations include abdominal pain , fever , hepatomegaly , urticaria , and so on . ectopic sites , except in the hepatobiliary system , are not so rare , and various sites have been reported , including the cecum , ascending colon , brain , eye , spine , subcutaneous tissues , and cervical and inguinal lymph nodes [ 7 - 9,12 - 16 ] . in the first reported case of ectopic fascioliasis in korea , a juvenile form of a fasciola species worm the ascending colon and cecum are located near the liver , which mean the usual routes toward the liver . our case is a rare occasion and more meaningful because abscesses , tracts , eggs , and adult flukes were found in the transverse colon , descending colon , or mesocolon . almost all fascioliasis cases occur by direct penetration through the bowel wall , and only a few cases of infection occur through lymphatic or blood circulation . in our case , numerous eggs , granulomas , and abscesses were found in the fibroadipose tissue of the mesocolon . no mucosal lesion or orifice within the cavity contained f. hepatica , and there was no evidence of bodies or eggs of f. hepatica in blood vessels , lymphatic vessels , or lymph nodes . we conclude that the parasite developed in the transverse colon and descending colon by direct penetration rather than through lymphatics or blood circulation . kim et al .   reported that a larva of anisakis species was found in the lymph node within the mesocolon . in addition , terranova type a larva was found on the serosal wall of the ileum in a patient whose clinical diagnosis was acute appendicitis . direct detection of flukes or eggs , serologic examination , and imaging findings are generally used for diagnosis of fascioliasis in humans . elisa test targeting clonorchis , paragonimus , cysticercus , and sparganum resulted in positive reactions against cysticercus and sparganum . in fact , elisa is important for detection of f. hepatica , particularly in cases involving difficult diagnosis . however , in our case , cross - reaction was observed with cysticercus and sparganum . several studies reported cross - reactions of fasciola with other parasites . however , those cross - reactions were only with schistosoma or cestode . there is no documented evidence indicating that igg of f. hepatica has cross - reactivity with the antigens of sparganum and cysticercus . nevertheless , the possibility of cross - reaction with these parasites can not be completely excluded . in an experimental study on cross - reactivity , lee and yong   found that the recombinant fatty acid binding protein from c. sinensis ( csfabp ) cross - reacted with sera of patients with fascioliasis and paragonimiasis . this csfabp is thought to bind with human bile acid . from 1993 to 2006 , in korea , the igg seroprevalence of clonorchiasis has been at the highest rate among cysticercosis , paragonimiasis , sparganosis , and clonorchiasis . however , because of the aforementioned cross - reactivity of clonorchiasis , it should be differentiated from other parasitic infections . use of different antigens may be required in order to preclude cross - reactions in elisa test . ct findings for peritoneal fascioliasis are mesenteric or omental infiltrations , lymph node enlargement , ascites , and mass or thickening of ligamentum teres . imaging of our case showed abscesses in the distal transverse colon and splenic flexure , which was unusual . the location of the abscess on ct images can support this possibility of direct penetration through the intestinal wall . histopathological examinations through surgical resection of the lesion or direct extraction of the fluke can make the confirmative diagnosis based on morphological identification . the adult worm has a flat and leaf - like appearance with a conical projection at the anterior end . we experienced an ectopic fascioliasis case in which the adult fluke and eggs were found at the site of surgical management . therefore , inclusion of f. hepatica should be considered in the differential diagnosis of parasitic infections with the help of the patient s diet history , eosinophilia , abdominal pain , and the screening elisa test .
we report here an ectopic case of fasciola hepatica infection confirmed by recovery of an adult worm in the mesocolon . 
 a 56-year - old female was admitted to our hospital with discomfort and pain in the left lower quadrant of the abdomen . 
 abdominal ct showed 3 abscesses in the left upper quadrant , mesentery , and pelvic cavity . on surgical exploration 
 , abscess pockets were found in the mesocolon of the sigmoid colon and transverse colon . 
 a leaf - like worm found in the abscess pocket of the mesocolon of the left colon was diagnosed as an adult fluke of f. hepatica . 
 histologically , numerous eggs of f. hepatica were noted with acute and chronic granulomatous inflammations in the subserosa and pericolic adipose tissues . conclusively , a rare case of ectopic fascioliasis has been confirmed in this study by the adult worm recovery of f. hepatica in the mesocolon .