A 45 years old female from Surkhet presented with the complain of fever for 4 months which was irregular in nature, pain in the right hypochondriac region with jaundice and occasional vomiting for same duration. She gave the history of drinking local river water with the habit of eating aquatic plant (water-cress), there was no history of consumption of raw fish. She had visited to different health institute of Nepal as well as India for seeking proper treatment, however no proper diagnosis was made. So, evaluated with different provisional diagnosis like hepatocellular carcinoma, obstructive jaundice, cirrhosis of liver etc. She belongs to a poor Family (daily labor) but has done all the required investigations for her provisional diagnosis with expenditure of NRs. 3-5 lakhs. Yet her diagnosis was not confirmed. Finally she got admitted in department of medicine (gastroenterology) of Tribhuvan University and Teaching Hospital (TUTH), Kathmandu, Nepal on August 2015. Her routine peripheral blood smear examination showed hyper-eosinophilia (27%). So, Endoscopic Retrograde Cholangiopancreatogram (ERCP) was done to evaluate the cause of her obstructive jaundice and an uncommon morphology of adult worm was seen.
Morphological characteristics of dead adult worm revealed flat, leaf like measuring approximately 2 to 2.5 cm in length by 1 cm in breadth and brown to pale grey in color . It had a distinct conical projection at the anterior end and broadly pointed posterior end. Patient stool sample was collected and processed for routine macroscopic and microscopy examination. For increased yield of ova, stool was concentrated by modified zinc sulphate concentration technique and wet mount was prepared for microscopy. On macroscopic examination of stool, it was yellowish-brown with soft consistency. Microscopic examination of the wet mount of the stool sample showed large, elliptical to oval, operculated, light yellowish brown ova measuring 140-142 µm by 70-75µm. The size of the detected ova was measured using cell sensation software version 1.12 for DP73 camera installed to the Olympus BX53 microscope used for the microscopy. The photographs of the ova was sent to CDC (Centre for Disease Control and prevention) for confirmation.
On the basis of morphological appearance of adult worm and characteristic feature of the detected ova and its measurement, Fasciola hepatica was identified. The photographs was confirmed as ova of Fasciola hepatica by CDC. Patient was treated with Nitazoxanide 500mg twice daily for 5 days and follow up stool examination two weeks after treatment revealed no ova of Fasciola hepatica.
Fascioliasis can be diagnosed by 40-60 rupees test (stool RME) and treated by approx. 4000 rupees (drug cost). So, patient health suffering and economical burden can be minimized by just established the diagnosis with routine examination of the stool.