Treatment experiences of pelvic bone hydatidosis

Progress of research on the diagnosis and treatment of bone cystic echinococcosis

Bone cystic echinococcosis (CE) is one of the most complex and dangerous of all echinococcoses. The lack of typical imaging features and clinical manifestations makes diagnosis and treatment of this disease difficult. X-ray and computed tomography (CT) images of bone CE are similar to those of bone cysts, giant-cell bone tumors, and bone metastases, but magnetic resonance imaging (MRI) shows good diagnostic value due to excellent soft-tissue imaging features. Serological tests cannot be used as a definitive diagnostic method for bone CE due to cross-reactivity, which can lead to false-positive or false-negative results. The development of novel antigens can open new frontiers in the diagnosis of the disease. Currently, views conflict on how to diagnose and treat bone CE. Both surgical and pharmacological treatments can be used, but determining which is appropriate is difficult due to the different sites and clinical manifestations of bone CE. Radical resection is not indicated for large-bone injuries, and Pharmacotherapy becomes important. This article reviews the progress of research into the pathogenesis and clinical manifestations of, and diagnostic strategies and treatment options for, bone CE. We aimed to provide a reference for clinical diagnosis and -treatment options.

Cystic echinococcosis of the bone

PURPOSE OF REVIEW

Cystic echinococcosis (CE) has a wide world distribution causing important morbidity. Osseous involvement is present in less than 4% of the CE cases. Its diagnosis and therapeutic management is full of challenges and low grade of evidence.

RECENT FINDINGS

The study summarizes literature evidence on the management of osseous CE with particular emphasis on new data regarding diagnosis and treatment.

SUMMARY

Clinical presentation of osseous CE depends on the skeletal area affected. Diagnosis is mostly based on radiological findings and serology. Recent advances with qPCR on osseous tissue samples seem to be a good option for diagnosis confirmation. Complete resection of the cystic lesion is the only curative option, but it is usually not possible performing palliative surgery and prolonged albendazole intake in most cases. Radiotherapy could be an option, but experience to date is only based on clinical cases.

Osseous hydatid disease: A mimic of other skeletal pathologies

Hydatid disease is still endemic in several regions worldwide including Morocco, and is caused in most cases by the larval form of 2 species of the tapeworm Echinococcus: E. granulosus and E. multilocularis. Primary hydatid disease of the bone without systemic involvement is rare. The disease has a silent clinical evolution until it reaches complicated stages. Complications may include pathological fracture, neural deficit, infection, and fistulization of the abscess. Preoperative diagnosis is based on clinical history, imaging findings, and serological tests, which lack high sensitivity and specificity. Although the interpretation of imaging studies can prove to be very confusing because the bone changes evolve with time, and the nonspecificity of these findings often leads to a mistaken diagnosis. The diagnosis requires a high index of suspicion, especially in patients who reside in or travel to sheep-raising areas where hydatid disease is endemic. A high index of suspicion is necessary for the diagnosis, especially in patients that live in or travel to sheep-raising areas where hydatid disease is endemic. The treatment of choice remains surgical, following the principles of a locally malignant lesion. Chemotherapy (albendazole alone or in combination with praziquantel) is indicated when surgery is not possible or as an adjuvant treatment. The prognosis is often poor. We report the case of a 28-year-old woman with long-standing pain in the left hip joint in which the imaging findings were thought of as being either tuberculous or neoplastic. The result of a CT-guided biopsy concurred with an unexpected diagnosis of a hydatid cyst. This case highlights that in the absence of a high index of suspicion for echinococcal infection, the semblance of imaging findings of hydatid disease in the bone to those of other skeletal pathologies can lead to misinterpretation.

Vertebral and pelvic echinococcosis in northwestern China

PURPOSE

Echinococcosis remains a major economic and severe public health problem in endemic areas. Bone echinococcosis is rare, and the vertebra and pelvis are the most common sites of echinococcosis involving the skeletal. Because of the clinical severe symptoms and high recurrence rate, it brings excellent trouble to patients.

METHODS

This study retrospectively analyzed the clinical manifestations, laboratory tests, radiological findings, and treatment of 44 patients with vertebral and pelvic echinococcosis during a period of 16 years (2005-2020).

RESULTS

The mean age was 43 years (25 males, 19 females; 19-68 years). The most common symptom was pain, followed by numbness, weakness, activity limitation, and progressive paraparesis. Enzyme-linked immunosorbent assay test (ELISA) results were positive in 18 cases (75%). There are 24 cases of hydatid infection of the spine, 14 hydatid infection of the pelvis, and six hydatid infection of both vertebra and pelvis. The site of infection was 13 (29.5%) thoracic, five (11.4%) lumbar, four (9.1%) lumbosacral, seven (15.9%) sacral, 19 (43.2%) ilium, seven (15.9%) hip, six (13.6%) ischium, five (11.4%) pubis, and two (4.5%) femur, respectively. The imaging findings were cystic dilatancy, septal, and irregular bone destruction. MRI has a special value in showing the relationship between the surrounding tissues and organs of cystic bone echinococcosis. All patients were followed up for at least one year. The mean follow-up time was 3.6 years.

CONCLUSIONS

Even in epidemic areas, the incidence of bone echinococcosis is relatively rare. However, when encountering the vertebral and pelvic destruction, consider bone echinococcosis's possibility, especially for the herdsmen in endemic regions.

IJRadiation therapy for recurrent hydatid cyst of the pelvic bone: a case report

BACKGROUND

Hydatid disease usually affects the liver, but can also extend to other locations, such as the bones. In these cases, complete resection of the bone is considered the only curative approach. However, this is rarely feasible, and patients are left with benzimidazoles as their only option. In this context, there is an evident need for alternative treatments that can improve results. We present the case of a patient with a treatment-refractory hydatid cyst of the bone, who successfully underwent radiotherapy (RT).

CASE SUMMARY

A 64-year-old woman was diagnosed with a hydatid cyst of the bone in the sacroiliac joint that caused her sciatalgia and paresthesia. She underwent treatment with albendazole and surgery, and was treated with further doses of albendazole after relapsing six months later. After 2 years, she required a new resection, achieving a stable disease for 2 more years. At this point, she began to suffer from more intense pain (visual analogue scale 6/10). Given that further surgery was no longer feasible, she underwent radiotherapy (54 Gy in 27 fractions). No treatment-related toxicity was observed. At 1 month after radiotherapy, the pain had completely disappeared; 9 months later, the patient remains asymptomatic. The titer of anti-Echinococcus-granulosus antibodies and the absolute volume of eosinophils decreased after treatment with radiotherapy. The cyst remains radiologically stable.

CONCLUSION

Although further studies are needed, radiotherapy seems to be effective for hydatid cysts that are refractory to other treatments.

Cystic Echinococcosis of the Ilium Treated with Curettage and Microwave Thermoablation Followed by Bone Cement Installation: A Novel Treatment Technique for a Rare Disease

Bone cystic echinococcosis (CE) is a rare condition requiring a high level of suspicion during primary diagnosis. Wide excision of the lesion is the gold standard of treatment, posing however extreme challenges in certain parts of the skeleton, since it may well be accompanied by increased morbidity. We report the case of a 35-year-old Caucasian female with iliac bone CE, referred to our department (a regional referral center for the treatment of patients with musculoskeletal tumors). The patient reported gradually increasing dull pain at the right iliac fossa and antalgic gait, with an onset of approximately 5 years before her referral. Bone CE diagnosis was established based on physical examination, imaging studies, and two subsequent CT-guided core needle biopsies, performed within a period of 3 months, of which the second was diagnostic. Following a musculoskeletal tumor multidisciplinary meeting, it was decided that the optional treatment was the surgical removal of the cyst. Aiming to minimize the morbidity accompanying a wide resection of the lesion, we performed extended curettage of the lesion through a typical iliac spine approach, followed by microwave ablation of the walls of the remaining bone cavity. The remaining iliac defect was treated with the installation of polymethyl methacrylate bone cement. The patient reported immediate remission of symptoms postoperatively and was able to return to everyday activities two weeks postoperatively. She began oral treatment with albendazole on the 7th postoperative day. She remained symptom-free for a period of 25 months, until she developed a seroma at the gluteal area, which was treated with simple drainage. On her latest follow-up six months later, she remained symptom-free and was able to perform all her previous activities. Microwave ablation may serve as a useful adjuvant modality when treating patients with bone CE, in order to prevent relapse of the disease.

Loosening of a Total Hip Arthroplasty Associated with a Periprosthetic Femoral Fracture Caused by Recurrent Hydatidosis of the Hip: A Case Report

CASE

A 35-year-old woman, who lived in an endemic area for echinococcosis, developed a periprosthetic fracture with loosening of a total hip arthroplasty that had been performed 9 years earlier for hydatidosis of the right proximal femur with a pathological femoral neck fracture. At that time, the patient did not have any signs of liver or lung involvement. She was successfully managed by a cemented revision hip arthroplasty without any signs of recurrence at the last follow-up of 5 years.

CONCLUSIONS

Total hip arthroplasty can offer effective management of proximal femur hydatidosis, despite the high rate of recurrence and mechanic failure.

Pelvic Bone Hydatidosis: A Dangerous Crippling Disease

Hydatid disease is one of the most complicated and devastating conditions caused by Echinococcus granulosus. This globally distributed disease continues to be an important public health concern in many low- and middle-income countries. The liver and the lungs are the most frequently involved sites, but virtually any organ system can be affected. Osseous hydatidosis is relatively less common, but it is extremely debilitating and difficult to manage due to frequent recurrences. Patients often demonstrate a delayed clinical presentation as bone involvement is predominantly a silent and slowly progressive disease with a long latent period. Radiological investigations play an important role in the diagnosis. Although standard therapeutic guidelines are not available, the treatment of choice is a combination of chemotherapy and surgery. Clinicians should perform a lifelong follow-up for early detection of potential recurrence and sequels. This paper aims to highlight hydatid disease of the pelvic bone as an important differential diagnosis of tubercular hip arthritis, especially in areas with high echinococcosis prevalence. 

Presentation Patterns, Diagnostic Modalities, Management Strategies, and Clinical Outcomes in Patients with Hydatid Disease of the Pelvic Bone: A Comparative Review of 31 Cases

Hydatid disease is a parasitic zoonosis commonly caused by Echinococcus granulosus. It characteristically involves the liver and the lungs but rare occurrences in other organs have also been reported. Bone involvement is distinctly uncommon, which is predominantly a silent and slowly progressive disease with a long latent period. We conducted a systematic literature search of MEDLINE, Cochrane, Embase, and Scopus databases. After a comprehensive review of the search results, a total of 31 cases of hydatid disease of the pelvic bone fulfilled the inclusion criteria. The data on patient demographics, epidemiology, lesion site, management, clinical outcomes, and follow-up were collected and analyzed. This review illustrates that hydatid disease should be considered among the differential diagnoses of unusual cystic lesions of the pelvic bone. Prompt diagnosis and appropriate management are of paramount importance to prevent bone destruction and serious complications in these patients. Long-term follow-up should be performed for potential recurrence.

Osseous cystic echinococcosis: A case series study at a referral unit in Spain

Background

Cystic echinococcosis (CE) is present in all continents, except for the Antarctica. Characteristically, CE lesions are found in the liver and the lungs, but virtually any part of the body may be affected (the spleen, kidneys, heart, central nervous system, bones, among others). It is estimated that the incidence of bone involvement in CE is 0.5% to 4%.

Methodology

A retrospective study was performed of patients with osseous CE treated at the National Reference Unit of Tropical Diseases of the Ramon y Cajal Hospital, Madrid, Spain, between 1989 and December 2017. Epidemiological, clinical, diagnostic and therapeutic data of patients with long-term follow-up were collected.

Main findings

During the study period, of the 104 patients with CE, 27 exhibited bone involvement (26%). The bones most frequently affected were the spine, followed by the ribs, pelvis, femur, tibia and the scapula. The most common symptom was pain followed by medullar syndrome and pathologic fracture. In total, 81.5% of patients underwent surgery for osseous CE at least once. As many as 96% received albendazol either in (mostly long-term) monotherapy or in combination with praziquantel.

Conclusions

The diagnosis and management of osseous CE is challenging. In many cases osseous CE should be considered a chronic disease and should be managed on a case-by-case basis. Lifelong follow-up should be performed for potential recurrence and sequels.

Echinococcosis occurs in humans as a result of infection by a cestodes of the genus Echinococcus. One of the species, E. granulosus, causes cystic echinococcosis (CE) in humans worldwide. In the lifecycle there is a definitive host (generally dogs) which host this parasites at the small bowel. From there, ground is shed with the eggs of the parasite through feces and the intermediate host (usually a sheep or other herbivores get infected). Humans act as an incidental intermediate host when they become infected through the consumption of water or food contaminated with Echinococcus eggs. Once the egg has been ingested, it penetrates the intestinal mucosa and through the circulatory system finds an anatomical site forming a cystic lesion (hydatid or hydatid cyst). Characteristically, CE are found in the liver and the lungs, but virtually any part of the body may be affected. Incidence of osseous CE is low, its diagnosis and management is challenging and there is little information published. In this study we report our experience at a referral unit during nearly 30 years in the management of a series of patients with osseous CE. Such information may be useful for other physicians when treating osseous CE.

Management of osseous cystic echinococcosis

INTRODUCTION

Osseous cystic echinococcosis (CE) is one of the most complicated and devastating conditions caused by Echinococcus granulosus. Its management is difficult and there is scant literature about it. Areas covered: A literature review was performed to provide an update on its diagnosis, treatment and follow-up. Expert commentary: In most cases diagnosis of osseous CE can only be confirmed by surgery. Osseous CE should be managed by experienced physicians and addressed as a chronic disease with therapies must be aimed at controlling the disease and its sequels or complications, rather than with a curative intent.

Successful Pelvic Resection for Acetabular Hydatidosis

BACKGROUND

Hydatidosis of the bone is a rare occurrence (0.9 to 2.5% of all localization of the disease). In those occurrences, the pelvic bone is the second most frequent localization. Curative treatment of pelvic bone hydatidosis is difficult and a consensus is yet to be found.

CLINICAL CASE

We report a case of hydatidosis of the ischium, extended to the homolateral hip. The patient was treated through hip resection using patient-specific cutting guides, followed by total hip reconstruction. Albendazole was administered to the patient for two months before the surgery and for three months following the surgery.

CONCLUSIONS

In a young patient, hydatidosis of the pelvic bone can be treated with satisfying results through wide resection of the hip coupled with an antiparasitic treatment administered before and after the surgery. Prosthetic reconstruction, similar to what is done in cancer surgery, restores good functions.

Musculoskeletal Hydatid Cysts Resembling Tumors: A Report of Five Cases

Although challenges in treatment of musculoskeletal hydatid cysts (HC) lesions have been documented, data regarding the musculoskeletal HC lesions resembling tumor is scarce. This paper presented 5 patients (3 males, 2 females) with a mean age of 41.6 years with tumor-like lesions of HC. Three of them had left ilium and acetabulum involvement, one involved left femur, and one involved left thigh muscle compartments. Pain was the main symptom and was seen in all patients. Clinical examination, radiologic evaluation, and histologic analysis were performed for diagnosis. Patients were treated through different surgical options, including simple debridement, bone cement filling with or without internal fixation, hip arthrodesis, reconstruction using hemipelvic replantation with femoral prosthesis and distal femur endoprosthetic replacement. After surgery, the operation region was washed by 20% hypertonic saline, and debridement was performed carefully without contamination. All patients received albendazole treatment. Cases were followed up 1 to 9 years for the recurrence. Walking difficulty and pain were the main symptoms during the follow-up. One patient was symptom-free. A reoccurrence in the perioperative soft tissue was detected in only one patient and control visits with antihelmintic treatment were recommended. We would like to emphasize that HC should be kept in mind for the differential diagnosis of the cystic or tumoral lesions of the musculoskeletal system, particularly in the endemic regions. Prompt diagnosis is of paramount importance for preventing destruction and complications.

Giant hydatid cyst of the pelvis, femur and retroperitoneal space: surgical treatment with extended hemipelvectomy

Hydatid disease of the bone is a very rare manifestation of the disease, and is often associated with debilitating symptoms. We present a rare case of skeletal hydatidosis in a 56-year-old man who had been misdiagnosed for many years. Massive involvement of the pelvic bones and soft tissues was evident. An extended hemipelvectomy was performed in order to achieve resection of the affected segments with a clear surgical margin. The patient recovered uneventfully and there are no signs of recurrence of the disease.