Echinococcus Presenting as Painless Jaundice

A previously well, 24-year-old male resident of Vancouver, British Columbia, presented to the emergency department with a twomonth history of gradual onset of painless jaundice, dark urine and pale stool.At the time of presentation, he experienced a dramatic rise in the levels of the following liver enzymes: alkaline aminotransferase 272 U/L; alanine aminotransferase 244 U/L; gamma-glutamyl transferase 487 U/L; and alkaline phosphatase 1085 U/L, with an international normalized ratio of 1.0 and an albumin level of 39 g/L.His serum bilirubin level was highly elevated (367 μmol/L) with a conjugated fraction of 282 μmol/L.Hepatitis was the presumptive diagnosis based on positive serology for hepatitis A. However, a computed tomography scan of the abdomen revealed a complex, cystic mass 10.9 cm × 17.9 cm in size in the epigastric region with rim calcifications (Figure 1).This was concerning for a malignant or infective process and the patient was referred to the hepatobiliary surgery service.The patient experienced no fever, cough, nausea, vomiting or abdominal pain.He had no known contacts with similar symptoms.He had travelled to Belgium, but had not travelled to the tropics or Northern Canada.There was no known exposure to animals, including canines.He underwent an endoscopic retrograde cholangiopancreatography with placement of bilateral biliary stents and ultrasound-guided percutaneous drainage of the hepatic abscess.The subsequent culture of the abscess fluid grew Candida albicans, which was treated with fluconazole.The patient became febrile and his jaundice did not improve and, thus, a right hepatectomy and cholecystectomy was performed.The surgical specimen contained a complex hydatid cyst 12 cm in diameter (Figure 2).There were numerous hyalinized profiles in the cyst wall consistent with daughter cysts (Figure 3).The final histological diagnosis was echinococcus with features suggestive of Echinococcus multilocularis.The patient was treated postoperatively with albendazole, 400mg/day orally.Subsequent serology was positive for serum immunoglobulin G antibodies to echinococcus confirmed by immunoblot.He remains asymptomatic without evidence of recurrence and his liver enzyme levels have normalized.

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