Biliary ascariasis without cholangitis: an unusual presentation in an endemic region

Biliary ascariasis is a clinical condition, in which the roundworm Ascaris lumbricoides migrates from the small intestine into the biliary tract. We report a case of a 21-year-old female patient from Skardu, Pakistan. The patient shows an unusual presentation that makes the diagnosis quite tricky. The symptoms include dull, persistent right hypochondrial pain, nausea, and vomiting without any signs of jaundice or fever. Moreover, the blood tests revealed only a mild increase in eosinophil count, just above the borderline, and completely normal liver function, a distinguishing feature of parasitic infections. Ultrasound showed a dilated bile duct containing a roundworm, indicating a parasite infection. Initially, the patient was given deworming medication. Furthermore, Magnetic resonance cholangiopancreatography (MRCP) findings were consistent with biliary ascariasis characterized by the presence of Ascaris within the hepatic biliary channels causing its significant dilatation. This case report highlights that lab reports can sometimes be misleading when making a diagnosis of biliary ascariasis. Additionally, there is a need for improvement in the healthcare system and sanitation.