A 19-year-old female presented with complaints of intermittent low-grade fever for two months, associated with right-sided mild upper abdominal discomfort, yellowish discolouration of the sclera and a history of black-coloured stool for 7-10 days. The patient belonged to a lower socio-economic status and was living in an overcrowded area. There was no obvious history of exposure to any pet animals. On examination, she was afebrile and hemodynamically stable with a pulse rate of 80 beats/min and a blood pressure of 112/64 millimeter of mercury (mmHg). She also had pallor and icterus. Abdominal examination revealed mildly tender hepatomegaly. The rest of the systemic examination findings were unremarkable. The relevant laboratory parameters were: low haemoglobin (6.1 gm/dL), leucocytosis (14 200/mm), eosinophilia (1.26 x 10/L), mildly elevated bilirubin (total -1.7 mg/dL, direct -1.3 mg/dL), elevated alkaline phosphatase (620 IU/L) and gamma-glutamyl transferase (364 IU/L); the remaining results were within normal limits. There was no previous history of any hepatic intervention. Emergency ultrasonography of the abdomen revealed multiple discrete and clustered hypo to anechoic lesions with a mildly hyperechoic irregular rim in the right lobe of the liver and mildly prominent central biliary radicles (Figure 1a, b). The gall bladder was mildly distended with an oedematous wall (Figure 1c). No obvious hematoma or pseudoaneurysm was found at ultrasonography (USG). The patient was started on empiric broad-spectrum intravenous antibiotics and transfused two units of blood.
Dual-phase computed tomography (CT) of the abdomen revealed multiple discrete and clustered variable-sized hypoechoic lesions with an enhancing rim in the right lobe of the liver, predominantly along the peripheral hepatic parenchyma (Figure 2). A few linear hypodense tracks were also depicted, consistent with the migration of larvae (Figure 2a and 2c). Small segmental portal thrombosis was found in segment VIII along with a few geographical areas of hypoperfusion noted as hypodensity on the portal-venous phase (Figure 2c). Mildly dilated biliary radicles were demonstrated on the minimum intensity projection (MinIP) images (Figure 2d). Additionally, there was a well-defined pseudoaneurysm of 1.1 cm size along the anterior branch of the right hepatic artery; however, no apparent active contrast extravasation was seen (Figure 3a, b).
Subsequent upper GI endoscopy showed haemobilia without any varices. Thus, pseudoaneurysm was suspected to be the cause for haemobilia. The branch of the right hepatic artery from which pseudoaneurysm originated was selectively catheterised with a microcatheter through a right femoral artery approach and the pseudoaneurysm was embolised with microcoils using a sandwich technique (Figure 4).
The following differential diagnoses were considered in view of the clinical and imaging findings: pyogenic liver abscesses, VLM, fascioliasis, cat-scratch disease, disseminated tuberculosis and atypical hydatid disease. Further investigations revealed positive toxocara immunoglobulin G (IgG) serology. Stool examination, hydatid serology Mantoux test were negative. Fluid aspirated from the lesions was negative for bacterial and fungal pathogens. Histopathological examination of fine needle aspiration showed eosinophilic abscesses with poorly defined eosinophilic granulomas and Charcot-Leyden crystals, suggestive of a parasitic infection.
Based on clinical, imaging and pathological findings with a positive toxocara IgG serology, a diagnosis of hepatic larva migrans was made and the patient was treated with albendazole (400 mg twice a day for two weeks). Oral prednisone (20 mg/day) was also added for one week and tapered gradually. The patient was discharged in a stable condition after the resolution of fever and abdominal pain. There was no sign of any further GI bleeding. Follow-up imaging was not available; however, she was clinically fine at six months follow-up on teleconsultation.