PMC8651557_01
The clinical course of the patient (schematic). Hematoxylin and eosin staining of the liver specimen shows some punctate necrosis on the lobule, apoptotic bodies in the hepatic cord, fatty degeneration of hepatocytes, mild inflammation in the portal area, and eosinophil infiltration in the inflammatory necrosis area.
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F1
An outline of the episodes is described in Figure 1. The hepatic histopathology reported mild inflammation in the portal area and eosinophil infiltration in the inflammatory necrotic area, with no evidence of malignancy, liver abscess, and parasitic infection on hospital day 20 (Figure 1).
Timeline with relevant data from the episode of care; curves of body temperature and eosinophils count. The blue line shows the body temperature values. The orange line shows the eosinophil counts. Horizontal thick lines show the medications administered. PIP-SBT, Piperacillin-sulbactam.
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F2
Routine blood parameters revealed elevated white blood cell and eosinophil count (Figure 2). However, the body temperature of the patient fluctuated several times, and the eosinophil count was not significantly reduced (Figure 2). During the period of hospital days 33 and 67, the patient still had repeated fever with a maximum temperature of 39 C (Figure 2). However, there was still a high fever up to 40 C (Figure 2), occasionally.
Imaging features of the patient. (A) Abdominal MRI enhancement showed that the right lobe of the liver scattered flakes, irregular shape, enhanced uneven enhancement on hospital day 2. (B) Abdominal CT enhancement showed liver multiple nodules, mass slightly low-density shadow, edge enhancement on hospital day 13. (C) Abdominal CT enhancement showed multiple cystic and tubular low-density shadows scattered in the liver, and some showed edge enhancement on day 33. (D) Abdominal CT enhancement showed multiple cystic and tubular low-density shadows scattered in the liver, some showed edge enhancement, and a few lesions were smaller than those before on follow-up day 69. (E) Abdominal MRI enhancement showed cystic and tubular shadows in the right lobe of the liver, with irregular shapes and edge enhancement in the enhanced part. Some lesions were smaller than before on follow-up day 137. (F) Abdominal MRI enhancement showed the right lobe of the liver scattered flakes, irregular shape, enhanced edge uneven enhancement, lesions significantly reduced on follow-up day 418.
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F3
Enhanced MRI of the upper abdomen showed the increased liver volume, uneven liver parenchyma signal, liver interstitial edema, and accumulated fluid in the abdominal cavity on hospital day 2 (Figure 3A). So, an enhanced CT of the lower abdomen was performed on hospital day 13, which showed multiple shadows of abnormal density in the liver and a small amount of effusion, suggesting the possibility of infectious and neoplastic lesions (Figure 3B). MRI of the upper abdominal was re-examined on hospital day 33, which indicated no absorption of intrahepatic lesions (Figure 3C). Meanwhile, combined with Chongqing epidemiological studies of Clonorchis sinensis, parasite infection was suspected and praziquantel was used as treatment. An enhanced MRI of the upper abdominal showed that the liver shadow had less absorption (Figure 3D). Meanwhile, the enhanced MRI of the upper abdominal reexamined on follow-up day 137 showed that there was no significant absorption of the lesions compared with the previous (Figure 3E). After more than 3 months after drug withdrawal on follow-up day 148, the enhanced MRI of the upper abdominal showed that the intrahepatic low-density shadow was smaller (Figure 3F), and the blood mNGS was negative (Table 1), suggesting the albendazole treatment was effective.
Diagnosis of Fasciola hepatica infection using metagenomic next-generation sequencing (mNGS). (A) The reads mapped to the Fasciola hepatica genome with coverage of 0.0001% in the liver tissue. (B) The distribution of species-specific reads aligning to the parasite in the liver tissue. (C) The reads mapped to the Fasciola hepatica genome with coverage of 0.0002% in the blood. (D) The distribution of species-specific reads aligning to the parasite in the blood.
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Fasciola hepatica genome in the liver biopsy and blood was 3 and 51, respectively (Figure 4). Finally, the disease was diagnosed with fascioliasis hepatica with triclabendazole as the first-line drug.