Evaluation of Nine Commercial Serological Tests for the Diagnosis of Human Hepatic Cyst Echinococcosis and the Differential Diagnosis with Other Focal Liver Lesions: A Diagnostic Accuracy Study

ACG Clinical Guideline: Focal Liver Lesions

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

Comparison of Methods in the Serologic Diagnosis of Cystic Echinococcosis

PURPOSE

Cystic echinococcosis (CE) is caused by the larval form of Echinococcus granulosus. Clinical, radiologic, pathologic, and serologic findings should be evaluated together for the diagnosis of CE. The sensitivity and specificity oalf serologic tests may vary depending on the method used. In this study, we aimed to detect IgG antibodies specific to E. granulosus using indirect hemagglutination assay (IHA), enzyme-linked immunosorbent assay (ELISA), indirect fluorescent antibodies (IFA) and western blot (WB) tests.

METHODS

In our study, the serum samples of 74 patients sent to our laboratory with suspicion of CE were studied using two different commercial IHA tests, ELISA, IFA and WB test. The test results were evaluated along with radiological findings and histopathological examinations, the latter being the gold standard.

RESULTS

Of all the patients, 51 (69%) were female and 23 (31%) were male. There was a statistically significant difference between males and females (χ2 = 9.7, p = 0.002). Out of 74 patients, positivity rates for Siemens IHA, Fumouze IHA, ELISA, IFA and WB test were positive as 33 (44.6%), 35 (47.3%), 43 (58.1%), 42 (56.7%) and 38 (51.3%), respectively. The sensitivity and specificity of the tests were as follows: 66.67 and 2.31% for Siemens IHA; 70.83% and 96.15% for Fumouze IHA; 85.42%, and 88.46% for ELISA; 83.33% and 88.46% for IFA; 72.92% and 88.46% for WB test.

CONCLUSION

There were statistically significant differences in between all five methods (p < 0,001). While the tests with the highest specificity was Fumouze IHA, the test with the highest sensitivity was the ELISA test. It was concluded that IHA and ELISA tests were more practical in practice because of their greater applicability.

Advances in Detecting Cystic Echinococcosis in Intermediate Hosts and New Diagnostic Tools: A Literature Review

Cystic echinococcosis (CE) is a zoonotic disease affecting humans and animals. Despite a lack of clarity about many details of parasite-intermediate host interactions, the nature of the immune responses triggered by hydatid infection has revealed new perspectives. This study discusses the latest advances in elucidating the immunologic mechanism of echinococcosis and its detection and potential approaches to enhance serodiagnosis accuracy. Moreover, nanobiosensors have been evaluated according to their potential to improve treatment efficiency and aid in an early diagnosis of cystic echinococcosis. The serum of an intermediate host can diagnose CE by analyzing antibodies induced by Echinococcus granulosus. Among the most notable features of this method are its noninvasive ability and high sensitivity, both of which make it an excellent tool for clinical diagnosis. Several serological tests, including ELISAs and immunoblotting, can detect these antibodies to assess the disease's state and determine the treatment outcome. A thorough understanding of what cross-reactivity means and the stage of the disease are crucial to interpreting serological results. Nanobiosensors have also proven better than conventional biosensors in detecting hydatid cysts. Additionally, they are highly sensitive and versatile when detecting specific biomarkers, improving diagnostic accuracy. These immunomodulatory molecules, induced by E. granulosus, are a good candidate for diagnosing cystic echinococcosis because they alter intermediate host immune responses. Hydatid cyst detection is also enhanced through nanobiosensors, which provide better accuracy.

Immunohistochemistry as a Reliable Tool for the Diagnosis of Cystic Echinococcosis in Patients from Sardinia, Italy-A Confirmatory Study

Cystic Echinococcosis (CE) is a zoonotic disease caused by the larval stage of the tapeworm Echinococcus granulosus sensu lato (s.l.). This study aims to investigate the use of two monoclonal antibodies (mAbEmG3 and mAbEm2G11) by immunohistochemistry (IHC) to confirm the diagnosis of CE in human patients, in particular in those cases in which other techniques fail to provide a correct or conclusive diagnosis. For this purpose, a survey on 13 patients was performed. These subjects were referred to Sardinian hospitals (Italy) from 2017 to 2022 and were suspected to be affected by CE. Our findings from these 13 patients showed the detection of E. granulosus sensu stricto by IHC in 12 of 13 echinococcal cysts, as one sample was of a non-parasitological origin. The results confirmed that IHC, by means of the mAbEmG3 and mAbEm2G11, is a reliable diagnostic tool that showed a very high performances when tested on strain of E. granulosus s.l. from Sardinia.

Ultrasound diagnosis of cystic echinococcosis: updates and implications for clinical management

The diagnosis of cystic echinococcosis (CE) is based on imaging. Detection of a focal lesion with morphological characteristics of Echinococcus granulosus sensu lato metacestode is the starting point for the diagnostic workup. In organs explorable with ultrasound (US), this is the method of choice for both aetiological diagnosis of CE and staging of the CE cyst. Staging in terms of lesion morphology is also needed when serology is added to the diagnostic workflow when imaging alone is inconclusive. Finally, staging guides the clinical management of uncomplicated CE, especially in the liver. This commentary provides an overview of the most up-to-date evidence backing the above-mentioned role of US in the diagnosis and clinical management of CE. Finally, we outline future perspectives for the improvement of CE diagnosis.

Head-to-Head Comparison of Nine Assays for the Detection of Anti-Echinococcus Antibodies: A Retrospective Evaluation

Background

Echinococcosis is a neglected tropical disease that is severely underdiagnosed in resource-limited settings. In developed countries, diagnosing echinococcosis is challenging, and reliable serological assays are urgently needed. In the Central European Alps, EM is more common than EG; however, data on the diagnostic performance of assays for EM cases are scarce. We evaluated the suitability of nine antibody assays for routine diagnostics.

Methods

Nine commercially available serological assays for detecting anti-Echinococcus antibodies were compared head-to-head using samples collected from 50 patients with echinococcosis and 50 age- and sex-matched control subjects. The assays are Anti-Echinococcus ELISA (IgG) (Euroimmun), Echinococcus IgG ELISA (DRG), Echinococcus IgG ELISA (IBL International), Echinococcus Western Blot IgG (LDBIO Diagnostics), EUROLINE WB (Euroimmun), Hydatidosis ELISA IgG (VirCell), Hydatidosis VIRCLIA IgG Monotest (VirCell), Ridascreen Echinococcus IgG (R-Biopharm), and Virapid Hydatidosis (VirCell). The cases were ranked according to the WHO-Informal Working Group on Echinococcosis (WHO-IWGE) criteria as confirmed, probable, or possible.

Results

The performance of the assays varied greatly, with overall sensitivities ranging between 50% and 88% and specificities between 62% and 100%. We observed a trend toward better performance with cases classified as "confirmed" using the WHO-IWGE criteria. Combined analysis with sequential screening and confirmatory testing resulted in a maximum sensitivity of 84% and specificity of 100%. Differentiation between EG and EM infections is clinically relevant but was found to be unreliable.

Conclusions

Echinococcus serological assays are highly variable in terms of sensitivity and specificity. Knowledge of the pre-test probability in the patient cohort is required to choose a suitable assay. A combined approach with screening and confirmatory assays may be the best diagnostic strategy in many situations.

Serological Comparison of Native Antigen ELISAs with Rapid ICT Test Kits for the Diagnosis of Human Alveolar and Cystic Echinococcosis in China

BACKGROUND

The aim of this study was to compare the diagnostic performance of native antigen ELISAs and ADAMU-AE/CE commercial ICT test kits in subjects either exposed to Echinococcus infection or with clinically diagnosed alveolar (AE) or cystic (CE) echinococcosis.

METHODS

A total of 370 subjects with a previous clinical confirmation of CE or AE from northwestern China were recruited. Serum samples were also obtained from 3923 children/teenagers during a community survey. All sera were tested using native antigen ELISAs. The ADAMU-AE/CE test kits were subsequently used for the serology of the 370 clinically confirmed individuals and of 251 children/teenagers that were ELISA antibody-positive for both Echinococcus species but ultrasound-negative during baseline survey. An analysis of the association between the serological tests and ultrasound classification was carried out amongst 89 AE and 164 CE cases. A Kappa consistency analysis was undertaken to compare the diagnostic performance of the native antigen ELISAs and the ADAMU kits and the ultrasound imaging results. The χ² test was also used for a comparison of the different seropositivity rates between the groups.

FINDINGS

There was poor consistency (Kappa = 0.26 and 0.28 for AE and CE respectively) between the native antigen ELISAs and the ADAMU kits for the diagnosis of AE and CE among the cases and the surveyed children/teenagers, but a relatively good consistency (Kappa = 0.63) between the ADAMU-AE kit and ultrasound observations for the AE cases. Additionally, of the 251 teenagers co-positive for both AE and CE antibodies by the native antigen ELISAs, only one was found positive by the ADAMU-AE kit, verified as a new AE case on subsequent ultrasound follow-up. The remainder (N = 250) were negative by serology using the ADAMU-AE/CE kits and by ultrasound examination. The two native antigen ELISAs did not discriminate well between cases of clinically diagnosed AE and CE. In contrast, ADAMU-AE and ADAMU-CE commercial ICT test kits readily differentiated cases of AE from CE with specificities of 99% for AE and 100% for CE.

CONCLUSIONS

The ADAMU-AE/CE kits proved reliable, accurate, and amenable diagnostic tools in the clinical setting for confirmation of suspected AE/CE cases. The native antigen ELISAs tests can provide useful information on the level of human exposure to Echinococcus infection.

'No cyst, no echinococcosis': a scoping review update on the diagnosis of cystic echinococcosis after the issue of the WHO-IWGE Expert Consensus and current perspectives

PURPOSE OF REVIEW

In 2010, the WHO-Informal Working Group on Echinococcosis (IWGE) published an Expert Consensus on the diagnosis and treatment of echinococcal infections. We provide an update on the diagnosis of cystic echinococcosis through a scoping review of the literature published after the release of the WHO-IWGE document.

RECENT FINDINGS

Ultrasound accurately and reliably depicts the pathognomonic signs of cystic echinococcosis (CE) stages compared with other imaging techniques. Among these, T2-wighted MRI is to be preferred to computed tomography, which has poor performance for the etiological diagnosis of CE. A negative serology cannot exclude the diagnosis of CE, while a positive serology, applied after the visualization of a CE-compatible lesion, may confirm a CE diagnosis. Serology alone must not be used to define 'CE' nor as 'screening' tool for infection. Other imaging and laboratory techniques did not show clinically applicable performances.

SUMMARY

In the absence of a focal lesion compatible with a CE cyst, no diagnosis of CE should be attempted. There is urgent need to achieve univocal CE case definitions and consensus diagnostic algorithm, as well as standardization of diagnostic methods and issue of a Target Product Profile of CE diagnostics, as advocated by the WHO in the 2021-2030 roadmap for neglected tropical diseases (NTDs).

Palliative Treatment for the Management of Advanced Pelvic Hydatid Bone Disease

Hydatid bone disease is a zoonotic parasitic infection that is caused primarily by the tapeworm Echinococcus granulosus, and it continues to be a major public health concern in pastoral regions. The reconstruction of limb function after limb salvage surgery remains a challenge for clinicians. The purpose of this study was to determine the clinical efficacy of palliative treatment of the management of advanced pelvic hydatid bone disease. From March 2005 to December 2018, medical records and images of patients with advanced pelvic hydatid bone disease treated with surgery combined with antiparasitic chemotherapy were evaluated retrospectively. The Enneking classification was applied to determine the location of the lesion, and the Musculoskeletal Tumor Society score system was used for outcome evaluation. Fifteen patients who met the criteria were included in this study, with a mean follow-up of 4.40 ± 1.76 years. All patients received treatment with surgery combined with antiparasitic chemotherapy. The mean number of surgical interventions per patient for pelvic cystic echinococcosis was 5.3 (range, 2-9 interventions per patient). Recurrence of pelvic hydatid bone disease occurred in 5 patients and was managed successfully through repeated debridement procedures. Palliative treatment with limb salvage surgery was an effective and practical approach to the management of advanced pelvic hydatid bone disease. Standard antiparasitic chemotherapy, which included albendazole at a dose of 10 mg/kg/day administered in two daily doses for 3 to 6 months, was also considered an essential part of the overall treatment strategy.

Application and evaluation of native antigen B from Echinococcus granulosus sensu stricto and E. canadensis alone or mixture for serodiagnosis of human G1-G3 and G6/G7 genotypes cystic echinococcosis sera, using ELISA and Western blotting

Cystic echinococcosis (CE) is one of the most important helminthic diseases in the world with different genotypes distribution. The application of specific genotype antigens together with sera from patients with specific cyst genotypes have not been reported, so far. The present study aimed to apply and evaluate native AgB from Echinococcus granulosus sensu stricto (Eg) and Echinococcus canadensis (Ec) alone or mixture for serodiagnosis of human G1-G3 and G6/G7 genotypes cystic echinococcosis sera, using ELISA and Western blotting. A total of 47 human sera along with 47 human CE cysts were collected. CE genotypes were determined. Native AgB were prepared from E. granulosus s.s and E. canadensis genotypes. ELISA and Western blot were performed on human specific G1-G3 and G6/G7 genotypes sera. Species specific native AgB were used alone or mixed. The sensitivity of ELISA using alone and mixed 1Eg-1Ec, 1Eg-2Ec, and 2Eg-1Ec of native AgB from E. granulosus s.s and E. canadensis genotypes for human G1-G3 sera were 92.10, 89.47, 97.37, 100, and 100%, respectively; while using AgBs, alone and mixed for human G6/G7 sera were 100%. The sensitivity of Western blotting using native AgB of E. granulosus s.s and E. canadensis genotypes alone and mixed 2Eg-1Ec were 78.95% and 100% for human G1-G3 and G6/G7 genotypes sera, respectively. The mixture of AgB from Echinoccus granulosus sensu stricto and Echinococcus canadensis genotypes increased ELISA sensitivity for the diagnosis of human CE. Preparation and application of native AgB from specific and prevalent genotypes of CE in endemic regions is recommended.

Circulating Small RNA Profiling of Patients with Alveolar and Cystic Echinococcosis

Alveolar (AE) and cystic (CE) echinococcosis are two parasitic diseases caused by the tapeworms Echinococcus multilocularis and E. granulosus sensu lato (s. l.), respectively. Currently, AE and CE are mainly diagnosed by means of imaging techniques, serology, and clinical and epidemiological data. However, no viability markers that indicate parasite state during infection are available. Extracellular small RNAs (sRNAs) are short non-coding RNAs that can be secreted by cells through association with extracellular vesicles, proteins, or lipoproteins. Circulating sRNAs can show altered expression in pathological states; hence, they are intensively studied as biomarkers for several diseases. Here, we profiled the sRNA transcriptomes of AE and CE patients to identify novel biomarkers to aid in medical decisions when current diagnostic procedures are inconclusive. For this, endogenous and parasitic sRNAs were analyzed by sRNA sequencing in serum from disease negative, positive, and treated patients and patients harboring a non-parasitic lesion. Consequently, 20 differentially expressed sRNAs associated with AE, CE, and/or non-parasitic lesion were identified. Our results represent an in-depth characterization of the effect E. multilocularis and E. granulosus s. l. exert on the extracellular sRNA landscape in human infections and provide a set of novel candidate biomarkers for both AE and CE detection.

Pediatric Echinococcosis of the Liver in Austria: Clinical and Therapeutical Considerations

Echinococcosis is considered a neglected disease in most European countries. However, migratory flows of populations, long-term stays in endemic areas, uninterrupted tourism (travel to Echinococcus-endemic countries), traveling dogs and dog translocations from endemic areas, and inappropriate hygiene practices are potential factors that alarm public health officials. Identifying a cyst-like mass in the liver or lung of an individual with a travel history of likely exposure to sheepdogs in an area where the parasite Echinococcus (E.) granulosus (sive cysticus) is endemic advocates for a prompt preliminary diagnosis of cystic echinococcosis (CE), no matter the age of the affected individuals. Routine imaging techniques, including ultrasonography, computed tomography (CT) scans, and magnetic resonance imaging (MRI) scans, are used to detect cysts. After a cyst has been discovered, serologic investigations are used to confirm the diagnosis. Typically, alveolar echinococcosis (AE) is found in older individuals. Yet young people are also affected because frequent oral exploration of the environment is a regular behavior for infants and toddlers. In this review, therapeutic considerations for pediatric echinococcosis—drug-based benzimidazole therapy; AE: atypical liver resection, the resection of individual or multiple segments, a right or left hemi-hepatectomy, or an extended hemi-hepatectomy; CE: PAIR-technique, cyst excision, liver segment(s) resection (laparoscopically or conventionally)—are revised following experience in one of the most affected regions of Europe. In addition, we performed a systematic review using three databases (i.e., PubMed, EMBASE, and Scopus) to evaluate the quality of evidence in published studies on pediatric echinococcosis.

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

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

Detection of Echinococcus granulosus sensu lato cysts and seroprevalence of cystic echinococcosis in cattle and camels in Maiduguri Abattoir

Cystic echinococcosis (CE) is a zoonotic disease of great importance worldwide. This study was conducted to determine the prevalence and antigenic profile of Echinococcus cysts (CE cysts) in camels and cattle. The lungs, livers, hearts, and kidneys of 560 animals, comprising 304 camels and 256 cattle slaughtered in the Maiduguri abattoir, were examined for CE. Blood samples were collected for serology. Protein profiles of CE fluids were analyzed using indirect Enzyme Linked Immunosorbent Assay while Sodium Dodecyl Sulphate Polyacrylamide Gel Electrophoresis (SDS-PAGE) was used to characterize the electrophoretic pattern of different CE cyst fluid samples. The overall prevalence of CE was 8.4%, 14.14% (95% CI = 10.65-18.54%) in camels and 1.60% (95% CI = 0.46-4.09%) in cattle. Adult camels 41 (16.21%) (95% CI = 12.15-21.27%) had a higher prevalence than the young camels 2 (3.92%) (95% CI = 0.33-13.97%) (p = 0.038). In cattle, only adults 4 (2.0%) had cysts. Higher prevalence of CE was recorded in male 22 (16.42%) (95% CI = 11.03-23.68%) than female 21 (12.35%) (95% CI = 8.16-18.21%) camels [p = 0.399] while only female cattle 3 (2.2%) had cysts. Higher prevalence of CE was recorded in the livers of 34 (11.18%) (95% CI = 8.08-15.25%) than in the lungs 25 (8.22%) (95% CI = 5.59-11.90%) of camels [p = 0.273]. Of the 47 cysts collected, 43 (91.49%) and 4 (8.51%) were from camels and cattle, respectively. A total of 18 (38.30%) fertile, 17 (36.17%) non-fertile, and 12 (25.53%) calcified cysts were recovered in animals. Overall seroprevalence of 52.63% (95% CI = 47.02-58.18%) and 35.55% (95% CI = 29.93-41.59%) were observed in camels and cattle in this study. The SDS-PAGE of camel CE cyst fluids revealed protein bands at 64kda, 91kda, 160kda, and 200kda molecular units while the purified cyst fluids revealed bands at 64kda, 91kda, 120kda, 160kda, and 200kda. Regular meat inspections and the exclusion of dogs from abattoir premises are strongly encouraged. Investigation into local prevailing factors encouraging transmission should be carried out.

Landscape analysis of NTD diagnostics and considerations on the development of a strategy for regulatory pathways

Access to quality-assured, accurate diagnostics is critical to ensure that the 2021–2030 neglected tropical disease (NTD) road map targets can be achieved. Currently, however, there is limited regulatory oversight and few quality assurance mechanisms for NTD diagnostic tools. In attempting to address such challenges and the changing environment in regulatory requirements for diagnostics, a landscape analysis was conducted, to better understand the availability of NTD diagnostics and inform future regulatory frameworks. The list of commercially available diagnostics was compiled from various sources, including WHO guidance, national guidelines for case detection and management, diagnostic target product profiles and the published literature. The inventory was analyzed according to diagnostic type, intended use, regulatory status, and risk classification. To estimate the global need and size of the market for each type of diagnostic, annual procurement data were collected from WHO, procurement agencies, NGOs and international organizations, where available and global disease prevalence. Expert interviews were also conducted to ensure a better understanding of how diagnostics are procured and used. Of 125 diagnostic tools included in this analysis, rapid diagnostic tools accounted for 33% of diagnostics used for NTDs and very few diagnostics had been subjected to regulatory assessment. The number of tests needed for each disease was less than 1 million units per annum, except in the case of two diseases, suggesting limited commercial value. Despite the nature of the market, and presumed insufficient return on commercial investment, acceptable levels of assurance on performance, quality and safety of diagnostics are still required. Priority actions include setting up an agile, interim, stepwise risk assessment mechanism, in particular for diagnostics of lower risk, in order to support national NTD programmes and their partners with the selection and procurement of the diagnostics needed to control, eliminate and eradicate NTDs.

Rapidly evolving landscape of in-vitro diagnostics is posing quality assurance challenges for manufacturers and regulators as well as creating product selection dilemmas for procurers, donors, and national programmes. In attempting to address such challenges, a landscape analysis of Neglected Tropical Diseases (NTD) diagnostics was conducted to provide insights for all stakeholders to support a future regulatory framework for NTD diagnostics. The inventory of commercially available diagnostics was compiled and analyzed and the global need and size of the market for each type of diagnostic was estimated. The results showed low commercial value and limited regulatory oversight on NTD diagnostics. Despite the insufficient return on commercial investment, reasonable assurance of product safety, performance and quality is required. One of the priorities is to establish a risk assessment mechanism, in particular for NTD diagnostics of lower risk, in order to support national NTD programmes, procurement agencies, donors and other partners with the selection and procurement of the diagnostics needed to achieve the 2021–2030 NTD road map targets.

Serological Assays for Alveolar and Cystic Echinococcosis—A Comparative Multi-Test Study in Switzerland and Kyrgyzstan

Both alveolar (AE) and cystic echinococcosis (CE) are lacking pathognomonic clinical signs; consequently imaging technologies and serology remain the main pillars for diagnosis. The present study included 100 confirmed treatment-naïve AE and 64 CE patients that were diagnosed in Switzerland or Kyrgyzstan. Overall, 10 native Echinococcus spp. antigens, 3 recombinant antigens, and 4 commercial assays were comparatively evaluated. All native E. multilocularis antigens were produced in duplicates with a European and a Kyrgyz isolate and showed identical test values for the diagnosis of AE and CE. Native antigens and three commercial tests showed high diagnostic sensitivities (Se: 86–96%) and specificities (Sp: 96–99%) for the diagnosis of AE and CE in Swiss patients. In Kyrgyz patients, values of sensitivities and specificities were 10–20% lower as compared to the Swiss patients’ findings. For the sero-diagnosis of AE in Kyrgyzstan, a test-combination of an E. multilocularis protoscolex antigen and the recombinant antigen Em95 appears to be the most suitable test strategy (Se: 98%, Sp: 87%). For the diagnosis of CE in both countries, test performances were hampered by major cross-reactions with AE patients and other parasitic diseases as well as by limited diagnostic sensitivities (93% in Switzerland and 76% in Kyrgyzstan, respectively).