Biliary ascariasis mimicking intra-abdominal TB – Can Endoscopic Ultrasound (EUS) "unearth" the worm?

Ascariasis remains a major burden of disease globally, with an estimated prevalence of 1 billion individuals being affected. Previous studies have highlighted a strong association and geographical overlap between worm infestation and TB infection. In these same studies, the occurrence of helminth-tuberculosis coinfection has been described and is postulated to be a result of immune modulation induced by both etiological organisms. An 81 year old male with history of laparoscopic cholecystectomy presented with acute pancreatitis and cholangitis. An abdominal Ultrasound was performed which excluded biliary dilatation and evidence of gall stones. Nevertheless, in view of a high index of suspicion of biliary obstruction, we proceeded with an Endoscopic Ultrasound (EUS) procedure which revealed multiple long, tubular, hyperechoic structures with an anechoic centre that spanned the entire length of the Common Bile Duct. The echogenic structures did not exhibit posterior acoustic shadowing and appeared mobile which was in keeping with biliary ascariasis. In addition, multiple large matted lymph nodes were observed at the periportal, hilar and -peripancreatic region. EUS-FNB of the biopsied hilar lymph node was in keeping with reactive lymphadenitis. Endoscopic Retrograde Cholangiopancreatography (ERCP) was subsequently performed and multiple linear imbricated, bile coated structures which was in keeping with macerated worms were trawled out from the CBD. Patient was given Albendazole therapy and repeat endoscopic evaluation revealed eradication of Ascariasis.