Treatment response of cystic echinococcosis to benzimidazoles: a systematic review. PLoS Negl Trop Dis. 2009;3:e524. [PMID: 19787039 PMCID: PMC2745697 DOI: 10.1371/journal.pntd.0000524]

Extracts and Terpenoids from Stevia Species as Potential Anthelmintics for Neglected Tropical Diseases Caused by Cestode Parasites

Cestodes are etiological agents of neglected diseases such as echinococcosis and cysticercosis, which are major public health problems. Antiparasitic treatment relies on a small number of approved drugs, which are often only partially effective, poorly tolerated and require prolonged administration. Thus, the discovery of novel potential treatments is critical. The Stevia genus (Asteraceae) includes species that are recognized as a source of bioactive compounds, with many species associated with medicinal uses. In this study, the cestocidal activity of four South American Stevia species that previously showed antiprotozoal activity was analyzed using a motility assay on the laboratory cestode model, Mesocestoides vogae. The four Stevia extracts showed cestocidal activity, with S. alpina var. alpina as the most active. The sesquiterpene lactones estafietin and eupatoriopicrin were purified from S. alpina var. alpina and S. maimarensis, respectively, and tested on M. vogae. Estafietin showed cestocidal activity, inhibiting parasite viability in a dose-dependent manner, even from the first day of incubation. Consistent with the motility effects, the extract of S. alpina var. alpina and estafietin induced marked alterations in the morphology of the parasite. The results of this report show that Stevia species represent a source of new molecules with potential for the treatment of neglected tropical diseases caused by cestodes.

Follow up study of symptomatic human cystic echinococcosis treatment with albendazole and praziquantel, in Uruguay

BACKGROUND

Cystic echinococcosis (CE) is a chronic disease considered a neglected one. Cystic echinococcosis is endemic in Uruguay and the region. Surgery, using various technical approaches, has the potential to safely remove the cyst(s) and lead to a complete cure in a high number of patients with simple forms of CE. However, surgery may be impractical in patients with multiple cysts in several organs, high surgical risk, or in patients with previous multiple surgeries. In these cases, the pharmacological treatment with the benzimidazolic drug Albendazole (ABZ) alone or combined with Praziquantel (PZQ), has been promising as the best choice to achieve improvement or cure.

METHODS

In this study, we analyze the results obtained on the anti-parasitic treatment of 43 patients diagnosed with CE between the years 2003 and 2020. Patients were treated before and/or after surgery with ABZ or the combination ABZ/PZQ. The standardize protocol of the anti-parasitic drug treatment before surgery was 7 days, 15 days or 1 month depending on the urgency and availability of the surgical procedure. All cases that involved confirmed locations on lungs underwent immediate surgery with minimal pre-treatment when possible. After surgery, the standardize protocol of anti-parasitic drug treatment consisted of six cycles of 30 days each and resting intervals of 15 days in between. ABZ was used in all cases, administered orally, twice daily, at a total dosage of 15 mg/kg/day, with food high in fat content for improved absorption. The follow up was carried out according to WHO-IWGE guidelines for 5 years.

RESULTS

Of the 43 patients fourteen were ≤ 15 years of age and had a differentiated pre-surgical treatment. From the ≥ 16 years of age, 36 completed the treatments and the 5 years follow up. Four patients changed geographical locations, without a forwarding contact, after the post-surgery treatment. No patient died during the study. Of the 36 patients that completed the study, 32 were treated only with ABZ; 93.75% achieved treatment success as determined by improvement or cure, and 6.25% treatment failure determined by no change or worsening. The last four patients received the ABZ/PZQ combination therapy and achieved 100% treatment success.

CONCLUSION

The pharmacological treatment resulted in a good option not only as palliative but also as potentially curative. The main relevance of its use was in cases with previous multiple surgeries or surgeries with potential life-threatening complications due to the number and location of cysts and concurrent comorbidities. A follow-up of at least 5 years would be recommended to assure remission and control of the transmission. More randomized trials are needed to provide clear clinical evidence of different pharmacological treatments for CE.

Treatment of uncomplicated hepatic cystic echinococcosis (hydatid disease)

BACKGROUND

Cystic echinococcosis is a parasitic infection mainly impacting people living in low- and middle-income countries. Infection may lead to cyst development within organs, pain, non-specific symptoms or complications including abscesses and cyst rupture. Treatment can be difficult and varies by country. Treatments include oral medication, percutaneous techniques and surgery. One Cochrane review previously assessed the benefits and harms of percutaneous treatment compared with other treatments. However, evidence for oral medication, percutaneous techniques and surgery in specific cyst stages has not been systematically investigated and the optimal choice remains uncertain.

OBJECTIVES

To assess the benefits and harms of medication, percutaneous and surgical interventions for treating uncomplicated hepatic cystic echinococcosis.

SEARCH METHODS

We searched CENTRAL, MEDLINE, two other databases and two trial registries to 4 May 2023. We searched the reference lists of included studies, and contacted experts and researchers in the field for relevant studies.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) in people with a diagnosis of uncomplicated hepatic cystic echinococcosis of World Health Organization (WHO) cyst stage CE1, CE2, CE3a or CE3b comparing either oral medication (albendazole) to albendazole plus percutaneous interventions, or to surgery plus albendazole. Studies comparing praziquantel plus albendazole to albendazole alone prior to or following an invasive intervention (surgery or percutaneous treatment) were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were symptom improvement, recurrence, inactive cyst at 12 months and all-cause mortality at 30 days. Our secondary outcomes were development of secondary echinococcosis, complications of treatment and duration of hospital stay. We used GRADE to assess the certainty of evidence.

MAIN RESULTS

We included three RCTs with 180 adults and children with hepatic cystic echinococcosis. Two studies enrolled people aged 5 to 72 years, and one study enrolled children aged 6 to 14 years. One study compared standard catheterization plus albendazole with puncture, aspiration, injection and re-aspiration (PAIR) plus albendazole, and two studies compared laparoscopic surgery plus albendazole with open surgery plus albendazole. The three RCTs were published between 2020 and 2022 and conducted in India, Pakistan and Turkey. There were no other comparisons. Standard catheterization plus albendazole versus PAIR plus albendazole The cyst stages were CE1 and CE3a. The evidence is very uncertain about the effect of standard catheterization plus albendazole compared with PAIR plus albendazole on cyst recurrence (risk ratio (RR) 3.67, 95% confidence interval (CI) 0.16 to 84.66; 1 study, 38 participants; very low-certainty evidence). The evidence is very uncertain about the effects of standard catheterization plus albendazole on 30-day all-cause mortality and development of secondary echinococcosis compared to open surgery plus albendazole. There were no cases of mortality at 30 days or secondary echinococcosis (1 study, 38 participants; very low-certainty evidence). Major complications were reported by cyst and not by participant. Standard catheterization plus albendazole may increase major cyst complications compared with PAIR plus albendazole, but the evidence is very uncertain (RR 10.74, 95% CI 1.39 to 82.67; 1 study, 53 cysts; very low-certainty evidence). Standard catheterization plus albendazole may make little to no difference on minor complications compared with PAIR plus albendazole, but the evidence is very uncertain (RR 1.03, 95% CI 0.60 to 1.77; 1 study, 38 participants; very low-certainty evidence). Standard catheterization plus albendazole may increase the median duration of hospital stay compared with PAIR plus albendazole, but the evidence is very uncertain (4 (range 1 to 52) days versus 1 (range 1 to 15) days; 1 study, 38 participants; very low-certainty evidence). Symptom improvement and inactive cysts at 12 months were not reported. Laparoscopic surgery plus albendazole versus open surgery plus albendazole The cyst stages were CE1, CE2, CE3a and CE3b. The evidence is very uncertain about the effect of laparoscopic surgery plus albendazole on cyst recurrence in participants with CE2 and CE3b cysts compared to open surgery plus albendazole (RR 3.00, 95% CI 0.13 to 71.56; 1 study, 82 participants; very low-certainty evidence). The second study involving 60 participants with CE1, CE2 or CE3a cysts reported no recurrence in either group. The evidence is very uncertain about the effect of laparoscopic surgery plus albendazole on 30-day all-cause mortality in participants with CE1, CE2, CE3a or CE3b cysts compared to open surgery plus albendazole. There was no mortality in either group (2 studies, 142 participants; very low-certainty evidence). The evidence is very uncertain about the effect of laparoscopic surgery plus albendazole on major complications in participants with CE1, CE2, CE3a or CE3b cysts compared to open surgery plus albendazole (RR 0.50, 95% CI 0.13 to 1.92; 2 studies, 142 participants; very low-certainty evidence). Laparoscopic surgery plus albendazole may lead to slightly fewer minor complications in participants with CE1, CE2, CE3a or CE3b cysts compared to open surgery plus albendazole (RR 0.13, 95% CI 0.02 to 0.98; 2 studies, 142 participants; low-certainty evidence). Laparoscopic surgery plus albendazole may reduce the duration of hospital stay compared with open surgery plus albendazole (mean difference (MD) -1.90 days, 95% CI -2.99 to -0.82; 2 studies, 142 participants; low-certainty evidence). Symptom improvement, inactive cyst at 12 months and development of secondary echinococcosis were not reported.

AUTHORS' CONCLUSIONS

Percutaneous and surgical interventions combined with albendazole can be used to treat uncomplicated hepatic cystic echinococcosis; however, there is a scarcity of randomised evidence directly comparing these interventions. There is very low-certainty evidence to indicate that standard catheterization plus albendazole may lead to fewer cases of recurrence, more major complications and similar complication rates compared to PAIR plus albendazole in adults and children with CE1 and CE3a cysts. There is very low-certainty evidence to indicate that laparoscopic surgery plus albendazole may result in fewer cases of recurrence or fewer major complications compared to open surgery plus albendazole in adults and children with CE1, CE2, CE3a and CE3b cysts. Laparoscopic surgery plus albendazole may lead to slightly fewer minor complications. Firm conclusions cannot be drawn due to the limited number of studies, small sample size and lack of events for some outcomes.

ACG Clinical Guideline: Focal Liver Lesions

Focal liver lesions (FLLs) have become an increasingly common finding on abdominal imaging, especially asymptomatic and incidental liver lesions. Gastroenterologists and hepatologists often see these patients in consultation and make recommendations for management of multiple types of liver lesions, including hepatocellular adenoma, focal nodular hyperplasia, hemangioma, and hepatic cystic lesions including polycystic liver disease. Malignancy is important to consider in the differential diagnosis of FLLs, and healthcare providers must be familiar with the diagnosis and management of FLLs. This American College of Gastroenterology practice guideline uses the best evidence available to make diagnosis and management recommendations for the most common FLLs.

Multiclassification of Hepatic Cystic Echinococcosis by Using Multiple Kernel Learning Framework and Ultrasound Images

To properly treat and care for hepatic cystic echinococcosis (HCE), it is essential to make an accurate diagnosis before treatment.

OBJECTIVE

The objective of this study was to assess the diagnostic accuracy of computer-aided diagnosis techniques in classifying HCE ultrasound images into five subtypes.

METHODS

A total of 1820 HCE ultrasound images collected from 967 patients were included in the study. A multi-kernel learning method was developed to learn the texture and depth features of the ultrasound images. Combined kernel functions were built-in Support Vector Machine (MK-SVM) for the classification work. The experimental results were evaluated using five-fold cross-validation. Finally, our approach was compared with three other machine learning algorithms: the decision tree classifier, random forest, and gradient boosting decision tree.

RESULTS

Among all the methods used in the study, the MK-SVM achieved the highest accuracy of 96.6% on the fused feature set.

CONCLUSION

The multi-kernel learning method effectively learns different image features from ultrasound images by utilizing various kernels. The MK-SVM method, which combines the learning of texture features and depth features separately, has significant application value in HCE classification tasks.

Percutaneous drainage and combined praziquantel-albendazole therapy: a novel approach for the treatment of simple echinococcal liver cysts

Cystic echinococcosis (CE) is a worldwide helminthic zoonosis causing serious disease in humans. The WHO Informal Working Group on Echinococcosis recommends a stage-specific treatment approach of hepatic CE that facilitates the decision on what therapy option is most appropriate. Percutaneous aspiration, instillation of a scolicide, e.g., ethanol or hypertonic saline, and subsequent re-aspiration (PAIR) have been advocated for treating medium-size unilocular WHO-stage CE1 cysts. PAIR can pose a risk of toxic cholangitis because of spillage of ethanol in the case of a cysto-biliary fistula or of life-threatening hypernatriaemia when hypertonic saline is used. The purpose of our study is to develop an alternative, safe, minimally invasive method to treat CE1 cysts, avoiding the use of toxic topic scolicides.We opt for percutaneous drainage (PD) in four patients: the intrahepatic drainage catheter is placed under CT-fluoroscopy, intracystic fluid is aspirated, and the viability of intracystic echinococcal protoscolices is assessed microscopically. Oral praziquantel (PZQ) is added to albendazole (ABZ) instead of using topical scolicidals.Protoscolices degenerate within 5 to 10 days after PZQ co-medication at a cumulative dosage of 250 to 335 mg/kg, and the cysts collapse. The cysts degenerate, and no sign of spillage nor relapse is observed in the follow-up time of up to 24 months post-intervention.In conclusion, PD combined with oral PZQ under ABZ coverage is preferable to PAIR in patients with unilocular echinococcal cysts.

Delayed Surgical Treatment of a CE1 Lung Cyst Resulting in Pericystectomy of CE4 Cyst

Lung is the second most common locationof cystic echinococcosis (CE), after the liver. Diagnosis of lung CE is often incidental, and clinical manifestations depend on the location and size of the cyst, the most common being chest pain, shortness of breath, expectoration of fragments of endocyst, and haemoptysis. Surgery is the primary treatment, with a minor role for medical therapy. Delayed diagnosis and treatment may have important consequences. We present a case of lung CE in whichsurgical treatment was delayed due to the first wave of COVID-19. Since surgery could not be performed immediately, the patient was kept on albendazole and the cyst stage moved from CE1 to CE3a, to CE4, eventually requiring a more aggressive pericystectomy instead of the commonly performed endocystectomy. The clinical and imaging characteristics of a rare CE4 cyst of the lung are reported.

Inhibition of AMPK activation in Echinococcus granulosus sensu stricto limits the parasite's glucose metabolism and survival

Cystic echinococcosis (CE) is a zoonotic parasitic disease caused by larvae of the Echinococcus granulosus sensu lato (s.l.) cluster. There is an urgent need to develop new drug targets and drug molecules to treat CE. Adenosine monophosphate (AMP)-activated protein kinase (AMPK), a serine/threonine protein kinase consisting of α, β, and γ subunits, plays a key role in the regulation of energy metabolism. However, the role of AMPK in regulating glucose metabolism in E. granulosus s.l. and its effects on parasite viability is unknown. In this study, we found that targeted knockdown of EgAMPKα or a small-molecule AMPK inhibitor inhibited the viability of E. granulosus sensu stricto (s.s.) and disrupted the ultrastructure. The results of in vivo experiments showed that the AMPK inhibitor had a significant therapeutic effect on E. granulosus s.s.-infected mice and resulted in the loss of cellular structures of the germinal layer. In addition, the inhibition of the EgAMPK/EgGLUT1 pathway limited glucose uptake and glucose metabolism functions in E. granulosus s.s.. Overall, our results suggest that EgAMPK can be a potential drug target for CE and that inhibition of EgAMPK activation is an effective strategy for the treatment of disease.

Diagnosis and management of complicated urogenital schistosomiasis: a systematic review of the literature

BACKGROUND

Currently, there are no standardized guidelines for the diagnosis or management of the complications of urogenital schistosomiasis (UGS). This systematic review of the literature aims to investigate the state of the art in reference to diagnostic approaches and the clinical management of this condition.

METHODS

A systematic review of literature published between January 1990 and January 2021 was conducted in the MEDLINE database, scoping for articles regarding diagnostic means or therapeutic options for the complications of UGS, namely obstructive uropathy, bladder cancer, abortion, ectopic pregnancy, infertility, kidney failure, urolithiasis and the need for invasive procedures. Relevant data were then extracted from the articles deemed eligible according to the inclusion criteria.

MAIN RESULTS

In total, 3052 articles were identified by the research query, of which 167 articles fulfilling inclusion criteria after title/abstract screening and full-text evaluation were included, 35% on both diagnostic and therapeutic aspects, and 51% on diagnosis and 14% on therapy. Ultrasound was the most frequently tool employed for the diagnosis of UGS complications showing a good performance. Concerning the management of hydronephrosis, the majority of available evidences came from community-based studies where universal treatment with praziquantel was used leading to decrease of prevalence of obstructive uropathy. Concerning studies on surgical procedures, laser endoureterotomy followed by stenting was mostly employed in adult patients leading to a crude cure rate of 60% (43 of 71 patients). In the case of severe hydronephrosis, surgery consisting of ureteral re-implantation showed excellent results with a crude cure rate of 98% (157 cured patients of 160 treated). Concerning bladder cancer, data on 93 patients with a clear diagnosis of UGS-related bladder were available reporting a variable and sometime combined approach based on disease stage. Available data on diagnosis and management of abortion, ectopic pregnancy, infertility, kidney failure, urolithiasis and the need for invasive procedures due to UGS are also presented.

CONCLUSIONS

The review produced a complete picture of the diagnostic and therapeutic options currently available for complicated UGS. These results can be useful both for guiding clinicians towards correct management and for tracing the direction of future research.

Albendazole Monotherapy for Pediatric Cystic Echinococcosis: A Case Series

BACKGROUND

Data regarding albendazole monotherapy for cystic echinococcosis (CE) are scarce, especially in children. We report our experience treating CE in children with albendazole monotherapy.

METHODS

A retrospective case series, 2005-2021, assessing factors leading to albendazole monotherapy, demographic, clinical, duration of treatment and follow-up, and outcome (changes in cyst size and side effects) characteristics.

RESULTS

Overall, we identified 18 patients with 31 cysts; liver: 68% (n = 21), lungs: 29% (n = 9), and kidney: 3% (n = 1). Mean cyst size was 4.5 ± 2.6 cm. Reasons for administrating albendazole monotherapy were small (< 4 cm) cyst size (56%), difficulty to operate (33%) and comorbidity (22%). Duration of treatment (range 1-32 months) was 1, 2-3, 4-6 and > 6 months in 28% (n = 5), 39% (n = 7), 17% (n = 3) and 17% (n = 3) of children, respectively. Duration of follow up (range 1-87 months) was 1, 2-3, 4-6 and > 6 months in 11% (n = 2), 11% (n = 2), 17% (n = 3) and 61% (n = 11) of children, respectively. Overall, 83% (n = 15) of patients experienced lack of cyst growth, and 72% (n = 13) experienced reduction in cyst size, while 44% (n = 8) experienced reduction larger than 50%. Full resolution was noted in 22% (n = 4) of patients. In three cases (17%) treatment failure was recorded: one (6%) recurrence, and two cases (11%) of cyst growth. Neutropenia was recorded in two patients (11%), and liver enzymes elevation was recorded in six patients (33%).

CONCLUSIONS

Albendazole monotherapy may be an adequate treatment for selected cases of CE disease in children, especially in CE with small, hepatic cysts.

Green Synthesis, Characterization, and Antiparasitic Effects of Gold Nanoparticles against Echinococcus granulosus Protoscoleces

Echinococcosis, or hydatidosis, is one of the most important zoonotic diseases, which is initiated by the larval stage in the clasts of Echinococcus granulosus. For the treatment of hydatidosis, surgery is still the preferred method and the first line of treatment for symptomatic patients. Unfortunately, most of the scolicidal agents that are injected inside cysts during hydatid cyst surgery have side effects, including leaking out of the cyst and adverse effects on the living tissue of the host, such as necrosis of liver cells, which limits their use. This work was carried out to study the lethal effect of green synthesized gold nanoparticles (Au-NCs) against hydatid cyst protoscoleces. Au-NCs were green synthesized using the Saturja khuzestanica extract. Au-NCs were characterized by UV-visible absorbance assay, electron microscopy analysis, X-ray diffraction (XRD), and Fourier transform infrared (FTIR) spectroscopy. Scolicidal properties of Au-NCs (1-5 mg/mL) were studied against protoscoleces for 10-60 min. The effect of Au-NCs on the expression level of the caspase-3 gene as well as the ultrastructural examination was studied by real-time PCR and scanning electron microscopy (SEM). The cytotoxicity of Au-NCs on hepatocellular carcinoma (HepG₂) and normal embryonic kidney (HEK293) cell lines was also studied by the cell viability assay. The obtained Au-NCs are cubes and have an average size of 20-30 nm. The highest scolicidal efficacy was observed at 5 mg/mL with 100% mortality after 20 min of treatment for hydatid cyst protoscoleces. In ex vivo, Au-NCs required more incubation time, indicating more protoscolicidal effects. Au-NCs markedly upregulated the gene level of caspase-3 in protoscoleces; whereas they changed the ultra-structure of protoscoleces by weakening and disintegrating the cell wall, wrinkles, and protrusions due to the formation of blebs. We showed the effective in vitro and ex vivo scolicidal effects of Au-NCs against hydatid cyst protoscoleces by provoking the apoptosis process of caspase-3 activation and changing the ultrastructure of protoscoleces with no significant cytotoxicity against human normal cells. However, additional studies should be conducted to determine the possible harmful side effects and accurate efficacy.

Eugenol Essential Oil and Nanoemulsion as Antihydatic Agents with Antifibrotic and Immunomodulatory Effects in Cystic Echinococcosis

Conventional scolicidal agents are still unsatisfactory in combating hydatid disease due to their low efficacy and increased drug side effects. Therefore, novel scolicides are required. This study aimed to evaluate the antihydatic and immunomodulatory effects of eugenol essential oil (Eug) and its nanoemulsion (Eug-NE) in cystic echinococcosis (CE). Eug and Eug-NE were administered orally to CE-infected rats and compared to albendazole (ABZ). Hydatid cyst development was assessed based on organ weight and hypertrophy indicators of the infected organs, along with a histopathological and histochemical evaluation of collagen content. The immunomodulatory effects of treatment on CE were evaluated by serum cytokine levels measurement of interferon-γ (IFN-γ) and interleukin (IL)-4 and immunohistochemical (IHC) analysis of signal transducer and activator of transcription 4 (STAT4) and GATA-binding protein 3 (GATA3) markers. Eug-NE was the most effective in reducing the cyst weights, organ weights, and hypertrophy indicators and improving histopathological lesions with reduced collagen content. Eug and Eug-NE significantly increased the IFN-γ levels and decreased the IL-4 levels, while IHC analysis demonstrated a significant reduction in STAT4 and GATA3 expression in all treated groups. Eug and Eug-NE demonstrated antihydatic and preventative effects, with a substantial decrease in liver fibrosis compared to that of ABZ. Besides their promising immunomodulatory effects, their good treatment response suggests their use as alternatives or complementary scolicidal agents in hydatid cyst treatment.

Antiparasitic Effects and Cellular Mechanisms of Formononetin (a Natural Isoflavone) Against Hydatid Cyst Protoscoleces

Background: The chemical agents applied to reduce the complications of hydatid cyst surgery are not free of side effects. Formononetin (FMN), as a natural isoflavone, has been shown to have various therapeutic benefits. Objectives: We studied the in vitro and ex vivo protoscolicidal activity and cellular mechanisms of FMN against hydatid cyst protoscoleces. Methods: Formononetin at 75, 150, and 300 μg/mL was mixed with hydatid cyst protoscoleces (103/mL), and the viability was determined in 5 to 60 min through eosin staining assay. The effect of FMN on caspase-3 activity was tested through a commercial colorimetric protease kit. In addition, the penetrability of the plasma membrane of protoscoleces after exposure to FMN was also determined by the SYTOX assay. Results: Formononetin at 300 μg/mL completely destroyed hydatid cyst protoscoleces after 30 minutes. While at 150 μg/mL, after 60 minutes of contact, 100% of protoscoleces were eliminated. By ex vivo assay, FMN showed its antiparasitic effect for longer periods. Based on these results, FMN at 300 μg/mL concentration completely eliminated hydatid cyst protoscoleces after 60 minutes of exposure. While at a concentration of 150 μg/mL after 60 minutes, 89.6% of protoscoleces were destroyed. Formononetin noticeably increased (P < 0.001) the activity of caspase-3 and the permeability of protoscoleces dose-dependently. Conclusions: Formononetin as a natural product showed promising effects on the protoscoleces of hydatid cysts, indicating that it can be considered a valuable scolicidal agent. However, additional investigations are necessary to evaluate its efficacy in animal models and human subjects.

High potency of magnetic iron oxide nanoparticles covered by piroctone olamine against cystic echinococcosis

This study examined the synthesis of magnetic iron oxide nanoparticles coated with PO (FOMNPsP) and assessed their in vitro, ex vivo, and in vivo effects against cystic echinococcosis. The FOMNPsP was synthesized through the alkalization of iron ions in a deoxygenated form. In vitro and ex vivo protoscolicidal effects of FOMNPsP (100-400 μg/mL) were evaluated on hydatid cyst protoscoleces by the eosin exclusion test for 10-60 min. The effect of FOMNPsP on caspase-3 gene expression and exterior ultra-structural of protoscoleces was assessed by real-time PCR and scanning electron microscopy (SEM), respectively. In vivo effects were assessed by evaluating the number, size, and weight of hydatid cysts among infected mice. The FOMNPsP size was < 55 nm, and the most frequent particles were in the 15-20 nm range. In vitro and ex vivo assays revealed that the highest protoscolicidal effect was observed at 400 µg/mL with 100% lethality. After exposure of protoscoleces with FOMNPsP, the level of gene expression of caspase-3 was dose-dependently increased (p < 0.05). By SEM, the FOMNPsP-treated protoscoleces showed wrinkles and bulges resulting from the formation of blebs. FOMNPsP significantly decreased (p < 0.01) the mean number, size, and weight of the hydatid cyst. FOMNPsP revealed the potent protoscolicidal traits through disrupting the cell wall and apoptosis induction. The results also indicated the promising effect of FOMNPsP in controlling hydatid cysts in the animal model. Although FOMNPsP is safe for human normal cells, more investigations are required to clarify its toxicity and precise mechanisms of action.

Anti-hydatidosis Potential of Sodium Valproate: Evaluating New Therapeutic Potential for Sodium Valproate

Background: Larval stage of Echinococcus granulosus is the main cause of the hydatid cyst. Surgery, which is both aggressive and high-risk, is the most common treatment for this type of cyst. Some medicines, such as mebendazole, are also used as a complementary approach to preventing the recurrence of hydatid cysts. Objectives: Considering the approved antiparasitic effects of sodium valproate (VPA) on some parasites, this research intended to examine the potential of VPA against protoscolices and hydatid walls. Methods: Liver hydatid cysts caused by E. granulosus were collected from a slaughterhouse. Protoscolices and hydatid cysts were exposed to RPMI and dimethyl sulfoxide (DMSO) media (control groups) or different concentrations of VPA and mebendazole in vitro. The viability of protoscolices was evaluated via light microscopy. Also, tissue changes and expression of apoptotic caspase-3 were examined in hydatid cyst walls (HCWs) using histological and immunohistochemical methods, respectively. Results: The mortality rates of VPA-treated and mebendazole-treated protoscolices were dose- and time-dependent. There was a significant difference between the intervention and control groups (P < 0.05). Tissue changes and apoptosis were observed in VPA-treated and mebendazole-treated HCWs. Conclusions: Valproate and mebendazole had significant effects on protoscolices and HCWs, although VPA exerted its effects more rapidly. It seems that VPA can be a new promising protoscolicidal agent and anti-hydatid medicine.

Very low frequency waves as selective probe for Cysticercus tenuicollis, Hydatid cyst and Coenurus cerebralis bio-analysis using single cell-signal recording

Comparative electric behavior of Cysticercus tenuicollis, Hydatid cyst and Coenurus cerebralis at the Very Low Frequency (VLF) region has been studied in detail. This investigation could be significant, because of the economic and public health importance of these parasitic infections in domestic animals. In this report, a single cell signal recording technique has been adopted for comparison using a stainless steel (type: 316, diameter: ~ 300 µm, height: 2.00 cm) two identical electrode system, implanted on the surface of the tested cysts with inter electrode distance of 0.50 cm at a ~ 6.0 giga ohm (GΩ) sealed condition (based on the situation of the implanted electrode system). This process was achieved based on applying electrical interaction between the cysts and the VLF electrical signal. Relative to the measured time domain signal (Current-time diagram), the frequency domain (Current-frequency diagram) was estimated via applying a "Discrete Fast Fourier Transform" (DFFT) algorithm at a fixed time interval (5.0 min). Factors, having important influence on the sensitivity of the detection system including the type (waveform) of different alternating-current (AC) triggering stimulus signals (such as direct current, square wave, triangular, sin (t), etc.), the amplitude, as well as the frequency were optimized automatically through a written "Visual Basic 6" program by one-factor-at-a-time method. Direct applying this AC triggering VLF voltage to the cysts resulted in tracing an AC electrical current vs. time that considered as the time domain wave. However, this electrical current was decayed rapidly versus time during maximum 30.0 s time scale. Applying the DFFT algorithm to the measured time domain, resulted in accessing to the frequency domain at the selected frequency range between 2 and 5 kHz that was considered as the selected frequency for the selective differentiation of C. tenuicollis, Hydatid cyst and C. cerebralis. The related probable mechanism of this process may be attributed to the correlation between the triggering potential and the cyst's electrical surface charge (Zeta potential) as the current source under similar conditions. The results of this study may help to introduce a new detection system for in vivo recognition of the cysts in future.

Benign liver lesions 2022: Guideline for clinical practice of Associazione Italiana Studio del Fegato (AISF), Società Italiana di Radiologia Medica e Interventistica (SIRM), Società Italiana di Chirurgia (SIC), Società Italiana di Ultrasonologia in Medicina e Biologia (SIUMB), Associazione Italiana di Chirurgia Epatobilio-Pancreatica (AICEP), Società Italiana Trapianti d'Organo (SITO), Società Italiana di Anatomia Patologica e Citologia Diagnostica (SIAPEC-IAP) - Part I - Cystic lesions

Benign liver lesions are increasingly diagnosed in daily clinical practice due to the growing use of imaging techniques for the study of the abdomen in patients who have non-specific symptoms and do not have an increased risk of hepatic malignancy. They include simple or parasitic cysts and solid benign tumors which differ widely in terms of prevalence, clinical relevance, symptoms and natural history and often lead to significant clinical problems relating to diagnosis and clinical management. Following the need to have updated guidelines on the management of benign focal liver lesions, the Scientific Societies mainly involved in their management have promoted the drafting of a new dedicated document. This document was drawn up according to the present Italian rules and methodologies necessary to produce clinical, diagnostic, and therapeutic guidelines based on evidence. Here we present the first part of the guideline, concerning the characterization of focal hepatic lesions detected by ultrasound, and the diagnosis and clinical management of simple and parasitic hepatic cysts, and of polycystic liver disease.

Paediatric pulmonary echinococcosis: A neglected disease

Echinococcosis is a worldwide public health problem causing considerable paediatric morbidity and mortality in endemic areas. The presentation of cystic echinococcosis (CE) varies by age. Unlike adults, where hepatic involvement is common, pulmonary CE is the dominant site in the paediatric population. Pulmonary cysts are typically first seen on chest X-ray, either as an incidental finding or following respiratory symptoms after cyst rupture or secondary infection of the cyst. In children, pulmonary cysts have a broad differential diagnosis, and a definitive diagnosis relies on the combination of imaging, serology, and histology. In countries with high infectious burdens from diseases such as acquired immunodeficiency syndrome (AIDS) and tuberculosis (TB), the diagnosis is additionally challenging, as atypical infections are more common than in developed countries. Pulmonary CE is treated with a combination of surgery and chemotherapy.

Surgical treatment of liver hydatid cyst in elderly patients: A propensity score-matching retrospective cohort study

BACKGROUND

Cystic echinococcosis is a clinically complex chronic parasitic disease and a major socioeconomic problem in endemic areas. The safety of liver resection in elderly patients is often debated among medical professionals. We analyzed the postoperative morbidity and mortality rates of elderly patients who underwent surgery at our unit.

METHODS

We retrospectively evaluated patients with liver hydatid cysts which were surgically removed at our unit. Patients were divided into two groups: Group 1 (patients < 70 years), and Group 2 (patients ≥ 70 years). Propensity score matching (PSM) and comparative analyses between groups were performed.

RESULTS

The unmatched cohort consisted of 279 patients (Group 1: 244; Group 2: 35). After PSM, we compared the outcomes for 56 patients from Group 1 to 31 patients from Group 2. A higher rate of severe complications was observed in Group 2 (25.8% vs 5.36%, p = 0.014). No difference was found in the rates of infectious, cardiorespiratory, or hemorrhagic complications between both groups, and in the mortality rate either (0.00% vs 6.45%, p = 0.124).

CONCLUSIONS

Liver surgery in selected elderly patients is safe and practicable. The low postoperative morbidity rate in these patients is acceptable, albeit higher, due to their comorbidities.

Turkish HPB Surgery Association consensus report on hepatic cystic Echinococcosis (HCE)

OBJECTIVES

Cystic Echinococcosis (CE) is one of the important problems of the Eurasian region. We aimed to prepare a consensus report in order to update the treatment approaches of this disease. This study was conducted by Turkish HPB Surgery Association.

MATERIAL AND METHODS

This study was conducted with the modified Delphi model. For this purpose, we conducted a three-stage consensus-building approach.

RESULTS

Six topics, including diagnosis, medical treatment, percutaneous treatment, surgical treatment, management of complications and posttreatment follow-up and recurrences in HCE were discussed.

CONCLUSION

The expert panel made recommendations for every topic.

Antiparasitic activity of Astragalus brachycalyx subsp. brachycalyx extract against hydatid cyst protoscoleces and its effect on induction of apoptosis: an in vitro and ex vivo study

Introduction: This study aims to evaluate in vitro and ex vivo antiparasitic activity of Astragalus brachycalyx subsp. brachycalyx. root chloroformic extract against hydatid cyst protoscoleces and its effect on induction of apoptosis. Methods: Various concentrations of the A. brachycalyx root chloroformic extract (56.25, 112.5, 225, and 450 mg/mL) were treated with hydatid cyst protoscoleces collected from the liver of infected sheep for 5-60minutes in vitro and ex vivo. Eosin exclusion test was also utilized to measure the mortality of protoscoleces. Moreover, the extract effect was assessed on apoptosis induction in hydatid cyst protoscoleces by caspase-3 activity measurement. Results: The mortality rate of protoscoleces in in vitro was 100% after being exposed to 450 and 225 mg/mL of A. brachycalyx extract for 20 and 30 minutes and in ex vivo for 30 and 60 minutes, respectively. Following 48 h treatment of protoscoleces, A. brachycalyx chloroformic extract at the doses of 56.25, 112.5, 225, and 450 mg/mL, dose-dependently motivated the caspase-3 enzyme ranging from 8.8% to 29.6% Conclusion: A. brachycalyx root chloroformic extract had a significant protoscolicidal effect; however, extra surveys are required to assess its efficacy and safety as a promising protoscolicidal agent in clinical settings.

Effects of green synthesized zinc nanoparticles alone and along with albendazole against hydatid cyst protoscoleces

Background

The current investigation aims to green synthesized the zinc nanoparticles (ZnNPs) using Lavandula angustifolia extract by microwave technique and its protoscolicidal effects alone and combined with albendazole against hydatid cyst protoscoleces.

Methods

Different concentrations of the ZnNPs (50, 100, and 200 μg/ml) alone and combined with albendazole (ALZ, 100 μg/ml) were treated with hydatid cyst protoscoleces obtained from liver of infected sheep for 5–60 min in vitro and ex vivo. Eosin exclusion examination was used to assess the viability of protoscoleces. The induction of apoptosis in hydatid cyst protoscoleces was assessed by measurement of the Caspase-3 activity of protoscoleces treated with various concentrations of ZnNPs.

Results

The size of green synthesized ZnNPs was ranged from 30 to 80 nm, most of these nanoparticles were between 50 and 60 nm in size. In vitro, the highest scolicidal effect of ZnNPs was observed at the concentration of 200 μg/ml, where it killed 81.6% of protoscolices. While the combination of these nanoparticles with ALZ, especially at the concentration of 200 μg/ml, completely killed the protoscolices after 10 min’ exposure. However, compared to in vitro assay, the drugs tested took longer to show their protoscolicidal effect.

Conclusion

Based on the obtained results, ZnNPs particularly in combination with albendazole displayed the potent protoscolicidal in vitro and ex vivo as an intraperitoneal model of administration of agents to hydatid cyst treatment; nevertheless, additional investigations are mandatory to evaluate the efficacy and safety Zn NPs as a favorable protoscolicidal agent in clinical setting.

•

ZnNPs particularly in combination with albendazole displayed the relevant protoscolicidal in vitro effects.

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ZnNPs particularly in combination with albendazole displayed the potent protoscolicidal ex vivo effects.

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ZnNPs induced the apoptosis through the activation of caspase-3 enzyme.

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Additional investigations are mandatory to evaluate the its efficacy and safety in clinical setting.

Muscle hydatid diseases: percutaneous treatment with Örmeci technique

Aim: To present results of percutaneous treatment with Örmeci technique for muscle hydatid diseases. Material and Method: Twelve patients (9 male, 3 female) with 16 hydatid cysts (10 CE Type 1, 6 CE Type3B) were treated by percutaneous treatment with Örmeci technique. The percutaneous puncture was performed under sonographic guidance using a 22-gauge Chiba needle as a one-step procedure in CE type 1 and 3A. However, two to six Chiba needles according to size of the cysts were used in different locations at the same time in the cyst of CE type 2, and 3B). For every 1 cm of the long diameter of the cyst lesion, 3cc of fluid from the cysts was aspirated, which was almost the same amount of cc in volume for the CE type 1 and CE type 3A hydatid cysts. A 2cc of pure alcohol (96 %) and 1cc of polidocanol 1% (ethoxysclerol 1%, Kreussler Pharma, Wiesbaden, Germany) were injected into the cysts right after the aspiration of CE type 1 and type 3A, without the aspiration of CE type 2 and 3B, for each centimeter of the long diameter of the cysts. The total amount of pure alcohol and polidocanol were injected equally among the CE type 2 and type 3B cyst’s needles. It was waited for five minutes for all scolexes to be killed and the needle/or needles were taken back. The patients with hydatid disease were followed up mean 34.75 ±14.39 (maximum 65-minimum 15) months. Findings: Fifteen out of 16 hydatid cysts (93.75%) cured. We had two complications of treatment. One patient had an abscess in the cyst after the percutaneous treatment. After the percutaneous drainage, patient was cured well, and he had no symptoms during the follow up. Another patient had torpidity in his leg after the treatment. After three months, he had no symptoms. In Conclusion, Percutaneous treatment with Örmeci technique is outpatient based, successful, safe, repeatable, cheap and It can be used as an alternative treatment in selected patients.

Automatic Classification of Hepatic Cystic Echinococcosis Using Ultrasound Images and Deep Learning

BACKGROUND

Hepatic cystic echinococcosis is the main form of hepatic echinococcosis, which is a life-threatening liver disease caused by parasites that requires a precise diagnosis and proper treatment.

OBJECTIVE

This study focuses on the automatic classification system of five different subtypes of hepatic cystic echinococcosis based on ultrasound images and deep learning algorithms.

METHODS

Three popular deep convolutional neural networks (VGG19, Inception-v3, and ResNet18) with and without pretrained weights were selected to test their performance on the classification task, and the experiments were followed by a 5-fold cross-validation process.

RESULTS

A total of 1820 abdominal ultrasound images covering five subtypes of hepatic cystic echinococcosis from 967 patients were used in the study. The classification accuracy for the models with pretrained weights (fine-tuning) ranged from 88.2 to 90.6%. The best accuracy of 90.6% was obtained by VGG19. For comparison, the models without pretrained weights (from scratch) achieved a lower accuracy, ranging from 69.4 to 75.1%.

CONCLUSION

Deep convolutional neural networks with pretrained weights are capable of recognizing different subtypes of hepatic cystic echinococcosis from ultrasound images, which are expected to be applied in the computer-aided diagnosis systems in future work.

Antiparasitic effects of Elettaria cardamomum L. essential oil and its main compounds, 1-8 Cineole alone and in combination with albendazole against Echinococcus granulosus protoscoleces

Background

The present investigation aims to determine the chemical structure and protoscolicidal effects of Elettaria cardamomum L. essential oil (ECEO) and its main compounds 1–8 cineole alone and along with albendazole (ALZ) against Echinococcus granulosus protoscoleces in vitro and ex vivo. We also decided to evaluate some cellular mechanisms such as the apoptotic activity and the permeability of plasma membrane of protoscoleces treated with ECEO and 1–8 cineole.

Methods

Hydatid cyst protoscoleces were divided into seven groups including protoscoleces treated with ECEO 50 µl/mL (T1), protoscoleces treated with ECEO 100 µl/mL (T2), protoscoleces treated with ECEO 200 µl/mL (T3), protoscoleces treated with 1–8 cineole 100 µg/mL (T4), protoscoleces treated with 1–8 cineole 200 µg/mL (T5), protoscoleces treated with 1–8 cineole 100 µg/mL + albendazole 50 µg/mL (T6), and protoscoleces treated with 1–8 cineole 200 µg/mL + albendazole ALZ-50 µg/mL (T7). The viability of protoscoleces were recorded by eosin staining examination. Moreover, the induction of apoptosis and the plasma membrane permeability of the protoscoleces treated with ECEO and 1–8 cineole were evaluated.

Results

The highest protoscolicidal effect of ECEO was observed at the dose of 200 µl/ml (T3). 1,8-Cineole alone and combined with ALZ, particularly at the dose of 200 µg/ml (T5 and T7), destroyed the 100% protoscolices after 10 min incubation. The ECEO (T1-T3) and 1–8 cineole alone (T4 and T5) and in combination with ALZ (T6 and T7) took longer to display their protoscolicidal effect ex vivo. The obtained results of relative fuorescent items exhibited that the protoscoleces incubated with ECEO and 1,8-Cineole, alter the permeability of plasma membrane by Sytox Green with increasing the concentration. The findings revealed exhibited that ECEO and 1,8-Cineole increasingly and dose-dependently induced activation of caspase-3 enzyme ranging from 6.8 to 23.3%.

Conclusion

Our obtained results revealed that ECEO and its main compound, 1,8-Cineole exhibited the potent protoscolicidal in vitro and ex vivo; and if more research is done on their efficacy and toxicity in animal models and even clinical setting, it can be suggested as a protoscolicidal agent to use during hydatid cyst surgery.

Echinococcosis in both heart and lungs, the first case reported in Albania

An 11-year-old male was admitted with cough and fever for the last 4 days and also complained of pain in the right lung for some weeks. The boy did not show any other symptoms and his past medical history was unremarkable as well. The radiologist findings showed an aspect that suggested for echinococcosis.At first, it was realised the heart intervention. About a 2-month period later, the child underwent another cyst removal in lung. He had begun taking albendazole 5 days before the heart intervention. The therapy was continued until the lung intervention and for 12 weeks post-operatively. The patient had an uneventful recovery and after about 4 years.

Advances in the treatment, diagnosis, control and scientific understanding of taeniid cestode parasite infections over the past 50 years

In the past 50 years, enormous progress has been made in the diagnosis, treatment and control of taeniid cestode infections/diseases and in the scientific understanding thereof. Most interest in this group of parasites stems from the serious diseases that they cause in humans. It is through this lens that we summarize here the most important breakthroughs that have made a difference to the treatment of human diseases caused by these parasites, reduction in transmission of the taeniid species associated with human disease, or understanding of the parasites' biology likely to impact diagnosis or treatment in the foreseeable future. Key topics discussed are the introduction of anti-cestode drugs, including benzimidazoles and praziquantel, and the development of new imaging modalities that have transformed the diagnosis and post-treatment monitoring of human echinococcoses and neurocysticercosis. The availability of new anti-cestode drugs for use in dogs and a detailed understanding of the transmission dynamics of Echinococcus granulosus sensu lato have underpinned successful programs that have eliminated cystic echinococcosis in some areas of the world and greatly reduced the incidence of infection in others. Despite these successes, cystic and alveolar echinococcosis and neurocysticercosis continue to be prevalent in many parts of the world, requiring new or renewed efforts to prevent the associated taeniid infections. Major advances made in the development of practical vaccines against E. granulosus and Taenia solium will hopefully assist in this endeavour, as might the understanding of the parasites' biology that have come from an elucidation of the nuclear genomes of each of the most important taeniid species causing human diseases.

In vitro evaluation of albendazole-loaded nanostructured lipid carriers on Echinococcus granulosus microcysts and their prophylactic efficacy on experimental secondary hydatidosis

To enhance the therapeutic effects of albendazole (ABZ) on Echinococcus granulosus protoscoleces and metacestodes, ABZ-loaded nanostructured lipid carriers (ABZ-NLCs) are prepared by the hot high-speed homogenization method. Protoscoleces and microcysts were treated in vitro with free ABZ and ABZ-NLCs (concentrations of 1, 5, and 10 μg/ml), and the corresponding effects were monitored by methylene blue exclusion test and scanning and transmission electron microscopy. Chemoprophylactic treatment was performed on Balb/C mice 1 day before intraperitoneal injection of viable protoscoleces. The drugs were administered daily by intragastric inoculation for a period of 30 days. The prophylactic efficacy was assessed based on the number and weight of cysts developed in treated mice. The ultrastructural alterations in cysts were examined by transmission electron microscopy. After 18 days, all the protoscoleces incubated with 10 μg/ml ABZ-NLCs were killed, while 51.25 ± 4.03% of the protoscoleces incubated with 10 μg/ml free ABZ were still viable. Microcysts treated with ABZ-NLCs underwent degenerative alterations in a shorter time than when free ABZ was applied. The mean weight of the cysts recovered from mice of ABZ-NLCs group was significantly lower than that of the free ABZ group (P < 0.05), yielding prophylactic efficacy of 92.45% and 38.53%, respectively. The cysts treated with ABZ-NLCs showed marked ultrastructural changes in the germinal layer. This study demonstrated that both in vitro and in vivo treatments with ABZ-NLCs are significantly more efficient than treatment with free ABZ against E. granulosus protoscoleces, metacestodes, and prevention of cyst development in mice.

Silybum marianum ethanolic extract: in vitro effects on protoscolices of Echinococcus granulosus G1 strain with emphasis on other Iranian medicinal plants

BACKGROUND

Cystic echinococcosis (CE), is a parasitic zoonosis caused by Echinococcus granulosus (E. granulosus) larvae in liver and lungs of both humans and animals. Surgical intervention is the mainstay for CE treatment, using scolicidal agents that inactivate live protoscolices. This study evaluated the scolicidal effects of Silybum marianum ethanolic extract and its combination with albendazole in vitro for the first time. Moreover, in a literature review, we investigated the effects of a wide range of Iranian medicinal plants on protoscolices of E. granulosus.

METHODS

S. marianum ethanolic extract was prepared and high-performance liquid chromatography (HPLC) analysis was used to establish the proportions of its component compounds in the extract. Cytotoxicity was evaluated in mouse macrophage cells (J774A.1 cell line) using MTT method. Next, the scolicidal activity of the extract alone and combined with albendazole was tested as triplicate at various concentrations incubated for 5, 10, 20, 30, and 60 min. Finally, protoscolex viability was determined using 0.1% eosin as a vital stain. PCR-RFLP and DNA sequencing techniques were used to characterize the genotype of E. granulosus.

RESULTS

HPLC analysis showed that S. marianum ethanolic extract contained mostly silydianin (14.41%), isosilybin A (10.50%), and silychristin (10.46%). The greatest scolicidal effects were obtained with the combination of S. marianum with albendazole (79%), S. marianum ethanolic extract alone (77%) and albendazole (69%), at a concentration of 500 μg/ml for 60 min, respectively (P < 0.05). Molecular analysis showed that all the cysts used were G1 genotype.

CONCLUSION

The data suggest that S. marianum ethanolic extract is a potential scolicide in vitro; however, further investigations are required to determine its efficacy in vivo.

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.

Effects of Zataria multiflora essential oil on the germinative cells of Echinococcus granulosus

Background

Novel and more efficient compounds are urgently required for medical treatment of cystic echinococcosis (CE). Germinative cell culture of Echinococcus granulosus could be used for anti-echinococcosis agent tests and other biological studies on CE. This study was performed to establish an in vitro cell culture model for E. granulosus germinative cells and to evaluate the lethal effect of Zataria multiflora essential oil (ZMEO) on the cultured cells.

Methods

The inner surface of germinal layers of CE cysts was scraped, and the obtained materials were trypsinized to obtain a suspension of single germinative cells. Medium 199 was used as the basic culture medium and was supplemented with fetal bovine serum, 2-mercaptoethanol, l-cysteine, l-glutamine, glucose, sodium pyruvate, hydatid fluid, amphotericin B and antibiotics. The cells were cultured at a concentration of 10⁴ cells/ml of culture medium and incubated at 37 °C. The culture medium was replaced every 7 days. Chemical composition of ZMEO was identified by GC-MS analysis. ZMEO was tested at concentrations of 0.5–8 mg/ml. Viability of the cells was assessed by trypan blue exclusion assay.

Results

A significant increase in the cell number was evident at 20, 30 and 45 days after cultivation. At 45 days of cultivation, the number of cells was approximately five-fold higher than on the first day. In GC-MC analysis, carvacrol, p-cymene, g-terpinene and thymol were found to be the main compounds of ZMEO. The lethal effect of ZMEO on the germinative cells at concentrations of 6, 7 and 8 mg/ml was 100% after 60, 25 and 7 min of exposure, respectively.

Conclusions

At 45 days of cultivation, the cell concentration was suitable for the desired in vitro experiments. A high lethal effect of ZMEO on the germinative cells of E. granulosus may be considered an opportunity for the introduction of a novel, more effective and safer therapeutic agent for treatment of CE using an herbal product.

Graphic abstract

Hydatid disease, hepatic injury and hypertonic saline: a clinical conundrum

Echinococcosis or human hydatid disease is a helminthic infection is caused by Echinococcus species. Classically, cystic echinococcosis is caused by Echinococcus granulosus sensu stricto, E. equinus, E. ortleppi and E. canadensis, though several other species have been implicated in hydatid disease. Echinococcus infection may lead to cystic disease of the liver, lungs and potentially other organs. Here we present a patient who had cystic disease of the lungs and liver. The patient initially experienced right upper quadrant pain and nausea, and later went on to develop a fever, cough and dyspnoea in the setting of hydropneumothorax. CT scan of the chest and abdomen revealed a large fluid collection at the left lung base and a large lobular complex fluid mass within the right lobe of the liver. Echinococcus titres were positive. The patient was commenced on albendazole; however, experienced significant derangement of liver enzymes within the following month. In light of this, the albendazole was ceased, and a hemi-hepatectomy was performed. During the hemi-hepatectomy there was some cyst content spillage, and subsequently a washout with hypertonic saline 3% was performed. This was followed by a course of praziquantel 1200 mg two times per day for 14 days. Repeat CT 6 months later demonstrated no evidence of recurrence.

Characterizing dynamic changes of plasma cell-free Echinococcus granulosus DNA before and after cystic echinococcosis treatment initiation

Over one million people are living with cystic echinococcosis (CE) and alveolar echinococcosis (AE). For CE, long-term albendazole treatment is often needed, which requires regular follow-up. Follow-up is mainly through imaging which is insensitive to subtle changes and subjective to experience. We investigated the changes of Echinococcus granulosus (Eg) cell-free DNA (cfDNA) in plasma of CE patients before and after albendazole treatment to evaluate its potential as an objective marker for treatment follow-up. Plasma samples of nine CE patients were collected before and after treatment. We identified Eg cfDNA from every sample through high-throughput sequencing. Eg cfDNA concentration and fragment length increased significantly after the treatment period. Ultrasound examination before and after the treatment initiation reflected the drug effects to a certain extent, as the cyst size of four patients reduced. Our findings indicated that Eg cfDNA from plasma could be a potential marker in the monitoring of CE treatment.

Tacrolimus, a rapamycin target protein inhibitor, exerts anti-cystic echinococcosis effects both in vitro and in vivo

In view of a growing need for new treatment options for human cystic echinococcosis (CE), we aimed to investigate the efficacy of mTOR pathway inhibitors against CE in vitro and in vivo. Among the seven mTOR inhibitors evaluated, tacrolimus (TAC) showed significant dose- and time-dependent killing of cultured protoscoleces and cysts in vitro. Notably, the oral administration of TAC (4 mg/kg/day) to CE mice model highly effectively reduced both the weight and number of parasitic cysts. Transmission electron microscopy revealed that TAC destroys the ultrastructure of cysts, both in vitro and in vivo. Furthermore, TAC had no significant effect on blood glucose, body weight, liver, or kidney functions in mice. We further observed that the ATP levels and glucose content of cysts reduced upon TAC treatment, indicating that inhibiting mTORC1 activity possibly affects glucose metabolism in the cysts of mice. Based on our experimental data, TAC emerged as a promising anti-cyst drug that efficiently inhibits the growth of cysts.

Application of target repositioning and in silico screening to exploit fatty acid binding proteins (FABPs) from Echinococcus multilocularis as possible drug targets

Fatty acid binding proteins (FABPs) are small intracellular proteins that reversibly bind fatty acids and other hydrophobic ligands. In cestodes, due to their inability to synthesise fatty acids and cholesterol de novo, FABPs, together with other lipid binding proteins, have been proposed as essential, involved in the trafficking and delivery of such lipophilic metabolites. Pharmacological agents that modify specific parasite FABP function may provide control of lipid signalling pathways, inflammatory responses and metabolic regulation that could be of crucial importance for the parasite development and survival. Echinococcus multilocularis and Echinococcus granulosus are, respectively, the causative agents of alveolar and cystic echinococcosis (or hydatidosis). These diseases are included in the World Health Organization's list of priority neglected tropical diseases. Here, we explore the potential of FABPs from cestodes as drug targets. To this end, we have applied a target repurposing approach to identify novel inhibitors of Echinococcus spp. FABPs. An ensemble of computational models was developed and applied in a virtual screening campaign of DrugBank library. 21 hits belonging to the applicability domain of the ensemble models were identified, and 3 of the hits were assayed against purified E. multilocularis FABP, experimentally confirming the model's predictions. Noteworthy, this is to our best knowledge the first report on isolation and purification of such four FABP, for which initial structural and functional characterization is reported here.

A systematic review of medicinal plants used against Echinococcus granulosus

Cystic echinococcosis (CE) is a zoonotic helminthiasis caused by different species of the genus Echinococcus, and is a major economic and public health concern worldwide. Synthetic anthelmintics are most commonly used to control CE, however, prolonged use of these drugs may result in many adverse effects. This study aims to discuss the in vitro/in vivo scolicidal efficacy of different medicinal plants and their components used against Echinococcus granulosus. Google Scholar, ScienceDirect, PubMed and Scopus were used to retrieve the published literature from 2000-2020. A total of 62 published articles met the eligibility criteria and were reviewed. A total of 52 plant species belonging to 22 families have been reported to be evaluated as scolicidal agents against E. granulosus worldwide. Most extensively used medicinal plants against E. granulosus belong to the family Lamiaceae (25.0%) followed by Apiaceae (11.3%). Among various plant parts, leaves (36.0%) were most commonly used. Essential oils of Zataria multiflora and Ferula asafetida at a concentration of 0.02, and 0.06 mg/ml showed 100% in vitro scolicidal activity after 10 min post application, respectively. Z. multiflora also depicted high in vivo efficacy by decreasing weight and size while also causing extensive damage to the germinal layer of the cysts. Plant-based compounds like berberine, thymol, and thymoquinone have shown high efficacy against E. granulosus. These plant species and compounds could be potentially used for the development of an effective drug against E. granulosus, if further investigated for in vivo efficacy, toxicity, and mechanism of drug action in future research.

Evaluation of the efficacy of albendazole sulfoxide (ABZ-SO)-loaded chitosan-PLGA nanoparticles in the treatment of cystic echinococcosis in laboratory mice

Albendazole is known as the drug of choice for medical treatment of cystic echinococcosis (CE). Albendazole sulfoxide (ABZ-SO), as the main active metabolite of albendazole, has low efficacy in the disease due to low water solubility and poor absorptivity. PLGA nanoparticles (NPs) enhance the dissolution of poorly soluble drugs, and chitosan (CS) coating enhances oral drug delivery of NPs. In this study, the efficacy of ABZ-SO-loaded CS-PGLA NPs in the treatment of CE was evaluated in laboratory mice. ABZ-SO-loaded CS-PGLA NPs were prepared by nanoprecipitation and characterized by dynamic light scattering method and scanning electron microscopy. Thirty mice were intraperitoneally infected by 1000 protoscoleces of Echinococcus granulosus. Ten months later, the mice were allocated into 3 groups: groups 1 and 2 were treated with ABZ-SO and ABZ-SO-loaded CS-PGLA NPs, respectively, and the mice in group 3 remained untreated as the control group. The drugs were administered by gavage for 45 days at a daily dose of 10 mg/kg. Finally, all mice were opened and the cysts were collected, counted, weighed, and measured separately. The therapeutic effect of ABZ-SO in the number, weight, and volume of the cysts were not statistically significant compared with those in ABZ-SO-loaded CS-PGLA NPs and the control group. However, the therapeutic effect of ABZ-SO-loaded CS-PGLA NPs in the weight and volume of cysts were statistically significant when compared with that in the control group (p ˂ 0.05). In conclusions, this study revealed that ABZ-SO-loaded CS-PGLA NPs could enhance the therapeutic efficacy of ABZ-SO in the treatment of CE in laboratory mice.

A case for adoption of continuous albendazole treatment regimen for human echinococcal infections

Cystic (CE) and alveolar (AE) echinococcosis are chronic, neglected parasitic diseases burdened by high morbidity and, for AE, by high mortality, if left untreated. CE and AE have a widespread distribution, including Europe. Albendazole (ABZ), a broad-spectrum benzimidazole drug widely used to treat parasitic infections, is the drug of choice for the management of CE and AE, and is parasitostatic on echinococcal metacestodes. In Europe, ABZ is licensed for interrupted “cyclic” treatment, for a maximum of 3 cycles. However, better efficacy with no increased side effects has been shown when the drug is administered continuously and for longer periods. Current international recommendations, on the basis of clinical, pharmacological, and biological studies, recommend continuous administration of ABZ for months to years for the treatment of CE and AE, and this schedule has been widely in use for the past 20 years. However, in Europe this internationally recommended schedule, with the exception of France, is technically “off-label”, and, as such, requires an informed consent by the patient and, in some countries, even precludes the reimbursement of the drug cost. Adding to the very high cost of the drug, frequent “out-of-stock” situation, and packaging format impractical for long therapies, these conditions put patients with CE and AE regularly at risk of treatment discontinuation and disease progression. European regulations envisage variations to marketing authorization, but postauthorization studies should be carried out by the holder of the license of the drug, in the form of randomized controlled trials. While such studies do not seem feasible and would probably not be ethically justified for CE and AE, European regulations envisage other possibilities in particular situations, which apply to CE and AE, but there is limited interest to invest in this perspective. We urge a coordination between stakeholders to find effective and feasible ways to take action to revise the benzimidazole dosage regimens for CE and AE and to ensure a fair, regular, and easy access to the appropriate treatment to those suffering from these serious diseases.

A rare case of coexisting tuberculosis with hydatid disease from North India with review of literature

Coexisting tuberculosis (TB) and hydatid disease in an immunocompetent individual is an extremely rare occurrence. Given the similarities in the clinical manifestations and morbidities of both, specific diagnosis in individuals coinfected with these is difficult. We, hereby present a case of a 17-year-old adolescent man diagnosed to be a coinfection of pulmonary TB with pulmonary and cardiac hydatid disease, with the review of cases having a similar presentation. The coexistence of these infections should be considered in endemic areas. Management can only be done by a multidisciplinary approach including surgical, microbiological, histopathological and radiological facilities. Complete surgical excision of the cyst is the treatment of choice and medical therapy for both aetiologies should be appropriate to achieve cure.

Seltene parasitäre Infektionen der Lunge

Pulmonale parasitäre Infektionen kommen weltweit vor, werden jedoch aufgrund der Seltenheit in Deutschland in den wenigsten Fällen differenzialdiagnostisch in Betracht gezogen. Parasitäre Lungenerkrankungen können unterschiedlichste pulmonale Manifestationen hervorrufen und sollten bei unklaren Befunden oder fehlendem Therapieansprechen differenzialdiagnostisch mit bedacht werden, um diese heilbaren Erkrankungen so früh wie möglich zu erkennen.

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.

The combination of Cytokines and albendazole therapy for prophylaxis and treatment of experimental/hydatid cyst

Albendazole is appropriate chemotherapy for treatment and prophylaxis of cystic echinococcosis (CE). The recent studies show Cytokine therapy could be useful for chronic and progressive diseases, therefore, the use of cytokine in prophylaxis and treatment of hydatidosis could be considerable. The aim of this study is to evaluate the efficacy of interleukin-12 + interferon-gamma, in combination with albendazole for prophylaxis and treatment of CE in Balb/c mice. Albendazole and cytokines were administrated for prophylaxis and treatment in CE. The efficacy of this agents were determined by measuring of size, weight, number of cysts, histology and lymphocyte response. Lymphocyte stimulation index and production of interleukin-12 and interferon-gamma were measured by MTT assay and ELISA respectively. Combination of albendazole and cytokines was very effective for prophylaxis and treatment in experimental CE.

Evaluation of the therapeutic efficacy of albendazole-loaded silver nanoparticles against Echinococcus granulosus infection in experimental mice

The drug of choice for treatment of hydatid disease, albendazole (ABZ) is a poorly water-soluble drug; thus, enhancing its solubility is required. Among metal nanoparticles (NPs), silver (Ag) NPs showed antimicrobial efficacies. Therefore, this study was conducted to evaluate nanosilver particles (Ag NPs) free or combined with albendazole against Echinococcus granulosus infection in vivo. In this study, besides the normal control group (GI) (n = 5), 80 mice were infected with 2000 viable protoscoleces intraperitoneally then divided equally (n = 20) into the infected control (GII), ABZ-treated (GIII), nanosilver-treated (GIV) and ABZ-loaded-Ag NPs-treated (GV) groups. On the 90th post-infection day, treatment was started and continued for 8 weeks then the experiment was terminated. Each mouse was subjected to measurement of hydatid cysts' sizes and weights, serum IFN-γ, liver enzymes; histopathological and transmission electron microscopy studies. In all treated groups, there were significant reductions of hydatid cysts' sizes and weights; however, the highest efficacy rate (63.9%) was detected in group V associated with obvious ultrastructure alterations of the cysts. The liver tissues of group II showed intense granulomatous reactions, congestion, fibrosis, necrosis and steatosis associated with significant increases in serum IFN-γ and liver enzymes. Interestingly, the best antiparasitic effect and the most significant reduction of IFN-γ towards the normal values were found in GV. Moreover, Ag NPs had reduced the toxic effects of ABZ such as necrosis, steatosis and the elevated serum liver enzymes. Therefore, loading ABZ on Ag NPs could be a potential method to improve ABZ efficacy against hydatid disease.

In vitro and in vivo effects of 3-bromopyruvate against Echinococcus metacestodes

While searching for novel anti-echinococcosis drugs, we have been focusing on glycolysis which is relied on by Echinococcus for energy production and intermediates for other metabolic processes. The aim of this study was to investigate the potential therapeutic implication of glycolytic inhibitors on Echinococcus. Our results demonstrate that at an initial concentration of 40 μM, all inhibitors of glycolysis used in the current experiment [3-bromopyruvate (3-BrPA), ornidazole, clorsulon (CLS), sodium oxamate and 2,6-dihydroxynaphthalene (NA-P₂)] show considerable in vitro effects against Echinococcus granulosus protoscoleces and Echinococcus multilocularis metacestodes. Among them, 3-BrPA exhibited the highest activity which was similar to that of nitazoxanide (NTZ) and more efficacious than albendazole (ABZ). The activity of 3-BrPA was dose dependent and resulted in severe ultrastructural destructions, as visualized by electron microscopy. An additional in vivo study in mice infected with E. multilocularis metacestodes indicates a reduction in parasite weight after the twice-weekly treatment of 25 mg/kg 3-BrPA for 6 weeks, compared to that of the untreated control. In particular, in contrast to ABZ, the administration of 25 mg/kg 3-BrPA did not cause toxicity to the liver and kidney in mice. Similarly, at the effective dose against Echinococcus larvae, 3-BrPA showed no significant toxicity to human hepatocytes. Taken together, the results suggest that interfering with the glycolysis of the parasite may be a novel chemotherapeutical option and 3-BrPA, which exhibited a remarkable activity against Echinococcus, may be a promising potential drug against cystic echinococcosis (CE) and alveolar echinococcosis (AE).

Sound Around the World: Ultrasound for Tropical Diseases

Ultrasound for diagnosis and staging of schistosomiasis and echinococcosis have paved the way over the past several decades for the application of ultrasound in tropical diseases. Until recently, the size and cost of ultrasound systems limited the application in low-resource settings. The increase in portable ultrasound systems has given more clinicians access to ultrasound, and clinically based protocols for the care of patients have emerged, such as focused assessment with sonography for HIV/TB and tropical cardiac ultrasound. This article explores the history and current use of ultrasound in these diseases and highlights their application in the care of patients.

Structural and Immunodiagnostic Characterization of Synthetic Antigen B Subunits From Echinococcus granulosus and Their Evaluation as Target Antigens for Cyst Viability Assessment

Background

Several tools have been proposed for serodiagnosis of cystic echinococcosis (CE), but none seems promising for cyst viability assessment. Antigens with stage-specific diagnostic value have been described, but few studies with well-characterized antigens and human serum samples have been performed. Antigen B (AgB) proteoforms hold promise as markers of viability, due to their differential stage-related expression and immunoreactivity.

Methods

Four AgB subunits (AgB1, AgB2, AgB3, AgB4) were synthesized and structurally characterized. Based on the preliminary evaluation of the subunits by western immunoblotting and enzyme-linked immunosorbent assay (ELISA), AgB1 and AgB2 were further tested in two ELISA setups and extensively validated on 422 human serum samples.

Results

All subunits showed a high degree of spontaneous oligomerization. Interacting residues within oligomers were identified, showing that both the N-terminal and C-terminal of each subunit are involved in homo-oligomer contact interfaces. No hetero-oligomer was identified. AgB1 and AgB2 ELISAs revealed different sensitivities relative to cyst stage. Of note, besides high specificity (97.2%), AgB1 revealed a higher sensitivity for active-transitional cysts (100% for CE1, 77.8% for CE2, 81.5% for CE3a, and 86.3% for CE3b) than for inactive cysts (41.7% for CE4 and 11.1% for CE5) and postsurgical patients (44%). Interestingly, 19 of 20 patients with spontaneously inactive cysts and 6 of 9 treated with albendazole >5 years earlier were negative on the AgB1 assay.

Conclusions

The structural characterization of subunits provides insights into the synthetic antigen conformation. The stage-related sensitivity of synthetic AgB1 holds promise as part of a multiantigen setting and deserves further longitudinal evaluation as marker of cyst viability.