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Aziz H, Seda P, Aswani Y, Gosse MD, Krishnakumari AJ, Pawlik TM. Cystic echinococcosis of the liver. J Gastrointest Surg 2025; 29:101974. [PMID: 39864780 DOI: 10.1016/j.gassur.2025.101974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2024] [Revised: 01/18/2025] [Accepted: 01/21/2025] [Indexed: 01/28/2025]
Abstract
BACKGROUND Cystic echinococcosis (CE) is a widely endemic helminthic disease caused by infection with metacestodes (larval stage) of the Echinococcus granulosus tapeworm, which is transmitted by dogs and found on every continent, except Antarctica. This study aimed to review the life cycle, epidemiology, symptoms, diagnostic methods, and treatment of E granulosus infection of the liver. METHODS A comprehensive review was conducted using MEDLINE/PubMed, Google Scholar, Cochrane Library, and the Web of Science, which were accessed between 1990 and 2024. The main search focused on "CE of the liver." The following terms were used: cystic echinococcosis, hydatidosis, E granulosus, echinococcus life cycle, liver cyst, albendazole, liver resection, pericystectomy, cystobiliary fistula, and percutaneous aspiration injection and reaspiration (PAIR). RESULTS CE should be considered in the differential diagnosis of hepatic cysts, especially among individuals with risk factors, such as those who have traveled to or immigrated from areas with a high prevalence. Echinococcus species require 2 hosts to complete their life cycle, with humans acting as intermediate hosts that become infected by ingesting eggs from contaminated environments, leading to cyst formation, typically in the liver or lungs. Symptoms are based on cyst size and location, such as abdominal pain, jaundice, respiratory distress, or neurologic deficits, and can lead to severe complications, such as cyst rupture, allergic reactions, sepsis, or secondary hydatidosis. Imaging plays a key role in evaluating cyst stage, size, location, and potential complications and in determining the appropriateness of a minimally invasive PAIR procedure. Although serum antibody tests typically have a low sensitivity, antigen assays or recombinant proteins may provide useful diagnostic information. For uncomplicated active cysts, the treatment options include chemotherapy alone or in combination with the PAIR technique. CONCLUSION Hepatic echinococcal cysts, which are relatively rare in North America, should be considered in the differential diagnosis of hepatic cysts, especially in individuals with risk factors.
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Affiliation(s)
- Hassan Aziz
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA, United States.
| | - Peyton Seda
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Yashant Aswani
- Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Matthew D Gosse
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Aparna Joshi Krishnakumari
- Department of Radiology, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, India
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, United States
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Shafiei R, Mohajerzadeh MS, Masomi HFA, Tavakoli M, Turki H, Firouzeh N. Discordance Therapeutic Protocol of Cystic Echinococcosis With WHO Guideline: A Descriptive Study Based on Liver Ultra-Sonographic Data in North Khorasan Province, Northeastern of Iran. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2024; 43:1279-1287. [PMID: 38497687 DOI: 10.1002/jum.16452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Revised: 03/07/2024] [Accepted: 03/08/2024] [Indexed: 03/19/2024]
Abstract
BACKGROUND Cystic echinococcosis (CE), a helminth-associated zoonosis caused by Echinococcus granulosus, poses a significant public health problem, particularly in pastoral-rearing regions. The lack of uniform guidelines led to variations in CE management. Based on ultrasound data, the World Health Organization Informal Working Group on Echinococcosis (WHO-IWGE) classification system categorizes cysts into active, transitional, and inactive groups. This study assesses whether the therapeutic approach from liver human operation cases in North Khorasan province aligns with the WHO-IWGE reference based on ultrasound data. METHODS The research is based on ultrasound data from liver CE human operation cases collected between 2018 and 2022. This retrospective study investigates the therapeutic protocol for (CE) in North Khorasan Province, Iran, comparing it with the WHO-IWGE guidelines. We collect data from previously registered patients' medical information from our studied area's main CE surgical hospital. Moreover, as the first hospitalized survey in Iran, this study reveals insights into patient demographics, cyst stage prevalence, and treatment modalities. RESULTS Notably, more than half of the patients were treated for CE1 stage cysts, and CE4 cases, which generally do not require surgery, underwent open surgery. The results suggest a need for adherence to the "watch-and-wait" approach in specific cases. All patients underwent successful surgeries, but we do not have access to follow-up data from patients after discharge. CONCLUSIONS This descriptive study contributes to understanding the implementation of WHO guidelines in a regional context, shedding light on the challenges and variations in CE management. It seems, retraining courses for surgeons are required to update their knowledge of standard CE diagnostic and treatment methods.
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Affiliation(s)
- Reza Shafiei
- Vector-Borne Diseases Research Center, North Khorasan University of Medical Sciences, Bojnurd, Iran
| | - Mina Sadat Mohajerzadeh
- Department of Radiology and Medical Physics, School of Medicine, North Khorasan University of Medical Sciences, Bojnurd, Iran
| | | | - Maryam Tavakoli
- Department of Radiology and Medical Physics, School of Medicine, North Khorasan University of Medical Sciences, Bojnurd, Iran
| | - Habibollah Turki
- Infectious and Tropical Diseases Research Center, Hormozgan Health Institute, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
| | - Nima Firouzeh
- Vector-Borne Diseases Research Center, North Khorasan University of Medical Sciences, Bojnurd, Iran
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Bumann S, Kuenzli E, Lissandrin R, Brunetti E, Goblirsch S, Henning L, Tamarozzi F, Neumayr A. Cardiac cystic echinococcosis-A systematic review and analysis of the literature. PLoS Negl Trop Dis 2024; 18:e0012183. [PMID: 38814859 PMCID: PMC11139302 DOI: 10.1371/journal.pntd.0012183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 04/30/2024] [Indexed: 06/01/2024] Open
Abstract
Human cystic echinococcosis (CE) is a parasitic infection caused by the larval stage of the tapeworm Echinococcus granulosus sensu lato, primarily affecting the liver and lungs. Although the heart is affected in only 0.02-2% of all CE cases, a considerable number of cases have been, and continue to be, published. However, due to the rare occurrence of cardiac CE and the resulting lack of clinical trials, knowledge about various aspects of the disease remains limited. To obtain a clearer picture of anatomical, clinical, diagnostic as well as therapeutic aspects of cardiac CE, we systematically reviewed the literature published between 1965 and 2022. The anatomical pattern of the affected cardiac structures follows the extension of the supplying capillary bed. The majority of patients (82.7%) are symptomatic and present with prolonged non-specific symptoms such as dyspnoea, chest pain and palpitations. Acute complications generally derive from cyst rupture, occur in 18.3% of cases and manifest as embolism, pericardial tamponade, or anaphylactic reaction in 83.2%, 17.8% and 10.9% of these cases, respectively. As for CE cysts localized in other organs, the diagnosis of cardiac CE is made by imaging. Serology plays a minor role due to its limited sensitivity. Unlike abdominal CE cysts, cardiac CE cysts are usually resected independent of their stage (active/inactive), because their presence impairs cardiac performance and carries the risk of long-term sequelae. More than 80% of patients are treated with a single surgical intervention. We found a disease-related case fatality rate of 11.1%. Since local recurrence was reported up to 108 months and secondary CE up to 72 months after surgery, patients should be followed up for a minimum of 10 years.
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Affiliation(s)
- Simone Bumann
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Esther Kuenzli
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Raffaella Lissandrin
- Division of Infectious and Tropical Diseases, University of Pavia, IRCCS S. Matteo Hospital Foundation, WHO Collaborating Centre on Clinical Management of Cystic Echinococcosis, Pavia, Italy
| | - Enrico Brunetti
- Division of Infectious and Tropical Diseases, University of Pavia, IRCCS S. Matteo Hospital Foundation, WHO Collaborating Centre on Clinical Management of Cystic Echinococcosis, Pavia, Italy
| | - Sam Goblirsch
- Department of Medicine and Pediatrics, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Lars Henning
- Department of Public Health and Tropical Medicine, College of Public Health, Medical and Veterinary Sciences, James Cook University, Queensland, Australia
| | - Francesca Tamarozzi
- Department of Infectious-Tropical Diseases and Microbiology, WHO Collaborating Centre on Strongyloidiasis and other Neglected Tropical Diseases, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Verona, Italy
| | - Andreas Neumayr
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- Department of Public Health and Tropical Medicine, College of Public Health, Medical and Veterinary Sciences, James Cook University, Queensland, Australia
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Richter J, Lindner AK, Geisel D, Fleckenstein FN, Torsello GF, Millet Pascual-Leone B, Ivanov O, Zöllner C, Wilde ACB, Equihua Martinez G. Percutaneous drainage and combined praziquantel-albendazole therapy: a novel approach for the treatment of simple echinococcal liver cysts. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:500-507. [PMID: 37729942 DOI: 10.1055/a-2084-3735] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
Cystic echinococcosis (CE) is a worldwide helminthic zoonosis causing serious disease in humans. The WHO Informal Working Group on Echinococcosis recommends a stage-specific treatment approach of hepatic CE that facilitates the decision on what therapy option is most appropriate. Percutaneous aspiration, instillation of a scolicide, e.g., ethanol or hypertonic saline, and subsequent re-aspiration (PAIR) have been advocated for treating medium-size unilocular WHO-stage CE1 cysts. PAIR can pose a risk of toxic cholangitis because of spillage of ethanol in the case of a cysto-biliary fistula or of life-threatening hypernatriaemia when hypertonic saline is used. The purpose of our study is to develop an alternative, safe, minimally invasive method to treat CE1 cysts, avoiding the use of toxic topic scolicides.We opt for percutaneous drainage (PD) in four patients: the intrahepatic drainage catheter is placed under CT-fluoroscopy, intracystic fluid is aspirated, and the viability of intracystic echinococcal protoscolices is assessed microscopically. Oral praziquantel (PZQ) is added to albendazole (ABZ) instead of using topical scolicidals.Protoscolices degenerate within 5 to 10 days after PZQ co-medication at a cumulative dosage of 250 to 335 mg/kg, and the cysts collapse. The cysts degenerate, and no sign of spillage nor relapse is observed in the follow-up time of up to 24 months post-intervention.In conclusion, PD combined with oral PZQ under ABZ coverage is preferable to PAIR in patients with unilocular echinococcal cysts.
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Affiliation(s)
- Joachim Richter
- Institute of International Health, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Andreas K Lindner
- Institute of International Health, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Dominik Geisel
- Department of Radiology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | | | | | | | - Olga Ivanov
- Institute of International Health, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Caroline Zöllner
- Department of Gastroenterology and Hepatology, Charité Universitätsmedizin Berlin, Berlin, Germany
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Chiodini PL. Medical management of cystic echinococcosis. Curr Opin Infect Dis 2023; 36:303-307. [PMID: 37593991 DOI: 10.1097/qco.0000000000000947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/19/2023]
Abstract
PURPOSE OF REVIEW Cystic echinococcosis is a neglected zoonosis for which humans are dead end hosts. It is not only widely distributed in sheep rearing areas of low-income and middle-income countries but also has a significant presence in wealthy countries, for example, in Europe. It results in considerable morbidity, and its current management is far from optimal. Medical management is with a benzimidazole, with the addition of praziquantel under some circumstances. RECENT FINDINGS Interest in mebendazole as an anticancer drug has stimulated research into new drug formulations to improve bioavailability and possibly reduce inter-individual variability in in-vivo drug levels, which may help its activity against cystic echinococcosis. Further evidence to support administration of albendazole with a fatty meal has been provided. GlaxoSmithKilne (GSK) has agreed to extend its albendazole donation programme to include echinococcosis. The search for new drugs has focussed on natural products, such as essential oils and on repurposing of existing drugs licensed for human use against other conditions. SUMMARY The medical treatment of cystic echinococcosis remains sorely neglected, with no new drugs for almost 40 years. We need a better understanding of how to use the drugs we do have, whilst seeking new ones. Drug repurposing may be the best pathway.
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Affiliation(s)
- Peter L Chiodini
- Faculty of Infectious and Tropical Diseases, The London School of Hygiene and Tropical Medicine, London, UK
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Luga P, Gjata A, Akshija I, Mino L, Gjoni V, Pilaca A, Zobi M, Martinez GE, Richter J. What do we know about the epidemiology and the management of human echinococcosis in Albania? Parasitol Res 2023:10.1007/s00436-023-07878-4. [PMID: 37272973 DOI: 10.1007/s00436-023-07878-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 05/11/2023] [Indexed: 06/06/2023]
Abstract
Echinococcosis is a life-threatening neglected zoonotic disease. Cystic echinococcosis (CE) due to Echinococcus (E.) granulosus usually involves livestock and dogs; alveolar echinococcosis (AE) due to E. multilocularis involves rodents and canines such as foxes and dogs. Human hosts are infected accidentally via hand to mouth and/or foodborne/waterborne pathways. Albania is deemed to be endemic for cystic echinococcosis (CE), but there is a scarcity of data to confirm this. A systematic literature search was performed in PubMed, Google Scholar, and in other medical sources. Because of the scarcity of existing information, data confirming CE cases were reviewed from the medical hospital records of Albania's largest Hospital, the Mother Teresa University Hospital (UHCMT) Tirana, and from a large private laboratory in Tirana (Pegasus laboratory). A total of eight eligible publications on 540 CE patients were found. Three hundred forty seven additional cases hospitalized in UHCMT from 2011 to 2020 were confirmed, as well as 36 laboratory cases and 10 Albanian cases notified in Germany. Taking all cases into account and considering 162 overlapping cases, 771 cases were documented from 2011 to 2020. The only case reported as AE was most likely a multi-organic CE. Surgery was the most frequent therapy approach used (84.7%). Autochthonous human CE seems to be widespread, and transmission is ongoing in Albania. CE patients in Albania undergo surgery more frequently compared with CE cases in other European countries. In order to establish a realistic estimate of prevalence and incidence of CE in Albania, mandatory notification should be reinforced. Stage-specific therapy can be used in CE to reduce therapy cost and diminish mortality by avoiding surgical overtreatment.
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Affiliation(s)
- Poleta Luga
- Institute of International Health, Global Health Center, Charité Universitätsmedizin, Corporate Member of Freie and Humboldt University Berlin and Berlin Institute of Health, 13353, Berlin, Germany
| | - Arben Gjata
- Tirana/General & Digestive Surgery Department, University of Medicine, No. 3. Dibrës Str. 370, Tirana, Albania
| | - Ilir Akshija
- Statistics Department, University Hospital Center "Mother Teresa", Tirana, Albania
| | - Ledina Mino
- Pegasus Med Laboratory, Bulevardi "Zhan D'Ark", Tirana, Albania
| | - Valbona Gjoni
- Department of National Reference Laboratories, Institute of Public Health, Aleksander Moisiu Str. 80, Tirana, Albania
| | - Arben Pilaca
- International Hospital Tirana, Dritan Hoxha Str, Tirana, Albania
| | - Michael Zobi
- Institute of International Health, Global Health Center, Charité Universitätsmedizin, Corporate Member of Freie and Humboldt University Berlin and Berlin Institute of Health, 13353, Berlin, Germany
| | - Gabriela Equihua Martinez
- Institute of International Health, Global Health Center, Charité Universitätsmedizin, Corporate Member of Freie and Humboldt University Berlin and Berlin Institute of Health, 13353, Berlin, Germany
| | - Joachim Richter
- Institute of International Health, Global Health Center, Charité Universitätsmedizin, Corporate Member of Freie and Humboldt University Berlin and Berlin Institute of Health, 13353, Berlin, Germany.
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