Description

A 58-year-old man suddenly lost consciousness at home and was immediately brought to the emergency department where he was declared dead. The deceased was suffering from schizophrenia and had reported upper abdominal pain for past few months. His sister stated that he was living alone under unhygienic conditions and had significant weight loss over the past 2 months.

At autopsy, six adult Ascaris worms were found infiltrating into the liver parenchyma through the common bile and hepatic duct (figure 1A). No adult Ascaris worm was found inside the cystic duct or gall bladder. About 50 mL of light green bile was present in the gallbladder, which suggested obstruction of the biliary channel at the level of the common bile duct (figure 1B). The liver showed marked dilation of the biliary channels with presence of an intraluminal adult worm (figure 1C, D). The weight of the liver was 1200 g.

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Figure 1

(A) A bunch of adult Ascaris infiltrated into the liver through common bile duct (CBD) and hepatic duct. (B) Light green colour of bile in the gallbladder suggests obstruction at the level of CBD. (C and D) Many intraluminal adult worms are present in the dilated biliary channels of the liver.

Histopathology of organs: Microscopic examination of the liver revealed ulceration of biliary mucosa with presence of larvae of Ascaris (black arrow), and acute and chronic inflammatory infiltrate in the subepithelial tissue (figure 2A, B). There was fibrosis in the biliary wall. Dilated biliary ducts showed the presence of a gravid Ascaris worm (figure 2C).

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Figure 2

(A and B) H&E stained sections of the liver show ulceration of biliary mucosa with presence of many larvae of Ascaris (black arrows) and mixed inflammatory infiltrate in the subepithelial tissue ((A), ×100; (B), ×200). (C) A gravid Ascaris is present in the dilated biliary duct ((C), ×40).

Ascariasis causing Ascaris lumbricoides is the largest intestinal nematode parasite known to be present in man.1 The adult worm usually lives in the lumen of the small intestine. Migration of one or two worms to the hepatobiliary duct and liver parenchyma causing hepatobiliary ascariasis is a well-known complication.2 In our case, there was massive hepatobiliary infestation of worms, which is rarely reported in the scientific literature. Hepatobiliary ascariasis is the most feared complication and can cause morbidity and mortality.3 Worm infestation might not be the cause of death in this patient, as parasitosis is common in tropical countries.