Acute liver failure in a case of Bancroftian filariasis.
Dr.
Dwijesh Kumar Panda, M.D. Ph.D (FILARIA)
Summary:
We report a case of acute liver failure associated with
Bancroftian filariasis in a young male. Absence of other etiological factors
rule out other causes of liver failure.
Treatment of the filariasis condition improved the liver function.
Introduction:
Bancroftian filarisis is associated with multiple clinical
presentations. Peripheral blood eosinophilia is a common association in
patients with filariasis. Tropical pulmonary eosinophilia is a common condition
in filarial endemic areas wherein peripheral blood eosinophilia is associated
with pulmonary symptoms. Acute eosinophilic glomerulonephritis has been
described in association with bancroftian filariasis. The presentation of a
case of Bancroftian Filarisis with liver failure is described below and an
etiological association between the two conditions is discussed.
Case report:
A 10 year old male child presented pain abdomen, fever, loss
of appetite, nausea and yellowish discoloration of the skin and eyes for 3
days. Fever was a low grade continuous type. Pain abdomen was more pronounced in the right
upper quadrant. There was no history of trauma
or drug intake of any kind. There
were no complaints pertaining to the respiratory or neurological system. A provisional diagnosis of acute Viral
hepatitis was made and hematological tests including routine hemoglobin count,
differential count, leukocyte count, liver function tests, Hbsag , urine for
bile salt and pigments and an Ultrasonogram of the abdomen and pelvis was
ordered. While the hemoglobin was in normal range, the differential count
revealed eosinophilia ( 79%) with a low neutrophil and lymphocyte count( 10%
each). Hbsag test was negative. Liver function tests revealed a raised SGOT (
2039 U/L), SGPT (1670 U/L), Alkaline phosphatase ( 533U/L), LDH ( 495 U/L), total bilirubin ( 12.24 mg/dl), Bilirubin
direct ( 10.27mg/dl), Bilurbin indirect ( 1.97 mg/dl). Serum protein was in
normal range and serum globulin was high (4.8g/dl) with a low albumin to
globulin ratio (0.7). bile salts and bile pigments were detected in the urine
sample. Ultrasonogram of the abdomen revealed a enlarged liver and a distended
gall bladder with thickened walls. Rest
of the intraabdominal structures appeared normal. Based on these findings
conservative treatment along the line of viral hepatitis was instituted. At the end of ten days , when the patient did
not report any clinical improvement, a repeat of the liver function tests was carried
out. Repeat tests revealed a mild
decrease in liver enzymes with a mild increase in the total and direct bilirubin.
The patient was continued under a conservative regimen for 4 weeks and repeat
liver function tests performed. At this time the SGOT and SGPT values showed
definite improvement, alkaline phosphatase values were normal but total and
direct biluribin values were still high.
Differential count repeated at this time showed persistent eosinophilia
(75%), elevated total leukocyte count ( 1 lac 12 thousands). No premature cells
in peripheral smear or toxic granules
were seen in the neutrophils. Absolute
eosinophil count was 39,640 ( normal
range: 50 – 400/cmm). Since the patient belonged to a filarial endemic
zone, a test for filarial antigen OG4C3
was carried out. The test for filarial antigen was positive ( 512 AU). A
diagnosis of Bancroftian filariasis with
acute liver failure was made and patient started on a course of diethylcarbamazine.
Over the next three weeks, patient reported rapid clinical improvement with
improved appetite, resolution of abdominal pain and fever. At the end of three
weeks a repeat of differential and leucocyte count revealed improvement in both
the parameters. A repeat of liver
function tests at this time showed normal values of the liver enzymes and
bilirubin count.
Discussion:
A raise in eosinophil differential count and absolute eosinophil count in a young male
with fever coming from a filarial endemic zone raised the suspicion towards
bancroftian filariasis. Persistently high liver enzymes with raised bilirubin
values that did not improve with conservative measures prompted us to search
for infective causes in absence of othe common etiologic factors for liver
failure. Og4c3 antigenic test for filarial has been proven to be of benefit to
detect infection with Wuchereria bancrofti
in case of inability to detect microfilaria in peripheral smear. Raised
eosinophil values in the absence of any premature cells in peripheral smear
ruled out the diagnosis of eosinophilic
leukemia. The improvement of both the clinical and hematological parameters with a course of
diethylcarbamazine clinches the diagnosis of acute liver failure with bancroftian
filariasis. The patient was last seen at a six month follow up and a repeat
clinical and hematological evaluation showed persistent improvement without any
recurrence of symptoms.
Addition- OG4C3 ELISA Test=
It is a semi-quantitative ELISA test for the detection of adult Filarial
antigen on 50 micro-litre of serum. Different titre groups are- 32,000, 8192 ,
2048 , 512, 128, 32, <10 Antigen Units. 512 and above antigen Units are
considered Positive and less thsn 512
Antigen Units are Negative.