Purpose or Case Report: Introduction
Hepatic visceral larva migrans (VLM) is an increasingly recognized parasitic manifestation wherein migratory nematode larvae get lodged in hepatic parenchyma leading to inflammatory granuloma or abscess formation. In this report, we describe a case of VLM presenting with upper gastrointestinal (GI) bleed secondary to a rare complication, a hepatic artery pseudoaneurysm. On literature search, only one such case is reported.
Case Report
A 13-year-old girl presented with abdominal pain and progressively increasing jaundice for the last 2 weeks. The patient had multiple episodes of hematemesis and melaena requiring 2 units of blood transfusion during this time. Ultrasound (USG) abdomen showed multiple ill-defined hyperechoic lesions in the right lobe of liver with presence of anechoic cystic areas within. A dual phase Computed Tomography (CT) scan of the abdomen revealed multiple confluent and discrete hypodense lesions in the right lobe of liver more apparent on portal venous phase, along with presence of a 1.5 cm pseudoaneurysm arising from posterior branch of right hepatic artery. A differential diagnosis of pyogenic liver abscesses, hepatic VLM, disseminated tuberculosis and immunodeficiency with invasive fungal infection was kept along with hepatic artery pseudoaneurysm leading to hemobilia. Lab investigations revealed peripheral eosinophilia (54%) and raised serum IgE (1600 IU/mL). Hydatid serology was negative. Based on these findings, a diagnosis of hepatic VLM was made and the patient was started on Albendazole (400 mg BD). The patient underwent Digital Subtraction Angiography and managed with successful embolization of the pseudoaneurysm using microcoils. There was significant improvement in jaundice and no recurrence of hematemesis over the next ten days along with rapid drop in peripheral eosinophilia. The patient subsequently remained asymptomatic over a follow-up period of 18 months. The inflammation caused by cytotoxic eosinophil-derived proteins associated with helminthic parasites may lead to vascular complications.
Conclusion
Hepatic VLM can be rarely associated with hepatic artery pseudoaneurysm presenting in the form of acute upper GI bleed in the background of progressive abdominal symptoms secondary to hepatic lesions. Prompt diagnosis and management with percutaneous angio-embolization for the aneurysm and anti-helminthic therapy for the underlying parasitic infestation is of paramount importance for a good clinical outcome.
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