A 27 year‐old Ethiopian woman presented with indolent weight loss; 3 weeks of post‐prandial abdominal pain and vomiting; and 1 week of dark urine, diarrhea, and itching. The patient’s medical and social history was unremarkable except for a recent visit to Addis Ababa. Physical exam was notable for scleral icterus and epigastric tenderness. Initial labs evidenced cholestatic liver injury with negative autoimmune markers. Initial CT interpretation noted moderate intrahepatic biliary duct dilation with gallbladder dilatation. A working diagnosis of obstructive cholangiocarcinoma was made and ERCP with brush biopsy was performed. Unexpectedly, the biopsy showed multinucleated giant cells and hooklet structures suggestive of echinococcus granulosus with no signs of neoplasm. CEA, AFP, and CA19‐9 levels returned within normal limits. Re‐evaluation of the CT found that what was initially thought to be a dilated gallbladder was in fact consistent with the hyatid cysts seen in echinococcosis. The patient was initiated on albendazole therapy and discharged with planned resection of the cyst.
Jaundice with abdominal pain is a condition commonly evaluated by hospitalists. As this case illustrates, a detailed history and judicious diagnostic testing should be used to broaden the work‐up beyond reflexive evaluation for gallstones and cholangitis. Although the incidence of echinococcosis in the United State is low, parasitic causes of hepatic disease should have been considered in our patient due to her ethnic background and recent travel. A better history would have revealed that while overseas, she consumed kitfo, a dish of raw beef eaten by most Ethiopians and a risk factor for echinococcus egg ingestion. In addition, our patient’s abdominal CT images were read with a preconceived belief of malignancy, anchoring heuristic bias against consideration of a parasitic infection and its accompanying radiographic interpretation. Echinococcosis’ initial phase is asymptomatic, with symptoms arising several months to years after ingestion. Clinical features depend on the size, number, and location of the cyst(s); the liver and lung are the most commonly affected organs. Diagnosis is based on imaging of the cystic structures with confirmation by serology. Our patient’s presentation was typical for the hepatic cystic form of the disease. Had a more thorough history been taken and a broader differential diagnosis formed, the patient and her family might have been spared the anguish of an unfortunate cancer misdiagnosis.
When assessing jaundice in foreign‐born persons or recent travelers, a broad differential and detailed history‐taking is essential to avoid missed diagnoses and heuristic errors. Cystic echinococcosis’ indolent presentation mirrors that of other causes of biliary obstruction including neoplasms. Its rarity in the US biases physicians to overlook it, but it is a common global disease and should be considered when evaluating travelers returning from endemic areas.
To cite this abstract:Chen D, Gandiga P. The Early Bird Gets the Worm: When to Suspect Echinococcosis. Abstract published at Hospital Medicine 2014, March 24-27, Las Vegas, Nev. Abstract 380. Journal of Hospital Medicine. 2014; 9 (suppl 2). https://www.shmabstracts.com/abstract/the-early-bird-gets-the-worm-when-to-suspect-echinococcosis/. Accessed November 18, 2019.