[A CASE OF FAMILIAL PULMONARY AND HEPATIC ECHINOCOCCOSIS)]

Echinococcus granulosus still remains a widespread disease. Moreover, there is a large number of patients in whom it is diagnosed rather late because its clinical presentation can be unspecific and symptoms vary. We report a familial case of the disease. Its specific feature was the onset with the bilateral pulmonary process and late involvement of the liver. This excluded other pulmonary diseases, such as pneumonia, tuberculosis or cancer.

Watch and Wait Management of Inactive Cystic Echinococcosis - Does the Path to Inactivity Matter - Analysis of a Prospective Patient Cohort

Background

Overdiagnosis and overtreatment are rarely discussed in the context of NTDs despite their relevance for patients under the care of health services with limited resources where the risks of therapy induced complications are often disproportionate to the benefit. The advantages of cyst staging-based management of patients with cystic echinococcosis (CE) are not yet fully explored. Questions are: Do inactive cysts (CE 4 and CE 5) need treatment and is there a difference between cysts which reach CE4 and CE5 naturally or by benzimidazole therapy?

Methodology/Principal findings

Analysis of long-term follow-up data from a prospective CE patient cohort of 223 patients of a national clinical center for echinococcosis. The event of interest “relapse” was defined as the reversal of a cyst from an inactive stage (CE4, CE5) back to an active stage. The watch &wait (ww) group included 30 patients with 46 inactive cysts who never received medical treatment. The benzimidazole-treated (med) group included 15 patients with 17 cysts. There was no relapse in the ww-group whereas 8/17 cysts showed relapse within 18 months after treatment in the med-group. Loss to follow-up was 15.5%.

Conclusions

Data from the watch & wait group impressively show how stable naturally inactivated cysts are in contrast to cysts which reach inactivity through treatment with benzimidazoles. A substantial proportion of patients can be spared from treatment through cyst staging. Cysts which inactivated through a natural course do not relapse with very high likelihood. We recommend follow up of 5 years to confirm the stability of the inactive stage. Cysts driven into inactivity through benzimidazole therapy instead need careful monitoring to identify those which reactivate (around 50% within 18 months). 5 years follow-up appears safe to make a final decision on the need for further monitoring.

Cystic echinococcosis (CE) is a zoonosis of worldwide distribution causing cystic lesions in the liver and lung. The prevalence of disease is highest in countries with limited resources. Overdiagnosis and overtreatment are increasingly discussed in medical practice not surprisingly also for patients with cystic echinococcosis. In neglected tropical diseases (NTD) this is particularly relevant since most patients are under the care of health services with limited resources where the risk of therapy induced complications are often disproportionate to the benefit of interventions. Our study aims at answering the following Questions: Do inactive cysts (CE 4 and CE 5) need treatment and is there a difference between cysts which reach CE4 and CE5 naturally or by benzimidazole therapy? Results of our study impressively show that a substantial proportion of patients can be spared from any treatment through cyst staging. Cysts which inactivated through a natural course of involution do not relapse with very high likelihood. To rule out unlikely events, we recommend follow up of 5 years to confirm the stability of the inactive stage. Cysts driven into inactivity instead need careful monitoring to identify those which reactivate (around 50% within 18 months). 5 years follow-up appears safe to make a final decision.

[Intrapleural rupture of pulmonary hydatid cysts]

INTRODUCTION

Intrapleural rupture of pulmonary hydatid cyst (PHC) is a rare but dangerous complication. The purpose of this study was to report the characteristics of this form of thoracic hydatidosis and analyze the favoring factors.

MATERIALS AND METHODS

Between 1996 and 2011, 75 patients were operated in our department for PHC ruptured in the pleura (PHCP). The characteristics of this group were compared with those of a control group of 300 patients randomly selected from patients operated during the same period for PHC.

RESULTS

PHCP patients were younger than controls (23 years old vs. 27,56) (P=0.03) with male predominance (70% vs. 46%) (P=0.01). The PHCP were often located in the lower lobes (64% vs. 48%) (P=0.03). Anatomic resections were more used in control group (P=0.03) whereas decortication and pleurectomy were more frequently in PHCP (P=0.001).

CONCLUSION

Young age, male sex, and basal locations of PHC promote their rupture in the pleura. Surgical treatment of these cysts requires less anatomic resections but more decortication and pleurectomy.

Epidemiology and clinical features of cystic hydatidosis in Western Sicily: A ten-year review

AIM: To assess retrospectively the epidemiological and clinical aspects of cystic echinococcosis (CE) and to evaluate follow-up and response to treatment in patients affected by CE.

METHODS: From January 2000 to December 2010, all patients affected by CE at the Infectious Diseases Units of the University of Catania and of Basilotta Hospital in Nicosia-Enna, were enrolled as participants in the study. Epidemiological, clinical and laboratory data were collected for each patient. Diagnosis of CE was performed using clinical imaging and laboratory parameters. Response to treatment was categorized as follows: “cure” as the disappearance or complete calcification of cyst/s; “improvement” as a reduction in the diameter and/or number of existing cysts; and “impairment” as an increase in the diameter and/or number of existing cyst/s and the onset of relapses (i.e., the onset of new cyst/s and an increase in the diameter of previously existing cyst/s and/or complications. Immunoglobulin E (IgE) titers and eosinophil percentages were evaluated at diagnosis, at six months after the initiation of treatment and again in the case of relapse. Hyper-eosinophilia was defined as an eosinophil percentage of ≥ 6%.

RESULTS: Thirty-two patients were diagnosed with CE in our Unit during the research period, with a male-female ratio of 2:1. At the time of diagnosis, 40% of patients presented a single CE cyst. Sixty percent showed multi-organ involvement. The liver-lung localization ratio was 2:1. Patients below the age of 50 at diagnosis were more likely to have multiple cysts (73.7% vs 35.5%, P < 0.05). Regarding treatment, 30 patients were treated medically and 16 surgically. Fourteen patients were treated both medically and surgically. Relapses were seen to be less frequent in patients treated with albendazole before and after surgery. Complete cure or an improvement was achieved in 23 patients. Impairment was observed in one patient. Two patients showed no improvement. Relapses were more frequent in those patients treated before 2005. At diagnosis, 71% of patients were positive for specific CE IgE, and 56.3% showed an eosinophil percentage of ≥ 6%. Patients who were diagnosed with hyper-eosinophilia developed complications more frequently than the other patients, but did not suffer relapses.

CONCLUSION: On the basis of our results, we propose cystic echinococcosis screening for family members of patients, appropriate pre- and post-surgery treatment and the assessment of anti-echinococcus IgE titer or eosinophil percentage as a therapy response marker in settings with limited resources.

[Up-to-date approaches in treatment of hydatid disease of the liver in childhood]

Sixty children (age 3-15 years) with hydatid disease of the liver were treated. The patients were divided into 2 equal groups (control and main groups).The hydatid disease of the liver was revealed in 22 (33.6%) patients, combined hydatid disease of the liver and lung were noted in 38 (66.4%) patients. The "capitonnage" of the residual cavity was applied in the control group and omentoplasty--in the main group. Chemotherapy with Nemazol (dose 10-15 mg/kg/day) was carried out. In order to reduce the negative influence of Nemazol on patients and to accelerate reparation processes of liver parenchyma Vobenzyme (2-3 pills/3 times/day) was applied. The number of complications was 23.2 % in the control group. The adhesive bowel obstruction was noted in 6.6% of patients, bleeding and jaundice in 3.3%, the residual cavity suppuration in 10%. Complications were registered in the main group in 6.6% of children (the adhesive bowel obstruction in 3.3%, preservation of the residual cavity after a year in 3.3%). The number of relapses in the control group was 6 (12%), there were no relapses in the main group. Thus the procedure of preoperative and postoperative chemotherapy allowed avoidance of the development of relapses of hydatid disease of the liver. Omentoplasty is the most rational method of treatment of residual cavity in surgery of hydatid disease of the liver in children.

[Imaging of hydatid cyst of the lung]

The pulmonary hydatid cyst is frequent in Mediterranean countries such as Morocco. Our analytic study concerned 70 cases of lung hydatid cysts collected from 2007 to 2010. Mean age was 35years and we noted a male predominance (53%). Forty-seven percent of patients belong to rural environment where 64% of them were in contact with dogs. The respiratory symptomatology was made mostly by cough (86%) and chest pain (70%). Diagnosis was based on radioclinical arguments with positive hydatic serology in some cases. The cyst was single in 84% of the cases, safe in 55% of the cases. The location in the right lung was dominant with a major affection of the right lower lobe. Conventional surgery was indicated in 67 cases. The liver hydatid cyst was discovered in 20% of cases and treated at the same time phases in 71% of cases. The evolution was good in 73% of the cases and marked by a recurrence in three of the operated cases.

Hydatid lung disease: an analysis of five years cumulative data from Kolkata

BACKGROUND AND OBJECTIVE

There is scarcity of clinical data regarding hydatid lung disease from Indian subcontinent. In this retrospective study we analyzed the cumulative data over five year's period from two tertiary care hospitals of Kolkata to determine the presentation, treatment and outcome of hydatid disease of lung.

METHOD

We analyzed 106 patients on the basis of clinical findings, radiological findings [chest X-ray--PA and lateral view, CT scan of thorax and upper abdomen, ultrasonography (USG) of thorax and upper abdomen] and serological test IgG ELISA (enzyme linked immunosorbent assay) against echinococcus granulosus antigen along with the mode of diagnosis, indications and types of surgery, and outcome of treatment with chemotherapy (albendazole), surgery and combined surgery with chemotherapy.

RESULT

There was female preponderance with median age of presentation 33 years with interquartile range of 7. At the time of diagnosis 14.15% patients were asymptomatic. Cough was the commonest symptom (73.58%) followed by chest pain (54.72%). Single sharply demarcated round or oval homogenous opacity was the commonest radiological sign (81.13%). Complicated cysts such as lung abscess, pleural involvement, pneumonitis and fibrosis were noted in 10.38%, 13.21%, 7.55% and 11.32% cases respectively. We found that serological test was only 77.01% sensitive. Eighty-two (86.32%) patients underwent surgery, and 56.10% of them received additional chemotherapy with albendazole. The types of operation performed were pericystectomy (in 91.46% cases), lobectomy (in 6.10% cases) and pneumonectomy (in 2.44% cases). Perioperative mortality was nil but morbidity was found in 10.98% cases with empyema (8.54%), the commonest complication. Thirteen inoperable patients were treated with albendazole, among them 8 showed reduction of cyst-size, 3 showed no change and 2 patients showed obliteration of cyst.

CONCLUSION

Surgery is a safe and effective way of treatment for thoracic hydatid cyst along with perioperative albendazole therapy. There is a scope for chemotherapy with albendazole in inoperable cases.

[Echinococcosis: the threat of the urban fox]

The incidence of alveolar echinococcosis in Switzerland is on the rise, probably due to the proliferation of foxes observed between 1980 and 1995 in both urban and rural areas. This is nevertheless a rare disease as humans are not a natural host for the parasite. Hepatic tumor-like lesions discovered during a workup for jaundice or abdominal pain is the most frequent mode of presentation. In the presence of typical radiological features (echography, CT-Scan, MRI), diagnostic confirmation can be made by serology. If diagnosis remains doubtful, a biopsy of the lesion with histopathological examination and PCR is indicated. Curative radical surgery is possible in only 25 to 35% of cases. In non-operable cases, long standing antiparasitic therapy allows to stop the progression of lesions.

Cystic echinococcosis of lung and heart coupled with repeated echinococcosis of brain--a case report

Echinococcosis is rarely encountered as a cystic brain disease. In this article we are presenting a case of a young woman repeatedly operated due to echinococcosis of lung, heart and brain. Recurrent brain ecchinococcosis developed despite preoperative and postoperative albendazol therapy after first and combined therapy with albendazol and praziquantel after the second brain surgery. The mechanism of recurrence remains unclear (primary infestation, dissemination after spontaneous or intraoperative cyst rupture or new infestation).

[Complex therapy of echinococcosis in children]

Results of the immune-enzyme assay (IEA) of children with liver and lung echinococcosis before and after the operation were analyzed. The IEA accuracy was 91% for liver echinococcosis and 57% for lung echinococcosis. Sensitivity was 86% and 55, respectively. IEA was a reliable method of disease recurrence detection postoperatively. Conservative treatment of hydatid disease consisted of Antiparasitic and auxiliary therapy and was successfully applied in 7 patients with liver echinococcosis and 3 kids with combined affection. Preventive chemotherapy was carried out in 115 patients. During the 5 years follow-up period no recurrences was registered.

Management of multiple echinococcosis in childhood with albendazole and surgery

BACKGROUND/PURPOSE

Multiple echinococcosis (ME) is a severe disease in childhood inaccessible to an initial radical surgical treatment. The aim of this study was to evaluate the efficacy of Albendazole in ME and to discuss the role of surgery in this pathology.

METHODS

Eleven patients were included in a prospective study between 1996 and 2004. ME was defined by the presence of 10 or more cysts in the same organ. Albendazole was given as 10 mg/kg daily continuously. Treatment outcome was defined as cure, improvement, stabilization or deterioration. Surgery was discussed after 1 year of treatment.

RESULTS

Our patients totalized 296 cysts located essentially on the liver (178 cysts) and the lungs (78 cysts). With exclusive Albendazole therapy, 57.7% pulmonary cysts and 96% peritoneal cysts were considered as cured. This rate was only 31.5% in hepatic localization. After surgical therapy, 67.4% of hepatic cysts were cured. No productive biliary fistula was observed. Two patients were operated laparoscpically. The total treatment duration ranged between 1 and 5 years. Parasitologic examination of operated cysts showed that 30% of them were viable even after 3 years of treatment.

CONCLUSION

Albendazole has proven a strong efficacy in pulmonary and peritoneal localizations. A complementary surgical treatment is often necessary in hepatic localizations and it is facilitated with previous Albenazole therapy. Combination of ABZ and surgery seems to have encouraging results and must be applied for those patients. The high rate of viable cysts after medical therapy is problematic and must incite to develop new antihelminthic agents.

[Treatment of alveolar echinococcosis: a multidisciplinary task]

Alveolar echinococcosis is characterized by a long asymptomatic period but, without treatment, up to 80% of patients may die within ten years of diagnosis. Owing to a lack of fast-acting and fully effective chemotherapy, partial radical hepatic resection is the only chance of cure. One-third of patients are now treated in this way, and complex vascular and biliary reconstruction procedures are sometimes necessary. Liver transplantation may also be indicated for highly selected patients (about 5%) with life-threatening complications after failure of other treatments. Interventional radiology and endoscopy can be used to drain liver abscesses and/or infected and obstructed bile ducts, either as palliative procedures or as a bridge to radical resection. Parasitostatic benzimidazole therapy, especially based on continuous albendazole administration, is mandatory for at least two years after radical resection, and for life in inoperable patients.

Is lobectomy necessary in the treatment of pulmonary hydatid cysts?

BACKGROUND

Hydatidosis is endemic in Turkey and many other areas of the world. The definitive treatment for pulmonary hydatidosis is surgical. The purpose of this study was the review of surgical therapy of our patients with pulmonary hydatid disease and the necessity of lobectomy.

METHODS

We reviewed 107 patients: 26 of whom were women and 81 were men. The median age was 30 years (range, 7-57 years). Chest roentgenogram, abdominal ultrasound and computed tomography of the chest and upper abdomen were carried out as diagnostic study. All patients underwent thoracotomy and cystotomy with or without capitonnage.

RESULTS

Four patients had two cysts in the same lobe and one patient had three cysts (one perforated and two intact) in the left lower lobe (4.6%). In nine patients, the cysts were >10 cm in diameter (8.4%). In 18 patients, the cysts were suppurative (16.8%). None of the patients required lobectomy. Of the 107 patients, prolonged air leaks (n = 8), atelectasis (n = 3) and empyema (n = 3; two had empyema preoperatively because of pleural perforation of cysts and the other had prolonged air leak) were observed in the postoperative period. There was no death.

CONCLUSION

The effective treatment of hydatid cysts in the lung is the complete excision of the cyst with maximum preservation of lung parenchyma. We believe that the decision of lobectomy must be taken very carefully, even in the case of infected hydatid cysts, atelectasis, giant cysts and multiple cysts in the same lobe.

Pulmonary hydatid cyst in HIV-1 disease

A 36-year-old male patient, a known case of retroviral disease, presented with clinical features suggestive of pneumonia and was found to have bilateral lower zone lung consolidation which on resolution showed a cystic change on the chest radiograph. A subsequent CT scan revealed the true nature of these cysts to be ruptured pulmonary hydatid cysts showing a 'water lily sign'. The rare association of pulmonary hydatid cyst and HIV from India is described.

Der Wurm in der Lunge

Die Lunge kann bei einer Vielzahl von Helminthiasen beteiligt sein. Sie ist entweder das Habitat der Würmer oder die pulmonalen Symptome sind Folge der Passage von Helminthenlarven während deren Reife- und Migrationsprozess im menschlichen Organismus. Entsprechend vielfältig und unspezifisch können bei einer pulmonalen Helminthiase die klinischen Symptome sein. Die klassische Trias von respiratorischen Symptomen, Eosinophilie im peripheren Blut und Infiltrate im Thorax-Röntgenbild ist nur eine der vielen möglichen Manifestationen. Es gibt kaum pathognomonische Zeichen, die sich spezifisch einer Helminthiase zuordnen lassen. Bei klinischem Verdacht kann mit einer detaillierten Anamnese das in Frage kommende Erregerspektrum eingegrenzt werden. Die Diagnose einer Helminthiase erfolgt entweder durch direkten Erregernachweis oder indirekt mit serologischen Methoden.

Ruptured hydatid cyst in the right thorax: differential diagnosis to pleural empyema

We present a case of a hydatid cyst (Echinococcus granulosus) rupturing into the right pleural cavity. Clinical and radiological findings were consistent with a pleural effusion caused by pneumonia and led primarily to a wrong diagnosis. Pleural fluid analysis was suspicious for parapneumonic pleural empyema. After thoracoscopy led to the correct diagnosis a combined surgical and chemotherapy approach achieved complete remission.

Modified PAIR technique for percutaneous treatment of high-risk hydatid cysts

PURPOSE

This paper presents a modification of the known method for percutaneous treatment of hydatid cyst, the PAIR technique. It aimed to achieve safe aspiration of large symptomatic cysts and cysts with a danger of impending rupture.

METHODS

We designed a coaxial catheter system to achieve concomitant evacuation of cyst contents while infusing scolicidal agent. Hypertonic saline is used to wash out cyst contents and to kill protoscolices. This was followed by injection of a sclerosant (ethyl alcohol 95%) into the residual cyst cavity to prevent formation of a cyst collection after the procedure. Seventeen cysts in 14 patients were successfully aspirated. Follow-up plain radiographs, ultrasonography and CT were performed weekly in the first 4 weeks and then at 3, 6 and 12 months for all patients. Seven patients (9 drained cysts) were followed up for 2 years and 1 patient for 3 years.

RESULTS

All cysts were successfully aspirated. The following morphologic changes were noticed: a gradual decrease in cyst size (17 cysts, 100%), thickening and irregularity of the cyst wall due to separation of endocyst from pericyst (7 cysts, 41%), development of a heterogeneous appearance of the cyst components (8 cysts, 47%) and development of pseudotumor (2 cysts, 12%). None of the treated cysts disappeared completely. No significant procedure-related complications were encountered.

CONCLUSION

This modified PAIR technique is a reliable method for percutaneous treatment of risky and symptomatic hydatid cysts.

Cystic hydatid disease: current trends in diagnosis and management

Cystic echinococcosis is endemic in certain parts of the world. The growth of the cyst is often slow, and the liver and lungs are the most frequently involved organs. Diagnosis is based on clinical signs and symptoms and epidemiological data, while ultrasonography is important for the classification of hydatid cysts. Although certain types of hydatid cysts are successfully treated by percutaneous aspiration, injection, and reaspiration, surgery remains the treatment of choice. We reviewed the current trends in the diagnosis and management of cystic echinococcosis, with special emphasis on hepatic and pulmonary involvement.

Salmonella typhi-infected lung hydatid cyst

A 12-year-old girl presented with hemoptysis, fever and weight loss. She was initially diagnosed and treated for presumed tuberculosis and a lung abscess. Salmonella typhi was isolated from the abscess. Hydatid cyst was diagnosed at surgery. This is the first reported case of a pulmonary hydatid cyst infected with S. typhi.

Endemic alveolar echinococcosis in Southern Belgium?

Until now, Belgium has been considered as a low-risk country for alveolar echinococcosis. However it was recently demonstrated by necropsy series that, in some parts of southern Belgium (Wallonia), up to 51% of the red foxes (Vulpes vulpes) may be infected by E. multilocaris. The authors, working in a university hospital in southern Belgium, described in 2002 the first autochthonous Belgian case of hepatic alveolar echinococcosis. More importantly, in 2004, they diagnosed three other patients with alveolar echinococcosis. One underwent surgical resection, but two others had bilateral pulmonary involvement at time of definite diagnosis. Palliative albendazole therapy was initiated. These patients had been diagnosed with hepatic mass from unknown origin for several months. The previous experience with the first case allowed the authors to consider and to confirm alveolar echinococcosis diagnosis, made by pathology and/or serological tests and imaging. These four patients with alveolar echinococcosis were living either in the Liege or the Luxembourg province. Considering the high prevalence of E. multilocaris infection of red foxes and the recent increase of the fox population due to rabies vaccination in southern Belgium, and also the presence of E. multilocaris infection of red foxes in northern Belgium, it is likely that not only Wallonia, but also maybe the whole Belgium, may face endemic alveolar echinococcosis in the next years.

Kyste hydatique du coeur et des vaisseaux, 4 observations

INTRODUCTION

The lung is the most frequent location of hydatid cysts (HC). Cardiac and vascular HC are rare, and the primary location in the pulmonary artery is exceptional.

OBSERVATIONS

We report three cases of right cardiac HC cyst revealed by pulmonary hydatidosis, and 1 case of a primary HC of the pulmonary artery revealed by haemoptysis. Treatment consisted in surgical resection of the cardiac and pulmonary artery HC. Post-surgical antiparasite chemotherapy, based on albendazole, was prescribed for all patients. The evolution was towards a post pneumonectomy syndrome in the patient with a HC in the pulmonary artery, major pulmonary hypertension in the case of pulmonary embolic hydatidosis and an extension of the hydatid lesions in the third patient. Treatment is ongoing in the fourth patient with the development of many parenchymatous cysts.

DISCUSSION

Cardiac and vascular hydatid cysts are rare and of bad prognosis. These cardiac and vascular cysts are of poor prognosis because of the risk of rupture and hematogenic dissemination. Treatments are only partially effective and more importance should be given to preventive treatment.

Multiple organ involvement hydatid cysts in a 2-year-old boy

The cerebral hydatid cysts caused by Echinococcus granulosus are rare and occur mostly during childhood in endemic areas. A 2-year-old boy was admitted with focal neurological signs in the left extremities. Magnetic resonance imaging of the brain showed a cyst lying from right parietooccipital region to the lateral ventricle. There were also multiple cysts in his lung and liver. The cerebral hydatid cyst was surgically extracted without complications. We suggest that a differential diagnosis of hydatid cyst should be considered when a brain mass is found in a patient, even 2 years old, from an endemic area of echinococcosis.

Hydatid disease with atypical localization: 4 cases report

Hydatid disease caused by Echinococcus often manifests as slowly growing cystic mass and mainly affects the liver or lung and rarely other parts of the body such as brain, heart, bone and muscle. Cyst may be single or multiple, uni-or multiloculated. In this paper 4 hydatic cases, multiple and atypically localized are presented. Of the 4 cases, 2 were known to suffer from hydatid disease, having had a hepatic cyst removal previously. Thus, when faced with a hydatid cyst in any part of the body, it is preferable to examine other parts of the body by radiological imaging methods.

[Imaging methods in the diagnosis and therapy of cystic echinococcosis]

Imaging studies, ultrasonography, play a central role for the diagnosis and follow-up of cystic echinococcosis (hydatid disease) due to the non-specific clinical symptoms and still inadequate sensitivity and specificity of currently available serological tests. Due to the increasing number of people immigrating to central Europe from countries with a high incidence of cystic echinococcosis, cystic echinococcosis has become an important differential diagnosis of cystic lesions. The imaging modality to localize and stage the disease depends on the organs affected. Ultrasonography is the most important imaging technique to screen for abdominal lesions (more than 75 % of the cases). Therefore, an expert committee of the WHO Working Group on echinococcosis has recently suggested a standardized ultrasonographic classification of hepatic cystic echinococcosis. This classification proofs to be very useful for staging echinococcal cysts with respect to parasite activity. Ultrasonography is not only an excellent tool for the primary diagnosis and therapeutic decision but also for follow-up of patients treated for cystic echinococcosis. Indications for computed tomography or magnetic resonance tomography are restricted to extra abdominal disease, patients not suited for ultrasonography because of obesity or meteorism, complicated cysts and planning of surgery or interventional therapy. Apart from surgery three other treatment options are well established: (1) chemotherapy with albendazole or mebendazole, (2) percutaneous drainage and sterilization (PAIR) and (3) observation of inactive echinococcal stages ("watch and wait" approach).

Pulmonary cystic hydatid disease in Ireland

BACKGROUND

Hydatid disease is rare in Ireland and its incidence and prevalence are unknown. Most cases are diagnosed by a combination of clinical findings, morphological features on imaging and by serological testing.

AIMS

We describe an Irish case of pulmonary hydatid disease detected at bronchoscopy by bronchoalveolar lavage, and discuss the diagnosis and treatment of the disorder.

CONCLUSION

The diagnosis of this rare disease requires a high index of suspicion. Treatment is primarily surgical, with a role for antihelminthic agents.

[Echinococcal cysts in the liver and lungs]

The authors present the case of a patient with relapsing parasitic cyst of the liver and a parasitic cyst of the lungs. The patient was treated by surgery. The cystectomy of the echinococcus cyst in the liver was made in the first stage and subsequently a resection of the lung tissue containing another echinococcus cyst was made. Pharmacological therapy by the anti-helmintic drug albendazol was a part of the treatment. There were no complications during both surgical interventions and the subsequent treatment. In the scolocidal liquid of the liver cyst, echinococcus organisms were diagnosed by microscopy and documented by photography.

Pulmonary echinococcosis

Echinococcosis or hydatid disease is caused by larvae of the tapeworm Echinococcus. Four species are recognised and the vast majority of infestations in humans are caused by E. granulosus. E. granulosus causes cystic echinococcosis, which has a worldwide distribution. Humans are exposed less frequently to E. multilocularis, which causes alveolar echinococcosis. E. vogeli and E. oligarthrus are rare species and cause polycystic echinococcosis. In cystic echinococcosis, humans are an accidental host and are usually infected by handling an infected dog. The liver and lungs are the most frequently involved organs. Pulmonary disease appears to be more common in younger individuals. Although most patients are asymptomatic, some may occasionally expectorate the contents of the cyst or develop symptoms related to compression of the surrounding structures. Other symptoms of hydatid disease can result from the release of antigenic material and secondary immunological reactions that develop from cyst rupture. The cysts are characteristically seen as solitary or multiple circumscribed or oval masses on imaging. Detection of antibody directed against specific echinococcal antigens is found in only approximately half of patients with pulmonary cysts. Surgical excision of the cyst is the treatment of choice whenever feasible.

[Alcohol treatment of hydatid cyst in a case of old hydatidosis with hepatic skip]

Hydatidosis is related to parasitical etiology, linked to Echinococcus granulosis and Echinococcus multilocularis. The authors describe an uncommon clinical case of old hydatidosis in an 80-year old woman, presenting hepatic skip , with localization to the right lung and kidney and burrowing to the posterior abdominal wall. Because of the patient's lack of compliance, percutaneous treatment with alcohol of the lumbar lesion with 95% ethanol is carried out under echographic guide, to improve quoad valetudinem prognosis. The authors indicate that the method target are: 1) multiple relapse lesions; 2) complicated anatomie area; 3) multiltle cyst; 4) marginal lesions. Moreover, this method shows important advantages such as be possibility of repetition, low invasivity, high patient's compliance, low rate of shock and dissemination and finally low cost.

Transdiaphragmatic extension of hepatic hydatid cyst

Transdiaphragmatic extension of hydatid cyst (HC) or cystic echinococcosis (CE) of the liver is a rare phenomenon. We report a case that presented as a right middle lobe consolidation. The diagnosis of transdiaphragmatic extension of hepatic hydatid cyst was suspected on CT scan of the chest and abdomen, and confirmed operatively. A successful outcome was achieved by a combination of pre- and post-operative albendazole therapy combined with surgery.

Hydatid lung disease (echinococcosis/hydatidosis)

Two Echinococcus species may exhibit medical relevance as causative agents of pulmonary forms of echinococcosis. Most importantly, infections with Echinococcus granulosus result in "cystic hydatid disease" or "cystic echinococcosis," which affects the lungs in a considerable ratio of cases. Echinococcus multilocularis, which causes "alveolar echinococcosis," affects the lungs relatively rarely and then usually upon metastasizing from primary hepatic lesions. Cystic echinococcus and alveolar echinococcus differ pathologically and clinically so greatly that they are considered separately in this article, although alveolar echinococcus is covered minimally because of its minor importance regarding lung infections.

Pulmonary hydatid and other lung parasitic infections

The lung may be infested by a great number of parasites. Hydatidosis is the most frequent parasitic lung disease. Diagnosis of lung hydatidosis is usually easy on chest radiography, ultrasonography, and CT scan, and immunodiagnosis may help in dubious cases. Surgery is necessary in most cases, but it must be conservative. Complex forms, such as disseminated disease and secondary lung hydatidosis (metastatic or bronchogenic) are difficult to treat and may be considered malignant. Medical treatment may be helpful in complex forms, in poor surgical risk patients, and in cases of preoperative spillage of hydatic fluid. Prevention programs are necessary in endemic areas, and research must be directed toward vaccination against the parasite. Other parasitic diseases are reported less frequently in the literature, and the majority of published articles are either case reports or only report a small number of cases. Clinical presentation is variable according to the great variety of parasites that may involve the lungs.

[Clinico-epidemiologic aspects of pulmonary echinococcosis in western Herzegovina from 1969 to 1998]

This research has included 111 pulmonary echinococcosis patients in the billy-mountainous, more cattle raising region of Western Herzegovina. Since 1969, the prevalence of pulmonary echinococcosis, which was 27 (0.15%) at the time, has had a slow declining tendency after the application of various epidemiological-preventive measures synchronized by the veterinarian and the medical services. It was not until 1998 the prevalence result fell down to 1 (0.01%). This study describes the therapy approach of surgery results with 82 patients who were operated on, as well as the prognosis of 29 other echinococcosis patients who rejected surgery but were regularly checked up. Apart form the progress in healing this disease, which is still found and presents a problem in the Mediterranean part of Herzegovina, because of its frequency and the difficulty in diagnostics; and particularly because of possible complications of this zoonosis. The possibility and the way of the albendazolom drug treatment have also been described here.

Tension pneumothorax associated with hydatid cyst rupture

SUMMARY

Hydatid disease is common in Turkey. Tension pneumothorax is rare, but it is an important complication of the hydatid cyst with significant morbidity and mortality. Tension hydropneumothorax secondary to the rupture of a hydatid cyst was detected in 5 of 185 spontaneous pneumothorax cases that were treated in the authors' clinic between 1992 and 1998. All patients were subjected to surgical treatment after urgent tube thoracostomy. No mortality or recurrence was observed at follow-ups of 9 to 24 months.

Hydatid cyst of the lung: diagnosis and treatment

Hydatid infestation of the lung can be primary or secondary. In three of four cases the cyst is a single one. Hydatidosis of a different location, particularly the liver, may be associated. The period of initial growth of primary hydatidosis is frequently asymptomatic. Bronchial fistulization is an important event in the evolution of the cyst. Intrapleural rupture constitutes a rare eventuality, but it is often as characteristic as it is severe. Secondary, metastatic hydatidosis, due to breaking of a primary visceral cyst in a vein or heart, is rare. A special form is so-called multiple malignant pulmonary hydatidosis, which causes progressive respiratory deficiency and right ventricular failure. There are a variety of radiographic images. Ultrasonography, computed tomography, and magnetic resonance imaging can recognize certain details of the lesions and discover others that are not visible by conventional radiography. For a specific serologic diagnosis, our experience favors the immunoglobulin G enzyme-linked immunosorbent assay and immunoelectrophoresis. Treatment is essentially surgical. In general, chemotherapy is used as a complement to operative treatment to avoid recurrence. Surgery has two objectives: to remove the parasite and to treat the bronchipericyst pathology and other associated lesions. The prognosis has changed during the last few years, and results are now commonly satisfactory. The most frequent complications are pleural infection and prolonged air leakage. Operative mortality does not exceed 1% to 2%. Despite the low mortality and the limited recurrence rate, it is necessary to remember the invading character of pulmonary hydatid disease, which sometimes makes therapy difficult and questionable. Prophylaxis is essential to eradicate the disease completely.

[The solitary echinococcal cyst--a rare cause of a round pulmonary focus]

HISTORY AND ADMISSION FINDINGS

A 29-year-old man from Kazakhstan presented with right-sided chest pain, cough, whitish sputum and a temperature up to 38.5 degrees C. He had been working in an animal farm for the previous two years.

INVESTIGATIONS

Laboratory tests showed increased inflammatory parameters (WBC 15.9 gpt/l with an increased proportion of band and segmented granulocytes, C-reactive protein (242.3 mg/dl). Chest radiogram showed an infiltration and effusion in the right base judged to be due to pneumonia. In addition there was a round homogeneous mass, 2.5 cm in diameter, at the lateral thoracic wall in the 8th lower lobe segment. Computed tomography (CT) of the lung and mediastinum confirmed these findings. Bronchoscopy, echocardiography, upper abdominal sonography and CT of the skull revealed no other space-occupying lesion.

DIAGNOSIS, TREATMENT AND COURSE

The right-sided pneumonia was successfully treated, at first with ceftriaxone (i.v.), later with ofloxacin (by mouth). An echinococcal cyst was considered especially because of the patient's profession in Kazakhstan in the differential diagnosis of the right-sided round mass and confirmed by an indirect haemagglutination test giving an antibody titre of 1:1024. In response a thoracotomy was performed and the mass, histologically an echinococcal cyst (E. granulosa), resected. There were no other cysts. There was no explanation for the right-sided pneumonia.

CONCLUSIONS

Even though Echinococcosis is rare in Central Europe, it should be included in the differential diagnosis of a round pulmonary mass. A detailed history, especially with regard to occupation and country of origin, is essential. Serological tests for specific Echinococcus antibodies, together with usual imaging procedures, will usually and quickly provide the diagnosis.

Hydatid disease in childhood: a retrospective analysis of 376 cases

During a 20-year period, 376 children with hydatid disease were treated at Hacettepe University Ihsan Doğramaci Children's Hospital. There were 223 males and 153 females with a mean age of 8.9+/-0.1 years. Hydatid cysts were localized in the lungs in 222 patients, in the liver in 56 patients, and in other organs in the remaining patients. Cough, fever, and abdominal pain were the most common symptoms. One hundred eight patients had medical, 182 patients had surgical, 73 patients had medical and surgical, and 4 patients had medical and percutaneous drainage treatment as the initial therapy. When evaluating the results of therapy, the relapse rate was higher in surgically treated patients than medically treated patients. We conclude that medical treatment of childhood hydatidosis is best, except in cases with complications such as infection, parenchymal compression or obstruction of airways, bile duct or viscera; all of these are indications for surgical therapy.

[Management of hydatid disease of the lung]

Cystic echinococcosis is a worldwide zoonose which is not infectious from man to man occurring seldom in our country. The diagnosis and the treatment of a case of a 4-year-old girl with large left-sided lung cyst were presented. Diagnosis was based on history, clinical findings, imaging techniques (conventional X-ray examination, ultrasonography, computer tomography), eosinophilia (7-50%) in blood smear, leucocytosis (28,000), increased sedimentation of blood (85 mm/hour), significantly elevated antibody against of Echinococcus in immunodiagnostic test (passive haemagglutination) with high sensitivity and specificity, light microscopic radiological and scanning electronmicroscopic analysis of cyst content. Continuous thoracic drainage, twice percutan drainage under CT guidance and a new technique for treatment as Puncture-Aspiration-Injection-Respiration and lavage with hypertonic sodium chlorate, long-term chemotherapy with benzimidazole-carbamates (Vermox: 20 mg/kg/day, Zentel: 30-50 mg/kg/day) were reported. The cyst was grown down into a solid mass as large as 4 cm. The body-weight of this child has grown 6 kilograms and laboratory parameters were normalized.

Nonsurgical therapy for pulmonary hydatid cyst disease

Therapeutic and diagnostic aspiration of Echinococcus granulosus liver cysts, but not pulmonary cysts, are increasingly being performed. Documented herein is the utility of percutaneous drainage and of albendazole treatment in a patient with a large recurrent, isolated, pulmonary echinococcal cyst for whom traditional therapy would have resulted in severe morbidity. Therapeutic options and possible complications are discussed.

Echinococcus

Echinococcosis (hydatid disease) is a zoonotic infection of human beings caused by the postlarval metacestode stage of the dog tapeworm, Echinococcus. Hydatid disease is more frequently the result of infection by Echinococcus granulosus and E. multilocularis species, which are more widely prevalent geographically than E. vogeli and E. oligarthus. The epidemiology, biology, and host-parasite relationships of echinococcal infection are discussed, and the clinical consequences of human infection are reviewed with particular emphasis on the pulmonary manifestations of the disease. The utility of serological and radiological techniques in diagnosis and management are reviewed. The efficacy of medical therapy and its relationship to the role of surgical intervention in the management of unilocular (cystic) and multilocular (alveolar) hydatid disease is discussed. Finally, the successes and failures of public health programs to control this zoonosis are noted.