Ascariasis of gall bladder associated with xanthogranulomatous inflammation and cholelithiasis
A 39-year-old female patient came with complaints of pain in the abdomen and vomiting since 3–4 days. The patient gave a past history of the passage of worms and treatment given outside about 6–8 months back. Local examination revealed tenderness all over the abdomen with a lump in the right iliac fossa. Rest of the systemic examination was unremarkable. The laboratory investigations revealed a hemoglobin level of 10.2 g% and total leukocyte count 13100/mm3 with predominant neutrophilia (74%). Stool examination was noncontributory. Liver function tests showed serum bilirubin 0.68 mg%, serum glutamic oxaloacetic transaminase (SGOT) 17 IU/l, serum glutamic pyruvic transaminase (SGPT) 20 IU/l, and serum alkaline phosphatase 290 IU/l. Kidney function tests were within normal limits. The computed tomography (CT) scan showed a markedly distended gall bladder with a luminal diameter of 4.5 cm. There was marked thickening of the wall near the neck region, measuring approximately 1.2 cm in thickness. Luminal contents were suggestive of debris. A large calculus was seen at the neck of the gall bladder, measuring 1.2 cm in the greatest diameter.\nThe patient was posted for laparoscopic cholecystectomy. Intraoperatively, dense adhesions were noted between the gall bladder serosa and the hepatic capsule; hence a decision was taken to convert the procedure into open cholecystectomy. The abdomen was opened by right subcostal incision and the firm adhesions were dissected out. The gall bladder was submitted for histopathological examination.\nGrossly, the gall bladder measured 12 × 5 × 3 cm. The external surface showed marked congestion and a large roughened area of adhesions []. On cutting open, the lumen contained a blackish brown necrotic material and multiple brownish black-colored calculi, the largest (1.5 × 1.2 × 0.5 cm) of which was impacted at the neck. The wall of the gall bladder showed variation in the thickness. It was 0.5 cm at the tip of the distended part, while markedly thickened (2.5 cm) around the neck region. The thickened portion was grayish white and showed yellowish nodular areas [].\nMultiple sections from the wall showed evidence of chronic inflammatory infiltrate of histiocytes admixed with lymphocytes and plasma cells. The histiocytes showed foamy, lipid-laden cytoplasm []. Foci of necrosis and inspissated bile along with polymorphs and nuclear debris were noted on the luminal side. In addition, the walls of eggs of nematodes with an outer crenated surface, indicating rugosities were seen. A foreign body-type giant cell reaction was noted in some of the broken egg shells. The walls of the eggs had crenated borders, were hence interpreted as Ascaris lumbricoides [].