Management and outcome of cardiac and endovascular cystic echinococcosis

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

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

Original algorithms for the detection of cardiovascular involvement of neglected tropical diseases

INTRODUCTION

Neglected tropical diseases (NTDs) introduce considerable morbidity and mortality on a global scale, directly impacting over 1 billion individuals as well as their families and communities. Afflicted individuals may have limited access to resources and care in these regions, contributing to a high proportion of chronic, progressive, and systemic disease. The cardiovascular system is at particular risk of demise for several NTDs, yet remains largely unstudied due in part to the lack of robust data collection mechanisms in the most impacted regions.

AREAS COVERED

The present review is a part of the Neglected Tropical Diseases and other Infectious Diseases affecting the Heart (NET-Heart) Project, aiming at summarizing the current knowledge on cardiovascular implications of NTDs and providing diagnostic as well as management recommendations which can be tailored to low-resource settings. The diagnostic and management algorithms of 13 unique NTDs are presented and summarized.

EXPERT OPINION

Recognizing cardiac manifestations of NTDs can significantly alter disease trajectory and all physicians benefit from improved knowledge about NTDs. Great potential exists to advance patient care by improving data collection, communication, and international collaboration.

Cardiac hydatid disease; a systematic review

BACKGROUND AND OBJECTIVES

Human cystic echinococcosis (CE), is a common health problem in low- and middle-income countries. Cardiac involvement is a relatively rare manifestation of Echinococcus infection. This study aims to summarize the evidence regarding the features of cardiac CE.

METHODS

Case series of the patients with cardiac CE, were included in this study. Non-English papers, case reports, reviews, letters, , commentaries, and conference abstracts were not included. A systematic search was conducted in PubMed and EMBASE databases and the risk of bias in the included studies was assessed using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist.

RESULTS

Out of 3985 results of the searches, finally 37 studies were included in this systematic review. Based on available evidence, cardiac involvement is an uncommon but serious presentation of CE which presents with some non-specific signs and symptoms. Dyspnea, chest pain, and palpitation are the most common symptoms of the disease and normal sinus rhythm is the most common Electrocardiogram (ECG) feature. The disease is not associated with high mortality in case of timely diagnosis and appropriate management.

DISCUSSION

Consecutive and complete inclusion of participants, statistical analysis, and appropriate reporting of the demographics were the sources of bias in the included studies. The exclusion of non-English papers was a limitation during the review process.

FUNDING

The research protocol was approved and supported by the Student Research Committee, Tabriz University of Medical Sciences (grant number: 69380).

REGISTRATION

This study was registered in the International prospective register of systematic reviews (PROSPERO ID: CRD42022381204).

Large right ventricular hydatid cyst in a child: a case report

BACKGROUND

Cystic Hydatid disease is a parasitic infection with a worldwide distribution. It is caused by the larval stages of a species of tapeworms known as Echinococcus granulosus. Even in endemic areas; Cardiac involvement by hydatidiosis is very rare and has atypical presentations as well as localization which make it undiagnosed in about 10% of cases. The left ventricle is the most Common chamber involved by the hydatid cyst and isolated involvement of the right ventricle is very rare, especially in children. The aim of the present study was to describe hydatid cardiac cyst of the right ventricle of a child.

CASE PRESENTATION

We present a rare case of an 8 year-old boy, living in a rural area, who was diagnosed with a cardiac hydatid cyst in the right ventricle. He also had multiple pulmonary hydatid cysts and presented with dyspnea, cough and atypical chest pain. The patient underwent surgery for the resection of pulmonary cysts and, subsequently, cardiac hydatid cyst. The outcome was favorable seven weeks after surgery and there was no clinical and echocardiographic recurrence.

CONCLUSION

Cardiac Echinococcosis must be suspected in endemic areas, diagnosed with appropriate imaging techniques, and treated appropriately.

Cardiac Hydatid Cyst: An Uncommon Cause of Complete Atrioventricular Block

Hydatidosis is a zoonosis caused by Echinococcus granulosus, leading to the formation of cysts on involved organs. Cardiac involvement is rare and can cause a wide range of complications secondary to rupture, embolization, or compression. Its diagnosis is challenging, and is generally confirmed through data related to clinical manifestations, environmental exposure, and laboratory and imaging exams. Surgical removal is necessary in most cases, in which an association with antiparasite therapy is recommended. The present article describes a case of a cardiac hydatid cyst associated with a complete atrioventricular block (AVB) in a young adult patient, with the need for a pacemaker implant, an atypical presentation, and scarce reports in the literature.

Precordial pain induced by the isolated cardiac hydatid cyst in interventricular septum: a case report

BACKGROUND

Human hydatid disease occurs after infection with Echinococcus granulosus, mainly involves liver and lung, while hydatid involves heart is infrequent. A great majority of hydatid diseases could be asymptomatic, and incidentally found through examination. Here, we reported a woman who suffered an isolated cardiac hydatid cyst located at the interventricular septum.

CASE PRESENTATION

A 48-year-old woman presented intermittent chest pain was admitted to the hospital. Imaging examination revealed a cyst located at the interventricular septum near the right ventricular apex. Considering medical history, radiological findings and serological results, cardiac hydatid disease was suspected. The cyst was successfully removed, while pathological biopsy confirmed the diagnosis of infection of Echinococcus granulosus. Postoperative course was uneventful, the patient was discharged from hospital without complications.

CONCLUSION

For symptomatic cardiac hydatid cyst, surgical resection is necessary to avoid progression of disease. During surgical procedure, appropriate methods to reduce the potential risk of hydatid cyst metastasis are essential. Besides surgery, combined with regular drug therapy is an effective strategy to prevent reappearance.

Extensive pulmonary artery embolisation caused by cardiac hydatid cyst rupture

This case study is a rare example of cardiac hydatidosis in a high-income country, where a middle-aged man presented with a ruptured right ventricular cyst causing anaphylaxis, pulmonary emboli and dissemination of Echinococcus throughout the lung. He survived the cyst rupture and underwent cardiac surgery but had incomplete resection and experienced progressive cardiopulmonary hydatidosis despite antihelminthic therapy. As a result, he experienced an array of cardiopulmonary sequelae over his lifespan. This case report highlights rare clinical manifestations of hydatid disease and potential complications of its treatment.

Cardiac Echinococcosis Associated with Other Organ Involvement: Report of Two Challenging Cases

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Cardiac echinococcosis is a rare but potentially fatal manifestation of hydatid disease.

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Antiparasitic agents with surgical cyst excision is the treatment of choice.

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Heart team decision-based management is warranted in cases of other organ involvement.

Imported cystic echinococcosis in Spain: a systematic review

BACKGROUND

Cystic echinococcosis (CE) is a zoonosis caused by Echinococcus granulosus (sensu lato). It is a neglected tropical disease with a global distribution, affecting an estimated 2-3 million people globally. Official reporting systems in Spain lack information concerning imported cases and their country of origin.

METHODS

This is a systematic review of the literature that was performed to obtain published cases of immigrant patients diagnosed with CE in Spain.

RESULTS

From the 21 included articles, a total of 84 cases of CE imported into Spain were documented from 1995 to 2018, with an average age of 33.2 years. The main countries of origin of the patients were Morocco with 30 cases (35.7%), Romania with 12 cases (14.3%) and Peru with 8 cases (9.5%). The most involved organ was the liver (28 cases [33.3%]). We found discrepancies between the published cases of imported CE in Spain and those reported by official authorities.

CONCLUSIONS

This review of the literature shows the lack of information and clarity in the mechanisms of CE notification in Spain. The disparity between these systems and the cases documented in the literature highlights a failure or shortcoming of the current reporting system.

Four pathways for hydatid pulmonary embolism

INTRODUCTION

Hydatid pulmonary embolism (HPE) is rare but remains an etiology that needs to be considered and kept in mind, especially in endemic areas, as regards nonthrombotic embolism.

METHODS

Between 2000 and 2014, 10 patients were treated in our department for the presence of hydatid material in the pulmonary arterial circulation. Through these 10 cases, we try to assess the radioclinical characteristics and results of the surgical treatment.

RESULTS

The study included six men and four women, average age 28 years. Discovery of HPE was made following the exploration of cardiorespiratory symptoms in nine cases and was incidental in a single patient. Computed tomography angiography (CTA) of the chest directly visualized the hydatid material in the pulmonary arteries in nine cases. Surgery consisted of an embolectomy under cardiopulmonary bypass in nine cases. This embolectomy was preceded by the treatment of an embolic hydatid cyst (HC) in seven cases (HCs of the right heart chambers in six cases and a liver HC ruptured in the inferior vena cava in one case), whereas for only one patient, who presented a HC pedunculated in the right ventricle and protruding into the pulmonary artery, the cure of the cardiac location was sufficient. Only one patient died on the third postoperative day.

CONCLUSION

Endoluminal hydatid involvement of pulmonary arteries is extremely rare. CTA chest has an important contribution to the positive diagnosis. Treatment is surgical when the patient's condition allows it.

Clinical management of cystic echinococcosis: state of the art and perspectives

PURPOSE OF REVIEW

This review draws attention to patients with cystic echinococcosis migrating from highly endemic to non-endemic countries with limited experience in cystic echinococcosis management, to ultrasound-based cyst staging, and to the WHO cyst classification as a powerful, to date underused tool to triage patients into the four currently available treatment modalities.

RECENT FINDINGS

In non- and low-prevalence countries, cystic echinococcosis is often misclassified. Differential diagnoses, such as simple cysts and other benign and malignant space-occupying lesions, have similar appearances on imaging. Serology is confirmatory but often disappointing due to sensitivity and specificity problems. There is increasing confidence in assigning uncomplicated cystic echinococcosis cysts to the four treatment modalities [drug treatment (benzimidazoles), percutaneous methods, surgery, watch and wait] on the basis of cyst stage (WHO cyst classification), size and location. However, current best practice is still not widely implemented outside cystic echinococcosis treatment centres, and further consolidation is needed by well-designed clinical trials. Recently published long-term follow-up studies have shown that patients with inactive cyst stages CE4 and CE5 benefit, especially since they do not need any treatment at all if they have not received prior benzimidazole or percutaneous therapy. Instead, cysts that have reached cyst stages CE4 and CE5 through drug treatment do need careful follow-up as they often relapse. Surgical procedures in which the cysts are opened and percutaneous approaches require very careful control of cyst content spillage to the peritoneum, pleura and intravascularly to prevent dissemination - a still too often neglected issue with severe consequences for patients.

SUMMARY

Though a neglected disease with predominantly expert-opinion-based treatment strategies, cystic echinococcosis patients can greatly benefit from interdisciplinary management in cystic echinococcosis treatment centres and cyst-stage-based assignment of treatment modalities. Increased suspicion for cystic echinococcosis in migrants from endemic to non-endemic countries is urgently needed at the current level of global mobility.

Cardiac and Pulmonary Cystic Echinococcosis With Massive Obstruction of the Pulmonary Vessel System in a 16-Year-Old Girl

We describe herein the management of a 16-year-old girl with cystic echinococcosis of the right ventricle and massive obstruction of the pulmonary vessel system by parasitic metastatic dissemination. After resection of the cardiac cyst, pulmonary thromboendarterectomy was performed to remove parts of the obstructive parasitic material. The treatment reduced the elevated pulmonary arterial pressure, improving the patient's overall condition.

The Echinococcoses: Diagnosis, Clinical Management and Burden of Disease

The echinococcoses are chronic, parasitic diseases that are acquired after ingestion of infective taeniid tapeworm eggs from certain species of the genus Echinococcus. Cystic echinococcosis (CE) occurs worldwide, whereas, alveolar echinococcosis (AE) is restricted to the northern hemisphere, and neotropical echinococcosis (NE) has only been identified in Central and South America. Clinical manifestations and disease courses vary profoundly for the different species of Echinococcus. CE presents as small to large cysts, and has commonly been referred to as 'hydatid disease', or 'hydatidosis'. A structured stage-specific approach to CE management, based on the World Health Organization (WHO) ultrasound classification of liver cysts, is now recommended. Management options include percutaneous sterilization techniques, surgery, drug treatment, a 'watch-and-wait' approach or combinations thereof. In contrast, clinical manifestations associated with AE resemble those of a 'malignant', silently-progressing liver disease, with local tissue infiltration and metastases. Structured care is important for AE management and includes WHO staging, drug therapy and long-term follow-up for at least a decade. NE presents as polycystic or unicystic disease. Clinical characteristics resemble those of AE, and management needs to be structured accordingly. However, to date, only a few hundreds of cases have been reported in the literature. The echinococcoses are often expensive and complicated to treat, and prospective clinical studies are needed to better inform case management decisions.

Usefulness of bubble study in echocardiographic diagnosis of contained rupture of hydatid cyst in the right ventricular outflow tract

We describe an adult female presenting with dyspnea in whom both transthoracic and transesophageal echocardiography detected a mobile sac-like structure in the right ventricular outflow tract (RVOT) containing a heterogenous echogenic mass. This sac-like structure markedly changed its shape and size during the cardiac cycle. These findings and the fact that the patient lived in a rural area raised the possibility that this was a hydatid cyst. A bubble study using normal saline was useful in detecting a contained rupture of the cyst. Bubble echoes were noted within the sac-like structure but did not penetrate the inner wall of the cyst which contained echogenic material, indicating that the rupture was confined only to the outer layers. At surgery, a 0.5 cm communication was noted between the cyst and the RVOT and pathology confirmed the diagnosis of hydatid cyst.

Helminthosis and eosinophilia in Spain (1990-2015)

The finding of blood eosinophilia in a patient is a relatively frequent reason to refer him/her to a Clinical Department of Infectious Diseases. The doctor usually intends to rule out a parasitic disease in the autochthonous population, travelers or immigrants. It is uncommon for an eosinophilia to be produced by protozoa infection, whereas helminth parasites are more frequently associated with an increase of eosinophil counts in the infected patient. Eosinophilia can be the only abnormal finding, or it could be part of more complex clinical manifestations suffered by the patient. Furthermore, many, but not all, helminth infections are associated with eosinophilia, and the eosinophil level (low, high) differs according to parasite stages, helminth species, and worm co-infections. The purpose of the present article is to carry out a systematic review of cases and case series on helminth infections and eosinophilia reported in Spain from 1990 to 2015, making a distinction between autochthonous and imported (immigrants and travelers) cases, and studying their relationship with immunodepression situations.

Parasitic infections in travelers and immigrants: part II helminths and ectoparasites

Travel and migration contribute to the emergence of certain parasites which may be imported into nonendemic areas. Noncontrolled importation of food products and animals may also contribute to the diagnosis of infections caused by helminths in nonendemic countries. Some helminth infections such as strongyloidiasis may be life-threatening, especially in immunocompromised patients, and outcome depends on correct diagnosis and treatment. Other helminth infections are neglected tropical diseases associated with chronic disease and/or disability. Major challenges concern the development of improved diagnostic techniques, safer and more effective drug therapies and identification of markers of response to treatment. The study of these imported infections in travelers and immigrants may provide opportunities for research which may not be readily available in resource-poor endemic countries. Updated reviews and guidelines are necessary as new data become available. The second part of this review focuses on infections in travelers and immigrants caused by helminths and ectoparasites.

Surgical treatment and outcome of cardiac cystic echinococcosis

OBJECTIVES

Cardiac cystic echinococcosis (CE), or hydatid cyst is exceptionally uncommon. We review the experience of surgical treatment of cardiac CE.

METHODS

Twenty-six patients (11 females; mean age, 28.9 ± 7.6 years) with cardiac CE undergoing surgical treatment from February 1978 to April 2013 were reviewed. The operative methods mainly included puncture-aspiration cystectomy, intact endocyst enucleation and total cyst resection.

RESULTS

Cardiac CE was located in the myocardium in 16 cases, pericardium in 8 and both myocardium and pericardium in 2. There were 21 cases with solitary hydatid cyst including at the left ventricle in 7, right ventricle in 5, right atrium in 2, interventricular septum in 1 and at the pericardium in 6; 5 cases were with multiple cysts. There was no operative mortality. All patients received albendazole postoperatively. The mean follow-up time was 68 ± 21 months (range 7-195 months) except for 4 who were lost to follow-up. There were three recurrences and one late death.

CONCLUSIONS

Cardiac cystic echinococcosis (CE) remains a very infrequent zoonotic infection. Presenting symptoms of cardiac hydatid disease are variable depending on the size, number and location of the cyst. Echocardiography, corroborated with computed tomography or magnetic resonance imaging, affords the best diagnostic and follow-up confirmation. Surgical treatment is associated with a low morbidity and mortality, and the selection of proper technique is very important to completely remove the hydatid cyst and prevent recurrence. Postoperative oral antiparasitic therapy is necessary for a definitive cure.

Echinococcus cysts affecting oromaxillofacial structures--a systematic review

OBJECTIVES

Cystic echinococcosis is a worldwide spread zoonosis and humans become accidental intermediate hosts. Any tissue can be affected. However, oromaxillofacial cystic echinococcosis is very uncommon and has never been studied systematically and no evidence-based treatment recommendations are available. Aim of this paper is to summarize the current knowledge and clinical experience with oromaxillofacial manifestations of cystic echinococcosis.

MATERIALS AND METHODS

PubMed database was accessed with a comprehensive, complex search strategy. Medical Subject Headings terms, wildcard search, truncated search terms and Boolean operators were used. No filters to restrict the results were set. Two evaluators jointly assessed the results in terms of defined criteria.

RESULTS

The search strategy retrieved 538 results in total. After evaluation 83 publications presenting 108 cases on oromaxillofacial cystic echinococcosis were included. Parotid gland, mandibular region and maxillary region were most commonly affected. Median patient age was 22 years (range 2.5 months to 81 years). Surgical treatment was performed in 97 cases.

CONCLUSIONS

In cases of oromaxillofacial cystic echinococcosis a thorough evaluation of the patients for further cysts is essential. Therapeutic treatment options are surgical or minimally invasive intervention and drug treatment with benzimidazoles. The diagnosis can be difficult and often require a multidisciplinary approach.

Intracavitary cardiac hydatid cysts with a high risk of thromboemboli. Invasive nature of cardiac echinococcosis

Hydatid cysts are a serious health problem in many countries that raise farm animals, and they usually involve the liver and lungs. Although cardiac involvement is a rare manifestation of hydatid cyst disease, its early diagnosis and surgical management are crucial. Patients with cardiac hydatidosis may develop acute life-threatening complications secondary to their invasion of surrounding cardiac structures, such as cyst rupture together with systemic and pulmonary dissemination. Therefore, surgical excision is the definitive method of treatment for cardiac hydatid cysts in order to prevent these potential life-threatening complications, even for asymptomatic patients. Herein, we report the case of a 36-year-old man who initially presented with pleuritic chest pain, hemoptysis, and dyspnea. This was followed by the revelation of multiple cardiopericardial hydatid cysts which were discovered via transesophageal echocardiography and multislice computed tomography. In this case, there was a higher risk of cyst rupture and thromboembolism during systemic and pulmonary circulation due to the invasive nature of the cysts which were located in the left atrium as well as between the pulmonary artery and aorta. The patient successfully underwent the removal of the multiple cardiac cysts under cardiopulmonary bypass by taking into account their relationship with the surrounding cardiac structures and the potential risk of local, systemic, and pulmonary dissemination. A pathological evaluation of the surgical specimens confirmed the diagnosis of cardiac echinococcosis and the aggressive nature of the cardiopericardial hydatid cysts by demonstrating their myocardial invasion.