Factors Associated with Echinococcosis-Induced Perioperative Anaphylactic Shock

Predictive Factors of Pulmonary Hydatid Complications in Children

BACKGROUND

Pulmonary echinococcosis in children has frequent and severe complications. The aim of our study was to determine predictive factors of pre and postoperative complications of pediatric pulmonary hydatid cyst.

METHODS

We conducted a retrospective descriptive and analytic study conducted from January 2010 to December 2018. The study population was divided into two groups to determine predictive factors of pre- and post-operative complications of pediatric pulmonary echinococcosis. Data were analyzed by IBM SPSS 21.0. A p-value of 0.05 was accepted as significant.

RESULTS

The study included 106 boys and 94 girls with a median age of 8 years. One hundred and thirty-eight patients (69%) had complicated pulmonary hydatid cyst preoperatively. Univariate analysis identified 12 predictive factors of pre-operative complications: rural origin (p = 0.0001), hydatid contact (p < 0.001), long period between the onset of symptoms and the first medical consultation (p = 0.0001), the autumn and the winter (cold seasons) (p = 0.0001), chest pain (p = 0.0001), hemoptysis (p = 0.023), fever (p = 0.0001), right side (p = 0.01), apical and para hilar location (p = 0.01), superior lobe (p = 0.05), superior right lobe (p = 0.0001), cyst size>5 cm (p = 0.02), positive hydatid serology (p < 0.0001). It identified 2 predictive factors of post-operative complications: giant cyst (p = 0.009) and not performing a capitonnage (p = 0.016). Multivariate analysis showed 4 independent pre-operative predictive factors of complications: rural area (p < 0.0001), fever (p = 0.006), right side (p = 0.02) and positive hydatid serology (p < 0.001). It identified 2 postoperative independent predictive factors of complications: not performing. capitonnage (p = 0.029) and solitary hydatid pulmonary cyst (p = 0.02).

CONCLUSION

Pulmonary hydatid cyst management in children needs a thorough appreciation of independent predictive factors of pre and postoperative complications in order to reduce their morbidity.

Anaphylaxis during puncture of a hepatic hydatid cyst

Although hydatid cyst infects many organs, it most commonly involves liver, lungs, and central nervous system. The goal of hydatid cyst treatment is to completely eliminate the parasite and to prevent recurrences with minimal mortality and morbidity. The procedure of puncture, aspiration, injection of a scolicidal, and reaspiration (PAIR) of a cyst has been introduced as an alternative to surgical method since it is less invasive and less morbid and is associated with a shorter hospital stay and a lower cost. Herein, we report an 11-year-old girl who developed anaphylaxis during the puncture of a hepatic hydatid cyst. The patient who developed anaphylaxis during the PAIR procedure was administered intravenous adrenaline, methyl prednisolone, and antihistaminic medication. She was intubated and provided assisted ventilation using a mechanic ventilator. The child was extubated 4 h after her admission to the pediatric intensive care unit. During follow-up, the contents of her hepatic hydatid cysts were aspirated through a catheter, followed by their irrigation with 20% sodium chloride and re-aspiration. Then, 97% ethyl alcohol was injected into the cyst cavity to make it collapse. The goal of this report was to draw attention to the rare occurrence of anaphylaxis during the PAIR procedure and to stress that clini-cians should be vigilant for this complication.

The role of memory T cells in Echinococcus granulosus-induced sensitization

OBJECTIVE

To investigate the changes in memory T cells and the related factors in mice by the establishment of a BALB/c mouse model of Echinococcus granulosus-induced sensitization.

METHODS

A sensitized BALB/c mouse model was established by intraperitoneal injection of E. granulosus. A control group (CTRL), a nonsensitized group infected with E. granulosus (CE), and a sensitized group infected with E. granulosus (ANPC) were set up. The pathological changes in lung tissue in mice, the change in memory T cells (CD4 Tm), and the change in peripheral blood nucleated interleukin-23 (IL-23) were detected using HE staining, flow cytometry, and liquid-phase multiple protein quantification techniques, respectively.

RESULTS

The individual percentage of mouse memory T cells was 9.14 ± 0.45, 25.23 ± 0.17, and 13.29 ± 0.32 in the CTRL, CE, and ANPC groups, respectively. The percentage of memory T cells in the ANPC group was higher than that in the CTRL group (t = 18.410, p < .001) but lower than that in the CE group (t = -80.147, p < .001). The levels of IL-23 in peripheral blood of mice in the CTRL, CE, and ANPC groups were 225.76 ± 27.16, 359.21 ± 28.67, and 215.69 ± 22.69, respectively. The level of IL-23 in peripheral blood of mice in the ANPC group was lower than that in the CE group (t = 9.609, p < .001), and there was no statistical difference with the CTRL group (t = 0.697, p = .502).

CONCLUSION

In the BALB/c mouse model of E. granulosus-induced sensitization, the expression of IL-23 in peripheral blood increased, and the memory T cell proliferated and became activated; there was a decrease in the content of IL-23 in peripheral blood and number of activated memory T cells in the sensitization group infected with E. granulosus. The E. granulosus-induced allergic reaction was related to IL-23 and the activation of memory T cells.

The regulatory role of differential microRNA expressions on cellular inflammatory factors IL-6 and IL-10 in Echinococcus granulosus-induced anaphylaxis

OBJECTIVE

To determine the pathogenesis and molecular targets of anaphylaxis caused by hydatid cyst fluid leakage.

METHODS

First, Balb/c mice were infected with Echinococcus granulosus, and then the anaphylaxis model was developed. The mice were separated into: anaphylaxis caused by the cystic echinococcosis group (ANPC), the cystic echinococcosis without anaphylaxis group (CE group), and the normal control group (CTRL). Following this, the spleen tissue was collected for microRNA (miRNA) sequencing. Using bioinformatics analysis, differentially expressed miRNAs (DEMs) were identified. Then, through the use of protein-protein interaction (PPI) networks, the key target genes for miRNA regulation associated with echinococcosis-induced anaphylaxis were identified.

RESULTS

ANPC and CE groups have 29 and 39 DEMs compared to the CTRL group, respectively. Based on these 25 DEMs, interactions between miRNA and mRNA were screened, and 174 potential target genes were identified. We performed gene ontology (GO) function and Kyoto Encyclopedia of Genes and Genomes pathway enrichment analysis on these 174 target genes, and the results revealed that the three pathways with the highest enrichment were the PI3K-Akt signaling pathway, FoxO signaling pathway, and Focal adhesion. The interaction analysis of PPI and miRNA-hub gene networks revealed that interleukin 6 (IL-6) was regulated by miR-146a-5p and miR-149-5p, while IL-10 was regulated by miR-29b-3p and miR-29c-3. Using reverse transcription polymerase chain reaction, we found that the miRNAs regulating IL-6 and IL-10 were significantly upregulated in the ANPC group, and there are three pathways involved in that process: Pathways of PI3K-Akt signaling, FoxO signaling, and Focal adhesion. IL-6 and IL-10 play an important role in cellular pyroptosis and apoptosis. Therefore, the aforementioned results provide significant reference value for elucidating the mechanism of cellular pyroptosis and apoptosis in echinococcosis-induced anaphylaxis, and for formulating tissue and organ protection strategies for patients with cystic echinococcosis when anaphylaxis is triggered by hydatid cyst rupture.

Popliteal Echinococcosis: A Long Journey from the Liver

INTRODUCTION

Intra-abdominal and pelvic seeding of hepatic cystic echinococcosis to various organs is a known feature of the disease. Dissemination into distal extremities is uncommon and in this report, we present a case of disseminated cystic echinococcosis extending toward the right popliteal fossa.

CASE PRESENTATION

A 68-year-old male presented with swelling in the right upper leg and discomfort in the right popliteal region. Work-up revealed various cystic mass lesions of different sizes within the liver, intra-abdominal cavity, right inguinal region, right femoral region, and right popliteal fossa. Diagnosis of hepatic cystic echinococcosis was made and the patient was started on medical therapy.

DISCUSSION

Hepatic cysts can be easily observed with ultrasonography and the WHO-Informal Working Group on Echinococcosis (WHO-IWGE) classification system is commonly used to further classify cysts. The work-up of the disseminated disease involves further radiological modalities such as computerized tomography and magnetic resonance imaging. Management includes medical therapy, percutaneous drainage, or surgery depending on hepatic cyst localization and the presence of dissemination.

CONCLUSION

Extrahepatic dissemination of cystic echinococcosis is commonly encountered in endemic areas. Rarely, hepatic cysts can spread beyond the abdomen towards the distal extremities. Therefore, cystic echinococcosis should be included in the differential diagnosis in endemic areas where patients present with cystic masses.

Perioperative Anaphylaxie – alte Zöpfe und Neues zu den Auslösern

Perioperative Anaphylaxien werden mit mindestens 1:6000 angegeben. Neue Kenntnisse der Pathophysiologie der anaphylaktischen Reaktionen beziehen die Auslösung über das Mastzell-related G-Protein und die Komplementaktivierungs-abhängige Pseudoallergie mit ein. Neu beschriebene Auslöser sind das Chlorhexidin oder Gelatine-Produkte, eingesetzt zur Blutstillung oder blaue Farbstoffe zur intraoperativen Markierung. Wachsamkeit ist in Hinblick auf biphasische Reaktionen geboten. Propofol darf mittlerweile bei Ei- und Sojaallergikern eingesetzt werden.

Peri‐operative refractory anaphylactic shock during hepatic hydatid cyst surgery

Serious intra-operative anaphylactic shock is an unusual complication. Identification of causative agents can be difficult due to the number of anaesthetic drugs administered in quick succession, many of which can potentially cause anaphylaxis. Most anaphylactic reactions respond to, and resolve with, adrenaline and steroids. However, they can be prolonged and life-threatening. Refractory anaphylaxis, unresponsive to repeated doses of adrenaline, is rare and associated with a high risk of mortality. Rupture of a hydatid cyst during surgery can cause anaphylaxis. Here, we present a rare case of refractory anaphylactic shock during surgical resection of a hepatic hydatid cyst, with severe haemodynamic instability requiring prolonged postoperative ventilation and triple inotropic support for seven days in the intensive care unit. We describe the management of this condition, primarily based on steroid therapy and escalating vasopressor support, particularly where limited response to adrenaline is encountered. Refractory anaphylaxis is a rare but life-threatening complication of hydatid cyst surgery. Therefore, anaphylactic reactions should always be anticipated, with the appropriate treatment and facilities readily available.

Construction of ceRNA regulatory network in mice with Echinococcosis-induced allergic reactions

BACKGROUND

Cystic echinococcosis (CE) is a common chronic zoonotic parasitic disease infected with the Echinococcus granulosus. This study aimed to construct the competitive endogenous RNA (ceRNA) network and investigate the mechanism of mice in echinococcosis sensitization.

METHODS

The animal model of echinococcosis was established in mice, and the RNA sequencing was then performed using cysts. The differentially expressed RNAs (DERNAs: DEmRNAs, DEmiRNAs, and DElncRNAs) were screened between anaphylactic mice or non-anaphylactic mice and controls, respectively. The interactions of two DERNAs groups were identified and the ceRNA network was constructed. Moreover, the potential biological functions and pathways of the DEmRNAs were explored by enrichment analyses. Finally, the qRT-PCR and the western blot were performed to validate the expression levels of key RNAs and proteins.

RESULTS

A total of 285 common DEmRNAs, 157 common DElncRNAs and 4 common DEmiRNAs were observed. CeRNA network contained 3 DElncRNAs, 4 DEmiRNAs, and 27 DEmRNAs corporately. Enrichment results revealed that the functions of DEmRNAs focus on biological functions and pathways that specifically interact with the immune inflammatory response. In addition, the expression of 1700099I09Rik, let-7a-5p, Ccl28 and IL-13 was validated by RT-qPCR and western blot.

CONCLUSION

In this study, ceRNA network associated with CE sensitization in mice was constructed. The DEmRNAs in this network may be key clues for the immune mechanism of CE sensitization.

Isolated renal hydatid disease: varied presentations, treatments, dilemmas, and the way ahead: case report series

Background

Hydatid disease is an infectious disease that affects several organs. Isolated renal involvement is very rare. The treatment for renal hydatid cyst ranges from minimally invasive percutaneous aspiration techniques to laparoscopic and open techniques. We describe five cases of isolated renal hydatidosis with varied presentations who were treated successfully by various methods.

Case presentation

The presenting symptoms included flank pain (n = 5), mass abdomen (n = 2), and hydaturia (n = 1). In 4 patients, the diagnosis of a hydatid cyst was known preoperatively, but one patient with a preoperative diagnosis of a simple cyst was found to harbor hydatidosis intra-operatively. Eosinophilia as a marker for the active disease was present in 60% (3/5), while echinococcal serology was positive in only 25% (1/4). Two cases were approached laparoscopically, while three required an open approach. Two patients were treated with nephrectomy due to the high bulk of the disease, while the other three underwent renal preserving cyst excision.

Conclusions

The presence of eosinophilia in the preoperative workup may indicate an infective/active hydatid disease. Echinococcal serology is representative of past hydatid infection but cannot reveal about current disease status. Cysts with varied attenuations and residence in an endemic region may support a renal hydatid cyst diagnosis. A holistic approach including clinical history, laboratory parameters, and imaging is needed for diagnosis. Surgical treatment requires cyst excision, along with precautions to prevent spilling. Nephrectomy may be preferred in cases with minimal residual function.

Perioperative Anaphylaxie – alte Zöpfe und Neues zu den Auslösern

Perioperative Anaphylaxien werden mit mindestens 1:6000 angegeben. Neue Kenntnisse der Pathophysiologie der anaphylaktischen Reaktionen beziehen die Auslösung über das Mastzell-related G-Protein und die Komplementaktivierungs-abhängige Pseudoallergie mit ein. Neu beschriebene Auslöser sind das Chlorhexidin oder Gelatine-Produkte, eingesetzt zur Blutstillung oder blaue Farbstoffe zur intraoperativen Markierung. Wachsamkeit ist in Hinblick auf biphasische Reaktionen geboten. Propofol darf mittlerweile bei Ei- und Sojaallergikern eingesetzt werden.

Should Pediatricians Be Aware of Cystic Echinococcosis? A Literature Review

Among parasitic hepatic cystic lesions, the most common disease is represented by cystic echinococcosis (CE), especially in high endemic countries. European epidemiology of CE in children is difficult to assess because of under-reporting but is increasing, because of high immigration flows from endemic countries and an increased awareness. Hydatidosis can be localized in every part of the body. The liver and lungs are the most common localizations in both children and adults. Multiorgan involvement is rarely reported in children. Different tests are available. Usually the sensitivity of serological screening tests is variable, ranging between 60% and 90%. The immunoblot assay is used as a confirmatory test because of its higher sensitivity and specificity. Radiological tests are the criterion standard for diagnosis of CE, with an ultrasound accuracy of approximately 90%. In case of inactive and uncomplicated cysts the watch-and-wait approach is recommended. Albendazole, currently used for 3 to 6 months consecutively represents the most commonly used drug in children even if there is limited experience in treating children younger than 6 years of age. Percutaneous treatment with the puncture, aspiration, injection, and reaspiration technique is a minimally invasive procedure. Surgery is indicated based on cyst characteristics in case of big cysts with multiple daughter cysts, single superficial cysts at risk of spontaneous or traumatic rupture, cysts related with the biliary tract in which the percutaneous treatment is contraindicated, and cysts compressing related structures.

Recurrent multiple-organ involvement of disseminated alveolar echinococcosis in 3 patients: Case report

RATIONALE

Alveolar echinococcosis (AE) is a rare but highly malignant form of echinococcosis caused by Echinococcus multilocularis. There have been very few reports on multiple-organ AE, especially AE in bones. Here we report 3 rare cases of disseminated multiple-organ AE from western China and its neighboring areas.

PATIENT CONCERNS

Patient 1 had back and left hip pain, headache, and weakness in left lower limb, often with minor epilepsy and fluctuation of blood pressure. Lower limbs Babinski sign was positive and muscular tension was above normal range. The second patient had pain in lower limbs and chest discomfort without fever, cough, sputum, chest tightness, or hemoptysis. Patient 3 had masses and pain in the back side of his right shoulder.

DIAGNOSES

The patients had been treated for AE multiple times and were positive for serum hydatid antigens. They were diagnosed as multiorgan AE involving liver, spinal cord, and many other organs.

INTERVENTIONS

The patients had undergone surgeries to decompress the spinal cord, remove lesions from tissues as required, and were put on albendazole for at least 2 years.

OUTCOMES

The patients responded well and AE recurrence has not occurred.

LESSONS

All 3 cases experienced multiple recurrences of AE due to missed diagnosis, misdiagnosis, or inappropriate treatment, which resulted in metastatic multiorgan AE. These cases demonstrated the need for more policy attention to battle AE endemic in western China.