Liver flukes: Fascioliasis
- Karin Leder, MBBS, FRACP, PhD, MPH, DTMH
Karin Leder, MBBS, FRACP, PhD, MPH, DTMH
- Section Editor — Travel Medicine
- Head of Infectious Diseases Unit
- Monash University, Australia
- Peter F Weller, MD, FACP
Peter F Weller, MD, FACP
- Editor-in-Chief — Infectious Diseases
- Section Editor — Tropical Medicine
- William Bosworth Castle Professor of Medicine
- Harvard Medical School
- Professor of Immunology and Infectious Diseases
- Harvard T. H. Chan School of Public Health
Fascioliasis is a trematode flatworm infection caused by Fasciola hepatica or Fasciola gigantica . F. hepatica has a worldwide distribution; F. gigantica occurs predominantly in the tropics. Both parasites are hermaphroditic, have similar life cycles, and cause similar clinical manifestations in humans. The organism causes "liver rot" among sheep and cattle, which are the definitive hosts; humans are incidental hosts.
Epidemiology — F. hepatica occurs globally, mainly in sheep-rearing areas of temperate climates. Infection is endemic in Central and South America (especially Bolivia and Peru), Europe (especially Portugal, France, Spain, and Turkey), Asia (especially China, Vietnam, Taiwan, Korea, and Thailand), Africa, and the Middle East . Sporadic cases have also been reported in the United States , Australia , and elsewhere . An estimated 2.4 to 17 million people are infected in more than 51 countries ; 91 million are at risk worldwide .
Sheep and cattle are the most important definitive hosts of F. hepatica; goats, buffalo, horses, camels, hogs, deer, and rabbits can also be infected. Snails are intermediate hosts. Humans are incidental hosts and most often acquire infection by eating watercress grown in sheep-raising areas. Infection may also be transmitted by other freshwater plants, including water lettuce, mint, alfalfa, and parsley. Humans can also acquire infection by drinking contaminated water containing viable metacercariae ; outbreaks have been described . The incidence of animal and human infection rises during wet years because of an increased number of snails and longer survival of encysted cercariae .
In some areas, endemicity is almost 100 percent. In endemic regions, very young children and women are most likely to be infected. There is a high incidence of coinfection with other parasites, especially echinococcosis.
Life cycle — The life cycle of fascioliasis begins with release of un-embryonated eggs into the biliary ducts, which are then passed in the stool of herbivores (definitive hosts) or humans (incidental hosts) (figure 1). Eggs become embryonated in water and release miracidia, which invade a snail (intermediate host), where the parasites undergo several developmental stages (sporocysts, rediae, and cercariae). The cercariae are released and encyst as metacercariae on aquatic vegetation.
- Mas-Coma S. Epidemiology of fascioliasis in human endemic areas. J Helminthol 2005; 79:207.
- Mahanty S, Maclean JD, Cross JH. Liver, Lung, and Intestinal Fluke Infections. In: Tropical Infectious Diseases: Principles, Pathogens and Practice, 3rd ed, Guerrant RL, Walker DH, Weller PF (Eds), Saunders Elsevier, Philadelphia 2011. p.854.
- Weisenberg SA, Perlada DE. Domestically acquired fascioliasis in northern California. Am J Trop Med Hyg 2013; 89:588.
- Sivagnanam S, van der Poorten D, Douglas MW. Hepatic lesions and eosinophilia in an urban dweller. Liver Int 2014; 34:643.
- Mas-Coma S, Valero MA, Bargues MD. Chapter 2. Fasciola, lymnaeids and human fascioliasis, with a global overview on disease transmission, epidemiology, evolutionary genetics, molecular epidemiology and control. Adv Parasitol 2009; 69:41.
- Keiser J, Utzinger J. Food-borne trematodiases. Clin Microbiol Rev 2009; 22:466.
- Chan CW, Lam SK. Diseases caused by liver flukes and cholangiocarcinoma. Baillieres Clin Gastroenterol 1987; 1:297.
- Bjorland J, Bryan RT, Strauss W, et al. An outbreak of acute fascioliasis among Aymara Indians in the Bolivian Altiplano. Clin Infect Dis 1995; 21:1228.
- Arjona R, Riancho JA, Aguado JM, et al. Fascioliasis in developed countries: a review of classic and aberrant forms of the disease. Medicine (Baltimore) 1995; 74:13.
- Harinasuta T, Pungpak S, Keystone JS. Trematode infections. Opisthorchiasis, clonorchiasis, fascioliasis, and paragonimiasis. Infect Dis Clin North Am 1993; 7:699.
- Adachi S, Kotani K, Shimizu T, et al. Asymptomatic fascioliasis. Intern Med 2005; 44:1013.
- Marcos LA, Terashima A, Gotuzzo E. Update on hepatobiliary flukes: fascioliasis, opisthorchiasis and clonorchiasis. Curr Opin Infect Dis 2008; 21:523.
- Sezgın O, Altintaş E, Tombak A, Uçbılek E. Fasciola hepatica-induced acute pancreatitis: report of two cases and review of the literature. Turk J Gastroenterol 2010; 21:183.
- Kaya M, Beştaş R, Cetin S. Clinical presentation and management of Fasciola hepatica infection: single-center experience. World J Gastroenterol 2011; 17:4899.
- Xuan le T, Hung NT, Waikagul J. Cutaneous fascioliasis: a case report in Vietnam. Am J Trop Med Hyg 2005; 72:508.
- Dalimi A, Jabarvand M. Fasciola hepatica in the human eye. Trans R Soc Trop Med Hyg 2005; 99:798.
- Saleha AA. Liver fluke disease (fascioliasis): epidemiology, economic impact and public health significance. Southeast Asian J Trop Med Public Health 1991; 22 Suppl:361.
- el-Shabrawi M, el-Karaksy H, Okasha S, el-Hennawy A. Human fascioliasis: clinical features and diagnostic difficulties in Egyptian children. J Trop Pediatr 1997; 43:162.
- Prociv P, Walker JC, Whitby M. Human ectopic fascioliasis in Australia: first case reports. Med J Aust 1992; 156:349.
- Price TA, Tuazon CU, Simon GL. Fascioliasis: case reports and review. Clin Infect Dis 1993; 17:426.
- Acosta-Ferreira W, Vercelli-Retta J, Falconi LM. Fasciola hepatica human infection. Histopathological study of sixteen cases. Virchows Arch A Pathol Anat Histol 1979; 383:319.
- Hillyer GV, Soler de Galanes M, Rodriguez-Perez J, et al. Use of the Falcon assay screening test--enzyme-linked immunosorbent assay (FAST-ELISA) and the enzyme-linked immunoelectrotransfer blot (EITB) to determine the prevalence of human fascioliasis in the Bolivian Altiplano. Am J Trop Med Hyg 1992; 46:603.
- Espino AM, Finlay CM. Sandwich enzyme-linked immunosorbent assay for detection of excretory secretory antigens in humans with fascioliasis. J Clin Microbiol 1994; 32:190.
- Mansour WA, Kaddah MA, Shaker ZA, et al. A monoclonal antibody diagnoses active Fasciola infection in humans. J Egypt Soc Parasitol 1998; 28:711.
- Apt W, Aguilera X, Vega F, et al. Treatment of human chronic fascioliasis with triclabendazole: drug efficacy and serologic response. Am J Trop Med Hyg 1995; 52:532.
- Espinoza JR, Maco V, Marcos L, et al. Evaluation of Fas2-ELISA for the serological detection of Fasciola hepatica infection in humans. Am J Trop Med Hyg 2007; 76:977.
- Gonzales Santana B, Dalton JP, Vasquez Camargo F, et al. The diagnosis of human fascioliasis by enzyme-linked immunosorbent assay (ELISA) using recombinant cathepsin L protease. PLoS Negl Trop Dis 2013; 7:e2414.
- Centers for Disease Control and Prevention. DPDx: Fascioliasis. http://www.cdc.gov/dpdx/fascioliasis/index.html (Accessed on August 04, 2015).
- Santiago N, Hillyer GV. Antibody profiles by EITB and ELISA of cattle and sheep infected with Fasciola hepatica. J Parasitol 1988; 74:810.
- Shaheen HI, Kamal KA, Farid Z, et al. Dot-enzyme-linked immunosorbent assay (dot-ELISA) for the rapid diagnosis of human fascioliasis. J Parasitol 1989; 75:549.
- Hassan MM, Saad M, Hegab MH, Metwally S. Evaluation of circulating Fasciola antigens in specific diagnosis of fascioliasis. J Egypt Soc Parasitol 2001; 31:271.
- Shehab AY, Hassan EM, Basha LM, et al. Detection of circulating E/S antigens in the sera of patients with fascioliasis by IELISA: a tool of serodiagnosis and assessment of cure. Trop Med Int Health 1999; 4:686.
- Hammouda NA, el Mansoury ST, el Azzouni MZ, Hussein ED. Detection of circulating antigens in blood to evaluate treatment of fascioliasis. J Egypt Soc Parasitol 1997; 27:365.
- Cevikol C, Karaali K, Senol U, et al. Human fascioliasis: MR imaging findings of hepatic lesions. Eur Radiol 2003; 13:141.
- Koç Z, Ulusan S, Tokmak N. Hepatobiliary fascioliasis: imaging characteristics with a new finding. Diagn Interv Radiol 2009; 15:247.
- Teke M, Önder H, Çiçek M, et al. Sonographic findings of hepatobiliary fascioliasis accompanied by extrahepatic expansion and ectopic lesions. J Ultrasound Med 2014; 33:2105.
- Van Beers B, Pringot J, Geubel A, et al. Hepatobiliary fascioliasis: noninvasive imaging findings. Radiology 1990; 174:809.
- Sezgin O, Altintaş E, Dişibeyaz S, et al. Hepatobiliary fascioliasis: clinical and radiologic features and endoscopic management. J Clin Gastroenterol 2004; 38:285.
- Dias LM, Silva R, Viana HL, et al. Biliary fascioliasis: diagnosis, treatment and follow-up by ERCP. Gastrointest Endosc 1996; 43:616.
- Keiser J, Utzinger J. Chemotherapy for major food-borne trematodes: a review. Expert Opin Pharmacother 2004; 5:1711.
- Drugs for Parasitic Infections, 3rd Ed, The Medical Letter, New Rochelle, NY 2013.
- Marcos LA, Tagle M, Terashima A, et al. Natural history, clinicoradiologic correlates, and response to triclabendazole in acute massive fascioliasis. Am J Trop Med Hyg 2008; 78:222.
- el-Karaksy H, Hassanein B, Okasha S, et al. Human fascioliasis in Egyptian children: successful treatment with triclabendazole. J Trop Pediatr 1999; 45:135.
- Hammouda NA, el-Mansoury ST, el-Azzouni MZ, el-Gohari Y. Therapeutic effect of triclabendazole in patients with fascioliasis in Egypt. A preliminary study. J Egypt Soc Parasitol 1995; 25:137.
- Laird PP, Boray JC. Human fascioliasis successfully treated with triclabendazole. Aust N Z J Med 1992; 22:45.
- Graham CS, Brodie SB, Weller PF. Imported Fasciola hepatica infection in the United States and treatment with triclabendazole. Clin Infect Dis 2001; 33:1.
- Picot S, Querrec M, Ghez JL, et al. A new report of triclabendazole efficacy during invading phase fasciolasis. Eur J Clin Microbiol Infect Dis 1992; 11:269.
- Calvopiña M, Guderian RH, Paredes W, et al. Treatment of human pulmonary paragonimiasis with triclabendazole: clinical tolerance and drug efficacy. Trans R Soc Trop Med Hyg 1998; 92:566.
- Villegas F, Angles R, Barrientos R, et al. Administration of triclabendazole is safe and effective in controlling fascioliasis in an endemic community of the Bolivian Altiplano. PLoS Negl Trop Dis 2012; 6:e1720.
- Fairweather I. Triclabendazole progress report, 2005-2009: an advancement of learning? J Helminthol 2009; 83:139.
- Garcia HH, Moro PL, Schantz PM. Zoonotic helminth infections of humans: echinococcosis, cysticercosis and fascioliasis. Curr Opin Infect Dis 2007; 20:489.
- Winkelhagen AJ, Mank T, de Vries PJ, Soetekouw R. Apparent triclabendazole-resistant human Fasciola hepatica infection, the Netherlands. Emerg Infect Dis 2012; 18:1028.
- Cabada MM, White AC Jr. New developments in epidemiology, diagnosis, and treatment of fascioliasis. Curr Opin Infect Dis 2012; 25:518.
- Rossignol JF, Abaza H, Friedman H. Successful treatment of human fascioliasis with nitazoxanide. Trans R Soc Trop Med Hyg 1998; 92:103.
- Favennec L, Jave Ortiz J, Gargala G, et al. Double-blind, randomized, placebo-controlled study of nitazoxanide in the treatment of fascioliasis in adults and children from northern Peru. Aliment Pharmacol Ther 2003; 17:265.
- Hien TT, Truong NT, Minh NH, et al. A randomized controlled pilot study of artesunate versus triclabendazole for human fascioliasis in central Vietnam. Am J Trop Med Hyg 2008; 78:388.
- Keiser J, Sayed H, el-Ghanam M, et al. Efficacy and safety of artemether in the treatment of chronic fascioliasis in Egypt: exploratory phase-2 trials. PLoS Negl Trop Dis 2011; 5:e1285.
- Danilewitz M, Kotfila R, Jensen P. Endoscopic diagnosis and management of Fasciola hepatica causing biliary obstruction. Am J Gastroenterol 1996; 91:2620.
- Richter J, Freise S, Mull R, Millán JC. Fascioliasis: sonographic abnormalities of the biliary tract and evolution after treatment with triclabendazole. Trop Med Int Health 1999; 4:774.
- Spithill TW, Piedrafita D, Smooker PM. Immunological approaches for the control of fasciolosis. Int J Parasitol 1997; 27:1221.
- Maleewong W, Wongkham C, Intapan PM, Pipitgool V. Fasciola gigantica-specific antigens: purification by a continuous-elution method and its evaluation for the diagnosis of human fascioliasis. Am J Trop Med Hyg 1999; 61:648.
- Intapan PM, Maleewong W, Wongkham C, et al. Excretory-secretory antigenic components of adult Fasciola gigantica recognized by infected human sera. Southeast Asian J Trop Med Public Health 1998; 29:579.
- Marcilla A, Bargues MD, Mas-Coma S. A PCR-RFLP assay for the distinction between Fasciola hepatica and Fasciola gigantica. Mol Cell Probes 2002; 16:327.
- FASCIOLA HEPATICA
- Life cycle
- Clinical manifestations
- - Acute (liver) phase
- - Chronic (biliary) phase
- - Ectopic fascioliasis
- - Pharyngeal fascioliasis
- - Microscopy
- - Endoscopy or surgery
- - Serology
- - Imaging
- Differential diagnosis
- - Triclabendazole
- - Alternative agents
- - Complications
- - Follow-up
- FASCIOLA GIGANTICA
- SUMMARY AND RECOMMENDATIONS