The first patient was a 27-year-old female with a history of fever, nausea, anorexia, weight loss, painful swallowing, and progressive epigastric pain radiating to her back who was admitted to the Imam Khomeini Hospital in Ardabil Province, northwest of Iran. She lived in a village that was not recognized as an endemic area of fascioliasis but had a history of husbandry, consuming contaminated local aquatic vegetables, and drinking well water.

She had received treatments on an outpatient basis but had not recovered and her symptoms were gradually becoming worse. On admission, she appeared to be in poor general condition. So within one month, after the onset of symptoms, she had lost 5 kg. Laboratory findings patient upon admission consisted of a white blood cell count of 6400/mm3 without any evidence of eosinophilia. Her platelet count and hemoglobin were normal. Some biochemical parameters, direct bilirubin was 9 mg/dl, total bilirubin 1.19 mg/dl, aspartate aminotransferase 36 IU/L, alanine aminotransferase 56 IU/L, alkaline phosphatase 227 IU/L and amylase 41 IU/L. Endoscopic ultrasound demonstrated distal common bile duct strictures (CBD) and a lesion in its proximal measuring 34×12 mm. Then, the patient underwent magnetic resonance cholangiopancreatography, which due to the presence of a filling defect in the proximal CBD, the possibility of a parasitic infection or cholangiocarcinoma was raised. No serological tests were performed but during the ERCP process, several live thin-shelled and grey-colored Fasciola parasites were directed into the duodenum (Fig. 1). Triclabendazole (10 mg/kg single dose) was prescribed for therapy. Multiple stool examinations by formalin ether concentration method for ova of Fasciola and parasites were negative during 6 months of follow-up.

The second patient was a 54-year-old rural female who was admitted to Imam Khomeini Hospital in Ardabil Province with abdominal pain, nausea, anorexia, and pain in the right upper quadrant radiating to between her shoulder blades in the last eight months. According to the patient, the pain was not positional and had nothing to do with eating. In her previous medical history, there was cardiovascular disease and type 2 diabetes associated with fatty liver disease. During the physical examination, the patient was sensitive to palpation in the epigastric region and right subcostal area. The patient did not have a fever or chills. Her laboratory results upon admission showed the number of neutrophils and monocytes only slightly increased. No eosinophilia were observed. Routine liver biochemical tests and serum amylase/lipase concentrations were normal. The ultrasonographic findings of the patient showed dilatation of the CBD accompanied by a stone 22 mm diameter in the gallbladder. She had no icterus, tenderness, gardening, organomegaly, or ascites. Therefore ERCP was performed for diagnostic and therapeutic purposes and surprisingly, live green-brown parasites of Fasciola and biliary stone were evacuated (Fig. 2). Serological tests were not performed for the diagnosis of fascioliasis and Egaten (Triclabendazole) 10 mg/kg as an oral single dose was started for therapy. There were no problems in laboratory testing after 4 months of follow-up.