Case studies emphasising the difficulties in the diagnosis and management of alveolar echinococcosis in rural China

Past and Present of Diagnosis of Echinococcosis: A Review (1999-2021)

The larval forms of taeniid cestodes belonging to the genus Echinococcus are the source of the zoonotic infection known as echinococcosis. Alveolar and cystic echinococcosis are caused by Echinococcus multilocularis and Echinococcus granulosus (s. s) respectively. It is endemic in several regions of the world. In this systematic review, we describe diagnosis, and the species (human, canids, livestock, and small rodents) affected by cystic (CE) and alveolar echinococcosis (AE). From 1999 to 2021, we searched the online directory through PubMed, SCOPUS, Web of Science, and google scholar. Among the 37,700 records found in the online databases, 187 publications met our eligibility requirements. The majority of investigations employed a range of diagnostic methods, such as ELISA, imaging, copro-PCR, necropsy or arecoline hydrobromide purgation, morphological cestode confirmation, and fecal sieving/flotation to detect and confirm Echinococcus infection. ELISA was the most commonly used method followed by PCR, and imaging. The research team retrieved data describing the incidence or assessment of the diagnostic test for E. multilocularis in humans (N = 99), canids (N = 63), small ruminants (N = 13), large ruminants (N= 3), camel (N= 2), pigs (N=2) and small mammals (N= 5). This study was conducted to explore the diagnostic tools applied to detect echinococcosis in humans as well as animals in prevalent countries, and to report the characteristic of new diagnostic tests for disease surveillance. This systematic review revealed that ELISA (alone or in combination) was the most common method used for disease diagnosis and diagnostic efficacy and prevalence rate increased when recombinant antigens were used. It is highly recommended to use combination protcols such as serological with molecular and imaging technique to diagnose disease. Our study identified scarcity of data of reporting echinococcosis in humans/ animals in low-income or developing countries particularly central Asian countries. Study reports in small rodents indicate their role in disease dissemination but real situation in these host is not refected due to limited number of studies. Even though echinococcosis affects both public health and the domestic animal sector, therefore, it is important to devise new and strengthe implementation of the existing monitoring, judging, and control measures in this estimate.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Difficulties in diagnosing the alveolar echinococcosis (case report)

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Alveolar echinococcosis is asymptomatic usually and detected an advanced stage.

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Differential diagnosis is difficult due to similarities with tumor and metastasis to the different organs.

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The cystic mass size can be very large.

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The resection and albendazole is beneficial.

Introduction

Alveolar echinococcosis is dangerous parasitic zoonose with the large endemic area. This disease has a high prevalence in Kazakhstan.

Presentation of case

We report on a 45-year woman suffering from alveolar echinococcosis with a huge cystic mass and difficulty of differential diagnosis. She was hospitalized for surgery with primary diagnosis of hydatid disease. The liver carcinoma was suspected during surgery due to the huge size and structure of the mass. This mass was totally removed. The alveolar echinococcosis was confirmed by histopathological examination.

Discussion

Essential features of this case are the large size of the lesion with a dense consistency and the germination of blood vessels, which unusual for alveolar echinococcosis. Total resection and Albendazole therapy was successful for patient, she didn't have a relapse during the follow-up examination.

Conclusion

This report may provide new aspects of visualization of alveolar echinococcosis and highlight the necessity for the upgrade of the diagnosis tactic.

Surgical treatment of extensive hepatic alveolar echinococcosis using a three-dimensional visualization technique combined with allograft blood vessels: A case report

RATIONALE

Hepatic alveolar echinococcosis (HAE) presents a high pathogenicity and case fatality rate. The main treatment for HAE is surgical resection. Giant lesions in the liver and invasion of the pathogen into the retrohepatic inferior vena cava are usually associated with a poor prognosis when radical resection cannot be performed.

PATIENT CONCERNS

A 56-year-old man who underwent hydatidectomy 7 years prior noted a recurrence of HAE. He was subsidized and admitted to our hospital for the purpose of surgical treatment.

DIAGNOSIS

By computed tomography, angiography and three-dimensional (3D) computed tomography reconstruction images, multiple, giant HAE with 75% stenosis was confirmed.

INTERVENTIONS

With the 3D visualization technique, we designed the surgical plan and performed radical resection of the lesions, including the invaded inferior vena cava, and maximized retention of normal liver tissue. The abdominal aorta of an organ donor was used for vascular allograft reconstruction.

OUTCOMES

The patient recovered gradually after the operation. He was followed up for 3 months, and the reconstructed vein patency was good.

LESSONS

The 3D visualization technique combined with a blood vessel allograft allowed us to expand indications for radical resection of extensive HAE.

Portal hypertension as a result of the incomplete surgically treated advanced alveolar echinococcosis: a case description

Background

Infection of Echinococcus multilocularis causes in humans the alveolar echinococcosis. Although the infection has world-wide distribution it is rarely detected. Diagnosis of alveococcosis is difficult because of not typical clinical picture and irregular results of radiological examinations suggesting neoplasmatic process which begins in the liver tissue or in the biliary tracts. The parasitic growth is slow, so the illness is quite often established in late invasion period. Treatment of long-lasting and late diagnosed infection is difficult and requires cooperation of parasitologists together with surgeons to avoid life-threatening organ dysfunction.

Case presentation

We describe a young male patient, diagnosed, according to the radiological, immunological and histological examination results, infection of Echinococcus multilocularis, who was treated with not radical resection of pathologic mass together with persistent albendazole intake. The right hepatectomy was performed. In addition, visible cysts were removed from the left lobe of the liver in nonanatomical resection and suspicious calcified lesions in hepatoduodenal ligament were also removed. After the operation portal hypertension, with splenomegaly and symptoms of the liver cirrhosis occurred (thrombocytopenia, collateral venous circulation, first degree varices oesophagii). The portal hypertension probably could be a result of incomplete surgery due to extended parasitic infection and liver anathomical changes due to performed procedures, because the portal hypertension and it’s further complications had not been observed before the operation.

Conclusions

Echinococcus multilocularis should be taken under consideration in differential diagnosis of irregular lesions within the liver. Lon-lasting invasion could be responsible for the irreversible secondary liver changes such as cirrhosis and portal hypertension. The surgery treatment (treatment of choice) is difficult and it’s results depends on the invasion period the patient is operated on. After the surgery the patient requires careful follow – up, to detect early complications.

Worldwide literature on epidemiology of human alveolar echinococcosis: a systematic review of research published in the twenty-first century

PURPOSE

Human alveolar echinococcosis (AE) is a potentially lethal zoonosis caused by the cestode Echinococcus multilocularis. The aim of this systematic review is to establish a comprehensive global AE literature overview taking into account the epidemiologically relevant AE research of the twenty-first century.

METHODS

We systematically searched the global literature published from 2001 through 2018 via MEDLINE, EMBASE, the Russian databases eLIBRARY.RU, CyberLeninka, the Chinese databases CNKI, VIP, Journals.

RESEARCH

ac.ir (Farsi language-based), Jordan E-Library (Arab language-based) and supplementary Google Scholar, in accordance with the PRISMA guidelines. QGIS software was used for the mapping of the affected countries.

RESULTS

We have listed 154 relevant publications in the final literature synopsis in consideration of our quality assessment. Including non-autochthonous cases, human AE was reported in 36 countries within the northern hemisphere from 2001 to 2018. The first publication of AE in Tajikistan, Pakistan, South Korea, Belgium, the Netherlands, Slovakia, Hungary, Lithuania, Latvia, Slovenia and Morocco occurred in this century; further first cases in Taiwan, Thailand, and Denmark were considered to be non-autochthonous by the authors. The highest total case numbers (n ≥ 100 in a single article) were reported in France, Germany, Switzerland, Poland, and Lithuania, including China and Kyrgyzstan with by far the highest prevalence figures.

CONCLUSIONS

Our paper emphasises the increasing spread of reported cases and the rise in its numbers in the literature of the twenty-first century, especially in western, northern and eastern Europe, as well as in central Asia. Epidemiological studies on human infections are lacking in many parts of the world.

Childhood suffering: hyper endemic echinococcosis in Qinghai-Tibetan primary school students, China

Background

As part of an ongoing program that aims to use early detection and timely treatment to improve the control of echinococcosis, especially in younger age groups, we undertook a series of active surveys among Qinghai-Tibetan children in the Qinghai Province of Northwestern China in 2011 and 2012. The significant outcomes that resulted from this study emphasize the need to draw attention to echinococcosis, both alveolar echinococcosis (AE) and cystic echinococcosis (CE), so that policy development is promoted and suitable avenues for control are identified in the highly endemic areas on the Tibetan Plateau.

Methods

A total of 19 629 primary school students, aged 6–18 years, with a dominant Tibetan background underwent abdominal ultrasound examination, and 86.4% of the compliant students donated 2–5 ml of venous blood for serological tests. All the abnormal ultrasound results were recorded. If identified as echinococcosis, the disease lesion was assessed according to the WHO-Informal Working Group on Echinococcosis (WHO-IWGE) classification for AE and CE. Among the surveyed students, the prevalence by school was compared among geo-locations, sex and age groups. The clinical image presentations were analyzed according to lesion number, size, the location in the liver and the classification stage. Statistical significance was set at P-value < 0.05 for comparisons among groups.

Results

A total of 341 students (1.7%) were identified by ultrasound as having either CE (119, 0.6%) or AE (222, 1.1%). The highest prevalence rates of childhood AE cases occurred in the Tehetu (12.1%) and Moba (11.8%) townships in Dari County. There was a high seropositive rate (37.0%) and a heterogeneous distribution of cases, with a prevalence ranged from 0 to 12.1% for AE and 0–2.9% for CE. Moreover, the seropositive rate ranged from 0.7–45.1% across different schools.

Conclusions

The high prevalence of echinococcosis in Qinghai-Tibetan primary school students reflects a lack of knowledge about Echinococcus spp. transmission. The combination of systematic education for children and regularly performed anthelmintic treatment for dogs could achieve the goal of sustainable hydatidosis control.

Electronic supplementary material

The online version of this article (10.1186/s40249-018-0455-y) contains supplementary material, which is available to authorized users.

Robust phase-retrieval-based X-ray tomography for morphological assessment of early hepatic echinococcosis infection in rats

Propagation-based phase-contrast computed micro-tomography (PPCT) dominates the non-destructive, three-dimensional inner-structure measurement in synchrotron-based biomedical research due to its simple experimental setup. To quantitatively visualize tiny density variations in soft tissues and organs closely related to early pathological morphology, an experimental study of synchrotron-based X-ray PPCT combined with generalized phase and attenuation duality (PAD) phase retrieval was implemented with the hepatic echinococcosis (HE) infection rat model at different stages. We quantitatively analyzed and evaluated the different pathological characterizations of hepatic echinococcosis during the development of this disease via our PAD-based PPCT and especially provided evidence that hepatic alveolar echinococcosis invades the liver tissue and spreads through blood flow systems with abundant blood supply in the early stage. Additionally, the infiltration of tiny vesicles in HE lesions can be clearly observed by our PAD-PPCT technique due to the striking contrast-to-noise ratio (CNR) and mass density resolution, which cannot be found by the medical imaging techniques, such as magnetic resonance imaging (MRI), computed tomography (CT), and ultrasound, in hospitals. The results demonstrated that our PAD-PPCT technique has a great potential for indicating the subtle structural information of pathological changes in soft biomedical specimens, especially helpful for the research of early micro-morphology of diseases.

Hepatic Alveolar Hydatid Cyst: A Brief Review of Published Cases from Iran in the Last 20 Years

CONTEXT

Echinococcus multilocularis is the cause of alveolar hydatid disease, which most commonly involves the liver in more than 90% of cases. This disease is endemic in northern Iran. However, there are very few published cases from Iran. In this article, we will review all of the published cases of hepatic alveolar echinococcosis from Iran regarding all aspects, including clinical, paraclinical, and treatment protocols.

EVIDENCE ACQUISITION

In this brief review, the published cases of hepatic Alveolar Echinococcosis (AE) from Iran were retrieved for review via a search in PubMed, Scopus, Google Scholar, IranMedex, scientific information database (SID), Magiran, and Irandoc (1995 - 2015) using the keywords Echinococcus multilocularis and Iran, Alveolar hydatid cyst and Iran, liver and Alveolar hydatid cyst and Iran, and Hepatic alveolar hydatid cyst and Iran. The following inclusion criteria were employed: 1, articles must be written in English or Farsi; 2, articles must have been published between 1995 and 2015; 3) cases must have been confirmed by pathological diagnosis.

RESULTS

There were 24 published cases of liver-involved alveolar hydatid cyst from Iran. The disease was more common in young- to middle-aged women in northeast Iran. The most common presenting signs and symptoms were abdominal pain with hepatomegaly and liver mass. Most of the patients were treated by surgery and albendazole. The few unresectable liver masses were treated by medical therapy. No liver transplantation for this disease was reported from Iran.

CONCLUSIONS

Hepatic alveolar hydatid cyst should be considered one of the important differential diagnoses of liver masses, especially in endemic areas of the world.

Multiorgan resection with inferior vena cava reconstruction for hepatic alveolar echinococcosis: A case report and literature review

Alveolar echinococcosis (AE) is a life-threatening parasitic disease characterized by its tumor-like growth. Radical operation is deemed the curable method for AE treatment if R0-resection is achievable. We present a 26-year-old AE patient with AE lesions invading the right lobe of the liver, the inferior vena cava, inferior lobe of right lung, the right hemidiaphragm, and the right kidney. On the basis of precise preoperative and intraoperative evaluations, a radical surgery that removed the huge lesion en bloc was performed successfully with skillful surgical techniques. This patient had an uneventful postoperative recovery and a good prognosis. Multiorgan resection is justified and unavoidable in selected patients when AE lesions invade different organs and the main vascular structures.

Application of 3D reconstruction for surgical treatment of hepatic alveolar echinococcosis

AIM: To evaluate the reliability and accuracy of three-dimensional (3D) reconstruction for liver resection in patients with hepatic alveolar echinococcosis (HAE).

METHODS: One-hundred and six consecutive patients with HAE underwent hepatectomy at our hospital between May 2011 and January 2015. Fifty-nine patients underwent preoperative 3D reconstruction and “virtual” 3D liver resection before surgery (Group A). Another 47 patients used conventional imaging methods for preoperative assessment (Group B). Outcomes of hepatectomy were compared between the two groups.

RESULTS: There was no significant difference in preoperative data between the two groups. Compared with patients in Group B, those in Group A had a significantly shorter operation time (227.1 ± 51.4 vs 304.6 ± 88.1 min; P < 0.05), less intraoperative blood loss (308.1 ± 135.4 vs 458.1 ± 175.4 mL; P < 0.05), and lower requirement for intraoperative blood transfusion (186.4 ± 169.6 vs 289.4 ± 199.2 mL; P < 0.05). Estimated resection liver volumes in both groups had good correlation with actual graft weight (Group A: r = 0.978; Group B: r = 0.960). There was a significant higher serum level of albumin in Group A (26.3 ± 5.9 vs 22.6 ± 4.3 g/L, P < 0.05). Other postoperative laboratory parameters (serum levels of aminotransferase and bilirubin; prothrombin time) and duration of postoperative hospital stay were similar. Sixteen complications occurred in Group A and 19 in Group B. All patients were followed for 3-46 (mean, 17.3) mo. There was no recurrence of lesions in Group A, but two recurrences in Group B. There were three deaths: two from cerebrovascular accident, and one from car accident.

CONCLUSION: 3D reconstruction provides comprehensive and precise anatomical information for the liver. It also improves the chance of success and reduces the risk of hepatectomy in HAE.

A Newly Discovered Epidemic Area of Echinococcus multilocularis in West Gansu Province in China

Alveolar echinococcosis (AE) is a lethal parasitic disease. In Gansu Province of China, all AE cases reported in literature were from Zhang and Min Counties, the southern part of the province. Here, we report the discovery of nine AE cases and one cystic echinococcosis (CE) case from Nanfeng Town of Minle County, in the middle of Hexi Corridor in west Gansu Province. The diagnosis of these cases were confirmed by serology, histopathology, computed tomography, B-ultrasound, immunohistochemistry method, DNA polymerase chain reaction and sequencing analysis. Because eight of nine AE cases came from First Zhanglianzhuang (FZLZ) village, we conducted preliminary epidemiological analyses of 730 persons on domestic water, community and ecology such as 356 dogs’ faeces of FZLZ, in comparison with those of other five villages surrounding FZLZ. Our studies indicate that Nanfeng Town of Minle County is a newly discovered focus of AE in China as a CE and AE co-epidemic area. Further research of Echinococcus multilocularis transmission pattern in the area should be carried for prevention of this parasitic disease.

The EEG of tropical encephalopathies

In addition to encountering most of the conditions treated by clinicians in the West, clinicians in the tropics are faced with unique tropical encephalopathies. These are largely but not entirely infectious in nature. Despite the relatively low cost of EEG technology, it remains unavailable in many low-income tropical settings even at the tertiary care level. Where available, the EEG recordings and interpretation are often of unacceptable quality. Nonetheless, there are existing data on the EEG patterns seen in malaria and a number of tropical viral, bacterial, and parasitic infestations.

Immunogenetics of human echinococcosis

Susceptibility and resistance to human Echinococcus infection and disease, although poorly understood, appear to reflect a complex interaction of parasite and host immunological and genetic factors. Disease stage, progression, and prognosis following treatment appear to be strongly influenced by cytokine and antibody profiles, and more recent evidence has suggested an important role of dendritic cells (DCs) and T regulatory cells (Tregs) in immunomodulation. Microarrays have supported these findings, highlighting both known and novel pathways involved in chronic murine disease. Genetic studies to date have been few and with limited success. Advanced genomic approaches, such as genome-wide association studies (GWAS), may provide further insight to identify the relevant pathways involved, thereby facilitating a new approach for the development of new clinical therapies.