Expert consensus for the diagnosis and treatment of cystic and alveolar echinococcosis in humans

Diagnosis of echinococcosis by detecting circulating cell-free DNA and miRNA

INTRODUCTION

Diagnosis of echinococcosis is difficult and usually performed based on clinical findings, imaging, and serological test. However, all of them have limitations, especially in follow-up approaches.

AREAS COVERED

Detection of cell-free DNA (cfDNA) and micro-RNA (miRNA) is currently a hot topic for diagnosis of echinococcosis diseases. For detecting cell-free DNA in echinococcosis patient's samples such as sera, some techniques are based on next-generation sequencing (NGS), DNA-deep sequencing, some are based on PCR-based methods, and a few works related to the detection of miRNA for the diagnosis of human echinococcosis.

EXPERT OPINION

In the detection of cell-free DNA in echinococcosis patient' samples, NGS and DNA-deep sequencing have shown high level of sensitivity, but are not suitable for routine clinical examination as they are expensive and inaccessible in the majority of endemic areas. However, PCR-based methods have shown a sensitivity of about 20-25%. To improve the sensitivity of these tests, improving the DNA extraction method, designing appropriate primers for detecting short-length fragments of circulating DNA, using a higher volume of a serum sample, and application of more sensitive PCR methods are recommended. In the field of miRNA detection, further works are recommended.

Cystic Echinococcosis in Children: Ten Years of Experience and Which Laboratory Result in Evaluating Ruptured Cases?

Aim Hydatid disease (Echinococcosis) is a common zoonosis in countries that are involved in livestock such as our country. Our study aims to evaluate pediatric cases with hydatid disease over the last decade in our region and to determine the significance of initial clinical and laboratory findings in distinguishing ruptured hydatid cyst cases. Materials and Methods A retrospective analysis was made on demographic characteristics, presenting symptoms, physical examination, laboratory and radiological findings, and treatments of children with hydatid disease who were treated in our hospital and followed up regularly between January 2011 and December 2020. Results The study sample of 42 cases included 19 (45.2%) girls, with a median age of 125.5 (34-209) months. The most common symptom was abdominal pain (50%), and the most common physical examination finding was decreased breath sounds (23.8%). Thirty-five (83.3%) patients had single organ involvement and 7 (16.7) patients had multiple organ involvement. Cysts were detected in the right lobe of the liver in 24 (75%) of hepatic hydatid cysts and the left lobe in 7 (58.3%) of pulmonary hydatid cysts. The median size of the cysts was 57.5 (12-140) mm. The initial IHA titer, eosinophil count, eosinophil percentage, and sedimentation value were statistically significantly higher in patients with ruptured cysts than in those without rupture (p= 0.002, p= 0.003, p= 0.003, p= 0.02, respectively). Conclusions Initial pathological examination findings and at initial laboratory findings such as high IHA titer, eosinophil count, eosinophil percentage, sedimentation value can be used to distinguish rupture cases.

Differential Gene Expression Profiling in Alveolar Echinococcosis Identifies Potential Biomarkers Associated With Angiogenesis

Background

Alveolar echinococcosis (AE) is a worldwide zoonosis caused by Echinococcus multilocularis. Alveolar echinococcosis is a severe chronic parasitic disease that exhibits a tumor-like growth, with the potential for invasion and distant metastasis; however, the molecular mechanism underlying this condition remains unclear.

Methods

Transcriptome analyses were performed to detect differentially expressed genes (DEGs) in samples from patients with AE with invasion and distant metastasis. The results were further verified by immunohistochemistry.

Results

A total of 1796 DEGs were identified, including 1742 upregulated and 54 downregulated DEGs. A subsequent functional analysis showed that the significant DEGs were involved in the angiogenesis process. Immunohistochemical analysis confirmed the reliability of the transcriptomic data.

Conclusions

These results suggest that angiogenesis is a possible mechanism underlying the tumor-like biological behavior observed during E multilocularis infection. Genes related to this process may play important roles in AE invasion and distant metastasis.

Risk Factors and the Character of Clinical Course of the Echinococcus multilocularis Infection in Patients in Poland

Alveolar echinococcosis (AE) is a chronic zoonotic disease caused by the larval form of Echinococcus multilocularis. In humans, it may become a serious chronic infection of the liver which resembles a slow malignant process leading to death when untreated. The aim of the study was an assessment of the risk factors of the E. multilocularis infections and the description of AE clinical course in the group of 36 patients with confirmed AE, hospitalized at the Department and Clinic of Tropical and Parasitic Diseases, Poznan University of Medical Sciences between 2013 and 2022. Among the study participants, most patients cultivated land, bred livestock, worked in the forest, or were employed in animal shelters. The E. multilocularis infection was diagnosed based on imaging and immunoassay techniques within 6 months in the majority of patients hospitalized in the Department. All patients hospitalized in the Department initiated anti-parasitic therapy at the moment of the diagnosis. Pharmacological treatment combined with surgery was applied in most of the study participants, who were presented with more advanced stages of infection. We conclude the following: 1. For humans in the risk group, regular abdominal imaging examinations and the detection of specific antibodies against E. multilocularis are recommended. 2. Regular screening tests in the hyperendemic areas of AE would increase the early detection of the disease and to improve the clinical prognosis in this extremely life-threatening parasitic disease.

Implementing deep learning models for the classification of Echinococcus multilocularis infection in human liver tissue

BACKGROUND

The histological diagnosis of alveolar echinococcosis can be challenging. Decision support models based on deep learning (DL) are increasingly used to aid pathologists, but data on the histology of tissue-invasive parasitic infections are missing. The aim of this study was to implement DL methods to classify Echinococcus multilocularis liver lesions and normal liver tissue and assess which regions and structures play the most important role in classification decisions.

METHODS

We extracted 15,756 echinococcus tiles from 28 patients using 59 whole slide images (WSI); 11,602 tiles of normal liver parenchyma from 18 patients using 33 WSI served as a control group. Different pretrained model architectures were used with a 60-20-20% random splitting. We visualized the predictions using probability-thresholded heat maps of WSI. The area-under-the-curve (AUC) value and other performance metrics were calculated. The GradCAM method was used to calculate and visualize important spatial features.

RESULTS

The models achieved a high validation and test set accuracy. The calculated AUC values were 1.0 in all models. Pericystic fibrosis and necrotic areas, as well as germinative and laminated layers of the metacestodes played an important role in decision tasks according to the superimposed GradCAM heatmaps.

CONCLUSION

Deep learning models achieved a high predictive performance in classifying E. multilocularis liver lesions. A possible next step could be to validate the model using other datasets and test it against other pathologic entities as well, such as, for example, Echinococcus granulosus infection.

[Diagnostic delaying factors in hepatic alveolar echinococcosis]

PURPOSE

The purpose of this study was to analyze the diagnostic workflow of patients with alveolar echinococcosis (AE) and to identify possible diagnosis-delaying factors.

METHODS

The number and type of diagnostic procedures of patients diagnosed with alveolar echinococcosis were investigated. The disease history was recorded on the basis of questionnaires, the available findings, and data supplements from the hospital information system (SAP). Statistical analyses were performed using SAS version 9.4 and Microsoft Excel version 16.43. The study population of the cross-sectional study included n = 109 patients with confirmed alveolar echinococcosis.

RESULTS

The definitive diagnosis of alveolar echinococcosis of the liver was made at 26.5 ± 65.0 (mean ± standard deviation) months (min - max: 0 - 344, median = 3). The majority of patients were diagnosed because of incidental imaging findings of the liver (n = 74/109 (67.9%)). A total of n = 56/74 (75.7%) of all incidental findings were diagnosed in an outpatient setting, while n = 15/74 (20.3%) of cases were diagnosed during inpatient hospitalization. On average, 1.1 ± 1.2 (0-11, median = 1) ionizing imaging modalities were used for each patient. Contrast-enhanced sonography was received by 0.3 ± 0.5 (0-2, median = 0) patients. Almost all patients (n = 104/109 (95.4%) had at least one suspected hepatic or extrahepatic malignancy at some time. Exclusion of suspected malignancy occurred at a mean of 4.1 ± 16.5 months (0 -133.8, median = 1).

CONCLUSIONS

The diagnostic clarification process of AE patients is lengthy and stressful. The psychological burden of a questionable malignant diagnosis is considerable. Early use of contrast-enhanced sonography and, if necessary, puncture of unclear hepatic masses helps to shorten the difficult diagnostic process.

A multi-epitope vaccine GILE against Echinococcus Multilocularis infection in mice

Introduction

The objective of this study is to construct a multi-epitope vaccine GILE containing B-cell and T-cell epitopes against Echinococcus Multilocularis (E. multilocularis) infection based on the dominant epitopes of E. multilocularis EMY162, LAP, and GLUT1.

Methods

The structure and hydrophobicity of GILE were predicted by SWISSMODEL, pyMOL, SOPMA and VMD, and its sequence was optimized by Optimum™ Codon. The GILE gene was inserted into pCzn1 and transformed into Escherichia coli Arctic express competent cells. IPTG was added to induce the expression of recombinant proteins. High-purity GILE recombinant protein was obtained by Ni-NTA Resin. BALB/c mice were immunized with GILE mixed with Freund's adjuvant, and the antibody levels and dynamic changes in the serum were detected by ELISA. Lymphocyte proliferation was detected by MTS. The levels of IFN-g and IL-4 were detected by ELISpot and flow cytometry (FCM). T cells were detected by FCM. The growth of hepatic cysts was evaluated by Ultrasound and their weights were measured to evaluate the immune protective effect of GILE.

Results

The SWISS-MODEL analysis showed that the optimal model was EMY162 _95-104-LAP_464-479-LAP_495-510-LAP_396-410-LAP_504-518-EMY162_112-126. The SOPMA results showed that there were Alpha helix (14.88%), Extended strand (26.25%), Beta turn (3.73%) and Random coil (45.82%) in the secondary structure of GILE. The restriction enzyme digestion and sequencing results suggested that the plasmid pCzn1-GILE was successfully constructed. The SDSPAGE results indicated that the recombinant protein was 44.68 KD. The ELISA results indicated that mice immunized with GILE showed higher levels of serum antibodies compared to the PBS group. The FCM and ELISpot results indicated that mice immunized with GILE secreted more IFN-g and IL-4. Immunization with GILE also led to a significant decrease in the maximum diameter and weight of cysts and stimulated the production of CD4⁺ and CD8⁺ T Cell.

Discussion

A multi-epitope vaccine GILE with good immunogenicity and antigenicity has been successfully constructed in this study, which may provide important theoretical and experimental bases for the prevention and treatment of E. multilocularis infection.

Differentiation of hepatic alveolar echinococcosis with a hemangioma-like pattern compared to typical liver hemangioma using contrast-enhanced ultrasound: a pilot study

PURPOSE

Echinococcus multilocularis infects humans as a false intermediate host, primarily with intrahepatic manifestation. Incorrect diagnostic interpretation of these liver tumors, especially the hemangioma-like pattern, can lead to progressive disease. The aim of the study was to investigate the differentiation of typical hemangioma and a hemangioma-like pattern of E. multilocularis using contrast-enhanced ultrasound (CEUS).

METHODS

This prospective clinical pilot study comprised patients with hemangioma (n = 14) and patients with alveolar echinococcosis (AE) and hemangioma-like pattern (n = 7). Inclusion criteria were the detection of a liver lesion according to a hemangioma-like pattern on E. multilocularis Ulm classification-ultrasound (EMUC-US) and "confirmed" or "probable" AE according to WHO case definition. The comparison group had hepatic hemangioma with typical B-scan sonographic morphology. All participants underwent conventional and contrast-enhanced ultrasonography.

RESULTS

The patient group comprised five men (71.4%) and two women (28.6%) with a mean average age of 64.1 ± 11.2 years. The patient group with hemangioma comprised nine female subjects (64.3%) and five male subjects (35.7%) with a mean average age of 56.1 ± 12.0 years. Early arterial bulbous ring enhancement (p < 0.0001) and iris diaphragm phenomenon could only be visualized in the patients with hemangioma (p < 0.0001). Furthermore, the patients with hemangioma exhibited hyperenhancement in the late phase (p = 0.0003). In contrast, the patients exhibited typical early arterial rim enhancement (p < 0.0001) and, in the portal venous and late phase, complete or incomplete non-enhancement (black hole sign; p = 0.0004).

CONSLUSION

The behavior of hemangioma-like AE lesions and typical liver hemangiomas is significantly different on CEUS. AE should be considered as a possible differential diagnosis, especially in high-endemic areas.

Multidetector computed tomography assessment of venous invasion in hepatic alveolar echinococcosis

PURPOSE

The objective of this study was to correlate multidetector computed tomography (MDCT) findings in hepatic alveolar echinococcosis (HAE) with intraoperative and postoperative histopathological results to identify reliable MDCT criteria for the diagnosis of HAE venous invasion.

METHODS

A total of 136 HAE patients who underwent CT examination were included in this study. The lesion-vessel contact angle, irregular wall, lumen stenosis and occlusion were evaluated.

RESULTS

A total of 614 veins were estimated. In total, 510 veins were invaded, and 104 veins were not. The invasion rate was 83.06%. In single CT findings, with a cutoff value of > 180° determined by receiver operating characteristic (ROC) curve analysis, the lesion-vessel contact angle performed the best (area under the ROC curve, AUC = 0.907, 95% confidence interval, 95% CI 0.872-0.941, p < 0.001), with a sensitivity, specificity and positive likelihood ratio (PLR) of 84.90%, 88.46%, and 7.35, respectively. Irregular wall and lumen stenosis showed the lowest diagnostic performance. Diagnostic performance was the highest when combining these criteria and signs (AUC = 0.932, 95% CI 0.905-0.960, p < 0.001).

CONCLUSION

The lesion-vessel contact angle > 180° had the best sensitivity and specificity in the diagnosis of HAE venous invasion, and good interobserver agreement had been noted. The diagnostic performance of the lesion-vessel contact angle > 180° had been further improved with the addition of lumen occlusion accompanied by irregular wall or lumen stenosis.

Food-borne zoonotic echinococcosis: A review with special focus on epidemiology

Echinococcosis is a neglected, WHO-listed cyclozoonotic parasitic disease that is caused by a number of species belonging to the genus Echinococcus. This disease is widespread across the globe, resulting in heavy economic losses for farmers and cystic disease in aberrant human hosts. This review paper briefly discussed taxonomy, a brief history, the magnitude of economic losses, host spectrum and life cycle, risk factors, and clinical manifestations. Furthermore, the copro- and sero-ELISA-based prevalence of echinococcosis on different continents was summarized. Finally, the authors analyzed the frequency and use of molecular epidemiology in the taxonomy of Echinococcus species based on molecular markers. This review will serve as a quick reference to Echinococcus.

Concomitant intramyocardial and hepatic hydatid cysts diagnosed by multi-modality imaging: A rare case report

Cardiac echinococcosis is a potentially fatal form of hydatid disease; yet, its diagnosis and treatment are challenging due to the variability in its clinical manifestations and due to its various unpredictable preoperative complications. Multi-modality imaging is shown to provide important guidance for the treatment and decision-making. We report a rare case of a 50-year-old woman who had concomitant cardiac and hepatic hydatid cysts. She presented with abdominal pain and elevated eosinophilic white blood cells. The initial abdominal ultrasound and computerized tomography revealed a large cyst in the liver. An intramyocardial cyst was detected by two-dimensional echocardiography. Three-dimensional echocardiography increased the confidence level of two-dimensional echocardiography by displaying the three-dimensional volume of the cyst and allowing visualization of its spatial characteristics and the relationships with adjacent cardiac structures, which was subsequently confirmed at surgery. Multi-detector computed tomography and magnetic resonance imaging helped localize and define the typical morphological features of the cyst. Serology and antigen detection were used for diagnosis. This rare case underlines the integration of clinical, multi-modality imaging, and pathological data in the diagnosis of concomitant intramyocardial and hepatic hydatid cysts. Surgical resection of cysts and anthelmintic medication were successful in the management of this patient.

Risk factors for post-endoscopic retrograde cholangiopancreatography cholangitis in patients with hepatic alveolar echinococcosis-an observational study

BACKGROUND

Hepatic alveolar echinococcosis (HAE) is considered to be one of the most deadly chronic parasitic diseases in the world. We have shown that the incidence of cholangitis in patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) was increased significantly. On this finding, we carried out, a preliminary study on the risk factors for cholangitis after ERCP.

AIMS

To retrospectively detect the risk factors for post-ERCP cholangitis in patients with biliary tract affected by HAE.

METHODS

The study included data from 51 cases of AE who had undergone therapeutic ERCP between January 2015 and December 2019. Demographic and treatment data were extracted from the medical records, and the association between potential risk factors and the development of post-ERCP cholangitis was evaluated using a collected database.

RESULTS

There were five cases of mild cholangitis after ERCP (Tokyo criteria), and no moderate or severe cholangitis occurred. The incidence rate of cholangitis after ERCP was 9.8%. Univariate analysis showed hilar bile duct stenosis (p = .016), endoscopic retrograde biliary drainage (p = .007), a stent diameter ≥8.5 Fr (p = .000) and single stent implantation (p = .010) were risk factors for post -ERCP cholangitis. All cases of cholangitis improved under conservative treatment.

CONCLUSION

Patients with hilar bile duct compression or endoscopic retrograde biliary drainage appeared to be more likely to develop post-ERCP cholangitis. The number and diameter of biliary stents may influence post-ERCP cholangitis. Sample size and clinical heterogeneity are two insurmountable difficulties, and a larger sample size needs to be collected to verify the risk factors for screening. KEY MESSAGESMany studies reported the post-ERCP complications in patients with hepatic alveolar echinococcosis and found that the incidence of post-ERCP cholangitis was significantly high. Therefore, we conducted a preliminary study on the risk factors of postoperative cholangitis in patients who underwent ERCP.The incidence rate of cholangitis after ERCP was 9.8%. We found that hilar bile duct stenosis, and endoscopic retrograde biliary drainage, were risk factors for cholangitis, and stent diameter and the number of stent implantation may influence the incidence rate of cholangitis after ERCP.Sample size and clinical heterogeneity are two insurmountable difficulties, and a larger sample size needs to be collected to verify the risk factors of screening.

[Extended Liver Resection with Complex Vascular Reconstruction in Locally Advanced Alveolar Echinococcosis]

BACKGROUND

Hepatic echinococcosis is rare in Germany. Liver resection is a potentially curative treatment, if a complete resection according to oncological standards can be achieved. Due to the infiltrating growth of E. multilocularis, liver resections can be challenging.

CASE

We present a case of hepatic echinococcosis with complete infiltration of left and middle hepatic vein and a partial infiltration of the right hepatic vein (RHV) and the vena cava (VCI). To better evaluate resectability, we performed a three-dimensional reconstruction based on the preoperative CT scan. Complete resection was achieved with an extended left hemihepatectomy (removal of segment 1-5 and partially segment 8) and tangential resection of the VCI and partial resection of the RHV. VCI was reconstructed with a bovine pericardial patch and the RHV was reconstructed end-to-end.

CONCLUSION

Liver resection may require complex vascular resections and reconstructions to achieve an R0 situation in the therapy of E. multilocularis. Three dimensional planning of the resection facilitated curative resection in the current case.

Alveolar and neotropical echinococcosis

The urgency of the problem of human alveolar and neotropic echinococcosis is due to polymorphism and the severity of clinical manifestations. The purpose and result of the work is to summarize the data available in the literature on the etiology, epidemiology, clinic, diagnosis, treatment, prevention of alveolar and neotropic echinococcosis in humans. Conclusion. The causative agent of human alveolar echinococcosis is E. multilocularis, neotropic – E. vogeli, E. oligarthra. The liver and lungs are most often affected, less often other organs of the abdominal cavity, bones, brain, spinal cord, eyes, etc. Diagnostics is carried out on the basis of a complex of clinical, instrumental, serological, molecular genetic studies. Treatment includes surgical removal of parasitic cysts and drug therapy.

Experimental treatment of cystic echinococcosis: Combination therapy with carvacrol and thymol versus albendazole

Cystic echinococcosis is a worldwide zoonotic disease caused by Echinococcus granulosus sensu lato (s.l.), which produces serious health and economic problems. For human treatment, chemotherapy with albendazole (ABZ), a derivative of benzimidazoles, is widely used. However, due to its low efficacy and the lack of alternatives to ABZ, novel compounds are urgently needed. Aromatic plants exhibit powerful pharmacological activities, are accessible, have a relatively low cost, and have generally mild toxicities, making them an effective choice to traditional therapies. In particular, the pharmaceutical properties of aromatic plants are partially attributed to essential oils (EOs). The aim of the present study was to assess the in vitro and in vivo effects of the combined carvacrol and thymol against E. granulosus sensu stricto (s.s.). The greatest protoscolicidal effect was observed with the 9:1 and 5:5 (carvacrol:thymol) combinations which caused a marked decrease in viability after 6 days post-incubation, agreeing with the ultrastructural changes obtained. Permeation of the cysts and loss of turgidity was observed with the incubation with the different combinations of carvacrol:thymol. In the clinical efficacy study, the combination of thymol (40 mg/kg) and carvacrol (40 mg/kg) caused a tendency to diminish the weight of the cysts in comparison with the control group. On the other hand, the treatment of infected mice with ABZ, thymol or carvacrol, caused a significant decrease in the weight of the cysts. In conclusion, we here demonstrated the efficacy of different concentrations of combined carvacrol and thymol against E. granulosus s.s. protoscoleces and murine cysts, where short periods of treatment were sufficient to achieve a pharmacological effect. Moreover, we observed a reduction in the weight of the cysts in experimentally infected mice after treatment with carvacrol and thymol. The strategy used has an advantage over synthetic drugs because natural compounds are generally safe and non-toxic. Moreover, the combination of two drugs with different modes of action would cause a reduction in the doses and treatment times. Based on the promising results obtained in vitro, in the future, different doses of the combined drugs will be assayed in vivo to determine the potential of these compounds for the treatment of cystic echinococcosis.

Benign liver lesions 2022: Guideline for clinical practice of Associazione Italiana Studio del Fegato (AISF), Società Italiana di Radiologia Medica e Interventistica (SIRM), Società Italiana di Chirurgia (SIC), Società Italiana di Ultrasonologia in Medicina e Biologia (SIUMB), Associazione Italiana di Chirurgia Epatobilio-Pancreatica (AICEP), Società Italiana Trapianti d'Organo (SITO), Società Italiana di Anatomia Patologica e Citologia Diagnostica (SIAPEC-IAP) - Part I - Cystic lesions

Benign liver lesions are increasingly diagnosed in daily clinical practice due to the growing use of imaging techniques for the study of the abdomen in patients who have non-specific symptoms and do not have an increased risk of hepatic malignancy. They include simple or parasitic cysts and solid benign tumors which differ widely in terms of prevalence, clinical relevance, symptoms and natural history and often lead to significant clinical problems relating to diagnosis and clinical management. Following the need to have updated guidelines on the management of benign focal liver lesions, the Scientific Societies mainly involved in their management have promoted the drafting of a new dedicated document. This document was drawn up according to the present Italian rules and methodologies necessary to produce clinical, diagnostic, and therapeutic guidelines based on evidence. Here we present the first part of the guideline, concerning the characterization of focal hepatic lesions detected by ultrasound, and the diagnosis and clinical management of simple and parasitic hepatic cysts, and of polycystic liver disease.

Robotic Liver Surgery for Alveolar Echinococcosis: A Single-Centre Experience

Alveolar echinococcosis (AE) is a rare disease caused by Echinococcosis multilocularis, which usually requires multidisciplinary management including surgery as the only curative approach. In recent years, minimally invasive strategies have been increasingly adopted for liver surgery. In particular, robotic surgery enables surgeons to perform even complex liver resections using a minimally invasive approach. However, there are only a few reports on robotic liver surgery for AE. Consecutive patients undergoing robotic liver surgery for AE were analysed based on the prospective database of the Interdisciplinary Robotic Centre of Ulm University Hospital. Between January 2021 and August 2022, a total of 16 patients with AE underwent robotic hepatectomy at our institution. Median age was 55.5 years (23−73), median body mass index (BMI) was 25.8 kg/m2 (20.2−36.8) and 12 patients (75%) were female. Anatomic resections were performed in 14 patients (87.5%), of which 4 patients (25%) underwent major hepatectomies (i.e., resection of >3 segments) including two right hemihepatectomies, one left hemihepatectomy and one extended right hemihepatectomy performed as associating liver partition with portal vein ligation staged (ALPPS) hepatectomy. There was no 90-day mortality, no postoperative bile leakage and no posthepatectomy haemorrhage. One patient developed posthepatectomy liver failure grade B after extended right hemihepatectomy using an ALPPS approach. One patient had to be converted to open surgery and developed an organ-space surgical site infection, for which he was re-admitted and underwent intravenous antibiotic therapy. Median length of postoperative hospital stay was 7 days (4−30). To our knowledge, this is the largest series of robotic liver surgeries for AE. The robotic approach seems safe with promising short-term outcomes in this selected cohort for both minor as well as major resections.

Cystic echinococcosis in northern Tanzania: a pilot study in Maasai livestock-keeping communities

Background

There are close similarities between the life-cycles of Echinococcus granulosus sensu lato (E. granulosus s.l.) that causes cystic echinococcosis (CE) in humans and Taenia multiceps/Coenurus cerebralis that causes cerebral coenurosis in small ruminants. Recent evidence highlights that livestock in Maasai communities of northern Tanzania are suffering from increases in the prevalence of cerebral coenurosis, leading to concerns about a possible concurrent increased risk of human CE. The aim of this study was to estimate the prevalence of human abdominal CE and the prevalence and species/genotypes of E. granulosus s.l. in livestock in Maasai communities.

Methods

Human CE was diagnosed by abdominal ultrasound on volunteers aged ≥ 7 years in five villages in the Longido and Ngorongoro Districts in northern Tanzania. Infection in ruminants was evaluated through inspection in local abattoirs, followed by molecular identification of one cyst per animal, with a priority for hepatic cysts, using PCR targeting of the cytochrome c oxidase I gene (COX1), followed by restriction fragment length polymorphism and multiplex PCR, and sequencing of non-E. granulosus s.l. samples.

Results

Ultrasound was performed on 823 volunteers (n = 352 in two villages in Longido District, and n = 471 in three villages of Ngorongoro). Hepatic CE cases were diagnosed only in Ngorongoro (n = 6; 1.3%), of which three had active cysts. Village-level prevalence of CE ranged between 0 and 2.4%. Of the 697 ruminants inspected, 34.4% had parasitic cysts. Molecular identification was achieved for 140 of the 219 (63.9%) cysts sampled. E. granulosus s.l. and T. hydatigena/Cysticercus tenuicollis were identified in 51.4% and 48.6%, respectively, of livestock cysts. E. granulosus s.l. was identified in livestock from both Longido (35.3% of 116 genotyped cysts) and Ngorongoro (91.2% of 34 genotyped cysts). Of the total of 72 E. granuslosus s.l. cysts identified in livestock, 87.5% were E. granulosus sensu stricto (G1–G3 genotypes), 9.7% were E. ortleppi (G5) and one cyst was E. canadensis (G6–10). The three active human cysts, which were removed surgically, were G1–G3 genotypes.

Conclusions

Multiple species/genotypes of E. granulosus s.l. are circulating in Maasai communities of northern Tanzania. Human CE was detected in villages of Ngorongoro District and a high prevalence of echinococcal cysts was observed in livestock in both districts. More precise estimation of the prevalence in this area and a better understanding of the specific risk factors for CE among Maasai communities in northern Tanzania is needed. Interventions targeting transmission routes common to both E. granulosus s.l. and T. multiceps would have dual benefits for preventing both human and livestock disease.

Graphical Abstract

Echinococcus granulosus sensu stricto and antigen B may decrease inflammatory bowel disease through regulation of M1/2 polarization

Background

Inflammatory bowel disease (IBD) is a chronic idiopathic disease characterized by inflammation-related epithelial barrier damage in the intestinal tract. Helminth infection reduces autoimmune disease symptoms through regulation of inflammatory responses based on hygiene theory. However, the underlying mechanisms remain unclear.

Methods

BALB/c mice were infected with microcysts of E. granulosus sensu stricto and drank water containing 3.5% dextran sodium sulfate (DSS) at the 100th day post-infection. After 7 days of drinking DSS, the mouse body weight change and disease activity index (DAI) were recorded every day, and colon length and histological score were evaluated after sacrifice. After injection with antigen B (AgB), inducible nitric oxide synthase (iNOS) and Fizz1 expression and F4/80⁺CD11c⁺ M1 and F4/80⁺CD206⁺ M2 in the peritoneal cells and colon tissues were analysed by qPCR and flow cytometry, respectively. Gut microbiota were profiled by 16S rRNA sequencing of the mouse faecal samples. For in vitro assay, RAW264.7 macrophages were cultured in medium containing AgB before induction by lipopolysaccharide (LPS). Then, NO in the supernatant was measured, and the expression of cytokine genes associated with macrophages were determined by qRT-PCR.

Results

Echinococcus granulosus s.s. infection and AgB significantly reduced the symptoms and histological scores of IBD induced by DSS (P < 0.05). Flow cytometry showed that AgB inoculation increased F4/80⁺ and CD206⁺ in peritoneal cells. The results of qPCR showed that AgB significantly decreased iNOS and increased Fizz1 expression in the colon of mice inoculated by DSS (P < 0.05). Furthermore, AgB injection led to significant changes in the profiles of five genera (Paraprevotella, Odoribacter, Clostridium cluster XlVa, Oscillibacter, and Flavonifractor) in faecal samples. In vitro analysis showed that AgB reduced NO levels (P < 0.01), with a significant decrease in iNOS expression (P < 0.05) in RAW264.7 cells induced by LPS.

Conclusions

Echinococcus granulosus infection and AgB may improve IBD conditions by inducing an M2-predominant cellular (F4/80⁺ CD206⁺) profile and decreasing type 1 macrophages (F4/80⁺CD11c⁺) in the intestinal lamina propria. In addition, AgB intervention induced changes in the microbiota condition of the gastrointestinal duct and reversed NO expression. Thus, AgB may be a drug candidate for IBD treatment.

Graphical Abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s13071-022-05498-y.

Societal drivers of human echinococcosis in China

BACKGROUND

Echinococcosis is a parasitic zoonotic disease that threatens human health and economic development. In China, 370 counties are endemic for echinococcosis. Qinghai-Tibet Plateau has the most patients and people at risk. Therefore, analyzing the societal factors related to susceptibility to the disease is critical for efficient prevention and control of echinococcosis.

METHODS

The demographic characteristics and lifestyle of echinococcosis cases were clustered using K-means cluster analysis to determine the main factors of risk of echinococcosis.

RESULTS

Middle-aged and young people as well as those with a low education level and herdsmen are at risk of contracting echinococcosis. Nomadism, domestic and feral dogs in the surrounding environment, and drinking heavily polluted natural surface water are the main behavioral risk factors. The cystic echinococcosis (CE) and alveolar echinococcosis (AE) cluster analysis focused on female, middle-aged, and young people, winter settlement and summer nomadism, and domestic and feral dogs in the surrounding environment. There were significant differences in lifestyle between Qinghai-Tibet Plateau cases and non-Qinghai-Tibet-Plateau cases.

CONCLUSION

According to the distribution of cases and CE and AE, this study identified the factors of risk of echinococcosis in the Qinghai-Tibet Plateau and non-Qinghai-Tibet Plateau. Adapted control techniques appropriate for the various epidemic areas should be established to serve as a reference for echinococcosis prevention.

Comparison of local ablation with Albendazole or laparoscopic hepatectomy combined with Albendazole in the treatment of early hepatic alveolar echinococcosis

Background

Echinococcosis (E) is a zoonotic parasitic disease caused by the larval morphology of echinococcosis tapeworms. Among the recognized species, two are of medical importance-E. granulosus and E. multilocularis-causing cystic echinococcosis (CE) and alveolar echinococcosis (AE) in humans, respectively. Diagnosis of AE is based on clinical manifestation and epidemiological data, imaging techniques, histopathology and/or nucleic acid detection, and serology. At present, WHO guidelines suggest that benzimidazoles (BMZ) are mandatory in all AE patients, temporarily after complete resection of the lesions and for life in all other AE cases. Interventional procedures should be preferred to palliative surgery whenever possible, and radical surgery is the first choice in all cases suitable for total resection of the lesion. However, some research centers have proposed that local ablation (LA) including radiofrequency ablation (RFA) and microwave ablation (MWA) is no less effective than radical surgery or better than simple medication in the early stage hepatic AE (WHO-IWGE PNM classification of AE: P1N0M0). This study attempted to compare the real efficacy of the above treatment methods, so as to find the best treatment for this kind of patient.

Methods

The data of patients with hepatic AE who underwent laparoscopic hepatectomy (LH), RFA, and MWA in Qinghai Provincial People's Hospital from January 2015 to January 2021 were collected. At the same time, the cases treated with Albendazole (ABZ) were collected together with the institution for disease control and prevention. According to the treatment methods, the above cases were divided into LH group, RFA group, MWA group, and medication group. The basic data and postoperative recovery indices of the four groups were compared, respectively.

Results

A total of 199 patients with hepatic AE were enrolled in this study, including 90 males and 109 females. The youngest was 5 years old and the oldest was 66 years old, with an average of 33.41±14.64 years old. 20.6% of the patients had hepatitis B (41/ 199). A total of 45 patients underwent ultrasound-guided RFA, 47 patients underwent ultrasound-guided MWA, 51 patients were treated with ABZ, and 56 patients underwent LH. There were no significant differences in baseline characteristics among the four groups (p > 0.05). The RFA group and MWA group were more advantageous than the LH group regarding operation time and incidence of postoperative complications (p < 0.05). But recurrence rate of the lesion in the LH group was significantly lower than the RFA group, MWA group, and medication group. However, there was no significant difference in recurrence-free survival time among the four groups (p >0.05).

Conclusion

LH has a significant effect in the treatment of early-stage hepatic AE, especially in terms of recurrence which is significantly better than LA and medication alone. Follow-up and adherence to ABZ therapy are essential if conservative treatment is to achieve better outcomes.

Cardiac Echinococcosis With Hepatic Involvement in a Child: A Case Report

Hydatidosis is endemic in Morocco. Cardiac localization of hydatid disease is a rare entity. Involvement of the interventricular septum is even rarer. We report the case of a 6-year-old girl with combined hepatocardiac hydatid disease. She was admitted with complaints of dyspnea, asthenia and vomiting. Ultrasound imaging and CT scan showed cystic lesions in the interventricular septum and in the liver. Serologic test results were positive. According to the biological and radiological findings, the diagnosis of echinococcosis with cardiac and hepatic involvement was suggested. Complete excision of the cardiac cyst was performed followed by anthelminthic treatment with albendazole as a supportive therapy. The confirmative diagnosis of hydatid disease was made by microscopic examination of the removed material. Our patient was referred to the department of general surgery to treat the liver lesions in the future. The postoperative period was unremarkable.

Targeting Echinococcus multilocularis PIM kinase for improving anti-parasitic chemotherapy

BACKGROUND

The potentially lethal zoonosis alveolar echinococcosis (AE) is caused by the metacestode larval stage of the tapeworm Echinococcus multilocularis. Current AE treatment options are limited and rely on surgery as well as on chemotherapy involving benzimidazoles (BZ). BZ treatment, however, is mostly parasitostatic only, must be given for prolonged time periods, and is associated with adverse side effects. Novel treatment options are thus urgently needed.

METHODOLOGY/PRINCIPAL FINDINGS

By applying a broad range of kinase inhibitors to E. multilocularis stem cell cultures we identified the proto-oncogene PIM kinase as a promising target for anti-AE chemotherapy. The gene encoding the respective E. multilocularis ortholog, EmPim, was characterized and in situ hybridization assays indicated its expression in parasite stem cells. By yeast two-hybrid assays we demonstrate interaction of EmPim with E. multilocularis CDC25, indicating an involvement of EmPim in parasite cell cycle regulation. Small molecule compounds SGI-1776 and CX-6258, originally found to effectively inhibit human PIM kinases, exhibited detrimental effects on in vitro cultured parasite metacestode vesicles and prevented the formation of mature vesicles from parasite stem cell cultures. To improve compound specificity for EmPim, we applied a high throughput in silico modelling approach, leading to the identification of compound Z196138710. When applied to in vitro cultured metacestode vesicles and parasite cell cultures, Z196138710 proved equally detrimental as SGI-1776 and CX-6258 but displayed significantly reduced toxicity towards human HEK293T and HepG2 cells.

CONCLUSIONS/SIGNIFICANCE

Repurposing of kinase inhibitors initially designed to affect mammalian kinases for helminth disease treatment is often hampered by adverse side effects of respective compounds on human cells. Here we demonstrate the utility of high throughput in silico approaches to design small molecule compounds of higher specificity for parasite cells. We propose EmPim as a promising target for respective approaches towards AE treatment.

Case Report: Diagnosis of vertebral alveolar echinococcosis upon next-generation sequencing in a suspected tuberculosis

Introduction

Alveolar echinococcosis (AE), caused by larval stages of Echinococcus multilocularis, is a rare zoonotic disease that mainly involves the liver. The diagnosis of extrahepatic AE is usually difficult. Here, we describe a rare case of vertebral alveolar echinococcosis with a suspected history of spinal tuberculosis, diagnosed by metagenomic next-generation sequencing (mNGS).

Case Presentation

A 44-year-old woman presented with repetitive neck and back pain, with a surgical history of suspected spinal tuberculosis. Magnetic resonance imaging (MRI) showed cystic masses in the craniocervical junction region and effusion around lumbar vertebrae. Multiple culture tests were performed to detect tuberculosis and other pathogens through puncture of the effusion and of cerebrospinal fluid, but the results were all negative. Finally, mNGS of the effusion fluid was performed and Echinococcus multilocularis were detected. The results were further confirmed by Sanger sequencing.

Conclusion

This case emphasizes a role of mNGS in the diagnosis of infectious diseases with unknown pathogen. As a newly emerged sensitive and accurate diagnostic strategy, mNGS provides clinicians an opportunity to clarify pathogens in complicated infectious cases, especially in patients with a history of multiple infections.

Silencing TUBB3 Expression Destroys the Tegument and Flame Cells of Echinococcus multilocularis Protoscoleces

Alveolar echinococcosis (AE), caused by infection with the larvae of Echinococcus multilocularis, is a neglected tropical disease and zoonosis that causes remarkable morbidity in humans and has economic importance in the livestock industry worldwide. The growth of this parasite resembles the invasion and proliferation of malignant tumours. Microtubules, especially the β-tubulin subunit in the exposed end, are the targets of many antitumour drugs. However, the role of TUBB3, which is the most studied isotype in solid tumours and is also a marker of biological aggressiveness associated with the modulation of tumour metastatic abilities in the growth and development of platyhelminths, is unknown. In this study, protoscoleces (PSCs) are cultivated in monophasic medium in vitro. Using electroporated short interfering RNA (siRNA), EmTUBB3 knockdown was performed with two EmTUBB3-specific siRNAs (siRNA-1 and siRNA-2). qRT–PCR was performed to detect the expression of TUBB3. PSCs viability and the evagination rate and number of body contractions were quantified under a light microscope. Scanning electron microscopy (SEM) and transmission electron microscopy (TEM) were used to observe the ultra-morphological changes of the parasites. After siRNA interference, the EmTUBB3 expression in E. multilocularis PSCs was significantly reduced. Reduced viability, a decreased evagination rate and a decreased number of body contractions were also documented. In particular, shrinkage and roughness of the tegument were observed. Ultrastructural changes included marked damage to flame cells, cracked cilia structures enclosed in the cell body and ruptured microtubule structures. EmTUBB3 possibly plays a crucial role in tegument and flame cell integrity in E. multilocularis PSCs. Novel drugs targeting this specific beta-tubulin isotype in E. multilocularis are potential methods for disease control and deserve further attention.

Evaluation of Potential Inflammatory Markers for Cystic Echinococcosis: P-selectin and Resistin

OBJECTIVE

Cystic echinococcosis (CE) is one of the most common zoonotic diseases worldwide. Diagnosis of CE is predominantly based on imaging techniques and serological tests are used in cases of non-characteristic imaging findings as diagnostic reference. However, serological test results cannot be completely reliable as they are affected by multi-factors. P-selectin and resistin are inflammatory markers that are altered during the acute stages of infection. In this purpose, inflammatory markers as P-selectin and resistin have been investigated for a potential diagnostic reference for CE diagnosis.

METHODS

A total of 60 patients who were diagnosed with CE and twenty-five healthy individuals were included in this study. Blood samples were obtained from all participants. Obtained sera were evaluated using the P-selectin and resistin ELISA kits for protein levels. Additionally, the relative expression of SELP (P-selectin) and RETN (resistin) genes were determined using the comparative CT (ΔΔCT) method between groups as CE patients with active and inactive cysts, CE patients and healthy controls.

RESULTS

SELP (13.9-fold change, p<0.05) and RETN (8.1-fold change, p<0.05) were differentially expressed in CE patients compared in the control group. Whereas resistin protein levels were significantly higher in CE patients than the healthy controls (p<0.001), the difference in P-selectin protein levels was not significant (p>0.05). There was no difference between active and inactive CE patients in terms of P-selectin and resistin in gene and protein levels (p>0.05).

CONCLUSION

Although there was no difference between the active and inactive CE patients, the good differentiation between the healthy controls and the CE patients suggested that resistin is a potential inflammatory diagnostic reference.

Isolated cardiac hydatid cyst of the right ventricle

A hydatid cyst is a parasitic disease that most commonly affects the liver and lungs: it rarely affects the heart: right ventricular involvement is even less common. A 33-year-old male patient with a cardiac cystic mass, detected during echocardiography, was evaluated. Early surgery was the best treatment option. A hydatid cyst is located in the right ventricular wall and detected during surgery. The cyst was drained and the defect in the right ventricle was quilted. Postoperative follow-ups occurred, and he was discharged with albendazole in good health.

Laparoscopic resection of hepatic alveolar echinococcosis: A single-center experience

Introduction

Alveolar echinococcosis (AE) remains a very rare disease requiring complete radical resection for curative treatment. While open approaches are common, safety and efficacy of laparoscopic resections remain unknown.

Methods

This is a single-center, retrospective cohort study with patients undergoing liver resection for hepatic AE at the Department of Visceral Surgery and Medicine, Bern University Hospital from December 2002 to December 2020. Postoperative outcomes of patients following laparoscopic hepatectomy (LH) for hepatic AE were compared with those of patients undergoing open hepatectomy (OH).

Results

A total of 93 patients underwent liver resection for hepatic AE. Laparoscopic hepatectomy was performed in 23 patients and open hepatectomy in 70 patients. While there were no significant differences in terms of gender, age and diagnostic tools, the majority of patients of the LH cohort were PNM stage 1 (78%) in contrast to only 39% in the OH cohort (p = 0.002). Patients undergoing laparoscopic hepatectomy were treated by minor liver resections in 91% and in 9% by major liver resections in comparison to the open hepatectomy cohort with 61% major liver resections and 39% minor resections. Laparoscopic hepatectomy was associated with shorter mean operation time (127 minutes vs. 242 minutes, p <0.001), lower major complication rate (0% vs. 11%, p = 0.322) and shorter mean length of hospital stay (4 days vs. 13 days, p <0.001). Patients with LH had a distinct, but not significant lower recurrence rate (0% vs. 4%, p = 0.210) during a mean follow-up of 55 months compared with a follow-up of 76 months in the OH cohort. After subgroup analysis of PNM stage 1 patients, similar results are seen with persistent shorter mean operation time (120 minutes vs. 223 minutes, p <0.001), lower major complication rate (0% vs. 8%, p = 0.759) and shorter length of hospital stay (4 days vs. 12 days, p <0.001).

Conclusion

Laparoscopy appears as a feasible and safe approach for patients with PNM stage 1 alveolar echinococcosis without impact on early disease recurrence.

In this retrospective cohort study laparoscopic hepatectomy for hepatic alveolar echinococcosis had no negative impact on perioperative outcomes, disease recurrence or survival compared with open hepatectomy. The importance of this finding is that the laparoscopic approach is feasible and safe for selected patients with hepatic alveolar echinococcosis, especially those with PNM stage 1.

Paediatric pulmonary echinococcosis: A neglected disease

Echinococcosis is a worldwide public health problem causing considerable paediatric morbidity and mortality in endemic areas. The presentation of cystic echinococcosis (CE) varies by age. Unlike adults, where hepatic involvement is common, pulmonary CE is the dominant site in the paediatric population. Pulmonary cysts are typically first seen on chest X-ray, either as an incidental finding or following respiratory symptoms after cyst rupture or secondary infection of the cyst. In children, pulmonary cysts have a broad differential diagnosis, and a definitive diagnosis relies on the combination of imaging, serology, and histology. In countries with high infectious burdens from diseases such as acquired immunodeficiency syndrome (AIDS) and tuberculosis (TB), the diagnosis is additionally challenging, as atypical infections are more common than in developed countries. Pulmonary CE is treated with a combination of surgery and chemotherapy.

Knowledge, attitudes, and practices of municipal veterinary practitioners towards echinococcosis

Cystic echinococcosis (CE) and alveolar echinococcosis (AE) are among the most relevant zoonoses in Europe. According to the European Food Safety Authority (EFSA), Echinococcus granulosus sensu lato causing CE is the most significant foodborne parasite in South-Western Europe, followed by Echinococcus multilocularis, the etiological agent of AE. Among the challenges and opportunities highlighted in the literature to combat these diseases are the need to evaluate and increase awareness of stakeholders. In Portugal, Municipal Veterinary Practitioners (MVP) are the animal health authority at the municipality level, playing a crucial role in diagnosis, prevention and control of infectious diseases in animals, helping to mitigate transmission to humans. However, their knowledge, attitudes, and practices (KAP) towards CE, as well as awareness of AE expansion across Europe, remain overlooked. In this work, a cross-sectional study was conducted for the first time in Portugal to bridge knowledge gaps concerning CE and AE, using an online self-administered questionnaire collecting information on the municipal kennel, KAP towards CE, and understanding of AE epidemiology. Eighty-three MVP from mainland and islands completed the questionnaire, with highest representability from the central-northern region. MVP had, on average, a medium to high level of knowledge of CE but acquaintance with AE was insufficient, although echinococcosis was frequently mentioned as target of health education sessions (77.0%). A high rate (60%) of reported entries into municipal kennels of stray dogs originating from countries with AE endemic areas was registered, suggesting that the presence of these potentially AE-infected stray dogs pose public health risks. Most kennels did not perform routine coprological analysis or faecal matter disinfection after dog internal deworming. The lack of proper training and well-conceived written plans of infection control and prevention were evidenced in several kennels. Altogether, our findings highlight the need to update knowledge and practice of MVP under the One Health approach, through reinforced education, training and communication involving all stakeholders.

Disseminated alveolar echinococcosis in a patient diagnosed by metagenomic next-generation sequencing: A case report

Background

Alveolar echinococcosis (AE) is a parasitic zoonosis with high mortality and disability rates. Diverse clinical manifestations and mimicking of differential diagnoses such as tuberculosis and malignancy pose a diagnostic dilemma. With the rapid development of molecular diagnostic techniques in recent years, metagenomic next-generation sequencing (mNGS) has become an attractive approach for the etiological diagnosis of infectious diseases.

Case presentation

we report a case of 51-year-old Chinese Tibetan male presented with 3-year low-back pain and 4-month discomfort in the right upper quadrant of the abdomen. He had been in good health. He was diagnosed with tuberculosis and was given anti-tuberculosis treatment a month prior to the visit, but the symptoms were not relieved. Abdominal computerized tomography (CT) revealed a hypodense lesion with uneven enhancement in the liver, and two ring-enhancing cystic lesions in the right abdominal wall. Lumbar spine enhanced MRI showed lesions of mixed density with uneven enhancement in the L1 vertebra and paraspinal tissue. The pathological results of the liver biopsy revealed parasitic infection and possibly echinococcosis. The metagenomic next-generation sequencing (mNGS) of the puncture fluid of abdominal cysts using Illumina X10 sequencer revealed 585 sequence reads matching Echinococcus multilocularis. Disseminated AE was diagnosed. Albendazole (400 mg, twice daily) was used, and the patient was in stable condition during follow-up.

Conclusions

mNGS may be a useful tool for the diagnosis of AE. The case would help clinicians to improve their diagnostic skills.

Approaches to reconstruction of inferior vena cava by ex vivo liver resection and autotransplantation in 114 patients with hepatic alveolar echinococcosis

BACKGROUND

Hepatic alveolar echinococcosis (AE) is most commonly found in retrohepatic inferior vena cava (RHIVC). Ex vivo liver resection and autotransplantation (ELRA) can better realize the radical resection of end-stage hepatic AE with severely compromised hepatocaval confluences, and reconstruction of the affected vessels. Currently, there is a scarcity of information regarding RHIVC reconstruction in ELRA.

AIM

To propose reasonable RHICV reconstruction strategies for ex vivo liver resection and autotransplantation.

METHODS

We retrospectively summarized the clinical data of 114 patients diagnosed with hepatic AE who treated by ELRA in our department. A total of 114 patients were divided into three groups according to the different reconstruction methods of RHIVC: Group A with original RHIVC being repaired and reconstructed (n = 64), group B with RHIVC being replaced (n = 43), and group C with RHIVC being resected without reconstruction (n = 7). The clinical data of patients, including the operation time, anhepatic phase, intraoperative blood loss, complications and postoperative hospital stay, were analyzed and the patients were routinely followed up. The normally distributed continuous variables were expressed as means ± SD, whereas the abnormally distributed ones were expressed as median and analyzed by analysis of variance. Survival curve was plotted by the Kaplan-Meier method.

RESULTS

All patients were routinely followed up for a median duration of 52 (range, 12-125) mo. The 30 d mortality rate was 7.0% (8/114) and 7 patients died within 90 d. Among all subjects, the inferior vena cava (IVC)-related complication rates were 17.5% (11/63) in group A and 16.3% (7/43) in group B. IVC stenosis was found in 12 patients (10.5%), whereas thrombus was formed in 6 patients (5.3%). Twenty-two patients had grade III or higher complications, with the complication rates being 17.2%, 16.3%, and 57.1% in the three groups. The average postoperative hospital stay in the three groups was 32.3 ± 19.8, 26.7 ± 18.2, and 51.3 ± 29.4 d (P = 0.03), respectively.

CONCLUSION

ELRA can be considered a safe and feasible option for end-stage hepatic AE patients with RHIVC infiltration. The RHIVC reconstruction methods should be selected appropriately depending on the defect degree of AE lesions in IVC lumen. The RHIVC resection without any reconstruction method should be considered with caution.

Records of Human Deaths from Echinococcosis in Brazil, 1995–2016

Simple Summary

Echinococcosis is a zoonotic disease relevant to public health in many countries. The disease is present in Brazil; however, it is often underreported due to the lack of mandatory notification of cases across all Brazilian states. The records of two national databases were accessed during the period of 1995–2016 to describe the registered cases and deaths from echinococcosis in the country. Demographic, epidemiological, and health care data related to the occurrence of disease, and deaths attributed to echinococcosis are described. During the study period, 7955 hospitalizations were recorded due to echinococcosis, with 185 deaths. In a second database recording just mortality, a further 113 deaths were documented. Deaths were observed in every state of Brazil. When comparing between states, there was great variability in mortality rates, possibly indicating differences in the quality of health care received by patients and reinforcing the need to expand the compulsory notification of the disease across the country.

Abstract

Echinococcosis is a zoonotic disease relevant to public health in many countries, on all continents except Antarctica. The objective of the study is to describe the registered cases and mortality from echinococcosis in Brazil, from 1995 to 2016. The records of two national databases, the Hospital Information System (HIS) and the Mortality Information System (MIS), were accessed during the period of 1995–2016. Demographic, epidemiological, and health care data related to the occurrence of disease and deaths attributed to echinococcosis in Brazil are described. The results showed that 7955 records of hospitalizations were documented in the HIS, during the study period, with 185 deaths from echinococcosis, and 113 records of deaths were documented in the MIS Deaths in every state of Brazil in the period. When comparing between states, the HIS showed great variability in mortality rates, possibly indicating heterogeneity in diagnosis and in the quality of health care received by patients. Less severe cases that do not require specialized care are not recorded by the information systems, thus the true burden of the disease could be underrepresented in the country. A change in the coding of disease records in the HIS in the late 1990s, (the integration of echinococcosis cases with other pathologies), led to the loss of specificity of the records. The records showed a wide geographic distribution of deaths from echinococcosis, reinforcing the need to expand the notification of the disease in Brazil. Currently, notification of cases is compulsory in the state of Rio Grande do Sul.

Pharmacological Profile, Bioactivities, and Safety of Turmeric Oil

The pharmacological attributes of turmeric have been extensively described and frequently related to the action of curcuminoids. However, there is also scientific evidence of the contribution of turmeric oil. Since the oil does not contain curcuminoids in its composition, it is crucial to better understand the therapeutic role of other constituents in turmeric. The present review discusses the pharmacokinetics of turmeric oil, pointing to the potential application of its active molecules as therapeutic compounds. In addition, the bioactivities of turmeric oil and its safety in preclinical and clinical studies were revised. This literature-based research intends to provide an updated overview to promote further research on turmeric oil and its constituents.

Coexistence of pulmonary hydatid cyst and tuberculosis in a child: a case report

Background

The echinococcosis and tuberculosis of the lungs are both endemic in Algeria.

The coexistence of echinococcosis and tuberculosis in the same lobe of the lung is exceptional.

Case presentation

A 10-year-old girl was admitted with a history of productive cough, fever, and chest pain.

Chest examination revealed decreased air entry at left lower lobe. Chest X-ray demonstrated a round left lower lobe with an air fluid interface. Chest CT scan with intravenous contrast showed a lingual hydroaeric formation measuring 5×6 cm with a detached membrane image.

A diagnosis of a complicated hydatid disease of the lung was made and the patient was subsequently started on oral albendazole before undergoing exploratory thoracotomy where partial cystectomy and the obliteration of the pericyst cavity. Histopathology was notable for echinococcosis membrane characteristics.

After 2 months, the patient re-presented with complaints of cough, hemoptysis, and dyspnea.

Radiographic images favored repermeabilization of bronchopleural fistulas.

The management was the closing of the bronchial openings.

Histological findings include image characteristic of the echinococcosis and tuberculosis.

The patient continued on albendazole and an anti-tuberculosis regimen, with concurrent functional physiotherapy sessions.

During the following 3-year follow-up, drastic clinical, radiographic, and functional improvement was noted.

Conclusion

Concurrent tuberculosis and echinococcosis infection should be taken into consideration when patients present with persistent bronchopleural fistula in endemic areas.

A multidisciplinary approach of different medical teams facilitates diagnosis and rapid treatment.

Dog Ownership and Risk for Alveolar Echinococcosis, Germany

Human alveolar echinococcosis is caused by the parasite Echinococcus multilocularis, and dog ownership has been identified as a risk factor. We sought to specify the factors of dog ownership underlying this risk by conducting a case–control study among dog owners in Germany. The analysis revealed an increased odds ratio of ≈7-fold for dog owners whose dogs roam unattended in fields, 13-fold for dog owners who feed their dogs organic waste daily, 4-fold for dog owners who take their dog to a veterinarian only in case of illness, and 10-fold for dog owners who have never been informed by a veterinarian about the risk for infection. The results highlight the risk for infection associated with various factors of dog ownership and the value of veterinarians informing owners about prevention.

Surgical treatment of liver hydatid cyst in elderly patients: A propensity score-matching retrospective cohort study

BACKGROUND

Cystic echinococcosis is a clinically complex chronic parasitic disease and a major socioeconomic problem in endemic areas. The safety of liver resection in elderly patients is often debated among medical professionals. We analyzed the postoperative morbidity and mortality rates of elderly patients who underwent surgery at our unit.

METHODS

We retrospectively evaluated patients with liver hydatid cysts which were surgically removed at our unit. Patients were divided into two groups: Group 1 (patients < 70 years), and Group 2 (patients ≥ 70 years). Propensity score matching (PSM) and comparative analyses between groups were performed.

RESULTS

The unmatched cohort consisted of 279 patients (Group 1: 244; Group 2: 35). After PSM, we compared the outcomes for 56 patients from Group 1 to 31 patients from Group 2. A higher rate of severe complications was observed in Group 2 (25.8% vs 5.36%, p = 0.014). No difference was found in the rates of infectious, cardiorespiratory, or hemorrhagic complications between both groups, and in the mortality rate either (0.00% vs 6.45%, p = 0.124).

CONCLUSIONS

Liver surgery in selected elderly patients is safe and practicable. The low postoperative morbidity rate in these patients is acceptable, albeit higher, due to their comorbidities.

Echinococcosis in a non-endemic country - 20-years' surgical experience from a Norwegian tertiary referral Centre

BACKGROUND

In Scandinavia, the incidence of cystic echinococcosis (CE) and alveolar echinococcosis (AE) is low and almost exclusively an imported disease following the trends of immigration. The aim of the study was to review available data on clinical management and outcome for patients treated at Oslo University Hospital, a referral centre for echinococcosis in Norway, with special emphasis on surgical treatment.

METHODS

All patients admitted with echinococcosis between January 2000 and December 2020 were identified. Medical records were reviewed retrospectively concerning patient demographics, treatment strategy, surgical procedures, complications and outcomes.

RESULTS

A total of 92 patients with median age 37 years (range 4-85) were identified. Sixty-eight patients (74%) were symptomatic. All patients, except for two, were immigrants to Norway and born in endemic areas. Ninety patients were diagnosed with CE and two with AE. Location of the cysts was most commonly in the liver (86%) followed by peritoneum, lungs, and spleen. All patients with active cysts were treated with albendazole. Surgical treatment was performed in 51 (56%) patients. The most common reason for abstaining from surgical treatment was that the diagnostic work-up revealed inactive cysts or interventional radiology was performed. Of the 51 patients who underwent surgery, a radical procedure was performed in 32 (64%) cases, a conservative procedure in 12 (24%), and a combination in six (12%). Clavien Dindo grade ≥3 complications occurred in 30%, and 90-day mortality was 2%. Bile leakage occurred in seven patients and was treated successfully with endoscopic retrograde cholangiopancreatography with biliary stent placement in all patients.

CONCLUSION

In a low-endemic area like Norway, management of echinococcus includes medical therapy, surgery, and/or interventional radiology. Surgical intervention seems to be effective, and is associated with acceptable morbidity rates.

One-tube nested MGB Probe Real-time PCR assay for detection of Echinococcus multilocularis infection in plasma cell free DNA

INTRODUCTION

The main objective of this study was to develop a One-tube nested MGB probe real-time PCR Assay for detecting Echinococcus multilocularis infection in human plasma cell free DNA (cfDNA).

METHODS

cfDNA was extracted from 10 E.m.-infected patients using a NucleoSnap DNA Plasma Kit and characterized by genomic sequencing. We designed nested PCR primers and MGB probe for Echinococcus multilocularis detection. The specificity, sensitivity and reproducibility of this assay were analyzed, and its validity was confirmed in 13 early stage clinical samples.

RESULTS

Several Echinococcus multilocularis-specific sequences were detected in the cfDNA of E.m.-infected patients, and CBLO020001206.1 was selected as the candidate sequence. We designed the primers and probe for the one tube nested real-time PCR. No cross-reactions with E.g. were observed. The detection limit was as low as 1 copy for Echinococcus multilocularis. The coefficients of variation were lower than 5% in intra- and inter-assays. 11 out of 13 patients were positive with nested MGB Probe PCR Assay and 3 patients were positive without outer primer in early stage Alveolar Echinococcosis pateints.

CONCLUSION

The one-tube nested MGB probe real-time PCR assay is a simple, rapid, and cost-effective method for detection of Echinococcus multilocularis infection in patients' Plasma DNA.

Surgical treatment of liver hydatic cyst and evaluation of cystobiliary fistula: experience of two centers

Objective: Intrabiliary rupture or cystobiliary fistula is the most common complication of hepatic hydatid cyst. In this article, our objective is to evaluate the clinical, laboratory, imaging, surgical treatment and results of cystobiliary fistulas, which is the most common complication of hydatid cysts. Material and Method: In our study, patients who underwent open surgery and were followed up and treated for hydatid cyst in the gastroenterology and general surgery outpatient clinic and service between years 2015-2021 were included. The clinical, laboratory, radiological and surgical results of 171 patients with hydatid cysts were retrospectively analyzed. Results: The mean age of 171 patients who underwent surgery for hydatid cyst was 44.8 (18-71), 68 of whom were men and 103 were women. Bile leakage was present in 50 patients (50 (29.23%)). There were 24 (48%) men and 26 (52%) women with bile leakage. The cyst diameter was 74.2 (36-170) mm and the number of cysts was 1.2 (1-2). The cysts were located in the right lobe of the liver in 116 (79%) patients, in the left lobe in 30 (15%) patients, and in both lobes in 25 (6%) patients. Cystobiliary fistula developed more frequently, especially in cysts located in the right lobe(36 (72%)). Cystobiliary fistula was most common in CE3 (Gharbi type 2) type (30 (60%)). Cystectomy+drainage was performed in 137 (80%) patients in all groups. Cystectomy and drainage were the most common surgical procedures. The cyst diameter was 10 cm in the group with cystobiliary fistula and was significant compared to the group without fistula (p&lt;0.001). Aminotransferase (AST and ALT) levels were high in patients with cystobiliary fistula (p=0.012, p=0.054). However, there was no significant difference between the two groups in alkaline phosphatase, total bilirubin, and gamma glutamyl transferase (p=0.231, p=0.097, p=0.544). Conclusion: Liver hydatid cyst is endemic in our country as well as in many other countries in the world. Complicated hepatic hydatid cysts require timely and appropriate treatment because of their life-threatening complications. Cytobiliary fistula is the most common complication. In the surgical treatment of hydatid cyst disease, the earlier the diagnosis of occult cystobiliary fistulas is made (especially in the preoperative or peroperative period), the easier the treatment is, and the risk of bile leakage and consequently the morbidity and mortality decreases. Our results and experience showed that treatment and complications are related to the location and size of the cyst, occult/large cystobiliary fistula, detectability of occult fistulas, experienced center and surgeon.

Cystic lesions of the brain: Think of the hydatid cyst

BACKGROUND

Hydatidosis is an endemic parasitosis in Tunisia that affect mostly the liver and the lung. Brain involvment is rare.

AIM

To focus on diagnostic, therapeutic and evolutive characteristics of cerebral hydatidosis.

METHODS

We report all cases of cerebral hydatidosis seen in the infectious diseases and neurosurgery departments between January 2013 and June 2020.

RESULTS

Six cases of intracranial hydatid cyst were reported. The male to female ratio was 3:3. Age ranged from 3 to 60 years with a median age of 20,5 years. All patients lived in rural areas. The clinical symptomatology was progressive in 4 cases. It was dominated by headache (all cases). Brain imaging confirmed the diagnosis in all cases. The hydatid cyst was solitary and supratentorial in 3 cases. All the patients were operated. Albendazole was prescribed immediately after surgery, for 6 months in 5 cases and for 3 years in the case of disseminated hydatidosis. The outcome was favorable without recurrence in all patients with an average follow-up of 3,5 ± 0,5 years.

CONCLUSION

Hydatid cyst of the brain is characterized by the severity of the neurological signs, the mandatory use of surgery because of life threatening and the excellent outcomes.

PAIR as A Treatment Option for Isolated Intramuscular Cysticercosis: A Case Report

Cysticercosis is a parasitic disease caused by Taenia solium. Central nervous system is the most common site of infestation. Other organs infested are subcutaneous tissue, eye, muscle, liver, and lung. Cysticercosis in muscle can occur in three forms: myalgic type, mass-like pseudotumor, and rarely pseudohypertrophic type. Solitary cysticercosis of muscle without involvement of the central nervous system is rare. In this case report, percutaneous-aspiration-injection-reaspiration (PAIR) has been used as a treatment option for isolated intramuscular cysticercosis of the anterior abdominal wall. Interventional radiological management along with medical management was done to observe complete resolution of the cyst.

Primary Renal Hydatid in Children

Isolated renal hydatid disease, caused by the larvae of the parasitic tapeworm Echinococcus granulosus is a rare phenomenon and accounts for only 2% of all reported cases. The authors report a case of a 12-year-old female who presented with right flank pain. Initial abdominal ultrasound revealed a complex cystic mass in the upper pole of the right kidney. A contrasted CT scan better defined it as a well-circumscribed cyst with multiple thin septations. Laboratory investigations showed eosinophilia and a positive IgG Echinococcus serology. Considering these radiological and laboratory findings, a tentative diagnosis of primary renal hydatid was made. With perioperative antihelmintic therapy, the authors used a combination of an open puncture-aspiration-injection-reaspiration technique pericystectomy to manage the isolated renal hydatid. Renal hydatid can easily be misinterpreted pre-operatively for more sinister renal cystic pathology, including cystic renal cell carcinoma. An accurate pre-operative diagnosis requires a high index of suspicion, especially in endemic regions. Surgical therapy, with perioperative antihelmintic therapy, offers the best chance of cure.

Prediction of benzimidazole therapy duration with PET/CT in inoperable patients with alveolar echinococcosis

Alveolar echinococcosis is a rare parasitic disease, most frequently affecting the liver, as a slow-growing tumor-like lesion. If inoperable, long-term benzimidazole therapy is required, which is associated with high healthcare costs and occasionally with increased morbidity. The aim of our study was to determine the role ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) in staging of patients with alveolar echinococcosis and to identify quantitative imaging parameters related to patient outcome and/or duration of benzimidazole therapy. In this single-center retrospective cohort study, 47 PET/CT performed for staging in patients with confirmed alveolar echinococcosis were analysed. In 43 patients (91%) benzimidazole therapy was initiated and was successfully stopped after a median of 870 days (766–2517) in 14/43 patients (33%). In inoperable patients, tests for trend of survivor functions displayed clear trends for longer benzimidazole therapy duration (p = 0.05; n = 25), and for longer time intervals to reach non-detectable serum concentration of Em-18 antibodies (p = 0.01, n = 15) across tertiles of SUVratio (maximum standardized uptake value in the echinococcus manifestation compared to normal liver tissue). Hence, in inoperable patients with alveolar echinococcosis, PET/CT performed for staging may predict the duration of benzimidazole therapy.

Analysis of Ultrasonographic Characteristics of Early Hepatic Alveolar Echinococcosis

Objective

This study aims to investigate the ultrasonographic characteristics of early hepatic alveolar echinococcosis (HAE) and improve the qualitative diagnostic ability of sonographers.

Methods

The data of 80 positive cases of HAE screened and diagnosed by ultrasonography and serum immunology (33 males and 44 females with a mean age of 44.12 ± 14.31 y) were used in the study. The imaging characteristics of the lesions (i.e., intrahepatic distribution, shape, size, echo, blood flow, and growth characteristics) were analyzed retrospectively, and the ultrasonographic characteristics of early lesions were discussed in combination with their basic pathological changes.

Results

Patients with lesions of the proliferative infiltration type accounted for 57.5% (46/80), the fibrous calcification type accounted for 26.25% (21/80), the necrotic liquefaction type accounted for 6.25% (5/80), and the mixed type accounted for 10% (8/80). Patients with lesions involving the right lobe and the left lobe accounted for 76.25% (61/80) and 11.25% (9/80), respectively, and with lesions involving both the left and right lobes accounted for 12.5% (10/80). There were statistically significant differences in diameter between all types of lesions (n = 88; F = 5.926 and P = 0.004). Focal hyperechoic and diffuse heterogenous nodular changes were the main manifestations of early proliferative infiltration lesions.

Conclusion

Ultrasonography is extremely valuable in the diagnosis of early HAE. Capillary hemangioma-like changes and hailstorm sign are the main characteristics of early lesions of HAE, and calcification is a common concomitant sign.