Human fascioliasis is caused by trematode flatworms, Fasciola hepatica and Fasciola gigantica. Humans acquire the infection by eating green vegetables like watercress, lettuce, mint, parsley or water chestnuts grown in sheep-raising areas or by drinking water containing viable metacercariae. The WHO has classified liver fluke infection as a neglected tropical disease. Humans are the incidental hosts for fascioliasis, sheep and cattle are the definitive hosts, and snails are the intermediate hosts.¹ Human cases with fascioliasis have been reported from many countries across the globe.² Exact prevalence data of fascioliasis in India is not available. Sporadic human cases are reported mainly from north and northeastern states apart from Mumbai and Vellore.^3,4 An animal surveillance study from Gujarat reported that nearly 25-33 % of studied samples were found to be positive for fascioliasis.⁵ Here, we describe four cases of human fascioliasis diagnosed at our center between 01 January 2016 to 31 December 2021 with an aim of increasing awareness amongst clinicians regarding human fascioliasis.

A 30-year-old Gujarati male, residing for more than 4 years in Kampala, Uganda presented with complaints of upper abdominal pain with decreased appetite and intermittent fever spiking up to 101-1020F for the last 4 months. He was a vegetarian, non-alcoholic, with no significant medical history or history of direct contact with animals.He underwent extensive work-up including computed tomography (CT) scan, ultrasound (USG) abdomen and serology for parasitic infections for his illness at a local hospital. His available investigations revealed leucocytosis with eosinophilia and a liver lesion on radiological examination. He received antibiotics, metronidazole for a working diagnosis of liver abscess without clinical benefit. His wife, a 27-year-old, also had complaints of right hypochondriac and lower chest pain, weight loss of 5 kg in 4 months and occasional episodes of high-grade fever. Her ultrasound examination also showed liver lesions. With this history, they visited India for further evaluation and treatment. 

F. hepatica is found throughout the world, with 2.4 to 17 million people estimated to be infected.6 Though the definitive hosts are cattle or sheep, a sporadic or endemic disease can occur in humans. Fasciola eggs are released from her bivores in the water bodies to form ciliated, swimming miracidia, which infect the intermediate host, lymnaeid snails. The infected snails release the cercariae that form cysts on fresh water plants, transmitting infections to humans on consumption of such plants.5,7 In the acute phase, examining a stool sample is usually inadequate as people don’t pass eggs in the faeces so early  in the course of infection.8 Aspiration of contents of the gallbladder, stomach or duodenum is useful for demonstration of eggs, as was done in our case.9 Serologic tests that include FAST-ELISA, indirect haemagglutination, complement fixation, indirect immunofluorescence, counter electrophoresis, and double-diffusion are quite sensitive; however, they may cross-react with other parasitic infections. In hepatic fascioliasis, confined, subcapsular, irregular branching lesions with periportal lymph-node enlargement are seen on CT or MRI scans.10 This was also observed in all our patients. Triclabendazole has been shown to be very effective against Fascioliasis.11 The drug is administered at a dose of 10 mg/kg for 1 or 2 days, and it is well-tolerated. The present case series highlights that peripheral eosinophilia in febrile patients with branching liver lesions on imaging should prompt a clinician for suspecting a liver fluke infection.