Cystic echinococcosis in a single tertiary care center in Rome, Italy

Accuracy of an experimental whole-blood test for detecting reactivation of echinococcal cysts

BACKGROUND

Cystic echinococcosis (CE) is a complex disease for which clear understanding of clinical manifestations is needed to avoid misdiagnosis, inappropriate treatment, and severe complications. We evaluated the accuracy of a whole-blood stimulation test based on Interleukin (IL)-4 detection in response to Antigen B (AgB) of Echinococcus granulosus sensu lato to discriminate cyst viability and detect cyst reactivation in patients with hepatic CE.

METHODOLOGY/PRINCIPAL FINDINGS

Thirty patients with CE3b cysts and 37 patients with spontaneously-inactivated CE4-CE5 cysts were recruited (T0). After enrollment, 5 patients with CE3b cysts received albendazole, resulting in cyst solidification (CE4) in 4/5. Within a two-year follow-up, the whole-blood test was repeated at two time-points, in ≥14 (T1) and in ≥4 (T2) patients per group. IL-4 and a panel of other soluble factors were measured in the stimulated plasma. Baseline IL-4 levels were significantly higher in patients with CE3b compared to those with CE4 cysts (p = 0.006). Test accuracy for CE3b diagnosis had a sensitivity of 33-60% and a specificity of 76-95%, depending on the cut-off applied. Overall, IL-4 levels did not change significantly over time in either group; however, patients within the CE3b group showed a significant decrease of IL-1ra, IL-6, IL-8, G-CSF, IFN-γ, IP-10, MCP-1, MIP-1α, FGF at T1 compared to T0 (p≤0.042).

CONCLUSIONS/SIGNIFICANCE

Whole-blood IL-4-response to AgB is significantly higher in patients with active compared to inactive CE but apparently not modulated over time after treatment. On the contrary, the levels of IL-1ra, IL-6, IL-8, G-CSF, IFN-γ, IP-10, MCP-1, MIP-1α, FGF significantly decreased in active CE during follow-up. Additional studies are needed to understand whether these findings might have a clinical significance for patients' follow-up.

Parasites of the liver - epidemiology, diagnosis and clinical management in the European context

Parasites in the liver cause significant global morbidity and mortality, as they can lead to recurrent cholangitis, cirrhosis, liver failure and cancer. Due to climate change and globalisation, their incidence is increasing, especially in Europe. The correct diagnosis of a hepatic parasite is often delayed because clinicians are unfamiliar with respective entities. Therefore, in this review, we aim to provide clinicians with a comprehensive clinical picture of hepatic parasites and to bring these neglected parasitic liver diseases to the wider attention of hepatology stakeholders in Europe and around the world.

Evidence of Low Prevalence of Cystic Echinococcosis in the Catanzaro Province, Calabria Region, Italy

Cystic echinococcosis (CE) is one of the neglected tropical diseases recognized by the WHO. Echinococcus granulosus sensu lato affects more than 1 million people worldwide and is responsible for high costs in the healthcare system. A clear knowledge of the prevalence of CE and its clinical characteristics could have an important impact on the approach to its diagnosis and to the public health planning of treatment and control interventions. We performed a prevalence study in four municipalities of Catanzaro Province, South Italy. This area is considered to be at high risk of CE because of ovine breeding. We screened by abdominal ultrasound 2,426 volunteers, four of whom had abdominal CE. Given the need for prevention and control programs for CE in endemic areas of Italy, a detailed mapping of prevalence of CE, to complement data obtained through hospital discharge records, appears imperative.

Two Human Cases of Echinococcus ortleppi Infection in the Lung and Heart in Vietnam

This is a report of 2 cases of human hydatidosis caused by Echinococcus ortleppi in Vietnam. The patients were a 12-year-old male (case 1) having a cyst of 10.0×9.0 cm size in the lung and a 50-year-old female with a 3.0×3.3 cm-sized cyst in the heart. Eosinophilia was 33.7% in the male and 45.8% in the female patient. C-reactive protein was increased to 16.5 mg/L in the male and 18.2 mg/L in the female. Both patients were positive for ELISA at OD=2.5 and 3.1, respectively. Echinococcus protoscolices were collected from the cysts by amniocentesis and surgery. The protoscolices were identified as E. ortleppi by morphology and analysis of mitochondrial NADH dehydrogenase 1 (nad1) gene sequence. Both patients were cured by surgical resection of the hydatid cyst combined with albendazole medication. The E. ortleppi infection in lung is the second report, and the other in the heart is the first in Vietnam.

Species specificity preliminary evaluation of an IL-4-based test for the differential diagnosis of human echinococcosis

The diagnosis of cystic echinococcosis (CE) is based on imaging, while serology is a complementary test of particular use when imaging is inconclusive. Serology has several limitations. Among them, false‐positive results are often obtained in subjects with alveolar echinococcosis (AE), rendering difficult the differential diagnosis. We set up an immune assay based on IL‐4‐specific production after stimulating whole blood with an antigen B (AgB)‐enriched fraction from E granulosus that associates with CE and CE cysts in active stage. We aimed to evaluate potential cross‐reactivity of this test using samples from patients with AE. Twelve patients with AE were recruited; IL‐4 levels ranged from 0 to 0.07 pg/mL. Based on the previously identified cut‐off of 0.39 pg/mL using samples from patients with CE, none of samples from AE patients scored positive. In contrast, almost 80% of samples from AE patients scored positive in serology tests based on different E granulosus‐derived antigenic preparations. Our preliminary data show that this experimental whole‐blood assay has no cross‐reactivity in our cohort of patients with AE, in turn indicating a high specificity of the assay for CE diagnosis. This result supports further work towards the development of improved diagnostic tests for CE.

Severe chest allodynia as an unusual first presentation of hydatid disease: a case report

Background

Cystic echinococcosis (CE) is a worldwide zoonosis and the liver is the most commonly affected organ. Clinical manifestations range from completely asymptomatic cysts to a potential lethal cyst rupture and anaphylaxis.

Case presentation

Severe chest allodynia was an unusual clinical presentation of hepatic cyst rupture in the retroperitoneal space, without any other specific symptoms. CE diagnosis was confirmed by computed tomography scan and magnetic resonance. The patient underwent hepatectomy with complete resolution of the neuropathic pain.

Conclusions

Retroperitoneal hydatid cyst rupture is a rare event and its clinical manifestation may mimic other chest neuropathies.

A T-cell diagnostic test for cystic echinococcosis based on Antigen B peptides

Cystic echinococcosis (CE) immunodiagnosis is still imperfect. We recently set-up a whole-blood test based on the interleukin (IL)-4 response to the native Antigen B (AgB) of Echinococcus granulosus. However, AgB is encoded by a multigene family coding for five putative subunits. Therefore, the aims of this study were to analyse the IL-4 response to peptides spanning the immunodominant regions of the five AgB subunits and to evaluate the accuracy of this assay for CE diagnosis. Peptides corresponding to each subunit were combined into five pools. A pool containing all peptides was also used (total pool). IL-4 evaluated by enzyme-linked immunosorbent assay was significantly higher in patients with CE compared to those without (NO-CE subjects) when whole-blood was stimulated with AgB1 and with the total pool. Moreover, IL-4 levels in response to the total pool were significantly increased in patients with active cysts. Receiver Operator Curve analysis identified a cut-off point of 0.59 pg/mL predicting active cysts diagnosis with 71% sensitivity and 82% specificity in serology-positive CE patients. These data, if confirmed in a larger cohort, offer the opportunity to develop new diagnostic tools for CE based on a standardized source of AgB as the peptides.

Epidemiology and Clinical Features of Hydatid Cyst in Northern Iran from 2005 to 2015

BACKGROUND

Human hydatid disease imposes significant impacts on public health by producing substantial morbidity and mortality in involved communities. This study aimed to evaluate the epidemiology and clinical features of hydatid cyst in northern Iran as a breeding center for the infection.

METHODS

In this cross-sectional study, the hospital records of all hydatidosis-affected patients admitted in three teaching hospitals of Mazandaran Province between Mar 2005-2015 were reviewed. Hydatidosis-relevant demographic characteristics, clinical findings, and laboratory data were collected. The descriptive statistical analysis was performed by SPSS software.

RESULTS

Totally, 79 patients with the mean age of 42.00±23.82 yr were admitted with cystic echinococcosis (CE) diagnosis. Moreover, the highest and the lowest prevalence of CE cases were in age ranges of 50-59 (19.0%) and more than 80 (5.0%) yr, respectively. Male/female ratio was 0.88 (47.0% vs. 53.0%). Majority of the cases were urban residents (54.0%) and had no close contact with animals (58.0%). Nearly, two third of the patients (n=54), the affected organ was liver. The diameter of the cysts was variable from 2 to 15 cm. Most of the patients had a single hydatid cyst. Four patients were diagnosed as secondary hydatid cyst. Medical treatment with antiparasitic agents was done for 47 individuals and in 7 cases; it was the only treatment approach. Percutaneous puncture-aspiration-injection reinjection (PAIR) technique was applied for 6 cases. Sixty-six patients underwent radical surgery. No data was available on eosinophil count or serological tests.

CONCLUSION

CE is approximately prevalent in Iranian population. Development of new diagnostic methods and therapeutic procedures is worthy. Moreover, it is necessary to design and develop a registry and surveillance system by a multidisciplinary team.

The first report of two cases of cystic echinococcosis in the lung by Echinococcus ortleppi infection, in Vietnam

In 2013, two cases of infection by Echinococcus that caused cystic echinococcosis in the lungs were reported. In the first case, there was a cyst of 6 × 7 cm in diameter, and in the second case, there were four cysts of 5 × 6 cm, 4 × 4 cm, 3.5 × 3 cm and 2.5 × 2 cm in diameter, respectively. In both cases, Echinococcus larvae were collected from the cysts. The larvae were identified as Echinococcus ortleppi by morphology and a molecular method (using reduced nicotinamide adenine dinucleotide hydrogenase [NADH] with 99%-100% homology compared with E. ortleppi in GenBank). This is the first time that this species has been found in humans in Vietnam.

Polyfunctional Specific Response to Echinococcus Granulosus Associates to the Biological Activity of the Cysts

BACKGROUND

Cystic echinococcosis (CE) is a complex disease caused by Echinococcus granulosus (E.granulosus), and its immunophatogenesis is still not clearly defined. A peculiar feature of chronic CE is the coexistence of Th1 and Th2 responses. It has been suggested that Th1 cytokines are related to disease resistance, whereas Th2 cytokines are related to disease susceptibility and chronicity. The aim of this study was to evaluate, by multi-parametric flow cytometry (FACS), the presence of CE specific immune signatures.

METHODOLOGY/PRINCIPAL FINDINGS

We enrolled 54 subjects with suspected CE; 42 of them had a confirmed diagnosis, whereas 12 were classified as NO-CE. Based on the ultrasonography images, CE patients were further categorized as being in "active stages" (25) and "inactive stages" (17). The ability of CD4+ T-cells to produce IFN-γ, IL-2, TNF-α, Th2 cytokines or IL-10 was assessed by FACS on antigen-specific T-cells after overnight stimulation with Antigen B (AgB) of E.granulosus. Cytokine profiles were evaluated in all the enrolled subjects. The results show that none of the NO-CE subjects had a detectable AgB-specific response. Among the CE patients, the frequency and proportions of AgB-specific CD4+ T-cells producing IL-2+TNF-α+Th2+ or TNF-α+Th2+ were significantly increased in the "active stages" group compared to the "inactive stages" group. Moreover, an increased proportion of the total polyfunctional subsets, as triple-and double-functional CD4 T-cells, was found in CE patients with active disease. The response to the mitogen, used as a control stimulus to evaluate the immune competence status, was characterized by the same cytokine subsets in all the subjects enrolled, independent of CE.

CONCLUSIONS

We demonstrate, for the first time to our knowledge, that polyfunctional T-cell subsets as IL-2+TNF-α+Th2+ triple-positive and TNF-α+Th2+ double-positive specific T-cells associate with cyst biological activity. These results contribute to increase knowledge of CE immunophatogenesis and the disease outcome in terms of control and persistence.

Epidemiology of Tropical Neglected Diseases in Ecuador in the Last 20 Years

Background

Tropical and zoonotic diseases are major problems in developing countries like Ecuador. Poorly designed houses, the high proportion of isolated indigenous population and under developed infrastructure represent a fertile environment for vectors to proliferate. Control campaigns in Ecuador over the years have had varying success, depending on the disease and vectors targeted.

Aims

In our study we analyse the current situation of some neglected diseases in Ecuador and the efficiency of the control campaigns (by measuring changes in numbers of cases reported) that the Ecuadorian government has been running to limit the spread of these infectious and parasitic diseases.

Results

Our study reveals that Brucellosis, Chagas Disease, Rabies and Onchocerciasis have been controlled, but small outbreaks are still detected in endemic areas. Leptospirosis and Echinococcosis have been increasing steadily in recent years in Ecuador since the first records. The same increase has been reported world-wide also. Better diagnosis has resulted in a higher number of cases being identified, particularly with regard to the linking of outdoor activities and contact with farm animals as contributing vectors. Improvements in diagnosis are due to regular professional training, implementation of automatized systems, establishing diagnosis protocols and the creation of an epidemiological vigilance network that acts as soon as a case is reported.

Conclusion

Control campaigns performed in Ecuador have been successful in recent years, although natural phenomena limit their efficiency. Leptospirosis and Echinococcosis infections remain a growing problem in Ecuador as it is worldwide.

The Italian registry of cystic echinococcosis (RIEC): the first prospective registry with a European future

Cystic echinococcosis (CE), a worldwide zoonosis, is highly endemic in southern and eastern Europe. Its actual prevalence is unknown due to the lack of efficient reporting systems designed to take into account the particular features of the disease. Neglect of CE makes diagnosis and clinical management difficult outside referral centres, with inconsistencies in clinical practice and often unnecessary procedures carried out that have associated risks and costs. The Italian registry of CE (RIEC) is a prospective multicentre registry of CE patients seen from January 2012 in Italian health centres; data are voluntarily submitted to the registry. Its aims are to show the prevalence of CE in Italy, bring the importance of this infection to the attention of health authorities, encourage public health policies towards its control, and stimulate biological, epidemiological and clinical research on CE. From January 2012 to February 2014, a total 346 patients were enrolled in 11 centres, outnumbering national reports of many CE-endemic European countries. We discuss preliminary data and challenges of the RIEC, template for the European registry of CE, which has been implemented within the Seventh Framework Programme project HERACLES (Human cystic Echinococcosis ReseArch in CentraL and Eastern Societies) since September 2014.

IL-4 specific-response in whole blood associates with human Cystic Echinococcosis and cyst activity

OBJECTIVES

Human Cystic Echinococcosis (CE) is estimated in 2-3 million global cases. CE diagnosis and clinical management are based on imaging and serology, which lacks sensitivity and does not provide cyst stage information. This study aimed to evaluate tools for improving diagnosis by analysing the Interleukin (IL)-4-response to Antigen B (AgB) of Echinococcus granulosus.

METHODS

Whole blood (WB) and peripheral blood mononuclear cells were stimulated with AgB. IL-4 levels were measured by enzyme-linked immunosorbent assay.

RESULTS

WB 1-day stimulation resulted the best experimental condition for evaluating AgB IL-4-response. IL-4 levels were significantly higher in CE patients than healthy donors (p ≤ 0.0001). A ROC analysis showed significant area under the curve (AUC) results (AUC, 0.85; p = 0.0001) identifying an IL-4 level cut-off point ≥0.39 pg/mL which predicted CE with 71.4% sensitivity and 93.3% specificity. Moreover, we found that IL-4 levels were significantly increased in patients with active cysts compared to those with inactive cysts (p ≤ 0.0001). ROC analysis showed significant AUC results (0.94; p = 0.0001) with a cut-off point of 4.6 pg/mL which predicted active cysts with 84.6% sensitivity and 92% specificity.

CONCLUSIONS

We found immunological correlates associated with CE and biological cyst activity.

A Neglected Zoonosis in Albania: why Echinococcosis is Becoming a Surgeon's Exclusivity?

Echinococcosis is an endemic zoonosis in the Mediterranean area, with Albania interested actually to a level that is becoming a public health concern. Authors describe preliminary data from the only tertiary (university) medical facility of Albania, positioned in the capital of the country (Tirana), with 333 new cases diagnosed and treated during the period 2005 - 2011. Out of all these 333 new cases an impressive majority of 91% had a surgical treatment right from the first admission, rendering the disease almost a surgical exclusivity. Even more, 80% of all patients from the study group were hospitalized straightforwardly in surgical wards, with options of surgical intervention's percentages outrunning figures from other sources and authors of the same geographical area. Such a situation, together with a very important level of patients' origin from highly urbanized areas such as those of the capital, suggest the necessity of well-organized interventions, among which might be the mandatory notification of all human cases with Echinococcus infection.