Fascioliasis is a zoonotic disease caused by infection of trematodes belonging to the genus Fasciola (F. hepatica and F. gigantica). Patient may be asymptomatic or present with gastrointestinal symptoms, chronic cholecystitis, cholangitis and liver abscesses which may be accompanied by biliary colic, epigastric pain, jaundice (obstructive jaundice), pruritus and upper right quadrant pain. We are reporting a first case of Fasciola gigantica from Nepal causing fascioliasis in a 22 year old male who was referred to surgery department of TUTH, Kathmandu, Nepal from a peripheral Hospital of Eastern Nepal for the evaluation of right upper abdominal pain with radiological investigation suggestive of sludge/ parasitic membrane within the common bile duct. Patient had history of consumption of water-cress and had eosinophilia on peripheral blood smear examination. ERCP showed the presence of a flat worm resembling Fasciola species and stool examination along with measurement of the detected ova revealed ova of Fasciola gigantica. Patient was treated with standard course of Nitazoxanide (500mg BID for 7 days) and follow up stool examination after 2 weeks revealed no ova of Fasciola gigantica. So patient with symptoms of obstructive jaundice, eosinophilia and history of water-cress consumption should be suspected for fascioliasis and investigated and treated accordingly. A Case Report of Fasciola gigantica for the First Time in Nepal Ranjit Sah 1 , Shusila Khadka 1 , Paleswan Joshi Lakhey 2 , Sumita Pradhan 2 , Keshab Parajuli 1 , Niranjan Prasad Shah 1 , Basista Rijal 1 , Jeevan Bahadur Sherchand 1 1. Department of Microbiology, Tribhuvan University and Teaching Hospital (TUTH), Institute of Medicine, Kathmandu, Nepal. 2. Department of Gastointestinal Surgery and Genaral Surgery, Tribhuvan University and Teaching Hospital (TUTH), Institute of Medicine, Kathmandu, Nepal The morphological characteristics of the dead adult worm revealed measurement of 1.5cm in length by 0.4cm in breadth (fig.3,4). It had a broader cephalic end with shorter cephalic cone and caudal end was oblong with rounded posterior end resembling Fasciola gigantica as compared 3 to Fasciola hepatica which has a distinct conical projection at the anterior end and broadly pointed posterior end. On macroscopic examination of stool, it was yellowish-brown with soft consistency. Microscopy examination of the wet mount preparation of the stool showed multiple yellowish, oval, operculated egg(fig. 5,6) having measurement ranging from 170-180μm in length by 105-115 μm in breadth (fig.7 ). On the basis of morphological appearance of adult worm and characteristic feature of the detected ova and its measurement, Fasciola gigantica was identified. The patient was treated with standard course of Nitazoxanide (500mg BID for 7 days) and follow up stool examination after 2 weeks revealed no ova of Fasciola gigantica We are reporting a case of Fasciola gigantica which has not been diagnosed earlier in Nepal in humans to our knowledge. Although fascioliasis is regarded as one of the most important platyhelminthic infection of Asia and Africa 4 . Its infection is known to cause biliary tract inflammation and obstruction. Symptoms may include fever, malaise, fatigue, anorexia, weight loss and peripheral eosinophilia. Symptoms may be absent in case of light infection. Infection is more common in indigenous people and farmers who share same water sources with their animals and have a habit of eating fresh-water aquatic plants such as water cresses 5 locally called seem-saag in Nepal. A study has revealed that out of 81 Fasciola flukes collected from cattles of 8 districts in Nepal showed 20 flukes (24.7%) were Fasciola gigantica 6 In fascioliasis, the causative agent could be Fasciola hepatica or Fasciola gigantica. In countries where both species co-exist, size and shape of the eggs passed in the faeces are crucial diagnostic feature 5 . The differentiation between Fasciola hepatica and Fasciola gigantica infection in humans is very important because of their different transmission and epidemiological characteristics. Studies have shown that the intermediate host for Fasciola gigantica is the Eurasia Radix auricularia and African Radix natalensis 7 . In Nepal, the intermediate host for Fasciola gigantica is yet to be studied. The recommended anti-parasitic agent for Fasciola gigantica is triclabendazole 10mg/kg body weight as a single dose 1 . However, we have treated our patient with nitazoxanide 500mg twice daily for 7 days as triclabendazole is not available in Nepal and nitazoxanide is an alternative choice 8 . The patient was improved with the treatment and his stool routine examination after 2 weeks revealed no ova of Fasciola gigantica. The adult worms were received in our laboratory and its morphological characteristics were studied. Patient stool sample was collected and processed for routine macroscopic and microscopy examination. For increased yield of ova, stool was concentrated by modified zinc sulphate concentration technique 4 and wet mount was prepared for microscopy. The size of the detected ova was measured using cell sensation software version 1.12 for DP73 camera installed to the Olympus BX53 microscope used for the microscopy. Cases with symptoms and/or investigations revealing biliary tract obstruction should also be ruled out for fascioliasis especially when there is eosinophilia on peripheral blood smear examination, as fascioliasis can simply be diagnosed by stool microscopy and can be treated by antihelminthic drugs rather than surgery as in other case of biliary tract obstruction. Fascioliasis is caused by infection of trematodes belonging to the genus Fasciola (F. hepatica and F. gigantica). Its infection is known to cause bile duct inflammation and biliary obstruction 1,2 . Fascioliasis can be presented as various clinical manifestation from mild to severe in nature. Patient may be asymptomatic or presents as gastrointestinal symptoms or biliary symptoms like biliary colic, epigastric pain, jaundice, pruritus and upper right quadrant pain which may result in chronic cholecystitis, cholangitis and liver abscesses 3 . We are reporting a case of a 22 years old male who was referred from peripheral hospital of eastern Nepal to department of Surgery, Tribhuvan University and Teaching Hospital (TUTH), Kathmandu, Nepal for further evaluation of upper abdominal pain with ultrasonographic finding suggestive of choledocholithiasis with thickened and dilated common bile duct. The patient has the history of consumption of water-cress. His routine peripheral blood smear examination showed eosinophilia (46%) and Magnetic Resonance Cholangiopancreatography (MRCP) was done which revealed multiple membrane like structure within common bile duct with mild dilatation of central intrahepatic biliary duct with differential diagnosis of sludge/parasitic membrane. So, patient was admitted in surgical ward on 11 th April for Endoscopic Retrograde Cholangiopancreatogram (ERCP). On ERCP common bile duct was dilated with membrane like filling defect and slightly prominent papilla. So, sphincterotomy was done followed by common bile duct basketing where an adult worm was removed (fig. 2) and it was send to the microbiology laboratory of TUTH by surgeon for further evaluation and identification. INTRODUCTION METHODS AND MATERIALS 1. Vedat Goral et.al A Case of Biliary Fascioliasis by Fasciola gigantica in TurkeyKorean J Parasitol. 2011 Mar; 49(1): 65–68 2. K.D. Chatterjee Parasitology 13 th edition 3. D.R Arora and Brij Bala Arora Medical Parasitology third edition, chapter 10, page 158-1607. 4. Mackie & McCartney Practical Medical Microbiology 14 th edition, chapter 43, page 769 5. Marcilla et.al A PCR-RFLP assay for the distinction between Fasciola hepatica and Fasciola gigantica Molecular and cellular Probes (2002) 16, 327-333 6. Shoriki T. et. al Molecular phylogenetic identification of Fasciola flukes in Nepal. Parasitol. Intl, 2014, Dec; 63(6): 758-62 7. D.P Mc Manus and J.P Dalton Vaccines against the zoonotic trematodes Schistosoma japonicum, Fasciola hepatica and Fasciola gigantica Parasitology 2006), 133, S43-S61 8. Jose et.al fascioliasis and Intestinal parasitoses Affecting School children in Atlixco, Puebla State, Mexio: Epidemiology and treatment with NitazoxanidePLOS neglected tropical disease November 2013, volume 7 issue 11 e2553 CONCLUSIONS DISCUSSION RESULTS REFERENCES Figure 7: Ova of Fasciola gigantica measuring 171 μm by 108 μm Figure 3. Dead adult worm of Fasciola gigantica ventral surface . Figure 4: Dead adult worm of Fasciola gigantica dorsal surface . ABSTRACT Dr. Ranjit Sah Institute of Medicine, Maharajgunj Medical Campus, TUTH, Kathmandu, Nepal Email:ranjitsah57@gmail.com Phone:+977- 9808182012 CONTACT Figure 5: Ova of Fasciola gigantica Figure 6: Next ova of Fasciola gigantica seen in same patient Keywords : Fasciola gigantica, Fascioliasis, Biliary symptoms, TUTH, Nepal Figure 1. ERCP showing dilated common bile duct with membrane like filling defect Fig 2. Adult worm during ERCP