Clonorchiasis Causing Biliary Obstruction 15 Years After Immigration to the United States

Abstract

Purpose: Gallstones are the most common cause of obstruction of the biliary system worldwide. In the United States, biliary obstruction causing cholangitis is a common cause of morbidity in adults. Besides gallstones, infection with pyogenic cholangiohepatitis secondary to Clonorchis sinensis has been found with increasing incidence due to immigration of persons from endemic areas. Typically, such cases of parasitic infection causing cholangiohepatitis occurs within the first year of immigration to the U.S. We report a patient who presented with biliary obstruction and cholangiohepatitis due to Chlorochis sinensis 15 years after immigration to the United States. A 50-year-old Chinese male with no significant past medical history presented with right upper quadrant pain to our outpatient clinic. He complained of several years of this pain without associated fever, chills, nausea, or vomiting. The patient immigrated from Taishan, a city in Southeast China, to the U.S. fifteen years prior. On physical exam he displayed obvious scleral icterus and RUQ tenderness; the remainder of the exam was otherwise normal. Labs revealed a liver function panel demonstrating an obstructive pattern and CA 19-9 of 73 (normal <40 U/mL). Both RUQ ultrasound and MRCP showed markedly dilated intra- and extrahepatic ducts. The patient underwent ERCP, confirming the imaging studies. Purulent drainage was noted to be emerging from the ampulla. Sphincterotomy was performed yielding multiple stones and sludge. The left intrahepatic duct was cannulated. Balloon sweeps of the left intrahepatic duct retrieved a flat, black worm roughly 2 cm in length with an oblong shape. The worm was removed with biopsy forceps. Pathology results identified Clonorchis sinensis. Brushings of the common bile duct were negative for malignant cells although many eosinophils were noted. The patient was successfully treated with Praziquantel. Infection by Clonorchis sinensis may lead to the insidious development of pyogenic cholangiohepatitis. Clonorchiasis is endemic to areas of Southeast Asia including, southern and northeastern China, eastern Russia, Vietnam, and Korea. Chlonorchis, which can be found in raw freshwater fish, have a life span of 20-25 years. As this case demonstrates, the long natural history of this parasite poses a challenge to clinicians in making the appropriate diagnosis in patients with biliary obstruction who may have immigrated years earlier.Figure