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Wang S, Ma Y, Wang W, Dai Y, Sun H, Li J, Wang S, Li F. Status and prospect of novel treatment options toward alveolar and cystic echinococcosis. Acta Trop 2022; 226:106252. [PMID: 34808118 DOI: 10.1016/j.actatropica.2021.106252] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 10/19/2021] [Accepted: 11/17/2021] [Indexed: 02/07/2023]
Abstract
Cystic echinococcosis (CE) and alveolar echinococcosis (AE) are the two most important global parasitic infectious diseases caused by species of Echinococcus granulosus and E. multilocularis, respectively. Although numerous trials have been performed in search of novel therapeutic options to curb the neglected zoonosis, no other nonsurgical options are currently available to replace the licensed anti echinococcal drugs albendazole (ABZ) and mebendazole (MBZ). A safer and more effective treatment plan for echinococcosis is therefore urgently needed to compensate for this therapeutic shortfall. Here, we present a review of the literature for state-of-the-art valuable anti-parasitic compounds and novel strategies that have proved effective against CE and AE, which includes details about the pharmaceutical type, practical approach, experimental plan, model application and protoscolecidal effects in vivo and in vitro. The content includes the current application of traditional clinical chemicals, the preparation of new compounds with various drug loadings, repurposing findings, combined programs, the prospects for Chinese herbal medicines, non-drug administrations and the exploration of target inhibitors based on open-source information for parasitic genes. Next the conventional experimental projects and pharmacodynamic evaluation methods are systematically summarized and evaluated. The demands to optimize the construction of the echinococcosis model and improve the dynamic monitoring method in vivo are also discussed given the shortcomings of in vivo models and monitoring methods.
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Affiliation(s)
- Sibo Wang
- Department of Orthopedics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Yibo Ma
- Laboratory of Translational Medicine, School of Medicine, Shihezi University, Shihezi 832000, Xinjiang, China
| | - Weishan Wang
- Laboratory of Translational Medicine, School of Medicine, Shihezi University, Shihezi 832000, Xinjiang, China
| | - Yi Dai
- Laboratory of Translational Medicine, School of Medicine, Shihezi University, Shihezi 832000, Xinjiang, China
| | - Haohao Sun
- Laboratory of Translational Medicine, School of Medicine, Shihezi University, Shihezi 832000, Xinjiang, China
| | - Jing Li
- Laboratory of Translational Medicine, School of Medicine, Shihezi University, Shihezi 832000, Xinjiang, China
| | - Shan Wang
- Laboratory of Translational Medicine, School of Medicine, Shihezi University, Shihezi 832000, Xinjiang, China.
| | - Feng Li
- Department of Orthopedics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China.
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In Vitro and In Vivo Efficacy of Albendazole Chitosan Microspheres with Intensity-Modulated Radiation Therapy in the Treatment of Spinal Echinococcosis. Antimicrob Agents Chemother 2021; 65:e0079521. [PMID: 34460300 PMCID: PMC8522759 DOI: 10.1128/aac.00795-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Currently, there is a lack of clinically safe and effective treatment for spinal cystic echinococcosis (CE). Recent studies have shown that albendazole chitosan microspheres (ABZ-CS-MPs) and irradiation have certain anti-abdominal echinococcosis ability, so this study aims to compare the in vitro and in vivo therapeutic effects of ABZ-CS-MPs, intensity-modulated radiation therapy (IMRT), and combination therapy on spinal echinococcosis. First, protoscoleces were processed by different treatments to evaluate their respective antiechinococcosis effects by monitoring the viability change of protoscoleces. Then, the apoptotic status of protoscoleces was evaluated by detecting the changes of mitochondrial membrane potential, the expression of apoptosis proteins, and the ultrastructural alterations of protoscoleces. After that, we constructed a gerbil model of spinal CE and further applied B-ultrasound and magnetic resonance imaging (MRI) technology to assess the size of hydatid in vivo. Finally, the cysts were obtained and weighed to compare the inhibition rate in different groups. The combined therapy increased protoscoleces mortality to over 90% after 18 days, which showed the highest scolicidal effect. Moreover, confocal imaging, expression of apoptotic proteins, and ultrastructural changes of protoscoleces showed the highest apoptotic rate in this group. In vivo, the combination treatment also exhibited the highest cyst inhibition rate (61.4%). In conclusion, our results showed that ABZ-CS-MPs combined with IMRT could be a new treatment option for spinal CE. We also provided a method to evaluate the growth and metastasis of hydatid in animals with B-ultrasound and MRI technologies.
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Mao T, Chungda D, Phuntsok L, Benjie T, Dondrup T, Dolma T, Li W. Pulmonary echinococcosis in China. J Thorac Dis 2019; 11:3146-3155. [PMID: 31463143 DOI: 10.21037/jtd.2019.07.31] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Pulmonary echinococcosis is a zoonotic parasitic disease caused by the larval stage of cestodes belonging to the genus echinococcus, which is the top killer of residents in pastoral areas and requires more attention. Prevention is the top priority; screening is another important strategy. Surgery is still the preferred treatment for pulmonary echinococcosis. Fortunately, the Chinese government has equipped each county hospital with CT machines. In the foreseeable future, the screening for pulmonary echinococcosis will begin in many areas including Tibet, which will allow us to cure early pulmonary echinococcosis in a more minimally-invasive way.
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Affiliation(s)
- Teng Mao
- Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200000, China
| | - Dawa Chungda
- Shigatse People's Hospital, Shigatse 850000, China
| | | | - Tse Benjie
- Shigatse People's Hospital, Shigatse 850000, China
| | | | - Tseten Dolma
- Shigatse People's Hospital, Shigatse 850000, China
| | - Weijiang Li
- Shigatse People's Hospital, Shigatse 850000, China
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Svrckova P, Nabarro L, Chiodini PL, Jäger HR. Disseminated cerebral hydatid disease (multiple intracranial echinococcosis). Pract Neurol 2018; 19:156-163. [PMID: 30305379 DOI: 10.1136/practneurol-2018-001954] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2018] [Indexed: 12/20/2022]
Abstract
Intracranial echinococcosis is relatively uncommon and usually occurs in the context of echinococcal lesions elsewhere in the body, mostly liver and lung. Multiple intracranial lesions can result from rupture of an initial single intracranial cyst (in cystic echinococcosis) or from dissemination of systemic disease of the lung, liver or heart (cystic and alveolar echinococcosis). The two main subtypes, cystic and alveolar echinococcosis, present differently and have distinct imaging features in the brain. We discuss the presentation, imaging findings and clinical course of three cases (two cystic and one alveolar) of intracranial echinococcal disease in adults.
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Affiliation(s)
| | - Laura Nabarro
- Department of Infectious Diseases and Microbiology, University College Hospital, London, UK
| | - Peter L Chiodini
- Hospital for Tropical Diseases, London, UK.,London School of Hygiene & Tropical Medicine, London, UK
| | - Hans Rolf Jäger
- Imaging Department, University College Hospital, London, UK.,Academic Neuroradiological Unit, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, London, UK
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Mao R, Wu G, Wang H, Lu P, Li J, Li H, Ainiwaer A, Bai Y, Shu M, Bao Y, Zhang W. Effects of X-ray on the metacestodes of Echinococcus granulosus in vitro. BMC Infect Dis 2017; 17:636. [PMID: 28934934 PMCID: PMC5609036 DOI: 10.1186/s12879-017-2741-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 09/15/2017] [Indexed: 11/19/2022] Open
Abstract
Background Radiotherapy may represent an alternative treatment modality for cystic echinococcosis (CE), but there is no adequate evidence for it up to now. In this study, we aim to investigate the parasiticidal effects of X-ray on the metacestodes of Echinococcus granulosus in vitro. Methods Protoscoleces obtained from sheep naturally infected with CE were cultivated in RPMI 1640 medium containing 10% fetal bovine serum (FBS) at 37 °C in 5% CO2. Upon encystation on day 14, the metacestodes were subjected to various intensities of X-ray. Metacestode structures were observed using light microscope and transmission electron microscopy (TEM), and Real-Time PCR was carried out to determine the expression of EgTPX, EgHSP70, EgEPC1 and Caspase-3. Results On day 14, encystation was noticed in the majority of protoscoleces in the control group. In the X-ray groups, the encystation rate showed significant decrease compared with that of the control group (P < 0.05), especially the groups subjected to a dose of ≥40 Gy (P < 0.01). Light microscope findings indicated the hooklets on the rostellum were deranged in the irradiation group, and malformation was noticed in the suckers in a dose dependent manner. For the TEM findings, the cellular structure of the germinal layer of the cysts was completely interrupted by X-ray on day 7. The expression of EgTPX, EgHSP70, EgEPC1 and Caspase-3 was up-regulated after irradiation, especially at a dose of ≥45Gy (P < 0.05). Conclusions X-ray showed parasiticidal effects on the metacestodes of E. granulosus. Irradiation triggered increased expression of EgTPX, EgHSP70, EgEPC1 and Caspase-3.
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Affiliation(s)
- Rui Mao
- Department of Radiation Oncology, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, China
| | - Ge Wu
- Department of Radiation Oncology, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, China
| | - Hui Wang
- State Key Laboratory Incubation Base for Xinjiang Major Diseases Research and Xinjiang Key Laboratory of Echinococcosis, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, China
| | - Pengfei Lu
- Department of Radiation Oncology, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, China
| | - Jun Li
- State Key Laboratory Incubation Base for Xinjiang Major Diseases Research and Xinjiang Key Laboratory of Echinococcosis, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, China
| | - Haitao Li
- State Key Laboratory Incubation Base for Xinjiang Major Diseases Research and Xinjiang Key Laboratory of Echinococcosis, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, China
| | - Aimudula Ainiwaer
- Department of Radiation Oncology, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, China
| | - Yiwei Bai
- Department of Radiation Oncology, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, China
| | - Mingyang Shu
- Department of Radiation Oncology, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, China
| | - Yongxing Bao
- Department of Radiation Oncology, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, China.
| | - Wenbao Zhang
- State Key Laboratory Incubation Base for Xinjiang Major Diseases Research and Xinjiang Key Laboratory of Echinococcosis, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, China.
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Turgut AT, Turgut M. Fatal Liver and Lung Alveolar Echinococcosis with Newly Developed Neurologic Symptoms due to the Brain Involvement. Surg J (N Y) 2017; 3:e90. [PMID: 28825028 PMCID: PMC5553502 DOI: 10.1055/s-0037-1603502] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 04/19/2017] [Indexed: 10/27/2022] Open
Affiliation(s)
- Ahmet Tuncay Turgut
- Department of Radiology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Mehmet Turgut
- Department of Neurosurgery, Adnan Menderes University Faculty of Medicine, Aydın, Turkey
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Mao R, Zhang WB, Qi HZ, Jiang T, Wu G, Lu PF, Ainiwaer A, Shang G, Xu L, Hao J, Shou X, Li HT, Li J, Zhang SA, Bao YX, Wen H. Efficacy of radiotherapy for the treatment of cystic echinococcosis in naturally infected sheep. Infect Dis Poverty 2017; 6:88. [PMID: 28464914 PMCID: PMC5414231 DOI: 10.1186/s40249-017-0301-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Accepted: 04/05/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Radiotherapy is commonly used to treat cancers. To date, there has been no study focusing on the effects of radiotherapy on hydatid disease in large animals. In this study, we aim to investigate the efficiency and safety of radiotherapy for treating hydatid disease caused by Echinococcus granulosus in naturally infected sheep. METHODS Ultrasound was used to screen naturally infected sheep in an echinococcosis endemic area in Xinjiang, China. A computer tomography (CT) scan confirmed the presence of hydatid cysts. Twenty sheep naturally infected with E. granulosus in the liver and/or lungs were randomly assigned into four groups receiving no irradiation, or X-ray irradiation of low (30 Gy), medium (45 Gy), and high dose (60 Gy), respectively. After three months of radiotherapy, a CT scan was performed to measure the changes in the cysts. The hepatic parasite cysts and host tissues were collected for histology and gene expression analysis. RESULTS In the animals subject to irradiation, no significant differences were observed in their appetite, daily activities, and weight before and after radiotherapy. Severe calcification was noticed in the cysts subject to a high dose of radiation compared with the groups subject to low and medium doses. Hematoxylin and eosin staining showed that irradiation contributed to the damage of the cyst structure and nucleus in the germinal layers. Quantitative PCR demonstrated that expression of TPX and HSP70 significantly decreased in a dose-dependent manner (P < 0.05). The expression of the EPC1 decreased in the medium- and high-dose groups compared with the low-dose group (P < 0.05). Meanwhile, the expression of radiation-related apoptosis genes caspase-3 and Gadd45 decreased with an increase in the irradiation dose. CONCLUSIONS Radiotherapy is an option with satisfactory efficiency and safety for treating cystic echinococcosis in sheep with partial response or stable disease at month 3. In future, inhibition of cystic activity using radiotherapy may serve as a new regimen for treating hydatid disease.
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Affiliation(s)
- Rui Mao
- Department of Radiation Oncology, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
| | - Wen-Bao Zhang
- State Key Laboratory Incubation Base for Xinjiang Major Diseases Research and Xinjiang Key Laboratory of Echinococcosis, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
| | - Hong-Zhi Qi
- Department of Radiation Oncology, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
| | - Tao Jiang
- State Key Laboratory Incubation Base for Xinjiang Major Diseases Research and Xinjiang Key Laboratory of Echinococcosis, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
| | - Ge Wu
- Department of Radiation Oncology, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
| | - Peng-Fei Lu
- Department of Radiation Oncology, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
| | - Abudula Ainiwaer
- Department of Radiation Oncology, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
| | - Ge Shang
- Department of Radiation Oncology, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
| | - Lin Xu
- Department of Radiation Oncology, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
| | - Jie Hao
- Department of Radiation Oncology, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
| | - Xi Shou
- State Key Laboratory Incubation Base for Xinjiang Major Diseases Research and Xinjiang Key Laboratory of Echinococcosis, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
| | - Hai-Tao Li
- State Key Laboratory Incubation Base for Xinjiang Major Diseases Research and Xinjiang Key Laboratory of Echinococcosis, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
| | - Jun Li
- State Key Laboratory Incubation Base for Xinjiang Major Diseases Research and Xinjiang Key Laboratory of Echinococcosis, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
| | - Song-An Zhang
- Department of Radiation Oncology, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
| | - Yong-Xing Bao
- Department of Radiation Oncology, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China.
| | - Hao Wen
- State Key Laboratory Incubation Base for Xinjiang Major Diseases Research and Xinjiang Key Laboratory of Echinococcosis, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China.
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Kern P, Menezes da Silva A, Akhan O, Müllhaupt B, Vizcaychipi KA, Budke C, Vuitton DA. The Echinococcoses: Diagnosis, Clinical Management and Burden of Disease. ADVANCES IN PARASITOLOGY 2017; 96:259-369. [PMID: 28212790 DOI: 10.1016/bs.apar.2016.09.006] [Citation(s) in RCA: 276] [Impact Index Per Article: 39.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The echinococcoses are chronic, parasitic diseases that are acquired after ingestion of infective taeniid tapeworm eggs from certain species of the genus Echinococcus. Cystic echinococcosis (CE) occurs worldwide, whereas, alveolar echinococcosis (AE) is restricted to the northern hemisphere, and neotropical echinococcosis (NE) has only been identified in Central and South America. Clinical manifestations and disease courses vary profoundly for the different species of Echinococcus. CE presents as small to large cysts, and has commonly been referred to as 'hydatid disease', or 'hydatidosis'. A structured stage-specific approach to CE management, based on the World Health Organization (WHO) ultrasound classification of liver cysts, is now recommended. Management options include percutaneous sterilization techniques, surgery, drug treatment, a 'watch-and-wait' approach or combinations thereof. In contrast, clinical manifestations associated with AE resemble those of a 'malignant', silently-progressing liver disease, with local tissue infiltration and metastases. Structured care is important for AE management and includes WHO staging, drug therapy and long-term follow-up for at least a decade. NE presents as polycystic or unicystic disease. Clinical characteristics resemble those of AE, and management needs to be structured accordingly. However, to date, only a few hundreds of cases have been reported in the literature. The echinococcoses are often expensive and complicated to treat, and prospective clinical studies are needed to better inform case management decisions.
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Affiliation(s)
- P Kern
- University Hospital of Ulm, Ulm, Germany
| | | | - O Akhan
- Hacettepe University, Ankara, Turkey
| | - B Müllhaupt
- University Hospital of Zurich, Zürich, Switzerland
| | - K A Vizcaychipi
- National Institute of Infectious Diseases, Buenos Aires, Argentina
| | - C Budke
- Texas A&M University, College Station, TX, United States
| | - D A Vuitton
- Université de Franche-Comté, Besançon, France
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Kvascevicius R, Lapteva O, Awar OA, Audronyte E, Neverauskiene L, Kvasceviciene E, Sokolovas V, Strupas K, Marcinkute A, Deplazes P, Müllhaupt B. Fatal Liver and Lung Alveolar Echinococcosis with Newly Developed Neurologic Symptoms due to the Brain Involvement. Surg J (N Y) 2016; 2:e83-e88. [PMID: 28824996 PMCID: PMC5553476 DOI: 10.1055/s-0036-1592122] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Accepted: 08/04/2016] [Indexed: 01/13/2023] Open
Abstract
The fox tapeworm
Echinococcus multilocularis
causes human alveolar echinococcosis, commonly affecting the liver. However, in ∼1% of cases, systematic spread of the disease involves the brain as well. A patient had a 6-year history of liver and lung alveolar echinococcosis that was considered not suitable for surgery, and treatment with albendazole was introduced. After the appearance of neurologic disturbances, an intracranial mass lesion was demonstrated by radiologic imaging. The lesion was surgically removed, and histologic analysis revealed metacestode tissue of
E. multilocularis
. Despite the surgical resection of the lesion, the patient died of progression of systemic alveolar echinococcosis. The authors highly recommend implementing neurologic monitoring to the follow-up algorithm for patients with systemically disseminated alveolar echinococcosis. When neurologic symptoms occur, radiologic imaging of the brain should be obtained immediately. Surgery should be considered for all intracranial echinococcal lesions, unless the lesion is located in the eloquent brain area.
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Affiliation(s)
- Robertas Kvascevicius
- Centre of Neurosurgery, Vilnius University Hospital Santariskiu Klinikos, Vilnius, Lithuania
| | - Ona Lapteva
- Centre of Neurosurgery, Vilnius University Hospital Santariskiu Klinikos, Vilnius, Lithuania
| | - Omar Al Awar
- Centre of Neurosurgery, Vilnius University Hospital Santariskiu Klinikos, Vilnius, Lithuania
| | - Egle Audronyte
- Centre of Neurology, Vilnius University Hospital Santariskiu Klinikos, Vilnius, Lithuania
| | - Laura Neverauskiene
- Department of Pathology, Republican Vilnius University Hospital, Vilnius, Lithuania
| | | | - Vitalijus Sokolovas
- Centre of Abdominal Surgery, Vilnius University Hospital Santariskiu Klinikos, Vilnius, Lithuania
| | - Kestutis Strupas
- Centre of Abdominal Surgery, Vilnius University Hospital Santariskiu Klinikos, Vilnius, Lithuania
| | - Audrone Marcinkute
- Hospital of Infectious Diseases and Tuberculosis, Affiliate of Vilnius University Hospital Santariskiu Klinikos, Vilnius, Lithuania
| | - Peter Deplazes
- Institute of Parasitology, University of Zürich, Zürich, Switzerland
| | - Beat Müllhaupt
- Swiss HBP Center, University Hospital of Zürich, Zürich, Switzerland
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Gamma-Ray Treatment of Echinococcus Protoscoleces prior to Implantation in Mice Reduces Echinococcosis. BIOMED RESEARCH INTERNATIONAL 2016; 2016:9027489. [PMID: 27610384 PMCID: PMC5004023 DOI: 10.1155/2016/9027489] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 04/20/2016] [Accepted: 05/30/2016] [Indexed: 11/18/2022]
Abstract
Echinococcosis is a serious parasitic disease caused by Echinococcus tapeworms. Protoscoleces are sometimes released during surgical treatment for hydatid cysts, causing the recurrence of echinococcosis. Protoscoleces may be susceptible to radiation therapy. In this study Echinococcus protoscoleces were cultured in vitro and then divided into four different γ-ray irradiation dose groups (10 Gy, 20 Gy, 40 Gy, and 80 Gy) and a blank group. The protoscoleces were then implanted into the abdominal cavity of mice. Four months later, we observed that the incidence and weight of cysts declined with the increase of irradiation dose. γ-ray irradiation can suppress the generation of Echinococcus originated from protoscolex, the reason of which is due to the damaging to the structure of Echinococcus. Irradiation may prevent echinococcosis recurrence after surgical removal of hydatid cysts.
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11
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Alam-Eldin YH, Badawy AF. Destructive effect of gamma irradiation on Echinococcus granulosus metacestodes. Parasitol Res 2015; 114:3145-50. [DOI: 10.1007/s00436-015-4533-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 05/06/2015] [Indexed: 12/18/2022]
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Neumayr A. Radiotherapy of osseous echinococcosis: where is the evidence? Int J Infect Dis 2015; 33:75-8. [PMID: 25582641 DOI: 10.1016/j.ijid.2015.01.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Accepted: 01/05/2015] [Indexed: 12/23/2022] Open
Affiliation(s)
- Andreas Neumayr
- Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Switzerland.
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13
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Xie Z, Chen L, Xie Q, Bao Y, Luo X, Yi C, Wen H. Surgery or radiotherapy for the treatment of bone hydatid disease: a retrospective case series. Int J Infect Dis 2015; 33:114-9. [PMID: 25559785 DOI: 10.1016/j.ijid.2014.12.037] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2014] [Revised: 12/17/2014] [Accepted: 12/18/2014] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Currently, there is no accepted treatment for inoperable bone hydatid disease where medical treatment has proved ineffective. Alternative treatment strategies are therefore urgently needed. Radiotherapy may constitute a treatment option, but there is currently a lack of adequate evidence. This study sought to retrospectively assess the efficacy and safety of surgery or radiotherapy in the treatment of bone hydatid disease in patients attending a single hospital in China. METHODS This was a retrospective case series analyzing clinical data from consecutive patients treated between January 2000 and December 2011. Patients with an Echinococcus sp infection were counselled about their disease and the potential treatment options, and made an informed decision between surgery and radiotherapy. All patients were followed up. The treatment outcome was observed in the two treatment groups based on the frequencies of relapse and complications, and self-evaluated patient satisfaction. RESULTS Of 40 patients (age range 25-57 years), 24 opted for surgery and 16 for radiotherapy. Relapse occurred in 14 patients (58%) post-surgery and in three patients (21%) post-radiotherapy. Bone defects, limb movement disorders, and pain were reported in seven patients (29%) post-surgery, while two patients (13%) reported hardening of the irradiated region or a limb after radiotherapy. Titres of parasite-specific antibodies decreased significantly after radiotherapy but not after surgical intervention. Patient satisfaction was significantly higher in the radiotherapy group. CONCLUSION This retrospective case series describes, for the first time, the clinical outcomes in a series of patients treated with radiotherapy for bone hydatid disease. Although no direct comparison between the treatment groups could be made due to methodological limitations of the study design, this study indicates that well-designed prospective randomized controlled clinical trials assessing radiotherapy may be warranted in patients with inoperable hydatid disease of the bones.
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Affiliation(s)
- Zengru Xie
- Department of Orthopaedics, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Liang Chen
- Department of Orthopaedics, The People Hospital of Lin-an, Zhejiang, China
| | - Qixin Xie
- College of Administration, Beijing University of Chinese Medicine, Beijing, China
| | - Yongxing Bao
- Tumour Centre, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Xuefeng Luo
- Department of Orthopaedics, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Chengpeng Yi
- Department of Orthopaedics, The People Hospital of Langzhong, Sichuang, China
| | - Hao Wen
- The Key Laboratory of Echinococcosis, The First Affiliated Hospital of Xinjiang Medical University, No. 137 South Liyunshang Road, Urumqi, Xinjiang 830054, China.
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Tamarozzi F, Vuitton L, Brunetti E, Vuitton DA, Koch S. Non-surgical and non-chemical attempts to treat echinococcosis: do they work? ACTA ACUST UNITED AC 2014; 21:75. [PMID: 25531730 PMCID: PMC4273701 DOI: 10.1051/parasite/2014071] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Accepted: 12/11/2014] [Indexed: 12/14/2022]
Abstract
Cystic echinococcosis (CE) and alveolar echinococcosis (AE) are chronic, complex and neglected diseases. Their treatment depends on a number of factors related to the lesion, setting and patient. We performed a literature review of curative or palliative non-surgical, non-chemical interventions in CE and AE. In CE, some of these techniques, like radiofrequency thermal ablation (RFA), were shelved after initial attempts, while others, such as High-Intensity Focused Ultrasound, appear promising but are still in a pre-clinical phase. In AE, RFA has never been tested, however, radiotherapy or heavy-ion therapies have been attempted in experimental models. Still, application to humans is questionable. In CE, although prospective clinical studies are still lacking, therapeutic, non-surgical drainage techniques, such as PAIR (puncture, aspiration, injection, re-aspiration) and its derivatives, are now considered a useful option in selected cases. Finally, palliative, non-surgical drainage techniques such as US- or CT-guided percutaneous biliary drainage, centro-parasitic abscesses drainage, or vascular stenting were performed successfully. Recently, endoscopic retrograde cholangiopancreatography (ERCP)-associated techniques have become increasingly used to manage biliary fistulas in CE and biliary obstructions in AE. Development of pre-clinical animal models would allow testing for AE techniques developed for other indications, e.g. cancer. Prospective trials are required to determine the best use of PAIR, and associated procedures, and the indications and techniques of palliative drainage.
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Affiliation(s)
- Francesca Tamarozzi
- Department of Clinical, Surgical, Diagnostic and Paediatric Science, University of Pavia, Via Brambilla 74, 27100 Pavia, Italy - WHO-Collaborating Centre for Clinical Management of Cystic Echinococcosis, Via Taramelli 5, 27100 Pavia, Italy
| | - Lucine Vuitton
- Gastroenterology and Endoscopy Unit, Besançon University Hospital, Bd Fleming, 25000 Besançon, France - WHO-Collaborating Centre for Prevention and Treatment of Human Echinococcosis, University of Franche-Comté and University Hospital, 25000 Besançon, France
| | - Enrico Brunetti
- Department of Clinical, Surgical, Diagnostic and Paediatric Science, University of Pavia, Via Brambilla 74, 27100 Pavia, Italy - WHO-Collaborating Centre for Clinical Management of Cystic Echinococcosis, Via Taramelli 5, 27100 Pavia, Italy - Division of Tropical Infectious Diseases, San Matteo Hospital Foundation, Via Taramelli 5, 27100 Pavia, Italy
| | - Dominique Angèle Vuitton
- WHO-Collaborating Centre for Prevention and Treatment of Human Echinococcosis, University of Franche-Comté and University Hospital, 25000 Besançon, France
| | - Stéphane Koch
- Gastroenterology and Endoscopy Unit, Besançon University Hospital, Bd Fleming, 25000 Besançon, France - WHO-Collaborating Centre for Prevention and Treatment of Human Echinococcosis, University of Franche-Comté and University Hospital, 25000 Besançon, France
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15
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Gripp S, Ernst R, Pohle S. Is radiation an effective therapy in echinococcus multilocularis? Strahlenther Onkol 2014; 190:591. [PMID: 24658607 DOI: 10.1007/s00066-014-0653-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Accepted: 03/05/2014] [Indexed: 11/29/2022]
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16
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Meilinger M, Stoeckl C, Pollheimer M, Kern P, Reisinger EC, Seeber K, Krause R, Flick H, Hoenigl M. Progressive alveolar echinococcosis after discontinuation of anthelmintic therapy. Parasit Vectors 2013; 6:287. [PMID: 24289745 PMCID: PMC3849844 DOI: 10.1186/1756-3305-6-287] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Accepted: 09/26/2013] [Indexed: 11/10/2022] Open
Abstract
We report a case of a female patient with alveolar echinococcosis (AE) who presented with progressive pulmonary and hepatic lesions and had a fatal outcome. AE affecting the liver, the lungs and the brain had been diagnosed 20 years ago and treated successfully with albendazole and stereotactic gamma knife therapy. Due to severe hair loss albendazole was stopped 14 years before presentation. Lesions had remained stable in imaging studies for at least 11 years, but then had started to progress. Lifelong anthelmintic maintenance therapy and regular follow-up may therefore be crucial in order to prevent such a dramatic clinical course.
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17
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Ulger S, Barut H, Tunc M, Aydin E, Aydınkarahaliloğlu E, Gokcek A, Karaoğlanoğlu N. Radiation therapy for resistant sternal hydatid disease. Strahlenther Onkol 2013; 189:508-9. [PMID: 23604185 DOI: 10.1007/s00066-013-0322-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Accepted: 01/23/2013] [Indexed: 12/28/2022]
Abstract
Hydatid disease is a zoonotic infectious disease for which there are known treatment procedures and effective antibiotics; however, there are resistant cases that do not respond to medication or surgery. We report a case diagnosed as hydatid disease of the chest wall and treated with radiation therapy (RT) after medical and surgical therapy had failed. In conclusion, RT represents an alternative treatment modality in resistant cases.
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Affiliation(s)
- S Ulger
- Department of Radiation Oncology, Ataturk Chest Disease and Thorasic Surgery Training and Research Hospital, Ankara, Turkey.
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18
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Abstract
Echinococcosis of the CNS is very rare. Cystic (CE) and alveolar echininococcosis (AE) vary in their clinical manifestations, course of disease, and prognosis, to the extent that clinicians should look at these two parasitic infections as distinctly different entities. CE causes displacement and pressure atrophy, while AE expands by infiltrative growth. Due to the embolic nature of CE and AE, CNS lesions are most commonly localized supratentorially in the middle cerebral artery. Symptoms and clinical signs are those of space-occupying lesions. Diagnosis is primarily based on imaging (MRI, CT); serology can help to confirm the diagnosis, but is unreliable. In vivo MRS techniques for immobile intracranial CE lesions have become feasible and will assist in diagnosing such lesions in the future. Patients with cerebral CE and AE need an individual therapeutic approach and should generally be managed by a multidisciplinary team of clinicians experienced in the management of CE and neurosurgeons. A minimum follow-up of 5 years, but ideally 10 years, is necessary. Treatment is difficult in advanced disease, in particular in AE, when curative surgery is not possible. AE and CE are among the most neglected infectious diseases and urgently need more attention to improve early detection in exposed populations, diagnosis, and treatment.
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Ozdol C, Yildirim AE, Daglioglu E, Divanlioglu D, Erdem E, Belen D. Alveolar hydatid cyst mimicking cerebellar metastatic tumor. Surg Neurol Int 2011; 2:13. [PMID: 21427774 PMCID: PMC3046418 DOI: 10.4103/2152-7806.76281] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2010] [Accepted: 01/04/2011] [Indexed: 01/24/2023] Open
Abstract
Background: Echinococcus multilocularis is a rare infestation in the world with a particularly increased incidence mainly in South America, Central Europe and Asia. Progression of alveolar Echinococcosis is more aggressive that can metastasize to lungs, brain and bones however brain involvement is usually rare with an incidence about 1%. Case Description: We report a 23-year-old man with a cerebellar Echinococcosis multilocularis mimicking a metastatic cerebellar tumor. Suboccipital craniotomy was performed for gross total removal of the tumor. Histopathological specimens confirmed the diagnosis of Echinococcosis multilocularis. Conclusion: Radical surgical excision should be recommended for single Echinococcosis multilocularis lesions particularly at infratentorial localization.
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Affiliation(s)
- Cagatay Ozdol
- Ankara Numune Education and Research Hospital, Neurosurgery Clinics, Ankara, Turkey
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20
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Echinococcus multilocularis: the impact of ionizing radiation on metacestodes. Exp Parasitol 2010; 127:127-34. [PMID: 20638383 DOI: 10.1016/j.exppara.2010.07.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2010] [Revised: 06/29/2010] [Accepted: 07/12/2010] [Indexed: 11/22/2022]
Abstract
Alveolar echinococcosis is caused by the metacestode stage of the fox tapeworm Echinococcus multilocularis. Current chemotherapeutical options for the treatment of echinococcosis are not satisfactory, and novel drugs and/or other potential means of therapy are needed. E. multilocularis metacestodes are characterized by almost potentially unlimited growth, and also display other features of cancerous tumours. In this study, we exposed metacestodes that were generated in vitro to 50-100 Gy ionizing irradiation, and subsequently investigated the short-term (10-12 days post-treatment) and long-term (14 weeks post-treatment) effects. We found, that in the short-term, no release of alkaline phosphatase (EmAP) activity as a measure for potentially induced damage and loss of viability could be detected, and that the protein expression pattern and protease activities in vesicle fluids and medium supernatants did not alter dramatically following irradiation. However, irradiation was associated with distinct morphological and ultrastructural alterations in the tissue of metacestodes, affecting most notably cell-cell contacts, mitochondrial shape, glycogen-storage cells and lipid droplet formation. These could be detected already at 10 days following treatment and remained as such also in the long-term. In addition, as determined after 14 weeks of culture, irradiation affected the proliferation and the growth of E. multilocularis metacestodes. Thus, we demonstrate that radiotherapy does not have a clear-cut parasitocidal effect, but can lead to metabolic impairment of E. multilocularis metacestodes, as reflected by the distinct morphological and structural alterations induced by irradiation treatment.
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21
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Tappe D, Weise D, Ziegler U, Müller A, Müllges W, Stich A. Brain and lung metastasis of alveolar echinococcosis in a refugee from a hyperendemic area. J Med Microbiol 2008; 57:1420-1423. [PMID: 18927422 DOI: 10.1099/jmm.0.2008/002816-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Alveolar echinococcosis (AE) of the liver with cerebral and pulmonary metastasis was diagnosed in a Tibetan monk who initially presented with severe headache to an emergency department in Germany. Multiple lesions with perifocal oedema and severe compression of the third ventricle were seen with computed tomography (CT) of the brain. Glioma or cerebral metastasis of a hitherto undiagnosed abdominal or pulmonary malignancy was suspected. CT scans of the lung and liver demonstrated further tumorous masses. Magnetic resonance imaging of the brain revealed the cystic nature of the cerebral lesions and the patient had a highly positive serology for AE. The echinococcal aetiology of the brain lesions was confirmed by PCR for this refugee from an area where two disease entities, AE and cystic echinococcosis, are hyperendemic.
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Affiliation(s)
- Dennis Tappe
- Department of Tropical Medicine, Medical Mission Hospital, Salvatorstrasse 7, 97067 Würzburg, Germany.,German Consiliary Laboratory for Echinococcosis, Institute of Hygiene and Microbiology, University of Würzburg, Josef-Schneider-Strasse 2, 97080 Würzburg, Germany
| | - David Weise
- Department of Neurology, University Hospital of Würzburg, Josef-Scheider-Strasse 11, 97080 Würzburg, Germany
| | - Uwe Ziegler
- Department of Tropical Medicine, Medical Mission Hospital, Salvatorstrasse 7, 97067 Würzburg, Germany
| | - Andreas Müller
- Department of Tropical Medicine, Medical Mission Hospital, Salvatorstrasse 7, 97067 Würzburg, Germany
| | - Wolfgang Müllges
- Department of Neurology, University Hospital of Würzburg, Josef-Scheider-Strasse 11, 97080 Würzburg, Germany
| | - August Stich
- Department of Tropical Medicine, Medical Mission Hospital, Salvatorstrasse 7, 97067 Würzburg, Germany
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22
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Takci E, Sengul G, Akar A, Uslu H, Alper F, Erdogan F, Aydin IH. Alveolar echinococcosis of the brain in five patients. J Clin Neurosci 2008; 15:1105-9. [PMID: 18653340 DOI: 10.1016/j.jocn.2007.09.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2007] [Revised: 09/27/2007] [Accepted: 09/30/2007] [Indexed: 12/13/2022]
Abstract
Cerebral alveolar echinococcis is a biologically aggressive infestation that mimics a malignant neoplasm radiologically and macroscopically. This paper describes the clinical and radiological aspects of the disease, with new diagnostic studies, and discusses the surgical treatment of this infestation. The records of five patients with cerebral alveolar echinococcis treated at our center between 2000 and 2004 were reviewed. Three patients underwent radical surgical treatment and received antihelminthic therapy post-operatively, two of whom experienced asymptomatic recurrence. Two patients with multiple lesions were treated with antihelminthic therapy alone. The prognosis was poor for these patients. Radical surgery combined with antihelminthic therapy of sufficient duration are mandatory to prevent the progression of symptoms but the disease continues to be difficult to cure.
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Affiliation(s)
- Erhan Takci
- Department of Neurosurgery, Medical School, Ataturk University, 25070, Yenisehir, Erzurum, Turkey
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Balak N, Cavumirza C, Yildirim H, Ozdemir S, Kinay D. Microsurgery in the removal of a large cerebral hydatid cyst: technical case report. Neurosurgery 2007; 59:ONSE486; discussion ONSE486. [PMID: 17038962 DOI: 10.1227/01.neu.0000232766.77094.79] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Surgery is presently the mainstay in the treatment of cerebral hydatid cysts, but removal without perforation of the cyst wall is critical. The Dowling-Orlando technique has been the main surgical choice for the intact removal of intracranial hydatid cysts. Dowling described his technique in 1929, well before the introduction of the microscope in neurosurgery. Using the operating microscope has not been reported in the removal of a large hydatid cyst. CLINICAL PRESENTATION The case of a 16-year-old male with a large, right parieto-occipital hydatid cyst is presented. INTERVENTION In this case, surgery was greatly aided by the use of the microscope in the initial stage of the removal of the cyst. Cyst extraction during the delivery process was continued without the aid of the microscope. The cyst was successfully removed intact. CONCLUSION The use of the magnification during the early part of the surgery of a hydatid cyst is extremely helpful because, at a crucial stage of the procedure, it prevents inadvertent damage of the very thin cyst wall and allows development of the critical surgical plane.
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Affiliation(s)
- Naci Balak
- Department of Neurosurgery, Bakirköy Education and Research Hospital, Istanbul, Turkey.
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24
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Altinörs N, Bavbek M, Caner HH, Erdogan B. Central nervous system hydatidosis in Turkey: a cooperative study and literature survey analysis of 458 cases. J Neurosurg 2000; 93:1-8. [PMID: 10883898 DOI: 10.3171/jns.2000.93.1.0001] [Citation(s) in RCA: 189] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Hydatidosis is both a medical and an economic problem in Turkey. The aim of this study was to analyze central nervous system (CNS) involvement in this disease, the related problems the disease causes, and its diagnostic and therapeutic aspects. METHODS The authors conducted an extensive literature survey of the subject, in which papers published by Turkish authors in international and domestic journals were carefully analyzed. In addition, the authors conducted a cooperative study in which data were gathered from 47 neurosurgery departments across the country. The purpose was to determine the current status of the disease in Turkey; thus, each unit was questioned about their experience over the past 5 years. Contrary to common belief, the incidence of hydatidosis has not decreased significantly in Turkey. However, computerized tomography and magnetic resonance imaging have tremendously increased diagnostic specificity. Incidences of morbidity and mortality have improved over time, according to the results of the cooperative study, although these changes are not statistically significant. This may be attributed to experience that has been gained and to more frequent use of chemotherapy, as reflected by the cooperative study data. The two statistically significant findings of that study were expanded use of chemotherapy in the management of hydatidosis, and a higher rate of extraneural involvement in the disease. The cooperative study revealed that chemotherapy was being used more often and that there was a wider range of indications for this treatment than previously reported. The higher rate of extraneural involvement was predictable because lesions in the CNS are typically secondary in this disease. With regard to the studies' findings on cases of spinal hydatid cysts, the authors found that administration of chemotherapeutic drugs was the only statistically significant parameter (t = 3.78, p < 0.05), with the rate of chemotherapy higher in the cooperative study. CONCLUSIONS Morbidity, mortality, and recurrence rates of hydatidosis uncovered by the cooperative study and the literature survey were not statistically significant.
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Affiliation(s)
- N Altinörs
- Neurosurgery Department, Başkent University, Ankara, Turkey.
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Abstract
Radiosurgery will celebrate its Golden Jubilee in the year 2001. More than 100,000 patients throughout the world have undergone radiosurgery since Lars Leksell first described the technique in 1951. Rapid developments in neuroimaging and even robotic technology in the past decade have contributed to improved outcomes and wider applications for radiosurgery. A variety of different radiosurgical techniques have been developed in the past two decades. Numerous studies have examined the benefits and risks of radiosurgery performed with various devices. The long-term results of radiosurgery are now available, and these results have established radiosurgery as an effective noninvasive treatment method for intracranial vascular malformations and many tumors. Additional applications of radiosurgery for the treatment of malignant tumors and functional disorders are being assessed. Radiosurgery is an impressive combination of minimally invasive technologies administered by a multidisciplinary team of surgeons, oncologists, medical physicists, and engineers.
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Borja J, Herreras A. Comparison of sulbactam/cefoperazone with imipenem as empirical monotherapy for febrile granulocytopenic patients. Clin Infect Dis 1999; 28:406-7. [PMID: 10064264 DOI: 10.1086/515109] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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