Case Discussion <Case Presentation>     A 75-year-old male farmer, a native of Hakka, was admitted due to worsening nausea, vomiting yellowish skin and tea color urine two days prior to admission.     He lived in Meinong Town, Kaohsiung County. He felt dull pain at the right upper quadrant intermittently in recent years before admission. The pain located at right subcostal region without radiation. It happened sometimes after meal. There was no fever, chills, nausea or vomiting. He was taken to a local medical doctor for help and gall bladder stone was told. Thus, he didn't pay too much attention to it.     About 2 months before this admission, he had yellowish skin progressively accompanied with tea color urine, and body weight loss for 5-10 kg was noted. There was no fever or clay color stool. He didn't pay attention to it and didn't go to hospital for help until 2 days ago.     Due to nausea, vomiting and general weakness, he was taken to our emergency room for help and then was admitted to our ward. His vital signs were normal, including body temperature. The physical examination revealed general cachexia and icteria. His sclera was jaundice and conjunctiva was pink. There was no abnormal finding over neck, chest and heart. His abdomen was scaphoid without OP scar. The bowel sounds was normal active. The liver and spleen size were within normal range by percussion. There was no palpable mass over abdomen. No Murphy's sign, Tuner's sign, Courvoisier's sign, or Cullen's sign was observed.     He denied any surgical history or trauma history. There was no hematological disease among his family member. He was a non-smoker. When he was young, he sometimes drank and ate raw fish (grass carp). He wasn't an intravenous drug user and denied any long-term drug used. There was no travel history or animal exposure history before admission. There was no past history of hepatitis, cholecystitis or biliary disease.     The abnormal laboratory data was WBC 10500 with eosinophil 12% (N 1-5%), Hb 10.7 g/dl (N 11.2-15.5 g/dl), GOT 172.8 IU/L, GPT 82.9 IU/L, total bilirubin 21.8 mg/dl, direct bilirubin 16.8 mg/dl, alkaline phosphatase 856 IU/L (N 100-300 IU/L), r-GT 280.3 IU/L (N 4-70 IU/L) and CEA 6.69 ng/ml (N <5). All laboratory data were shown in Table below. The stool examination for parasite ova was negative. The result of chest x-ray was normal. The abdominal image finding, including echogram and computed tomography, revealed intrahepatic duct dilatation with a mural mass-like lesion was noted at the common hepatic duct (Figure 1).     The initial diagnosis was obstruction jaundice, Klatskin tumor related. After percutaneous transhepatic cholangiodrainage (Figure 2)., there was several leaf-like worm found in the drainage bag (Figure 3).. The bile study revealed WBC 1 (Neu./Lym. 1/0) and RBC 0 per-milliliter, and the cytology of bile revealed many ovoid, flask-shaped ova, which had pronounced shoulders at the rim of the operculum and a minute spine at the end (Figure 4).. Clonorchis sinensis infestation was impressed. We performed fluoroscopic sonoguided biopsy from the tumor. The pathological report revealed cholangiocarcinoma (Figure 5). <Laboratory Results> WBC Neu.  Lym.  Eosin. Hb Hct  MCV PLT 10500/cc 61% 21% 12% 10.7g/dl  30.3% 99.0 fL 337000/cc BUN Cr GOT GPT Na K 7.9 mg/dL 1.08 mg/dL 172.8IU/L 82.9 IU/L 133.6 mEq/L 3.63 mEq/L Glucose Total bilirubin Direct bilirubin Alk-P r-GT 96.6 mg/dL 21.8 mg/dL 16.8 mg/dL 856 IU/L 270.3 IU/L Lipase IgE AFP CEA 27.8 IU/L 3200 IU/dl (N: 10-180) 3.46 ng/ml (N<20) 6.69 ng/ml (N <5) <病案分析>     中華肝吸蟲主要流行於中國大陸、日本、韓國、越南及台灣等東南亞國家，也是台灣地區重要的人畜共通寄生蟲之一。許多流行病學調查報告顯示，台灣某些鄉鎮或村落為高感染地區，如南投縣國姓鄉、高雄縣美濃鎮、旗山鎮、屏東縣竹圍、頭崙、新田等三村及苗栗縣獅潭鄉等，其感染率均在10％以上。中華肝吸蟲之感染多與國人嗜食淡水魚生魚片、生魚粥等未經熟煮之食物及其他生食習慣有關，而上述飲食習慣則常見於客家村的日常生活，故客家住民之感染率遠高於原住民及閩南住民。同時中華肝吸蟲流行地區如高雄縣美濃鎮、屏東縣、苗栗縣等地區多為客家人聚集，因此中華肝吸蟲的感染應與客家族群間有密切的關係。     此蟲常約一至二公分，寬0.3至0.5公分，其第一中間宿主是淡水螺類，第二中間宿主為淡水魚，包含魚種頗多且多為食用魚類，例如草魚、鰱魚、吳郭魚等。它以囊狀幼蟲形態寄生在魚肉內，當人類食用含有此幼蟲，未完全煮熟魚類或生魚片就很容易被感染。此囊狀幼蟲進入腸道，約七至十小時內即經由總膽管移行至肝內的小膽管內，四週後即發育成熟開始產卵，每隻成蟲每日排卵平均三四千個，頗為驚人。中華肝吸蟲的壽命可長達一、二十年，這段感染期間幾無異狀，肝功能檢查除了極少數人鹼性磷酸脢稍會上升，可多是正常。但蟲體在膽道系統內容易引起其他併發症，發生膽道結石、膽囊炎的比例相對增加，亦會造成膽管內皮細胞的變性，是生成膽管癌的主要因素之一。由於在其生活史中牽涉到畜養的魚類，是相當重要的人畜共通寄生蟲病因。     感染中華肝吸蟲後所引起之症狀因人而異，輕微感染者一般無症狀表現，但如果在短期內食入大量的囊狀幼蟲，會產生急性感染症狀，包括發燒、腹瀉、上腹疼痛、厭食、肝腫大及壓痛、黃疸等症狀；若沒有再次重複感染時，其症狀轉為不明顯。但若長期重複感染時，則會造成肝功能障礙，包括膽管炎、膽管阻塞、膽結石、肝結石、及多發性肝膿瘍等，甚至發生膽管癌情形。     由於中華肝吸蟲的囊狀幼蟲非常怕高溫，因此食物食用前必須充分煮熟，餐具澈底清洗，並養成良好衛生習慣，就可有效預防中華肝吸蟲傳染。 繼續教育考題 1. (A) Which of the following statement was NOT symptom / sign of gallstone and biliary colic? 1. vague epigastric fullness and dyspepsia 2. gradual onset and persisted for 0.5 to 5 hours, then subsided gradually 3. may radiate to right scapular or shoulder 4. sometimes accompany with nausea and vomiting 5. fever or chills may happen A 1,2 B 1,3 C 1,2,3 D 1,3,4 E  2,4,5 2. (A) This 75-year-old male with fatigue and tea-colored urine was taken to your clinics. Physical examination reveals icteric sclerae but otherwise is unremarkable. Which of the following conditions is LEAST likely to account for these finding before any further evaluation? A Autoimmue hemolytic anemia B  Pancreatic cancer C  Gallbladder cancer D Primary biliary cirrhosis E Viral hepatitis 3. (D) Which of the following disorders are possible in a patient with icteric sclera and a positive reaction of bilirubin by urine dipstick test? 1. Autoimmue hemolytic anemia 2. Thalassemia intermedia 3. Acute hepatitis 4. Common bile duct obstruction A 2,4 B 1,3 C 1,4 D 3,4 E 1,2 4. (C) Which of the following conditions do you prefer if the eosinophil ratio is elevated in the WBC differential count? A Pyogenic disease B Acute leukemia C Parasite disease D Addison's disease E Mononucleosis 5. (E) Which of the following conditions has NOT elevated IgE level? 1. Atopic dermatitis 2. Allergic rhinnitis 3. Parasite disease 4. Ataxia Telangiectiasia 5. Malignancy A 1,2 B 2,4 C 2,5 D 3,5 E 4,5 6. (C) Which of the following statement is NOT true? A “Courvoisier's sign positive” means distal common bile duct obstruction B “Charcot's triad” means biliary colic, jaundice, fever and chills. C  The pain character of biliary colic was intermittent, not steady. D Patient, which can't tolerate endoscopic retrograde cholangiopancreatography, may shift to magnetic resonance cholangiopancreatography study. E The typical film of Endoscopic retrograde cholangiopancreatography of Clonorchis sinensis infection revealed several filling defects over biliary tree. 7. (B) Which of the following parasite infection would NOT cause eosinophilia？ A Toxocara spp. B Entamoeba histolytica C Trichnella spiralis D Clonorchis sinensis E Opisthorchis viverrini 8. (A) Which of the following match was incorrect between parasite infection and cancer? 1. Paragonimus westermani --- adenocarcinoma of lung 2. Clonorchis sinensis --- cholangiocarcinoma 3. Opisthorchis viverrini --- cholangiocarcinoma 4. Schistosoma haematobium --- urinary bladder caner 5. Fasciolopsis buski --- colon cancer  A 1,5 B 1,3 C 2,4 D 3,5 E 3,4 9. (A) Endoscopic retrograde cholangiopancreatography is a good diagnostic tool for the obstructive jaundice. Which is not the complication of endoscopic retrograde cholangiopancreatography? A Peritonitis B Pancreatitis C Cholangitis D  Bleeding E Aspiration pneumonia 10. (B) Which of the following drugs was adequate for treat clonorchis sinensis infection ? A Metronidazole B Praziquantel C Mebendazole D Paromomycin E TMP-SMX