Sudden death due to hydatid disease: a six-year study in the northern part of Tunisia

Cardiac cystic echinococcosis-A systematic review and analysis of the literature

Human cystic echinococcosis (CE) is a parasitic infection caused by the larval stage of the tapeworm Echinococcus granulosus sensu lato, primarily affecting the liver and lungs. Although the heart is affected in only 0.02-2% of all CE cases, a considerable number of cases have been, and continue to be, published. However, due to the rare occurrence of cardiac CE and the resulting lack of clinical trials, knowledge about various aspects of the disease remains limited. To obtain a clearer picture of anatomical, clinical, diagnostic as well as therapeutic aspects of cardiac CE, we systematically reviewed the literature published between 1965 and 2022. The anatomical pattern of the affected cardiac structures follows the extension of the supplying capillary bed. The majority of patients (82.7%) are symptomatic and present with prolonged non-specific symptoms such as dyspnoea, chest pain and palpitations. Acute complications generally derive from cyst rupture, occur in 18.3% of cases and manifest as embolism, pericardial tamponade, or anaphylactic reaction in 83.2%, 17.8% and 10.9% of these cases, respectively. As for CE cysts localized in other organs, the diagnosis of cardiac CE is made by imaging. Serology plays a minor role due to its limited sensitivity. Unlike abdominal CE cysts, cardiac CE cysts are usually resected independent of their stage (active/inactive), because their presence impairs cardiac performance and carries the risk of long-term sequelae. More than 80% of patients are treated with a single surgical intervention. We found a disease-related case fatality rate of 11.1%. Since local recurrence was reported up to 108 months and secondary CE up to 72 months after surgery, patients should be followed up for a minimum of 10 years.

Africa-wide meta-analysis on the prevalence and distribution of human cystic echinococcosis and canine Echinococcus granulosus infections

BACKGROUND

Echinococcosis is a neglected zoonosis of increasing public health concern worldwide. According to the World Health Organization, 19,300 lives and 871,000 disability-adjusted life-years are lost globally each year because of cystic echinococcosis. Annual costs associated with cystic echinococcosis were estimated at US$ 3 billion because of treatment of cases and losses in the livestock industry.

METHODS

We performed the random-effects model of meta-analysis using 51-year (1970-2021) data available from AJOL, Google Scholar, PubMed, Science Direct, Scopus and Web of Science. We also applied the Joanna Briggs Institute critical appraisal instrument for studies reporting prevalence data, the Cochran's Q-test, Egger's regression test and the single study deletion technique to respectively examine within-study bias, heterogeneity, across-study bias and sensitivity.

RESULTS

Thirty-nine eligible studies on human cystic echinococcosis (HCE) from 13 countries across the five African sub-regions showed an overall prevalence of 1.7% (95% CI 1.1, 2.6) with a statistically significant (P < 0.001) sub-group range of 0.0% (95% CI 0.0, 14.1) to 11.0% (95% CI 7.6, 15.7). Highest prevalences were observed in Eastern Africa (2.7%; 95% CI 1.4, 5.4) by sub-region and Sudan (49.6%; 95% 41.2, 58.1) by country. Another set of 42 studies on Echinococcus granulosus infections (EGI) in dogs from 14 countries across the five African sub-regions revealed an overall prevalence of 16.9% (95% CI 12.7, 22.3) with a significant (P < 0.001) variation of 0.4 (95% CI 0.0, 5.9) to 35.8% (95% CI 25.4, 47.8) across sub-groups. Highest prevalences of E. granulosus were observed in North Africa (25.6%; 95% CI 20.4, 31.6) by sub-region and Libya (9.2%; 95% CI 5.7, 13.9) by country.

CONCLUSION

Human cystic echinococcosis and EGI are respectively prevalent among Africans and African dogs. We recommend a holistic control approach that targets humans, livestock, dogs and the environment, which all play roles in disease transmission. This approach should involve strategic use of anthelminthics in animals, standardized veterinary meat inspection in abattoirs, control of stray dogs to reduce environmental contamination and proper environmental sanitation. Mass screening of humans in hyper-endemic regions will also encourage early detection and treatment.

Paediatric anaphylaxis in South Africa

Introduction

Anaphylaxis is a severe, life-threatening generalized hypersensitivity reaction. While guidelines to reduce the morbidity, risk, and mortality of anaphylaxis are widely available, adherence to these is often suboptimal. We aimed to audit paediatric anaphylaxis at a South African tertiary allergy referral centre, comparing our data to those of the large Network of Severe Allergic Reactions (NORA) registry.

Methods

Children treated for severe allergic reactions between January 2014 and August 2016 were identified for screening using ICD-10 coding of all admissions and discharges, pharmacy records of adrenaline autoinjector dispensing, and additional referrals from the allergy department to the study. Screened participants not meeting the inclusion criteria after preliminary questioning and/or folder review were excluded. Data were collected via a standardized questionnaire using direct interviews, and captured on a local web-based registry.

Results

Of the 156 episodes analysed, >40% were graded as severe and nearly two-thirds of patients were seen for a recurrent episode. Males, younger children, and individuals of mixed-race ethnicity were more frequently affected. Skin and mucosa were most commonly involved, followed by respiratory and gastrointestinal involvement; cardiovascular and other systemic involvement occurred infrequently. Specific IgE assay was the most frequently requested test. Food-related triggers (peanut, hen's egg, fish, cashew nuts and cows' milk) predominated and decreased with age. Anaphylaxis was strongly correlated with atopic conditions. While prophylactic measures were almost universally instituted, adrenaline was rarely used, by both lay persons and healthcare professionals. Hospital admissions were infrequent, and no deaths were recorded.

Conclusion

Management of anaphylaxis can be improved. Specifically, the use of adrenaline prior to hospital arrival remains suboptimal. Ongoing education and training of patients, parents, teachers, and healthcare workers is identified as an area requiring intensification.

A simple score for predicting urinary fistula in patients with renal hydatid cysts

Hydatid cyst is a major health problem in developing countries. The kidney is in third position of organs affected by hydatid cyst. One of the complications of renal hydatid cyst is a urinary fistula. The purpose of this study is to identify preoperative predictive factors of urinary fistula in renal hydatid cyst and to develop a scoring system for this disorder. We retrospectively analyzed all patients operated for renal hydatid cysts between January 2000 and December 2020. We divided our patients into two groups according to whether or not the renal hydatid cysts opened in the urinary tract. Predictive factors of the presence of a urinary fistula have been studied to obtain a simple score to predict the presence of a urinary fistula. Differences were considered significant if p < 0.05. Urinary fistula was detected in 33 of 96 patients. Univariate analyses showed significant differences in patient age, cyst size, location, hydaturia, eosinophil count, and platelet count between patients with and without urinary fistula. In multivariate analyses, hydaturia (p < 0.005), eosinophil count >500/mm³, (p = 0.01), cyst diameter >5 cm (p = 0.02), and upper or lower renal pole location (p = 0.003) were significant and independent predictors of urinary fistula. A score was developed to predict the opening of the cyst in the urinary tract. The total score varies between 0 and 15. The resulting area under the receiver operator characteristic curve was 0.798 (95% CI, 0.726–0.866; p = 0.023). At a cutoff point ≥8, the specificity achieved was 100%. Preoperative detection and management of urinary fistula are important issues in the treatment of renal hydatid cyst. Developing a scoring system based on routinely measured laboratory and radiologic factors will help the clinician to manage patients with renal hydatid cysts. External studies are needed to validate this new scoring system in routine clinical practice.

Hydatid Disease, an Uncommon Etiology of Death in Forensic Practice

ABSTRACT

In Tunisia, hydatid cyst is an endemic parasitic disease. The cyst may remain asymptomatic, discovered accidentally, or in case of a complication, the most serious of which is sudden death. We propose, in this article, to analyze the degree of involvement of the cyst in the mechanism of death, through the review of 25 cases. A total of 7932 autopsy cases were performed during the study period. Twenty-five cases of hydatid cyst discovered at autopsy were collected and death was attributed to hydatid cyst in 13 cases. The seat of the cyst was variable and death was due to anaphylaxis in 10 cases, to hydatious embolism in 2 cases and to cardiac arrhythmia, resulting from a cardiac localization of a large hydatid cyst, in 1 case.Although rare, echinococcosis can be a life-threatening disease. Its involvement in the death mechanism remains difficult in many cases.

Sudden death related to the gastrointestinal system in Tunisia: A 13 year autopsy study

Sudden gastrointestinal (GI) death is an unexpected death due to digestive system causes mainly found after autopsy. The literature is rich in articles that studied sudden death due to cardiac causes while sudden GI deaths remain less well-documented. We retrospectively investigated all cases of gastrointestinal death at the Department of Forensic Medicine in Tunis, over 13 years (January 1, 2006 to December 31, 2018). Two hundred and eight cases were collected. The mean age of our series was 51.06 ± 20.99 years. No history of digestive disorders was reported in 78.4%, and no family history of sudden death was found in any cases. A male predominance was found in most epidemiological characteristics of the sample with a significant statistical rate in some features. Non-specific abdominal pain was the most described symptom (n = 92). Perforation of GI tract was the common mechanism involved in the death of 55 cases, of which 44 were related to ulcer perforation. These ulcer perforations were statistically more reported in smokers and people suffering from schizophrenia. Intestinal obstruction was the second commonest cause of death, mainly found in the elderly. Sudden death in children was most frequently caused by acute intussusception. This study highlights that systematic study of sudden death due to GI causes might provide opportunities to identify avenues for overall health improvement.

Fatal anaphylactic shock: A review of postmortem biomarkers and diagnostics

Diagnosing anaphylactic shock postmortem is challenging since differential diagnoses exist and the forensic pathologist often faces subtle findings and lacks relevant information which prevents reaching an opinion of certainty. This review provides an overview of the literature covering research and existing recommendations on the postmortem diagnosis of anaphylactic shock. In order to harmonize the approach and provide guidance for diagnosing deaths from anaphylactic shock in the six forensic centers in Sweden, a guidance protocol aligned with the notion of a holistic view in the approach was devised. Areas in need of further studies include both immunohistological and biochemical investigations to stratify quantitative approaches based on condition and anaphylactic trigger and to lay the ground for and possibly establish alternative matrices.

Giant pulmonary hydatid cyst in children

BACKGROUND

Lungs are the second most common site for hydatid disease after the liver. Giant hydatid cyst (GHC) of the lung is a special clinical entity in children and is related to higher lung tissue elasticity.

AIM

To compare clinical and imaging features, types of surgical interventions, and postoperative complications in pulmonary GHC and non-giant pulmonary hydatid cysts (NGHC) in children.

METHODS

A retrospective study was undertaken. The data analyzed were taken from medical records of children with pulmonary hydatid cyst (PHC) hospitalized in a pulmonary department in Tunisia between January 2004 and February 2019. Cysts were divided according to their size into GHC ( ≥10cm) and NGHC (<10cm).

RESULTS

In the study period, 108 PHC were recorded in 84 children. GHC accounted for 21 (19.4%) and NGHC for 87 (80.6%). The median of age of the children was 11 years (IQR 1-9, IQR 3-14) and the mean age was 11.6 years (10.5 in GHC vs. 11.4 years in NGHC). Hemoptysis was found in 25% of the GHC group vs. 48.4% of the NGHC group (P=0.27). Cysts were multiple in 23.8% of cases and predominated in the right in 64.3% of cases and in the inferior lobes in 71.4% of the cases. GHCs were less frequently complicated (60% vs. 78.1% in NGHC, P≤0.11), although not significantly. Parenchymal resection was realized in 50% of GHC vs. 18.8% of NGHC (P=0.006). No significant difference was found in postoperative complications between the two groups and there was no recurrence in either group.

CONCLUSION

GHC is a special clinical entity in children. It requires major surgery with parenchymal resection, and therefore early diagnostic and therapeutic management is warranted.

Brain and Cardiac Concomitant Localization of the Hydatid Cyst

Hydatid cyst is a parasitic infestation that is usually observed in the liver and lungs. The localization in the brain and the heart is exceptional. Here, we report a 11-year-old boy who was diagnosed to have two large hydatid cysts of the heart and brain. We discuss this unusual presentation of hydatid cyst and its management.

Sudden death and hydatid cyst: A medicolegal study

The discovery of a hydatid cyst at autopsy poses the problem of its involvement in the mechanism of death. The aim of this study is to analyse the epidemiological and etiopathogenic characteristics of death attributed to hydatid disease, to discuss the mechanism of death and to propose preventive measures. This is a retrospective descriptive study of 26 cases of death with hydatid cyst autopsic discovered, collected at the forensic department of Fattouma Bourguiba University Hospital of Monastir (Tunisia) over a period of 27 years (from 1990 until 2017). In 26 cases, hydatid cyst was observed during autopsy of sudden death cases, which corresponds to 0.33% of the total of autopsies in this period. Of the 26 victims, 13 (50%) were men; the mean age was 43 years. Most victims were from rural zones (18 cases). In 20 cases, the complicated cyst was hepatic. It was cardiac in two cases. Of all cases, three cysts were cracked, and nine were broken. Of the 26 cases, only 15 were implicated in the death mechanism. Death was attributed to anaphylaxis in 12 cases, hydatid pulmonary embolism in 1 case, cardiac arythmia in one case and hemothorax in one case. Sudden death is the most dangerous complication of the hydatid cyst which can be discovered at autopsy. Several causes may explain its occurrence, the most common of which is anaphylactic shock.

A systematic review exploring the relationship between infection and sudden unexpected death between 2000 and 2016: A forensic perspective

Death due to infectious diseases is a major health concern worldwide. This is of particular concern in developing countries where poor-socio economic status and a lack of healthcare resources contribute to the high burden of disease. In some cases death due to infection can be acute and aggressive, and death may occur without a diagnosis whilst the person is still alive. These deaths may ultimately lead to a medico-legal autopsy being performed. There are various mechanisms by which sudden death due to infection may occur. In addition, there are many risk factors associated with sudden death due to infection, which differ between infants and older individuals. However, it is unclear which pathogens and risk factors are most frequently associated with sudden death due to infection. Therefore a systematic review of articles and case reports published between 1 January 2000 and 30 June 2016 was undertaken in order to (1) explore the relationship between pathogens and their causative role and (2) identify the relationship between predisposing and/or risk factors associated with sudden death due to infection. Major databases were searched and after critical appraisal 143 articles were identified. It was found that respiratory infections and deaths involving bacterial pathogens were most commonly associated with these deaths. In addition the most common risk factors in infants were exposure to tobacco smoke and co-sleeping. In adults the most common risk factors were co-morbid conditions and illnesses. This information aids in a better understanding of these deaths and highlights the need for more research in this field, particularly in developing countries.

Analysis of Lethality in Echinococcal Disease

The information on mortality from echinococcosis is important not only for a better understanding of the severity of the disease, but also for evaluating the effectiveness of public health interventions. The aim of this research was to study the causes of mortality from echinococcosis. We have collected and analyzed the materials of 1,470 patients in 10 age - groups in the Republic of Armenia (from 2000 to 2016). To find out the causes of mortality from echinococcosis, we have analyzed the medical histories and protocols of postmortem examinations of 19 deaths from echinococcosis and 17 deaths due to other indirect causes not associated with the parasite. The average annual death rate from echinococcosis is 0.007 per 10,000 population, and the mortality is 1.29 (per 100 patients). The highest mortality occurs in people aged 70-79. Mortality from echinococcosis is also recorded among the unoperated children. The rupture of the parasitic cyst and hepatic insufficiency are major among the direct causes of mortality. Sometimes the hydatid cysts unrecognized during the life were first diagnosed at autopsy. Insufficient qualification of doctors in the field of helminthology, as well as the latent course of the disease or manifestation of minor symptoms in echinococcosis over a long period often led to medical errors. Further decline in mortality can be achieved by early diagnosis, timely hospitalization and treatment before the development of severe complications worsening the prognosis and outcomes of surgical intervention.

Non-thrombotic Pulmonary Embolism Due to Liver Hydatic Cyst: A Case Report

Background:

A non-thrombotic pulmonary embolism is defined as embolization to the pulmonary circulation. It may be caused by microorganisms, foreign bodies, different cell types or gas in the pulmonary circulation. Pulmonary hydatid cyst-induced embolization is a rare complication of heart or liver hydatid cysts.

Case Report:

We describe the fatal case of a 15-year-old boy without any known prior illness who was admitted to the hospital after feeling unwell and dropping to the ground while playing ball. During the autopsy, a lesional mass, with dimensions of 13x6 cm, was observed in the left lobe of the liver. The histomorphological examination of pulmonary sections showed scolices observed in pulmonary vessel lumina, thus a non-thrombosis hydatid embolism was diagnosed. Based on the findings, the cause of death was recorded as a non-thrombotic hydatid embolism.

Conclusion:

The present case is interesting because a non-thrombotic pulmonary embolism rarely results in sudden death, and a definitive diagnosis was possible only by a histopathological examination.

Hydatid Disease Involved in the Heart, Liver, and Kidney That Caused Sudden Death: Case Report

Hydatid disease is a parasitic infestation caused by ingestion of eggs of echinococcal species. For Echinococcus granulosus, the definitive host is the dog, and sheeps are the usual intermediate hosts. Humans are accidental intermediate hosts, infected by ingestion of food contaminated with eggs shed by dogs or foxes. The most common organs that hydatid disease encountered are the liver and lungs. Involvement of the kidney is rare and usually accompanies the other organ involvements. Cardiac involvement of echinococcosis is also very rare. We report the case of a 31-year-old woman with a 6-year history of asthma who collapsed after strenuous activity and died despite the interventions carried out. At autopsy, cystic masses were detected in the apex of the heart, in the right kidney, and in the liver. There were no macroscopic pathologic findings in the other organs. Microscopic examination revealed the diagnosis of hydatid cyst in the heart, right kidney, and liver besides medial hypertrophy of the lung vessels. Cause of death was attributed to hydatid cyst and its complications. Patients who have symptoms akin to asthma at clinical presentation have to be further investigated for organic cardiac and pulmonary diseases such as hydatid cyst, especially in endemic countries.