Spinal cystic echinococcosis--a systematic analysis and review of the literature: part 1. Epidemiology and anatomy

Challenges and pitfalls in managing lumbosacral hydatid disease: Lessons learned from clinical practice

OBJECTIVE

Lumbosacral hydatid disease (LHD), a rare skeletal parasitic disease that involves the lumbosacral region. In this study, we summarized the diagnostic and therapeutic procedures for patients with LHD to provide insights into managing this rare disease.

METHODS

Between 2000 and 2023, 16 patients diagnosed with LHD were retrospectively analyzed. Each patient's medical records and follow-up details, were carefully assessed. The average follow-up period was 11.25 ± 6.41 years, providing valuable insights into treatment durability and effectiveness.

RESULTS

The diagnosis was confirmed via imaging, serological tests, and pathological examination. The clinical symptoms included lumbago with lower limb numbness (25 %) and urinary and fecal incontinence (25 %). All patients underwent surgery, with an average of 2.6 surgeries per patient. Thirteen (81.25 %) patients experienced recurrence postoperatively.

CONCLUSION

LHD is a severe and complex skeletal parasitic disease with significant diagnostic and therapeutic challenges. Effective management requires a comprehensive strategy involving surgery and additional therapies.

The multifaceted musculoskeletal hydatid disease

Musculoskeletal hydatid disease is rare and can be located anywhere but most commonly the bone and muscles of the spine, pelvis, then the lower limbs. Imaging is essential for its diagnosis, performing the pre-therapeutic assessment, guiding possible percutaneous treatments, and providing post-therapeutic follow-up. Musculoskeletal hydatidosis can take several forms that may suggest other infections and tumors or pseudotumors. MRI and CT are superior for its diagnosis but ultrasound and radiography remain the most accessible examinations in developing countries where this parasitosis is endemic. In this review, we provide an overview of this disease and describe its different imaging patterns in soft tissue and bone involvement that should be sought to support the diagnosis.

Case report: a rare case of intradural and pleural wall cystic echinococcosis

BACKGROUND

Cystic echinococcosis (CE) is prevalent in livestock farming regions around the world. However, it remains relatively rare compared to other infectious diseases. CE typically affects the liver, lungs, brain, and kidneys. Spinal and pleural wall involvement is exceedingly rare. We report a unique case of intradural and pleural wall CE in a young male, successfully treated with surgery and postoperative medication.

CASE PRESENTATION

A 19-year-old Tibetan male from the Qinghai-Tibet Plateau was diagnosed with intradural and pleural wall CE through imaging, serology, and surgical pathology. According to the Dew/Braithwaite & Lees (BL) classification, his condition was an exceptionally rare form of spinal echinococcosis, compounded by an even rarer pleural wall involvement. Prompt surgical intervention and postoperative medication resulted in significant improvement in spinal cord compression symptoms.

CONCLUSIONS

This case highlights the diagnostic and therapeutic challenges of rare CE locations. MRI proved superior to CT in diagnosing bony cystic echinococcosis. Early surgical intervention combined with medication facilitates spinal cord function recovery, providing valuable insights for managing similar cases.

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.

Echinococcoses - A Primer for Radiologists

BACKGROUND

Cystic (CE) and alveolar (AE) echinococcoses are zoonotic parasitoses that may pose diagnostic problems due to their relative rarity in Middle Europe.

METHODS

Based on a recent literature search and the observation of casuistics from a national echinococcosis treatment center, epidemiological, radiological, and therapeutic fundamentals are presented and important differences between AE and CE are discussed.

RESULTS AND CONCLUSION

AE and CE must be regarded as completely different diseases, which differ from each other in every significant aspect. This applies not only to the epidemiological background of the patients but also to the biology of the diseases and their respective imaging features.

KEY POINTS

· AE and CE are very distinct from one another and must be considered separately.. · AE is endemic in Middle Europe and is known as malignant parasitosis due to its destructive growth form.. · CE is primarily seen in Middle Europe in individuals with migration background and has a rather benign character..

CITATION FORMAT

· Weber TF, Mokry T, Stojkovic M. Die Echinokokkosen - Einblicke aus Sicht der Radiologie. Fortschr Röntgenstr 2023; 195: 1106 - 1121.

Advances in diagnosis and management of atypical spinal infections: A comprehensive review

Atypical spinal infections (ASIs) of the spine are a challenging pathology to management with potentially devastating morbidity and mortality. To identify patients with atypical spinal infections, it is important to recognize the often insidious clinical and radiographic presentations, in the setting of indolent and smoldering organism growth. Trending of inflammatory markers, and culturing of organisms, is essential. Once identified, the spinal infection should be treated with antibiotics and possibly various surgical interventions including decompression and possible fusion depending on spine structural integrity and stability. Early diagnosis of ASIs and immediate treatment of debilitating conditions, such as epidural abscess, correlate with fewer neurological deficits and a shorter duration of medical treatment. There have been great advances in surgical interventions and spinal fusion techniques for patients with spinal infection. Overall, ASIs remain a perplexing pathology that could be successfully treated with early diagnosis and immediate, appropriate medical, and surgical management.

Echinococcus granulosus promotes bone resorption by increasing osteoclasts differentiation

Osseous cystic echinococcosis (CE) is a rare disease caused by Echinococcus granulosus, which is characterized by high morbidity, disability, and mortality. However, it is severely neglected due to its mainly regional epidemic. The development of osseous CE is usually accompanied by severe bone erosion and destruction at the site of infection; however, there is a gap in research on the mechanism of this phenomenon. The current treatment for this disease is single-sided, ineffective, and has a high rate of disability and recurrence. Our study investigated the mechanism of bone destruction caused by osseous CE and provided a theoretical basis for basic research and innovative ideas for treating clinical disease. A co-culture system of osteoclast progenitor cells and protoscoleces (PSCs) was established to test the effects of PSCs on osteoclast differentiation. We also created two disease models of spinal and femoral CE, with the highest incidence of osseous CE. We verified the effect of E. granulosus on osteoclasts at the infection site in vivo. The stimulatory effect of E. granulosus on osteoclast formation was confirmed by in vivo and in vitro experiments. This study elucidates the elementary mechanism of bone destruction in osseous CE and fills a gap in the field of basic osseous CE research, which is conducive to treating the disease.

Progress of research on the diagnosis and treatment of bone cystic echinococcosis

Bone cystic echinococcosis (CE) is one of the most complex and dangerous of all echinococcoses. The lack of typical imaging features and clinical manifestations makes diagnosis and treatment of this disease difficult. X-ray and computed tomography (CT) images of bone CE are similar to those of bone cysts, giant-cell bone tumors, and bone metastases, but magnetic resonance imaging (MRI) shows good diagnostic value due to excellent soft-tissue imaging features. Serological tests cannot be used as a definitive diagnostic method for bone CE due to cross-reactivity, which can lead to false-positive or false-negative results. The development of novel antigens can open new frontiers in the diagnosis of the disease. Currently, views conflict on how to diagnose and treat bone CE. Both surgical and pharmacological treatments can be used, but determining which is appropriate is difficult due to the different sites and clinical manifestations of bone CE. Radical resection is not indicated for large-bone injuries, and Pharmacotherapy becomes important. This article reviews the progress of research into the pathogenesis and clinical manifestations of, and diagnostic strategies and treatment options for, bone CE. We aimed to provide a reference for clinical diagnosis and -treatment options.

Cystic echinococcosis of the bone

PURPOSE OF REVIEW

Cystic echinococcosis (CE) has a wide world distribution causing important morbidity. Osseous involvement is present in less than 4% of the CE cases. Its diagnosis and therapeutic management is full of challenges and low grade of evidence.

RECENT FINDINGS

The study summarizes literature evidence on the management of osseous CE with particular emphasis on new data regarding diagnosis and treatment.

SUMMARY

Clinical presentation of osseous CE depends on the skeletal area affected. Diagnosis is mostly based on radiological findings and serology. Recent advances with qPCR on osseous tissue samples seem to be a good option for diagnosis confirmation. Complete resection of the cystic lesion is the only curative option, but it is usually not possible performing palliative surgery and prolonged albendazole intake in most cases. Radiotherapy could be an option, but experience to date is only based on clinical cases.

Surgical outcome and prognostic factors for 39 recurrent spinal hydatid cysts

Background

Cystic bone echinococcosis accounts for 0.5-4% of all reported cases, and 45% occur in the spine. Our aim was to review the clinical and radiological features, surgery, and outcomes for 39 patients with recurrent spinal hydatidosis.

Methods

Thirty-nine reports of patients with recurrent spinal hydatidosis (2011-2020) were followed for an average of 9.28 ± 5.60 months.

Results

Lesions occurred in descending order in the; lumbar (48.7%), thoracic (43.6%), and cervical spine (7.7%). Total cyst resection was achieved in 28 of 39 patients (71.8%). Intraoperative cyst rupture occurred in 13 patients (33.3%). The postoperative American Spinal Injury Association (ASIA) score was "good" in 82% of patients. Those with "poor" postoperative ASIA scores had a 41% incidence of recurrent thoracic hydatid cysts; further, they demonstrated significantly higher recurrence rates if cysts had ruptured intraoperatively (P = 0.001). In addition, laminectomy, subtotal original cyst resection (P < 0.007), and a thoracic location were all significantly associated with higher recurrence rates (P < 0.04).

Conclusion

The majority of patients demonstrated improvement following surgery for cervical hydatid cysts. Notably, those with poor outcomes typically experienced intraoperative ruptures of their thoracic hydatid cysts, contributing to high cyst recurrence rates.

Incidentally diagnosed multiple intradural extramedullary spinal hydatidosis in a young adult: A case report and review of the literature

Key Clinical Message

Although quite rare, vertebral hydatidosis should always be considered as a differential diagnosis for spinal presentations, particularly in endemic areas for echinococcosis.

Abstract

In this paper, we report a rare case of asymptomatic multiple intradural, extramedullary spinal hydatidosis, incidentally diagnosed in a patient with signs and symptoms of a true protruded disc. Although quite rare, vertebral hydatidosis should always be considered as a differential diagnosis for spinal presentations, particularly in endemic areas for echinococcosis.

Vertebral and pelvic echinococcosis in northwestern China

PURPOSE

Echinococcosis remains a major economic and severe public health problem in endemic areas. Bone echinococcosis is rare, and the vertebra and pelvis are the most common sites of echinococcosis involving the skeletal. Because of the clinical severe symptoms and high recurrence rate, it brings excellent trouble to patients.

METHODS

This study retrospectively analyzed the clinical manifestations, laboratory tests, radiological findings, and treatment of 44 patients with vertebral and pelvic echinococcosis during a period of 16 years (2005-2020).

RESULTS

The mean age was 43 years (25 males, 19 females; 19-68 years). The most common symptom was pain, followed by numbness, weakness, activity limitation, and progressive paraparesis. Enzyme-linked immunosorbent assay test (ELISA) results were positive in 18 cases (75%). There are 24 cases of hydatid infection of the spine, 14 hydatid infection of the pelvis, and six hydatid infection of both vertebra and pelvis. The site of infection was 13 (29.5%) thoracic, five (11.4%) lumbar, four (9.1%) lumbosacral, seven (15.9%) sacral, 19 (43.2%) ilium, seven (15.9%) hip, six (13.6%) ischium, five (11.4%) pubis, and two (4.5%) femur, respectively. The imaging findings were cystic dilatancy, septal, and irregular bone destruction. MRI has a special value in showing the relationship between the surrounding tissues and organs of cystic bone echinococcosis. All patients were followed up for at least one year. The mean follow-up time was 3.6 years.

CONCLUSIONS

Even in epidemic areas, the incidence of bone echinococcosis is relatively rare. However, when encountering the vertebral and pelvic destruction, consider bone echinococcosis's possibility, especially for the herdsmen in endemic regions.

Imaging Manifestations and Misdiagnosis Analysis of Six Cases of Bone Hydatid Disease

We retrospectively evaluated the clinical and imaging features of 6 patients with bone hydatid disease confirmed by surgery and pathological examination. Among the 6 patients, 2 were infected with Echinococcosis granulosus metacestode and 4 were infected with E. multilocularis metacestode. The 2 cases with cystic echinococcosis were diagnosed by computed tomographic (CT) examination, and other 4 cases were diagnosed by magnetic resonance (MR) imaging. On the initial evaluation, 1 case each was misdiagnosed as a giant cell tumor or neurogenic tumor, and 2 were misdiagnosed as tuberculosis. The imaging manifestations of bone hydatid disease are complex, but most common findings include expansive osteolytic bone destruction, which may be associated with sclerosing edges or dead bone formation, localized soft tissue masses, and vertebral lesions with wedge-shaped changes and spinal stenosis. Combining imaging findings with the patient's epidemiological history and immunological examinations is of great help in improving the diagnosis and differential diagnosis of bone hydatid disease.

Case Report: Diagnosis of vertebral alveolar echinococcosis upon next-generation sequencing in a suspected tuberculosis

Introduction

Alveolar echinococcosis (AE), caused by larval stages of Echinococcus multilocularis, is a rare zoonotic disease that mainly involves the liver. The diagnosis of extrahepatic AE is usually difficult. Here, we describe a rare case of vertebral alveolar echinococcosis with a suspected history of spinal tuberculosis, diagnosed by metagenomic next-generation sequencing (mNGS).

Case Presentation

A 44-year-old woman presented with repetitive neck and back pain, with a surgical history of suspected spinal tuberculosis. Magnetic resonance imaging (MRI) showed cystic masses in the craniocervical junction region and effusion around lumbar vertebrae. Multiple culture tests were performed to detect tuberculosis and other pathogens through puncture of the effusion and of cerebrospinal fluid, but the results were all negative. Finally, mNGS of the effusion fluid was performed and Echinococcus multilocularis were detected. The results were further confirmed by Sanger sequencing.

Conclusion

This case emphasizes a role of mNGS in the diagnosis of infectious diseases with unknown pathogen. As a newly emerged sensitive and accurate diagnostic strategy, mNGS provides clinicians an opportunity to clarify pathogens in complicated infectious cases, especially in patients with a history of multiple infections.

Disseminated alveolar echinococcosis in a patient diagnosed by metagenomic next-generation sequencing: A case report

Background

Alveolar echinococcosis (AE) is a parasitic zoonosis with high mortality and disability rates. Diverse clinical manifestations and mimicking of differential diagnoses such as tuberculosis and malignancy pose a diagnostic dilemma. With the rapid development of molecular diagnostic techniques in recent years, metagenomic next-generation sequencing (mNGS) has become an attractive approach for the etiological diagnosis of infectious diseases.

Case presentation

we report a case of 51-year-old Chinese Tibetan male presented with 3-year low-back pain and 4-month discomfort in the right upper quadrant of the abdomen. He had been in good health. He was diagnosed with tuberculosis and was given anti-tuberculosis treatment a month prior to the visit, but the symptoms were not relieved. Abdominal computerized tomography (CT) revealed a hypodense lesion with uneven enhancement in the liver, and two ring-enhancing cystic lesions in the right abdominal wall. Lumbar spine enhanced MRI showed lesions of mixed density with uneven enhancement in the L1 vertebra and paraspinal tissue. The pathological results of the liver biopsy revealed parasitic infection and possibly echinococcosis. The metagenomic next-generation sequencing (mNGS) of the puncture fluid of abdominal cysts using Illumina X10 sequencer revealed 585 sequence reads matching Echinococcus multilocularis. Disseminated AE was diagnosed. Albendazole (400 mg, twice daily) was used, and the patient was in stable condition during follow-up.

Conclusions

mNGS may be a useful tool for the diagnosis of AE. The case would help clinicians to improve their diagnostic skills.

Case Report: Imaging-Guided Percutaneous Catheterization and Microwave Ablation of a Bone Hydatid Cyst with Soft-Tissue Component

Cystic echinococcosis (CE) of the bone is a rare disease compared with CE of the viscera, and the most involved bony structures are the spine and the pelvis. Both the diagnosis and the treatment of bone CE are challenging for several reasons. The combination of surgery and antimicrobial therapy is the most common approach, the results are far from adequate. Luckily, percutaneous treatment has appeared on the horizon for bone lesions as a more practical option with fewer drawbacks in light of current reports. This article deals with the successful result of ablation-assisted percutaneous treatment of a bone CE lesion and a soft tissue CE lesion treated by modified catheterization technique in a male patient with left hip pain that was unresponsive to previous surgery for CE.

A Case of Extensive Thoracolumbar Spinal Intradural Cystic Echinococcosis

Spinal cystic echinococcosis (CE) is a rare but devastating form of a neglected parasitic disease caused by the larval stage of the cestode Echinococcus granulosus. CE or hydatid disease, most commonly affects the liver and lungs. Spinal CE occurs in less than 1% of all cases. Patients with cysts confined to the intradural space typically present with neurological impairment due to compression of the spinal cord. We report a case of a 32-year-old woman with unusual, extensive spinal intradural CE, located at the T2 to L5 levels. She was treated with surgical removal of the cystic lesions by laminectomy and instrumentation. Long term oral albendazole was recommended postoperatively. Her status was medically stable at 5-year follow up, but lower limbs paralysis, urinary retention and bowel dysfunction persisted.

Spinal hydatid cyst as cause of neurological injury in a patient from Brazilian amazon region

Echinococcus granulosus infection is the primary cause of spinal hydatidosis. We describe the case of a 22-year-old man from the Brazilian Amazon region with crural spastic paraparesis and back pain. Radiological examinations showed multilocular lesions involving compression of the thoracic spine and rib injury. The patient underwent vertebrectomy with spinal stabilization and thoracoplasty with resectioning of the costal arch. Subsequently, the patient was prescribed oral treatment with albendazole. Marked recovery of the neurological status was achieved. Bone hydatid disease is rare, accounting for 0.5%-0.4% of all hydatid cysts, affecting the spine in 50% of cases. The treatment of choice is surgery accompanied by antiparasitic medication.

Unusual imaging characteristics of thoracic hydatid disease

Abstract Cystic echinococcosis (hydatid disease) is a zoonotic parasitic disease, caused by ingestion of Echinococcus granulosus eggs, that can result in cyst formation anywhere on the body. Hydatid disease is frequently seen in regions where there is human-animal contact and poor socioeconomic development. The prevalence of the disease ranges from 0 to 79 cases/100,000 population. Hydatid cysts are typically found in the liver and lungs, being less common in other parts of the body. Computed tomography or magnetic resonance imaging is often used in order to clarify the sites affected by a hydatid cyst, such as the cranial and thoracic regions, which also facilitates the surgical evaluation and minimizes complications. Although rare, hydatid cysts in atypical locations can provoke unusual complications, with unpredictable findings and symptoms. This essay discusses the radiological aspects of rare thoracic hydatid cysts.

Incurable and refractory spinal cystic echinococcosis: A case report

BACKGROUND

Although the incidence and cure rate of spinal hydatidosis are low, the recurrence rate of spinal hydatidosis is high, and the prognosis of spinal hydatidosis is poor. Therefore, we report a typical case of refractory spinal hydatidosis to increase spine surgeons’ awareness of the disease and reduce misdiagnosis and recurrence.

CASE SUMMARY

A 48-year-old man presented with back pain, significant weight loss, and paralysis of both lower limbs. The patient was misdiagnosed with spinal tuberculosis in an outside hospital. However, spinal magnetic resonance imaging (MRI) showed hyperintense cystic components on T2-weighted images and hypointensity on T1-weighted images. A lobulated, multiocular, honeycomb-appearance, septated cystic mass protruding intraspinally and compressing the spinal cord at segments T8–T9 was present. Paravertebral polycystic lobular lesions presented as a “bunch of grapes”. The ELISA test result for Echinococcus granulosus was positive. Then, a diagnosis of spinal hydatidosis and lung hydatid disease was made, and the patient underwent left transthoracic approach lobectomy, paravertebral lesion debridement, and subtotal vertebrectomy with vertebral body replacement of segments T8 and T9 by a mesh cage. The patient also underwent albendazole chemotherapy before and after surgery. One year after stopping the drug therapy, the patient developed recurrent T5 vertebral lesions and underwent a second subtotal vertebrectomy surgery. The patient is currently in good condition and is receiving long-term medication and follow-up.

CONCLUSION

The MRI feature of a “bunch of grapes” is a typical imaging indication of spinal hydatidosis. Subtotal vertebrectomy is a risk factor for postoperative recurrence. Total spondylectomy makes it possible to cure spinal hydatidosis, but antiparasitic drug therapy is also an important supplementary therapy to multimodal therapy. It is preferable for patients with spinal hydatidosis to receive life-long antiparasitic medication therapy and follow-up.

Multiple debridement of cavity lesions combined with antiparasitic chemotherapy in the treatment of mid or advanced spinal echinococcosis: a retrospective study of 33 patients

OBJECTIVE

The purpose of this study was to evaluate and document the complications and outcomes (bone and functional) of multiple debridement of cavity lesions combined with antiparasitic chemotherapy in the treatment of mid or advanced spinal echinococcosis.

METHODS

From January 2007 to February 2019, the medical records and imaging of all patients with mid or advanced spinal echinococcosis, who were treated by multiple debridement of cavity lesions, were evaluated retrospectively. The Braithwaite and Less classification system of spinal echinococcosis and the Frankel classification system were used to evaluate the results, both preoperatively and postoperatively.

RESULTS

Between January 2007 and February 2019, 33 patients met the criteria and were included in this study, with a mean postoperative follow-up time of 4.9 (1-10) years. They included 18 males (54.5%) and 15 females (45.4%), with a mean age of 41.5 years (range 23-70 years). A satisfactory recovery of lower-limb motor function was found in 32 patients, while 24 patients (72.7%) presented with recurrence of spinal echinococcosis.

CONCLUSIONS

Multiple debridement and spinal cord decompression, combined with antiparasitic chemotherapy after surgery, are effective methods for delaying or preventing disease progression or recurrence. A recurrence of infection is common in most cases. CT and MRI are the preferred methods for diagnosing this disease.

In Vitro and In Vivo Efficacy of Albendazole Chitosan Microspheres with Intensity-Modulated Radiation Therapy in the Treatment of Spinal Echinococcosis

Currently, there is a lack of clinically safe and effective treatment for spinal cystic echinococcosis (CE). Recent studies have shown that albendazole chitosan microspheres (ABZ-CS-MPs) and irradiation have certain anti-abdominal echinococcosis ability, so this study aims to compare the in vitro and in vivo therapeutic effects of ABZ-CS-MPs, intensity-modulated radiation therapy (IMRT), and combination therapy on spinal echinococcosis. First, protoscoleces were processed by different treatments to evaluate their respective antiechinococcosis effects by monitoring the viability change of protoscoleces. Then, the apoptotic status of protoscoleces was evaluated by detecting the changes of mitochondrial membrane potential, the expression of apoptosis proteins, and the ultrastructural alterations of protoscoleces. After that, we constructed a gerbil model of spinal CE and further applied B-ultrasound and magnetic resonance imaging (MRI) technology to assess the size of hydatid in vivo. Finally, the cysts were obtained and weighed to compare the inhibition rate in different groups. The combined therapy increased protoscoleces mortality to over 90% after 18 days, which showed the highest scolicidal effect. Moreover, confocal imaging, expression of apoptotic proteins, and ultrastructural changes of protoscoleces showed the highest apoptotic rate in this group. In vivo, the combination treatment also exhibited the highest cyst inhibition rate (61.4%). In conclusion, our results showed that ABZ-CS-MPs combined with IMRT could be a new treatment option for spinal CE. We also provided a method to evaluate the growth and metastasis of hydatid in animals with B-ultrasound and MRI technologies.

Determining the Frequency of Cystic Echinococcosis among Suspected Cases Referred to Health Centers Southwest Iran, and Post-Treatment Serologic Follow-up

Background:

This study was designed to determine the frequency of hydatidosis in Khuzestan Province, Iran and to evaluate the antibody changes in infected individuals after treatment.

Methods:

Overall, 454 sera were collected from health centers of Khuzestan Province, southern Iran (from 2013 to 2018). Demographic data such as age, gender and history of disease were recorded. Serum samples were investigated for antibody against CE by ELISA using antigen B. Thirty six of cases were followed up after treatment.

Results:

Among the 454 evaluated cases, antibody against CE was detected in 184 (40.52%) including 115 (62.5%) females and 69 (37.5%) males. Age distribution was from 8–97 yr, the highest prevalence of hydatid cyst was observed in age group 40–49 years. Liver was the most infected organ (76.63%). Relapse of CE occurred in 23 of patients. In the majority of patients the antibody decreased, whereas in some cases increased CE antibody observed during post-treatment follow up.

Conclusion:

Current study indicated the high prevalence of hydatidosis and rate of relapse after treatment among suspected patients. Therefore, long periods and regular follow-up of patients after treatment is necessary and for these monitoring, antibody assay can be an appropriate method.

Large multicystic spinal lesion in a young African migrant: a problem of differential diagnosis

We describe a rare case of large, fully cystic spinal schwannoma in a young adult from The Gambia. The initial clinical suspicion was spinal cystic echinococcosis. He came to our attention reporting progressive walking impairment and neurological symptoms in the lower limbs. An expansive lesion extending from L2 to S1 was shown by imaging (ie, CT scan and MRI). Differential diagnoses included aneurysmal bone cyst and spinal tuberculosis and abscess; the initial suggested diagnosis of spinal cystic echinococcosis was discarded based on contrast enhancement results. The final diagnosis of cystic schwannoma was obtained by histopathology of the excised mass. Cystic spinal lesions are rare and their differential diagnosis is challenging. Awareness of autochthonous and tropical infectious diseases is important, especially in countries experiencing consistent migration flow; however, it must be kept in mind that migrants may also present with ‘non-tropical’ pathologies.

Computed tomography and magnetic resonance imaging of hydatid disease: A pictorial review of uncommon imaging presentations

Hydatid disease (HD), also known as echinococcal disease or echinococcosis, is a worldwide zoonosis with a wide geographic distribution. It can be found in almost all parts of the body and usually remains silent for a long period of time. Clinical history can be varied based on the location, size, host immune response, and complications.

The most common imaging modalities used for diagnosis and further evaluations of HD are ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI). Although conventional radiography may be the first used tool, rarely can lead to a definite judgment. Clinical indications and cyst location may alter the choice of imaging. MRI and CT would be useful when the involved area is inaccessible for ultrasound or surgical treatment is required. CT is particularly valuable for osseous organ involvements and the presence of calcifications in the cyst and also demonstrates the size, number, and local complications. MRI can differentiate HD from neoplasms in cases with an unusual appearance on imaging. Moreover, it is preferable in biliary or neural involvements. Besides, more detailed images of MRI and CT could help to resolve the diagnostic uncertainty.

Imaging is the main stem for HD diagnosis. Brain, orbit, muscle, bone, and vascular structures are less commonly involved areas. Familiarity with typical clinical presentation, CT scan and MR imaging findings of HD in this sites facilitate the radiologic diagnosis and guiding appropriate treatment.

Acute infectious myelopathies

PURPOSE OF REVIEW

The patient who presents with an acute spinal cord syndrome with weakness/paralysis of the limbs presents a diagnostic. Two important syndromes are acute transverse myelitis (ATM) and acute flaccid paralysis (AFP). Both can be caused by a number of infectious and noninfectious causes. Since 2014 there have been outbreaks of acute flaccid myelitis (a subgroup of AFP) in the United States, with a national surveillance program underway. In addition, there have been increasing reports of ATM from new and emerging pathogens, and opportunistic infections in immunocompromised hosts.

RECENT FINDINGS

Infectious causes of ATM or AFP need to be ruled out first. There may be important clues to an infectious cause from epidemiologic risk factors, immune status, international travel, MRI, and laboratory findings. We summarize key features for the more common pathogens in this review. Advances in laboratory testing have improved the diagnostic yield from cerebrospinal fluid, including real-time polymerase chain reaction, metagenomic next-generation sequencing, and advanced antibody detection techniques. These tests still have limitations and require clinical correlation.

SUMMARY

We present a syndromic approach to infectious myelopathies, focusing on clinical patterns that help narrow the diagnostic possibilities.

Echinococcosis of the spine

Echinococcosis or hydatid disease affecting the spine is an uncommon manifestation of Echinococcus granulosus infection of the spine.More commonly found in endemic areas, it causes significant morbidity and mortality as it grows slowly and produces symptoms mainly by compressing the spinal cord.As diagnostic methods are non-specific, diagnosis and management are usually delayed until the disease is advanced, thereby therapy is usually unlikely.Treatment is usually surgical, aiming at cyst excision, spinal cord decompression and spinal stabilization.This article summarizes the clinical findings of echinococcosis of the spine, discusses the specific laboratory and diagnostic findings, lists the current treatment options, and reviews the patients' outcomes.The aim is to prompt clinicians to be aware of the possibility of echinococcosis as a possible diagnosis in endemic areas. Cite this article: EFORT Open Rev 2021;6:288-296. DOI: 10.1302/2058-5241.6.200130.

Parasitic infections of the spine: case series and review of the literature

OBJECTIVEAlthough parasitic infections are endemic to parts of the developing world and are more common in areas with developing economies and poor sanitary conditions, rare cases may occur in developed regions of the world.METHODSArticles eligible for the authors' literature review were initially searched using PubMed with the phrases "parasitic infections" and "spine." After the authors developed a list of parasites associated with spinal cord infections from the initial search, they expanded it to include individual diagnoses, using search terms including "neurocysticercosis," "schistosomiasis," "echinococcosis," and "toxoplasmosis."RESULTSTwo recent cases of parasitic spinal infections from the authors' institution are included.CONCLUSIONSKey findings on imaging modalities, laboratory studies suggestive of parasitic infection, and most importantly a thorough patient history are required to correctly diagnose parasitic spinal infections.

Vertebral hydatid cyst infection. A case report

Hydatidosis is a common parasitic zoonosis in Middle Eastern, African, and Mediterranean populations whit primarily and well known involve of liver and lungs, but some complications are extremely rare and underrated. Particularly Hydatid cystic disease of the skeletal is one of the rarest clinical manifestations and when occurs involve in almost 50% of cases the spine. This manifestation is extremely debilitating, hard to correctly identify and manage. We want to underline this rare involve of spine to avoid misdiagnosis and complications.

Cell-mediated and humoral immune profile to hydatidosis among naturally infected farm animals

Background and Aim

Cystic echinococcosis (CE) is a widespread parasitic disease caused by Echinococcus granulosus tapeworm infect different intermediate hosts including sheep, cattle, and camels. The intermediate host's immune response to the hydatid cyst is still conflict and complex. The current study was designed to evaluate the immune response in sera of hydatid naturally infected sheep, cattle, and camels in the form of features of inflammatory cell infiltrations, levels of Th1 and Th2 cytokines, besides the humoral specific immunoglobulin G (IgG) responses.

Materials and Methods

Thirty-nine sheep, 74 cattle, and 79 camels' sera were collected and considered as CE naturally infected and ten samples from each species were graded as non-infected. Lung specimens were collected for histopathological examination. The quantitative concentrations of tumor necrosis factor-α, interleukin (IL)-6, IL-4, and IL-10 were determined. Different antigens were prepared from hydatid cyst; hydatid cyst fluid of lung origin hydatid cyst fluid of liver origin, hydatid cyst protoscoleces of lung origin (HCP-g), hydatid cyst protoscoleces of liver origin, hydatid cyst germinal layer of lung origin, and hydatid cyst germinal layer of liver origin; and characterized by gel electrophoresis and Western blotting analysis. The total specific IgG level against E. granulosus infection was measured using an indirect enzyme-linked immunosorbent assay.

Results

The results indicated that the cellular immune response in the infected tissues was characterized by inflammatory cell penetration. The pro-inflammatory Th1 cytokine profile was predominant in infected animals in comparison with non-infected ones. However, the humoral immune response was seen as a high level of IgG in infected animals. The presented data approved that the HCP-g antigen could be considered as a delegate antigen for all other prepared antigens with an immunoreactive band at molecular weights 32 kDa.

Conclusion

This study provides a fundamental insight into the events that manipulate cellular and humoral immune profiles in an intermediate host; sheep, cattle, and camel that naturally infected with CE. Hence, it was concluded that CE is a constant disease and confirm the reactivity Th1 in combating hydatid cyst. Besides, it could lead to the activation of the humoral immune response in the form of a high level of IgG.

Cystic Echinococcosis of the Bone: A European Multicenter Study

Cystic echinococcosis (CE) is a zoonosis caused by the larval stage of the tapeworm Echinococcus granulosus. In humans, the infection induces the formation of parasitic cysts mostly in the liver and lungs, but virtually any organ can be affected. CE of the bone is one of the rarest forms of the disease, yet it is also extremely debilitating for patients and hard to manage for clinicians. Unlike abdominal CE, there is currently no expert consensus on the management of bone CE. In this study, we conducted a survey of the clinical records of seven European referral centers for the management of patients with CE and retrieved data on the clinical management of 32 patients with a diagnosis of bone CE. Our survey confirmed that the patients endured chronic debilitating disease with a high rate of complications (84%). We also found that diagnostic approaches were highly heterogeneous. Surgery was extensively used to treat these patients, as well as albendazole, occasionally combined with praziquantel or nitaxozanide. Treatment was curative only for two patients, with one requiring amputation of the involved bone. Our survey highlights the need to conduct systematic studies on bone CE, both retrospectively and prospectively.

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.

Inefficient and abortive classical complement pathway activation by the calcium inositol hexakisphosphate component of the Echinococcus granulosus laminated layer

Persistent extracellular tissue-dwelling pathogens face the challenge of antibody-dependent activation of the classical complement pathway (CCP). A prime example of this situation is the larva of the cestode Echinococcus granulosus sensu lato, causing cystic echinococcosis. This tissue-dwelling, bladder-like larva is bounded by a cellular layer protected by the outermost acellular "laminated layer" (LL), to which host antibodies bind. The LL is made up of a mucin meshwork and interspersed nano-deposits of calcium inositol hexakisphosphate (calcium InsP₆). We previously reported that calcium InsP₆ bound C1q, apparently initiating CCP activation. The present work dissects CCP activation on the LL. Most of the C1 binding activity in the LL corresponded to calcium InsP₆, and this binding was enhanced by partial proteolysis of the mucin meshwork. The remaining C1 binding activity was attributable to host antibodies, which included CCP-activating IgG isotypes. Calcium InsP₆ made only a weak contribution to early CCP activation on the LL, suggesting inefficient C1 complex activation as reported for other polyanions. CCP activation on calcium InsP₆ gave rise to a dominant population of C3b deposited onto calcium InsP₆ itself that appeared to be quickly inactivated. Apparently as a result of inefficient initiation plus C3b inactivation, calcium InsP₆ made no net contribution to C5 activation. We propose that the LL protects the underlying parasite cells from CCP activation through the combined effects of inefficient permeation of C1 through the mucins and C1 retention on calcium InsP₆. This mechanism does not result in C5 activation, which is known to drive parasite-damaging inflammation.

Osseous cystic echinococcosis: A case series study at a referral unit in Spain

Background

Cystic echinococcosis (CE) is present in all continents, except for the Antarctica. Characteristically, CE lesions are found in the liver and the lungs, but virtually any part of the body may be affected (the spleen, kidneys, heart, central nervous system, bones, among others). It is estimated that the incidence of bone involvement in CE is 0.5% to 4%.

Methodology

A retrospective study was performed of patients with osseous CE treated at the National Reference Unit of Tropical Diseases of the Ramon y Cajal Hospital, Madrid, Spain, between 1989 and December 2017. Epidemiological, clinical, diagnostic and therapeutic data of patients with long-term follow-up were collected.

Main findings

During the study period, of the 104 patients with CE, 27 exhibited bone involvement (26%). The bones most frequently affected were the spine, followed by the ribs, pelvis, femur, tibia and the scapula. The most common symptom was pain followed by medullar syndrome and pathologic fracture. In total, 81.5% of patients underwent surgery for osseous CE at least once. As many as 96% received albendazol either in (mostly long-term) monotherapy or in combination with praziquantel.

Conclusions

The diagnosis and management of osseous CE is challenging. In many cases osseous CE should be considered a chronic disease and should be managed on a case-by-case basis. Lifelong follow-up should be performed for potential recurrence and sequels.

Echinococcosis occurs in humans as a result of infection by a cestodes of the genus Echinococcus. One of the species, E. granulosus, causes cystic echinococcosis (CE) in humans worldwide. In the lifecycle there is a definitive host (generally dogs) which host this parasites at the small bowel. From there, ground is shed with the eggs of the parasite through feces and the intermediate host (usually a sheep or other herbivores get infected). Humans act as an incidental intermediate host when they become infected through the consumption of water or food contaminated with Echinococcus eggs. Once the egg has been ingested, it penetrates the intestinal mucosa and through the circulatory system finds an anatomical site forming a cystic lesion (hydatid or hydatid cyst). Characteristically, CE are found in the liver and the lungs, but virtually any part of the body may be affected. Incidence of osseous CE is low, its diagnosis and management is challenging and there is little information published. In this study we report our experience at a referral unit during nearly 30 years in the management of a series of patients with osseous CE. Such information may be useful for other physicians when treating osseous CE.

Cystic Echinococcosis of the Bone in Kazakhstan

Cystic echinococcosis (CE) is a parasitic zoonosis caused by E. granulosus primarily affecting the liver and lungs. CE of the bone is by far the most debilitating form of the disease and is very difficult to manage as it mimics malignant tumors. We reviewed bone CE cases admitted to a reference oncological hospital in Kazakhstan from January 2010 to February 2017. Among eight patients, the mean age was 33.5 years, and the male/female ratio was 1 : 3. Patients were examined by X-ray (8/8), CT (7/8), and MRI (3/8). CE was in the spine (2 cases), pelvis (3 cases), and long bones (humerus, tibia, and femur; one case for each). All patients were treated surgically. No perioperative albendazole was administered. No patient received albendazole afterwards. The mean hospital stay was 25 days. Interventions are urgently needed to assess the burden of CE in Kazakhstan and to inform clinicians of the existence of the disease.

Management of osseous cystic echinococcosis

INTRODUCTION

Osseous cystic echinococcosis (CE) is one of the most complicated and devastating conditions caused by Echinococcus granulosus. Its management is difficult and there is scant literature about it. Areas covered: A literature review was performed to provide an update on its diagnosis, treatment and follow-up. Expert commentary: In most cases diagnosis of osseous CE can only be confirmed by surgery. Osseous CE should be managed by experienced physicians and addressed as a chronic disease with therapies must be aimed at controlling the disease and its sequels or complications, rather than with a curative intent.

Spinal Hydatid Cyst Disease

OBJECTIVE

A hydatic cyst (HC) is a zoonotic infection affecting the liver and lungs, with rare spinal involvement. We discuss the long-term results in 8 patients with spinal HC who were monitored at our clinic for 7 to 15 years.

METHODS

The demographic data and clinicopathologic characteristics of 8 patients with spinal HC diagnosed between 2000 and 2016 were evaluated for their contribution to recurrence, and the long-term follow-up results were examined.

RESULTS

Four male and 4 female patients with a median age of 30.75 years (range, 17-45 years) at the first surgery were included. Infections were localized in the thoracic (3), thoracolumbar (1), lumbar (1), sacral (1), cervicothoracic (1), and lumbosacral (1) regions. Two patients had secondary HCs that spread from another organ (lung and kidney). Patients underwent 2 to 5 surgeries during the study period, with an average follow-up time of 8.5 years (range, 7-15 years) after the first surgery. The surgical treatments included an anterior corpectomy and anterior plate for a patient with cervical localization and cystectomy for a patient with sacral localization; the other patients underwent cystectomy with corpectomy and stabilization with an anterior approach, cyst excision and laminectomy with a posterior approach, or additional posterior transpedicular screw stabilization. The patients were prescribed albendazole.

CONCLUSIONS

Spinal HC treatment is difficult, particularly in patients with vertebral and paraspinal involvement, spinal instability, and recurrence. Long-term follow-up is critical, and patients require medical and surgical treatment, with regular clinical, radiologic, and serologic examinations. The cysts must be removed without rupture during surgery, and the surgical area must be irrigated with hypertonic saline solution to reduce the risk of recurrence.

Vertebral alveolar echinococcosis-a case report, systematic analysis, and review of the literature

Alveolar echinococcosis caused by Echinococcus multilocularis is an infrequent zoonosis with a high degree of disability, morbidity, and mortality, especially in disease clusters of the northern hemisphere. The diagnosis is complicated by extended incubation time, diverse clinical manifestations, and mimicking of differential diagnoses. The primary organ affected is the liver, but extrahepatic disease is possible, with vertebral involvement in only a few dozen cases described worldwide. Although vertebral alveolar echinococcosis seems to be rare, it might be under diagnosed, and it might be seen more often as the number of people with immunocompromised conditions increases. Recognition of this syndrome is crucial, because advances in medical and surgical management strategies since the introduction of benzimidazole in 1976 have controlled and relieved symptoms in most cases. In this Grand Round, we present the case of a 75-year-old woman who was referred for biopsy of a lumbar lesion 3 months after she was diagnosed with chronic myeloid leukaemia. The diagnosis of hepatic alveolar echinococcosis with metastasis to the lumbar spine and paravertebral region as well as the brain was confirmed by biopsy, PCR, and serology. The patient was given albendazole and referred for palliative surgery with the aim of pain control. Clinical features of the case are presented and discussed in the context of the literature. This case and review illustrate the complexity of extrahepatic alveolar echinococcosis manifestations and the necessity of an interdisciplinary approach.

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.

Recurrence of chest wall hydatid cyst disease involving the thoracic spine in an Australian patient

Hydatid disease involving the spine is a relatively uncommon occurrence. The cestode Echinococcus granulosus is the primary pathogen associated with hydatid disease and most patients present with signs and symptoms of spinal cord compression depending on the location of the spinal involvement. We present a rare case of recurrent hydatid disease with extensive hemithorax involvement, including the thoracic spine, associated with spinal cord compression. This case highlights the role of staged and minimally invasive spine surgery in spinal hydatid disease with spinal cord compression, the importance of ongoing medical treatment and long term follow-up.

Neurosurgical approaches to spinal infections

Spinal infection is rare. Clinical suspicion is important in patients with nonmechanical neck and/or back pain to make the proper diagnosis in early disease. Before planning surgery, a thorough evaluation of the spinal stability, alignment, and deformity is necessary. Timing of surgery, side of approach, appropriate surgical technique, and spinal instruments used are crucial. Biomechanical preservation of the spinal column during and after the infection is a significant issue. Postoperative spine infection is another entity of which spinal surgeons should be aware of. Proper septic conditions with meticulous planning of surgery are essential for successful spine surgery and better outcome.

Parasitic and rare spinal infections

The imaging features of spinal parasitic diseases and other rare infections are herein discussed. These diseases are distributed worldwide, with increased prevalence in areas with poor sanitary conditions and in developing countries. In nonendemic areas, sporadic cases may occur, consequent to increased international travel and immunocompromising conditions. Infectious diseases are usually treatable, and early detection is often crucial. A thorough comprehension of the imaging patterns associated with the clinical features, epidemiology, and laboratory results allows the radiologist to narrow down the options for differential diagnosis and facilitates the timely implementation of appropriate therapies.

Case report of an epidural cervical Onchocerca lupi infection in a 13-year-old boy

A 13-year-old boy presented with fever and neck pain and stiffness, which was initially misdiagnosed as culture-negative meningitis. Magnetic resonance images of the brain and cervical spine demonstrated what appeared to be an intradural extramedullary mass at the C1-3 level, resulting in moderate cord compression, and a Chiari Type I malformation. The patient underwent a suboccipital craniectomy and a C1-3 laminectomy with intradural exploration for excisional biopsy and resection. The lesion containing the parasite was extradural, extending laterally through the C2-3 foramina. Inflammatory tissue secondary to Onchocerca lupi infection was identified, and treatment with steroids and doxycycline was initiated. At the 6-month follow-up, the patient remained asymptomatic, with MR images demonstrating a significant reduction in lesional size. However, 10 weeks postoperatively, the infection recurred, necessitating a second operation. The patient was treated with an additional course of doxycycline and is currently maintained on ivermectin therapy. This is the second reported case of cervical O. lupi infection in a human. In the authors' experience, oral doxycycline alone was insufficient in controlling the disease, and the addition of ivermectin therapy was necessary.

A rare and unexpected clinical progress and location on a primary extradural spinal hydatid cyst in a pediatric patient: a case report

BACKGROUND

Involvement of spine in patients with hydatid disease (HD) is less than 1% and primary intra-spinal extradural HD is extremely rare. Although this disease is introduced as benign pathology according to its clinical presentation and biological behavior, intraoperative rupture of the cyst may aggravate the patients' outcome in the long-term especially in pediatric patient population.

CASE PRESENTATION

We report a 9-year-old girl who presented a progressive neurological deterioration due to an enlargement of a ventrally located extradural hydatid cyst within the thoracic spinal canal. Total removal of the cyst was achieved by preserving the capsule integrity for preventing potential seeding. Our preoperative initial diagnosis based on the radiological findings was confirmed as cyst hydatid histopathologically.

CONCLUSION

Cyst hydatid should be considered in the differential diagnosis of the presence of homogenous cystic lesions with regular shape inside the spinal canal especially in patients from endemic region. To our knowledge, this pediatric patient is the first case of cyst hydatid located ventral side of the spinal cord extradurally located inside the spinal canal showing no extension.