Chronic Fasciola hepatica infection in a patient with cutaneous visceral loxoscelism: paediatric case report
We present the case of a 9-year-old girl from the Peruvian Andean Region (Ancash), diagnosed with fascioliasis, who was also suffering from severe malnutrition. Initially, she was referred for treatment of skin necrosis caused by cutaneous visceral loxoscelism, but during hospitalisation she developed persistent vomiting and pancreatitis. Magnetic resonance cholangiography showed dilation of the intrahepatic and common bile ducts. Endoscopic retrograde cholangiopancreatography identified an adult Fasciola spp. specimen. She also expelled adult worms of Ascaris lumbricoides during vomiting. Delivery of triclabendazole was initiated via a nasogastric tube initially and subsequently via the rectal route, although absorption was limited due to persistent oral intolerance. The patient later developed upper gastrointestinal bleeding and sepsis of abdominal origin and died. During this period, the patient remained on broad-spectrum antibiotic therapy, although sepsis was attributed to persistent biliary obstruction. Fascioliasis and ascariasis should remain in the differential diagnosis for pancreatitis and cholestasis in paediatric patients from endemic areas. Oral triclabendazole is the treatment of choice for fascioliasis, but surgical management should be considered in cases of persistent biliary obstruction or treatment failure, usually seen in complicated chronic infections.