Contributed by Su Zheng, MD, PhD, J Thomas Molina, MD, PhD, Karen Schoedel, MD, and Sheldon Bastacky, MD
Published on line in January 2002
The patient was a 35-year-old Asian man from Thailand, who presented with jaundice, fatigue and weight loss of 10 to 15 pounds over the past few months. His blood tests showed the following results: AST 121 IU/L, ALT 112 IU/L, ALP 539 IU/L, GGTP 570 IU/L, total bilirubin 13.5 mg/dl, direct bilirubin 10.1 mg/dl. CT scan demonstrated: 1) multiple hepatic and pulmonary lesions; 2) dilatation of bilateral hepatic ducts and common bile duct with thickened walls and infiltration of periportal soft tissues; 3) large volume of ascites; 4) heterogeneous and nodular omentum (Figure 1). ERCP revealed multiple strictures in the intra- and extra-hepatic biliary system (Figure 2). Serum levels for tumor marker CA19-9 was 320,000 U (reference <38.0 U) and CEA was 52 ng/ml (reference <5 ng/ml). Alpha-fetoprotein was within the normal range. Bile fluid and bile duct brushing specimens were obtained from the ERCP procedure and sent to the Pathology Department. The patient also underwent ultrasound-guided paracentesis; 60 ml of ascites was collected and submitted to Pathology for evaluation.
The wet preparation made from the bile fluid (Figure 3) showed clusters of small, yellow-brown, urn-shaped parasitic ova with a convex operculum resting on "shoulders" and a small knob at the opposite end. The specimen from the bile duct brushing (Figures 4 & 5) revealed loose clusters of atypical ductal epithelial cells characterized by nucleomegaly, hyperchromasia, coarse chromatin and irregular nuclear membrane. Numerous bacterial forms and scattered ova were also seen. Cytologic evaluation of the peritoneal fluid (Figures 6 & 7) identified numerous similar atypical cells, which were immunoreactive for CEA (Figure 8) and negative for calretinin.