Multiple myeloma with Echinococcus granulosus infection diagnosed by detection of oligoclonal bands: A case report

RATIONALE

Isoelectric focusing electrophoresis (IFE) is currently recognized as the gold standard for detecting oligoclonal bands (OCBs) in cerebrospinal fluid (CSF). To the best of our knowledge, however, no study has reported on type III OCBs using IFE. In this paper, we report on a rare case of multiple myeloma (MM) with Echinococcus granulosus infection diagnosed by IFE.

PATIENT CONCERNS

A 71-year-old man complained of weakness of the right lower extremity accompanied with fever (temperature range 37.8°C-38.2°C) for more than 6 months.

DIAGNOSES

MM with E granulosus infection.

INTERVENTIONS

The IFE results identified a unique monoclonal band, indicating that the patient may have MM in conjunction with a distinct pathogen infection. He received anthelmintic treatment and bortezomib-thalidomide-dexamethasone therapy.

OUTCOMES

The patient was followed up for 15 months. During that time, his temperature returned to normal, his Medical Research Council Grading of Muscle Power scale became 5, and his vital signs stabilized.

LESSONS

Detection of OCB type III indicated that the patient was diagnosed with MM accompanied by E granulosus infection. Thus, IFE of CSF may be an auxiliary diagnostic method for MM in the future.

Establishing and evaluation of a polymerase chain reaction for the detection of Echinococcus multilocularis in human tissue

BACKGROUND

Alveolar echinococcosis (AE) is caused by metacestode larva of the tapeworm Echinococcus multilocularis. AE diagnostics currently rely on imaging techniques supported by serology, but unequivocal detection of AE is difficult. Although polymerase chain reaction (PCR)-based methods to detect tapeworm DNA in biopsies have been suggested for several species, no validated protocol adhering to accepted guidelines has so far been presented for AE diagnostics. We herein established a PCR protocol for metacestode biopsies and technically evaluated the method using isolated parasite DNA and cells, biopsies of clinically relevant material, and formalin fixed paraffin-embedded (FFPE) human tissue blocks. We compared the results with an immunochemical (IHC) approach using the monoclonal antibody Em2G11 specific for the antigen Em2 of E. mulitlocularis.

METHODOLOGY/PRINCIPAL FINDINGS

Based on tapeworm 12S rDNA sequences we established and validated a PCR protocol for robust detection of as little as 50 parasite cells per specimen and report 127 cases of positive identification of Echinococcus species in samples from humans and animals. For further validation, we analyzed 45 liver, heart, brain, and soft tissue samples as well as cytological probes of aspirates of FFPE-material from 18 patients with clinically confirmed AE. Of each patient we analyzed (i) fully viable lesions with laminated layer; (ii) tissue with mAbEm2G11-positive small particles of E. multilocularis (spems); (iii) mAbEm2G11-negative tissue adjacent to the main lesion; and (iv) lymph node tissue with mAbEm2G11-positive spems. To identify the areas for the PCR-based approach, we performed IHC-staining with the monoclonal antibody Em2G11. Micro-dissected tissue of these areas was then used for PCR-analysis. 9 of 15 analyzed samples with viable E. multilocularis lesions with laminated layer were positive by PCR. Of this group, all samples preserved for less than 6 years (6/6) were tested positive. 11 of 15 samples of spems and 7 of 9 samples of the control group mAbEm2G11-negative tissue were negative by PCR. We further show that all probes from lymph nodes with spems are PCR negative.

CONCLUSIONS/SIGNIFICANCE

We present a sensitive PCR method for the detection of E. multilocularis in human tissue, particularly in fresh biopsy material and tissue blocks stored for less than 5 years. While the diagnostic sensitivity of material containing only spems was higher using IHC, PCR detection was possible in IHC negative liver tissue and in patients with negative serology. Our results support the view that spems do not contain parasitic DNA or viable cells of the parasite. spems thus most probably do not directly contribute to metastasis formation during AE.

Echinococcus multilocularis Infection, Southern Ontario, Canada

Alveolar echinococcosis, the disease caused by infection with the intermediate stage of the Echinococcus multilocularis tapeworm, is typically fatal in humans and dogs when left untreated. Since 2012, alveolar echinococcosis has been diagnosed in 5 dogs, 3 lemurs, and 1 chipmunk in southern Ontario, Canada, a region previously considered free of these tapeworms. Because of human and animal health concerns, we estimated prevalence of infection in wild canids across southern Ontario. During 2015–2017, we collected fecal samples from 460 wild canids (416 coyotes, 44 foxes) during postmortem examination and analyzed them by using a semiautomated magnetic capture probe DNA extraction and real-time PCR method for E. multilocularis DNA. Surprisingly, 23% (95% CI 20%–27%) of samples tested positive. By using a spatial scan test, we identified an infection cluster (relative risk 2.26; p = 0.002) in the western-central region of the province. The cluster encompasses areas of dense human population, suggesting zoonotic transmission.

Intense Focus of Alveolar Echinococcosis, South Kyrgyzstan

Human alveolar echinococcosis (AE) is a highly pathogenic zoonotic parasitic disease caused by Echinococcus multilocularis. An ultrasound study in southern Kyrgyzstan during 2012 revealed a prevalence of 4.2% probable or confirmed AE and an additional 2.2% possible AE, representing an emerging situation. The risk for probable or confirmed AE was significantly higher in dog owners.

Analysis of factors affecting outcomes of pregnancy complicated by Echinococcus: an algorithm for approach and management

PURPOSE

The management of hydatid disease (HD) co-occurring with pregnancy remains a challenge for physicians. We aimed to determine factors that were related to fetal and maternal outcomes in HD complicated pregnancies and then develop an approach/treatment algorithm.

METHOD

All patients at the participating hospitals were first analyzed to determine whether they had HD. Only patients diagnosed with HD during the course of their pregnancy were included. Certain cyst-related factors (diameter, localization, increase in size, and viability) and certain pregnancy-related factors (treatments, gestational week, maternal co-morbidities, and delivery type) were investigated. Nonlinear principal component analysis (NPCA) was performed to determine the relationships between the categories of variables.

RESULTS

Out of 12,926 pregnancies, 27 cases were diagnosed with HD. In 13 cases, each developed at least one fetal problem. Using Albendazol in first trimester, presence of an active cyst, increased diameter by more than 1 cm during pregnancy and a cyst diagnosed in the second trimester were associated with at least one fetal problem. According to the NPCA results, cyst diameter when first diagnosed was related to fetal outcomes; a cyst greater than 10 cm was associated with "at least one fetal problem". Cysts 5-10 cm in diameter were in a neutral position, while 2-5 cm in diameter were in the "no problems" group.

CONCLUSIONS

HD mostly affects fetus. If cyst-related and pregnancy-related variables are optimal, close follow-up on a monthly is the best course of action. However, in high-risk conditions, percutaneous interventions or surgery should be considered.

Molecular characterization of Echinococcus granulosus sensu lato from farm animals in Egypt

Little is known on the diversity and public health significance of Echinococcus species in livestock in Egypt. In this study, 37 individual hydatid cysts were collected from dromedary camels (n=28), sheep (n=7) and buffalos (n=2). DNA was extracted from protoscoleces/germinal layer of individual cysts and amplified by PCR targeting nuclear (actin II) and mitochondrial (COX1 and NAD1) genes. Direct sequencing of amplicons indicated the presence of Echinococcus canadenesis (G6 genotype) in 26 of 28 camel cysts, 3 of 7 sheep cysts and the 2 buffalo derived cysts. In contrast, Echinococcus granulosus sensu stricto (G1 genotype) was detected in one cyst from a camel and 4 of 7 cysts from sheep, whereas Echinococcus ortleppi (G5 genotype) was detected in one cyst from a camel. This is the first identification of E. ortleppi in Egypt.

[Immunorehabilitation in patients with paecilomycosis-complicated echinococcosis and asthma]

Paecilomycosis is a new type of systemic mycosis caused by different species of fungi of the genus Paecilomyces. Paecilomycosis-complicated echinococcosis and asthma run a severe course. A complication of mycosis is accompanied by secondary immunodeficiency. A good result was obtained in the treatment of ill children by using the fungicide diflucan and the immunomodulator polyoxidonium. In the examinees with paecilomycosis-complicated echinococcosis, secondary immunodeficiency was characterized by a statistical significant reduction in the blood levels of the lymphoid cells CD3+, CD4+, CD8+, CD16+, CD21+, by phagocytosis, a decrease in its quantitative parameters, and an increase in the counts of immunoglobulins and circulating immunocomplexes. To normalize the immune status in patients with paecilomycosis-complicated echinococcosis, it is expedient to postsurgicallyuse fungicides, such as nizoral, diflucan, orungal, mycosyst, and the immunomodulators polyoxidonium and irillen.

Time course of gene expression profiling in the liver of experimental mice infected with Echinococcus multilocularis

BACKGROUND

Alveolar echinococcosis (AE) is a severe chronic parasitic disease which behaves like a slow-growing liver cancer. Clinical observations suggest that the parasite, Echinococcus multilocularis (E. multilocularis) influences liver homeostasis and hepatic cell metabolism. However, this has never been analyzed during the time course of infection in the common model of secondary echinococcosis in experimental mice.

METHODOLOGY/PRINCIPAL FINDINGS

Gene expression profiles were assessed using DNA microarray analysis, 1, 2, 3 and 6 months after injection of E. multilocularis metacestode in the liver of susceptible mice. Data were collected at different time points to monitor the dynamic behavior of gene expression. 557 differentially expressed genes were identified at one or more time points, including 351 up-regulated and 228 down-regulated genes. Time-course analysis indicated, at the initial stage of E. multilocularis infection (month 1-2), that most of up-regulated pathways were related to immune processes and cell trafficking such as chemokine-, mitogen-activated protein kinase (MAPK) signaling, and down-regulated pathways were related to xenobiotic metabolism; at the middle stage (month 3), MAPK signaling pathway was maintained and peroxisome proliferator-activated receptor (PPAR) signaling pathway emerged; at the late stage (month 6), most of up-regulated pathways were related to PPAR signaling pathway, complement and coagulation cascades, while down-regulated pathways were related to metabolism of xenobiotics by cytochrome P450. Quantitative RT-PCR analysis of a random selection of 19 genes confirmed the reliability of the microarray data. Immunohistochemistry analysis showed that proliferating cell nuclear antigen (PCNA) was increased in the liver of E. multilocularis infected mice from 2 months to 6 months.

CONCLUSIONS

E. multilocularis metacestode definitely exerts a deep influence on liver homeostasis, by modifying a number of gene expression and metabolic pathways. It especially promotes hepatic cell proliferation, as evidenced by the increased PCNA constantly found in all the experimental time-points we studied and by an increased gene expression of key metabolic pathways.

Proteomic analysis of the Echinococcus granulosus metacestode during infection of its intermediate host

Cystic hydatid disease (CHD) is caused by infection with the Echinococcus granulosus metacestode and affects both humans and livestock. In this work, we performed a proteomic analysis of the E. granulosus metacestode during infection of its intermediate bovine host. Parasite proteins were identified in different metacestode components (94 from protoscolex, 25 from germinal layer and 20 from hydatid cyst fluid), along with host proteins (58) that permeate into the hydatid cyst, providing new insights into host-parasite interplay. E. granulosus and platyhelminth EST data allowed successful identification of proteins potentially involved in downregulation of host defenses, highlighting possible evasion mechanisms adopted by the parasite to establish infection. Several intracellular proteins were found in hydatid cyst fluid, revealing a set of newly identified proteins that were previously thought to be inaccessible for inducing or modulating the host immune response. Host proteins identified in association with the hydatid cyst suggest that the parasite may bind/adsorb host molecules with nutritional and/or immune evasion purposes, masking surface antigens or inhibiting important effector molecules of host immunity, such as complement components and calgranulin. Overall, our results provide valuable information on parasite survival strategies in the adverse host environment and on the molecular mechanisms underpinning CHD immunopathology.

Echinococcus multilocularis in Austrian foxes from 1991 until 2004

The prevalence rates of Echinococcus multilocularis in foxes (n=5600) evaluated in several Austrian surveys conducted between 1991 and 2004 were analysed for spatial and temporal differences. Data from early studies (1993-1997) in which the intestinal scraping technique (IST) was utilized were compared with data from recent (1999-2004) investigations, which made use of the shaking in a vessel technique (SVT), and it was assessed whether or not the infection rates of Austrian foxes had increased between the investigated intervals. In total, data from 85 districts are presented and both the retrospective and recent data are available from 39 of these districts. A Bayesian hierarchical model of parasite prevalences is presented which (i) accounts for differences in the sensitivity of IST and SVT, (ii) incorporates spatial auto-correlation between neighbouring districts, (iii) investigates the possibility of a temporal shift in the infection status of foxes, and (iv) quantifies uncertainty at each level of the model. The national average prevalence rates in the mid-1990s and at the turn of the millennium were 2.4% (95% confidence intervals 1.1-4.8) and 3.9% (95% confidence intervals 1.5-8.4) respectively. Above average prevalence rates were observed in the western and the northern parts of the country. Evidence is also presented for a temporal augmentation of the prevalence rates in some districts in the northern and eastern parts of the country. These findings are in concordance with several investigations in other European states where both newly emerged areas and elevated levels of transmission in existing endemic areas have been found. None of the districts investigated here showed significant evidence of a drop in prevalence.

Secondary infection of intracranial hydatid cyst with Clostridium ramosum

INTRODUCTION

Brain involvement in hydatid disease occurs in 1-2% of all Echinococcus granulosus infections. Secondary infection of intracranial hydatid cysts is extremely rare.

CASE REPORT AND DISCUSSION

In this case report, we present a secondary infection of an intracranial hydatid cyst due to Clostridium ramosum, which is an extremely rare infectious pathogen in neurosurgical practice, and a potential pitfall in neuroradiological investigations.

Infected primary hydatid cyst of retroperitoneum

An infected primary solitary hydatid cyst of the retroperitoneum that displaced the right kidney and liver and elevated the diaphragm is described. It showed pericystic calcification and contained an air-fluid interface. No other hydatid cyst was demonstrable in any organ. The cyst was treated by surgery together with povidone-iodine irrigation and albendazole prophylaxis for secondary infestation. In these lesions, increased CT density of the mother cyst and lower densities of the daughter vesicles are pathognomonic. In the present case, secondary bacterial infection further increased the CT density of the mother cyst, while the daughter vesicles remained uninfected and were visible as lower densities.