Emerging human alveolar echinococcosis in Hungary (2003-2018): a retrospective case series analysis from a multi-centre study

Molecular analyses of exosome-derived miRNAs revealed reduced expression of miR-184-3p and decreased exosome concentration in patients with alveolar echinococcosis

Both E. multilocularis and host-derived exosomes are involved in the pathogenic process of alveolar echinococcosis (AE). Exosomes secrete miRNAs that have regulatory roles in host-pathogen interactions in multiple ways. In the present study, we collected and purified supernatants of E. multilocularis cultures, as well as human plasma exosomes. High-throughput sequencing showed the identities of 45 exosomal miRNAs in E. multilocularis. The lengths of these miRNAs ranged from 19 to 25 nucleotides (nt), with the majority (n = 18) measuring 22 nt. Notably, emu-let-7-5p emerged as the most abundant among these miRNAs, with a detected count of 33,097 and also length of 22 nt. Nanoparticle tracking analysis (NTA) showed that the concentration of exosomes in the plasma of AE patients was lower compared to that in the healthy individuals. This result suggested that the concentration of plasma exosomes was able to distinguish AE patients from healthy individuals. Using qRT-PCR to assess the relative expression of 10 miRNAs of E. multilocularis, we showed that the expression of miR-184-3p was downregulated significantly in the exosomes of plasma from AE patients compared to that in the control group. In summary, this study indicates that AE induces a reduction in the concentration of human plasma exosomes, as well as downregulating miR-184-3p in infected individuals.

Plasma Circulating Cell-Free DNA Facilitated the Detection of an Alveolar Echinococcosis Patient Initially Misdiagnosed as Cystic Echinococcosis: A Case Report

Echinococcosis, especially alveolar echinococcosis (AE), is becoming an emerging/re-emerging disease with a growing number of cases reported globally. The diagnosis of echinococcosis is based mainly on imaging, which may be challenging when the image presentation is atypical. We reported one patient with suspected cystic echinococcosis (CE) by imaging. The cell-free DNA (cfDNA) obtained from sequencing the patient's plasma before the operation showed that this patient probably had AE with 45 reads mapped to the Echinococcus multilocularis reference genome (Read-Pairs Per Million = 0.24). The patients underwent surgery, and the pathological result showed that the patient had AE. The conventional polymerase chain reaction (PCR) of her lesion sample extraction also indicated that the infection was caused by Echinococcus multilocularis. The follow-up ultrasound after three months indicated no recurrence. We demonstrated that the differentiation of CE and AE by imaging may not be that easy, with further elaboration on the differentiation between AE and CE in different aspects. We demonstrated that it is possible to use patients' plasma cfDNA mapped to Echinococcus references before the operation to obtain the objective clue of the lesion to facilitate diagnosis.

Mitochondrial genetic diversity and phylogenetic relationships of Echinococcus multilocularis in Europe

The cestode Echinococcus multilocularis is the causative agent of alveolar echinococcosis, a fatal zoonotic parasitic disease of the northern hemisphere. Red foxes are the main reservoir hosts and, likely, the main drivers of the geographic spread of the disease in Europe. Knowledge of genetic relationships among E. multilocularis isolates at a European scale is key to understanding the dispersal characteristics of E. multilocularis. Hence, the present study aimed to describe the genetic diversity of E. multilocularis isolates obtained from different host species in 19 European countries. Based on the analysis of complete nucleotide sequences of the cob, atp6, nad2, nad1 and cox1 mitochondrial genes (4,968 bp), 43 haplotypes were inferred. Four haplotypes represented 62.56 % of the examined isolates (142/227), and one of these four haplotypes was found in each country investigated, except Svalbard, Norway. While the haplotypes from Svalbard were markedly different from all the others, mainland Europe appeared to be dominated by two main clusters, represented by most western, central and eastern European countries, and the Baltic countries and northeastern Poland, respectively. Moreover, one Asian-like haplotype was identified in Latvia and northeastern Poland. To better elucidate the presence of Asian genetic variants of E. multilocularis in Europe, and to obtain a more comprehensive Europe-wide coverage, further studies, including samples from endemic regions not investigated in the present study, especially some eastern European countries, are needed. Further, the present work proposes historical causes that may have contributed to shaping the current genetic variability of E. multilocularis in Europe.

Integrative analysis of serum-derived exosomal lncRNA profiles of alveolar echinococcosis patients

Alveolar echinococcosis is a severe zoonotic disease caused by the pseudotumoral intrahepatic development of the larval stage of the tapeworm Echinococcus multilocularis. The diagnosis of alveolar echinococcosis is hard since it has features of liver cancer. LncRNAs are among the non-coding RNAs that have received the most attention in recent biomarker studies. Here, we aimed to identify the serum-derived exosomal lncRNAs associated with alveolar echinococcosis in humans with RNA-seq. After RNA isolation from exosomes, we performed RNA-seq to determine the lncRNAs. We found 8 target genes in the cis direction and a total of 6468 gene targets for lncRNAs were identified in the trans direction. Totally 621 mRNA transcripts were found as differentially expressed between the controls and patients. 278 of them were up-regulated and 343 were down-regulated. Moreover, 234 lncRNAs were found as differentially expressed between the controls and patients. 58 of them were up-regulated, and 176 of them were down-regulated. The top five biological pathways regulated by identified lncRNAs were detected in this study. As a result, it is thought that these results will contribute to lncRNA-based biomarker studies that can be used in the early diagnosis of alveolar echinococcosis in humans.

Genetic diversity of Echinococcus multilocularis specimens isolated from Belgian patients with alveolar echinococcosis using EmsB microsatellites analysis

The genetic diversity of Echinococcus multilocularis (E. multilocularis) specimens isolated from patients with alveolar echinococcosis (AE), is a major field of investigation to correlate with sources of infection, clinical manifestations and prognosis of the disease. Molecular markers able to distinguish samples are commonly used worldwide, including the EmsB microsatellite. Here, we report the use of the EmsB microsatellite polymorphism data mining for the retrospective typing of Belgian specimens of E. multilocularis infecting humans. A total of 18 samples from 16 AE patients treated between 2006 and 2021 were analyzed through the EmsB polymorphism. Classification of specimens was performed through a dendrogram construction in order to compare the similarity among Belgian samples, some human referenced specimens on the EWET database (EmsB Website for the Echinococcus Typing) and previously published EmsB profiles from red foxes circulating in/near Belgium. According to a comparison with human European specimens previously genotyped in profiles, the 18 Belgian ones were classified into three EmsB profiles. Four specimens could not be assigned to an already known profile but some are near to EWET referenced samples. This study also highlights that some specimens share the same EmsB profile with profiles characterized in red foxes from north Belgium, the Netherlands, Luxembourg and French department near to the Belgian border. Furthermore, Belgian specimens present a genetic diversity and include one profile that don't share similarities with the ones referenced in the EWET database. However, at this geographical scale, there is no clear correlation between EmsB profiles and geographical location. Further studies including additional clinical samples and isolates from foxes and rodents of south Belgium are necessary to better understand the spatial and temporal circumstances of human infections but also a potential correlation between EmsB profiles and parasite virulence.

Global and local drivers of Echinococcus multilocularis infection in the western Balkan region

The cestode, Echinococcus multilocularis, is one of the most threatening parasitic challenges in the European Union. Despite the warming climate, the parasite intensively spread in Europe's colder and warmer regions. Little is known about the expansion of E. multilocularis in the Balkan region. Ordinary least squares, geographically weighted and multi-scale geographically weighted regressions were used to detect global and local drivers that influenced the prevalence in red foxes and golden jackals in the southwestern part of Hungary. Based on the study of 391 animals, the overall prevalence exceeded 18% (in fox 15.2%, in jackal 21.1%). The regression models revealed that the wetland had a global effect (β = 0.391, p = 0.006). In contrast, on the local scale, the mean annual precipitation (β = 0.285, p = 0.008) and the precipitation seasonality (β = - 0.211, p = 0.014) had statistically significant effects on the infection level. The geospatial models suggested that microclimatic effects might compensate for the disadvantages of a warmer Mediterranean climate. This study calls attention to fine-scale analysis and locally acting environmental factors, which can delay the expected epidemic fade-out. The findings of our study are suggested to consider in surveillance strategies.

Young Age of Alveolar Echinococcosis Patient in Armenia: A Case Report

Human alveolar echinococcosis (AE) remains a serious public health concern in endemic areas and a challenge for clinicians. Here a confirmed case of human AE in a patient from Armenia who had not visited a known Echinococcus multilocularis endemic area is reported. In October 2012, a 12-year-old girl from a little Armenian village, presented with paroxysmal pain in the right lumbar area to the children's medical center (MC). The girl mentioned having close contact with an animal, like a cat. She was admitted to the surgical department with a diagnosis of a malignant liver tumor in the right lobe. In November 2012, the patient underwent laparotomy, removal of the hepatic lesion and abdominal cavity drainage. The histopathological examination of the biopsy material confirmed the main diagnosis of liver AE with suppurative lesions. The patient was given albendazole (ABZ) following 20 days in the hospital, but she stopped receiving the preventive chemotherapy at home and even missed the dispensary visits. It later caused complications, and in July 2016, the child had once again surgery. In January 2017, the child was readmitted to the MC with no content from the external biliary drainage tube in the previous 6 hours. Bile flow improved after flushing the drainage with saline solution and suturing the enterostomy tube. In February 2017, the child visited MC for examination, and the drainage of the bile ducts was blocked, although she had neither discomfort nor jaundice. It was recommended to continue the patient's follow-up, to receive ABZ and to undergo a liver transplant surgery.

Emergence of Echinococcus multilocularis in Central Continental Croatia: A Human Case Series and Update on Prevalence in Foxes

Human alveolar echinococcosis (HAE), caused by the metacestode stage of Echinococcus multilocularis, has emerged in many European countries over the last two decades. Here, we report the first data on the new HAE focus with increasing incidence in central Croatia, describe its clinical presentation and outcomes in diagnosed patients, and provide an update on the prevalence and geographic distribution of Echinococcus multilocuaris in red foxes. After the initial case in 2017 from the eastern state border, from 2019 to 2022, five new autochthonous HAE cases were diagnosed, all concentrated in the Bjelovar-Bilogora County (the county incidence in 2019 and 2021: 0.98/10⁵, in 2022: 2.94/10⁵/year; prevalence for 2019-2022: 4.91/10⁵). The age range among four female and two male patients was 37-67 years. The patients' liver lesions varied in size from 3.1 to 15.5 cm (classification range: P2N0M0-P4N1M0), and one patient had dissemination to the lungs. While there were no fatalities, postoperative complications in one patient resulted in liver transplantation. In 2018, the overall prevalence of red foxes was 11.24% (28/249). A new focus on HAE has emerged in central continental Croatia, with the highest regional incidence in Europe. Screening projects among residents and the implementation of veterinary preventive measures following the One Health approach are warranted.

Risk factors for post-endoscopic retrograde cholangiopancreatography cholangitis in patients with hepatic alveolar echinococcosis-an observational study

BACKGROUND

Hepatic alveolar echinococcosis (HAE) is considered to be one of the most deadly chronic parasitic diseases in the world. We have shown that the incidence of cholangitis in patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) was increased significantly. On this finding, we carried out, a preliminary study on the risk factors for cholangitis after ERCP.

AIMS

To retrospectively detect the risk factors for post-ERCP cholangitis in patients with biliary tract affected by HAE.

METHODS

The study included data from 51 cases of AE who had undergone therapeutic ERCP between January 2015 and December 2019. Demographic and treatment data were extracted from the medical records, and the association between potential risk factors and the development of post-ERCP cholangitis was evaluated using a collected database.

RESULTS

There were five cases of mild cholangitis after ERCP (Tokyo criteria), and no moderate or severe cholangitis occurred. The incidence rate of cholangitis after ERCP was 9.8%. Univariate analysis showed hilar bile duct stenosis (p = .016), endoscopic retrograde biliary drainage (p = .007), a stent diameter ≥8.5 Fr (p = .000) and single stent implantation (p = .010) were risk factors for post -ERCP cholangitis. All cases of cholangitis improved under conservative treatment.

CONCLUSION

Patients with hilar bile duct compression or endoscopic retrograde biliary drainage appeared to be more likely to develop post-ERCP cholangitis. The number and diameter of biliary stents may influence post-ERCP cholangitis. Sample size and clinical heterogeneity are two insurmountable difficulties, and a larger sample size needs to be collected to verify the risk factors for screening. KEY MESSAGESMany studies reported the post-ERCP complications in patients with hepatic alveolar echinococcosis and found that the incidence of post-ERCP cholangitis was significantly high. Therefore, we conducted a preliminary study on the risk factors of postoperative cholangitis in patients who underwent ERCP.The incidence rate of cholangitis after ERCP was 9.8%. We found that hilar bile duct stenosis, and endoscopic retrograde biliary drainage, were risk factors for cholangitis, and stent diameter and the number of stent implantation may influence the incidence rate of cholangitis after ERCP.Sample size and clinical heterogeneity are two insurmountable difficulties, and a larger sample size needs to be collected to verify the risk factors of screening.

Alveolar echinococcosis in nutria (Myocastor coypus), invasive species in Slovenia

The present report describes a case of Echinococcus multilocularis infection in nutria (Myocastor coypus) culled in the central area of Slovenia. Post-mortem exam showed multiple cystic lesions in the liver. Gross examination, as well as parasitological and histopathological examinations, revealed numerous cysts of various sizes, filled with yellow clear fluid and displacing most of the liver parenchyma. The cyst lumina contained numerous protoscolices approximately 100 μm in diameter and calcareous corpuscles. The protoscolices had two visible suckers and a rostellum with birefringent hooks. The lesions were consistent with an E. multilocularis cyst. Molecular analysis confirmed that the nutria was infected with E. multilocularis. To our knowledge, this is the first report of echinococcosis in nutria in Slovenia that presents gross, parasitological, and histological lesions and the result of molecular analysis. Nutrias in Slovenia are dangerous invaders but can also be a relevant bioindicator of the presence of the parasite in the environment.

Echinococcus multilocularis protoscoleces enhance glycolysis to promote M2 Macrophages through PI3K/Akt/mTOR Signaling Pathway

Alveolar Echinococcosis (AE) is a zoonotic parasitic disease caused by Echinococcus multilocularis, but its pathogenesis remains unclear. The primary objective of this study is to explore whether Echinococcus multilocularis protoscoleces (PSCs) regulate macrophage polarization and glucose metabolism by PI3K/Akt/mTOR signaling pathway. We found that large numbers of CD68⁺ macrophages gathered in close liver issue from the lesion in AE patients. PSCs preferentially differentiated into M2 macrophages and the expressions of HK1, PFKL, PKM2, PI3K, Akt, p-Akt, mTOR and p-mTOR increased. The above results show that Echinococcus multilocularis protoscoleces enhance glycolysis to promote M2 macrophages through PI3K/Akt/mTOR signaling pathway.

Recent advances in ultrasound in the diagnosis and evaluation of the activity of hepatic alveolar echinococcosis

Echinococcosis is a worldwide neglected zoonotic disease. Alveolar echinococcosis (AE) poses a more serious threat to life and health than cystic echinococcosis, and has been one of the world's most lethal chronic parasitosis. Assessment of metacestode activity status is essential for individual treatment strategy design for a given AE patient, and fluorodeoxyglucose positron-emission tomography (FDG-PET) has been the gold standard. In this study, we reviewed previous evidence on AE activity assessment using contrast-enhanced ultrasound (CEUS), and its comparison with FDG-PET. The results showed good consistency between them, indicating CEUS as a suitable substitute for FDG-PET. With its advantage as being readily portable, widely available, and not costly, CEUS is more suitable for use in the developing countries and rural areas.