Human cystic echinococcosis in southwest Iran: a 15-year retrospective epidemiological study of hospitalized cases

Seroprevalence of human cystic echinococcosis in individuals occupationally exposed to Canidae in Central Iran: A case-control study

Echinococcus granulosus is a widespread zoonotic tapeworm that causes human cystic echinococcosis. Human CE, transmitted via dogs or Canidae feces, poses a public health challenge and exemplifies the One Health Theory. This survey was conducted to determine the seroprevalence of CE in individuals occupationally exposed (IOE) to dogs, livestock wool, and contaminated soil due to egg shedding from dogs/Canidae in industrial slaughterhouses and livestock fields, compared to a healthy control group in Isfahan province, central Iran. In a case-control study, 401 sera from IOE, including slaughterhouse workers, animal husbandry unit workers, wool industry workers, farm workers, livestock farmers, butchers, and veterinarians in the case group, were matched with 401 archived samples from the general population. All 802 samples were tested for echinococcosis IgG using ELISA. Out of 802 sera, 7 (0.9 %) tested positive for Echinococcus IgG. The seroprevalence in the IOE and control groups was 1.2 % (5/401) and 0.5 % (2/401), respectively. Although there was a 2.5-fold estimated risk of CE in IOE compared to the control group, this was not statistically significant. Based on the current study's findings, the overall seroprevalence of CE in the Isfahan area is similar to that of other regions in Iran.

A rare case of recurrent spinal hydatid cyst in a 17-year-old man with neurological deficits and balance impairment

BACKGROUND

Hydatid cysts are caused by the larval stage of the tapeworm parasite Echinococcus granulosus, leading to a rare but significant zoonotic infection. This disease is primarily observed in regions with prevalent agricultural and livestock practices. While the liver, lungs, and brain are most affected, spinal involvement is notably rare. Hydatid cyst disease develops gradually and is usually asymptomatic in the early stages. Symptoms usually emerge when the cysts enlarge sufficiently to cause compression. Effective treatment typically combines surgical intervention with antiparasitic medication to reduce the risk of recurrence, highlighting the necessity of a comprehensive approach to treatment and follow-up.

CASE PRESENTATION

A 17-year-old male from Afghanistan, now residing in Iran, presented with muscle weakness in his lower extremities, primarily in the right leg, back pain, and impaired balance. The patient had a history of previous surgical resection for a primary spinal hydatidosis in Afghanistan. Upon examination, he exhibited reduced muscle strength, sensory loss in the right lower limb, paresthesia in the left medial forearm, hyperactive deep tendon reflexes in both legs and a positive Babinski sign on the right. Imaging revealed signs of previous laminectomy at T2 and T3 and a well-defined cystic mass at the T2 level. Surgical intervention was performed to decompress and resect the cyst, and pathological examination confirmed it as a hydatid cyst. Post-surgery, the patient was prescribed chewable albendazole (400 mg twice daily) for six months to prevent recurrence. Routine follow-ups and physiotherapy sessions were recommended after.

CONCLUSION

Patients with spinal hydatidosis often exhibit spinal cord compression symptoms. When imaging modalities reveal multiple cysts and there is a history of residency in an endemic area, spinal hydatid cyst should be considered. Although rare, spinal hydatid cysts are difficult to treat completely. This case highlights the critical need for precise surgical removal, adequate postoperative medication, and long-term follow-up in managing of spinal hydatid cysts.

Analysis of a Large 19-Year Database in Vascular Surgery in Southern Iran: Evaluation of Trends and Limitations

BACKGROUND

Large databases with data elements of clinical interest are essential for carrying out high-quality observational studies. Such databases have become increasingly popular for clinical research in fields like vascular surgery. Our goal is to create a solid and reliable database of the patients who have been admitted and undergone different vascular surgery procedures over 19 years and to provide surgeons with the current trends and limitations in managing patients with vascular disease.

METHODS

The database of patients operated in Namazi Hospital, the referral center for vascular surgery in Southern Iran, from 2001 to 2019, was retrieved and patients undergoing vascular procedures were parted. Demographic and perioperative data were evaluated and patients were categorized into subgroups based on the type and cause of operation. All data were analyzed with SPSS version 26.0 (IBM, NY, USA).

RESULTS

During the period of our study, a total of 226,051 operations were performed at the Namazi Hospital. Among these operations, 6,386 (2.82%) vascular surgery-related operations were entered into our study. The average age of the patients in our study was 53.22 ± 18.92 years (range: 1 day old-97 years) and 4,061 (63.6%) were male. Furthermore, 147 (2.3%) were operated by multiple surgeons. Moreover, 798 (12.5%) of the patients were admitted postoperatively to the intensive care unit, while the rest (5,588; 87.5%) in the common surgery ward. The cause of operation in 609 (9.5%) of the cases was trauma. Based on wound categorization, 5,132 (80.4%) were type I (clean). The most frequent operation performed in our center was arterial reconstruction and limb revascularization (31.4%), followed by hemodialysis access (31.3%). The most frequent surgery in the age group of less than 18 years was fasciotomy, in the 19-40 years group was tumor (56.8%) and varicose veins (52.9%), and in the 41-60 years group was implantation of ventral venous port catheter (47%). Only carotid and thoracic outlet syndrome surgeries were significantly higher in females. The remaining operations were all significantly higher among male patients. Finally, carotid body tumor surgery was the most frequent operation requiring intensive care unit monitoring.

CONCLUSIONS

We demonstrated, for the first time, an overview of vascular surgeries performed in a referral tertiary center in Southwest Iran. There is an increase in the number of surgical procedures in the field of vascular surgery, and large databases will be a valuable tool for addressing critical problems in this field and also the healthcare system.

Evaluation of the features of cystic echinococcosis with concurrent super-infection: a retrospective study in Southern Iran

OBJECTIVE

Superinfection of cystic echinococcosis (CE) is a life-threatening complication with significant morbidities, which can be prevented with early diagnosis and treatment. This study aims to examine the clinical characteristics, diagnostic methods, and treatment options for superinfected CE, as there is currently limited information available on the differences between superinfected and non-infected CE in terms of clinical features, serological and radiologic findings.

METHODS

This cross-sectional study was conducted on hospital records of patients who were diagnosed with hydatid cysts in a 15-year period (2004 to 2018) in two main university-affiliated referral centers in Fars province, southern Iran. Patients' information regarding the demographical and clinical features related to CE, age, sex, previous history of CE or recurrence, size and location of CE, and length of hospital stay were collected. Moreover, the characteristics of concurrent infections with hydatid cysts were recorded.

RESULTS

A total of 586 surgeries due to CE were performed on 501 patients, of which 67 (11.43%) had reoperations due to the recurrence of the disease. A total of 30 (5.99%) incidences of superinfection were observed. There were no statistically significant differences in terms of laboratory and imaging findings between CE patients with concurrent infections and other CE patients (p-value > 0.05). Among the patients with super-infection, four had fungal infections of the lungs. Aspergillus fumigatus was the causative pathogen in all four patients that were diagnosed with fungal superinfection. All patients underwent surgical excision with favorable long-term outcomes.

CONCLUSION

Our study revealed a 5.99% incident rate of CE superinfection. Regarding the concurrent fungal infections in hydatid cysts, the patient's symptoms and laboratory and imaging findings are inconclusive and histopathological evaluation seems to be the most reliable option. Surgical resection is the gold-standard treatment option with favorable outcomes and potentially can be curative.

Aspergillus Coinfection in a Hydatid Cyst Cavity of Lung in an Immunocompetent Host: A Case Report and Review of Literature

Aspergilloma (a saprophytic infection) typically colonizes lung cavities due to underlying diseases such as tuberculosis, bronchiectasis, cavitary lung cancer, sarcoidosis, and pulmonary infarctions. Rarely, aspergilloma has been noted within a hydatid cyst. Even if this was the case, it is more common to find the coexistence of aspergilloma and pulmonary echinococcal cysts in immunocompromised individuals. It is, however, very uncommon to find this coinfection in normal immune status individuals. Here, we report on the successfully treated case of a 30-year-old immunocompetent female from Western Nepal with histologically proven coinfection by these two pathogens. She had a prolonged history of exposure to domesticated dogs. She suffered from hemoptysis from time to time for 3 years with increased frequency in the last 30 days. She was misdiagnosed clinically during a past medical visit at a local health center. Her computed tomography (CT) scans showed well-defined nonenhancing cystic lesions in the anterior basal segment of the right lower lobe adjacent to the major fissure. She underwent enucleation of the cyst via right posterolateral thoracotomy. On further histopathological evaluation, laminated membranes of the ectocyst along with fungal elements were found, and periodic acid-Schiff (PAS) staining revealed Aspergillus in the form of septate hyphae and acute angle branching. Owing to patient's economic constraints and unavailability in our center, DNA testing and molecular characterization could not be performed which further highlights the essence of diagnosing and managing such cases in resource poor settings. Eventually, we reviewed 12 confirmed cases of this coinfection in immunocompetent individuals during a period of 7 years (2015-2022) comparing them to a systematic review of 22 confirmed cases of the same coinfection from 1995 to 2014.

Hospital-based retrospective analysis of 224 surgical cases of lung hydatid cyst from southern Iran

BACKGROUND

The lungs are considered the second-most frequent location for hydatid cyst in human. The current retrospective hospital-based study aimed to assess the epidemiological data, clinical presentation, and treatment outcomes of lung hydatid cyst in patients who underwent surgery for this disease in Fars province, southern Iran.

METHODS

In this retrospective study, hospital records of 224 pulmonary hydatid cyst patients were assessed in two main university-affiliated hospitals in Fars Province, southern Iran. Clinical features of patients, epidemiological data, cyst features, surgical interventions, and treatment outcomes were reviewed and analyzed.

RESULTS

A total of 224 hydatid cyst cases of the lung were reviewed. Male patients accounted for the majority of cases (60.4%). The average age of the patients was 31.13 (± 19.6), ranging from 2 to 94 years old. Of the 224 patients, 145 (75.9%) cases had only one single cyst and mostly 110 (53.9%) located in the right lung. Also, 6 (2.9%) cases had cysts in both lungs. The lower lobe of the lungs was the most common location of the hydatid cyst. The average size of lung hydatid cyst was 7.37 cm (SD = 3.86; rang: 2-24) while for the cyst areas was 42.87cm2 (SD = 52.76; range: 2-488). Regarding the surgical method, 86 (38.6%) cases were operated by lung resection surgery while 137 (61.4%) cases had lung preserving one. The chief complaints of the patients were cough (55.4%) and dyspnea (32.6%). Relapse was documented in 25 (11.16%) of cases.

CONCLUSIONS

Lung hydatid cyst is a common infection in southern Iran. Lung preserving surgery is the method of choice for the management of hydatid cyst. Relapse, which was not uncommon in our study, is a challenging feature of hydatid cyst management.

Bronchobiliary fistulae as a complication of untreated pulmonary hydatid cyst presenting with bilioptysis: A report of two cases

We reported two patients, a 45-year-old lady and a 48-year-old man, known cases of untreated liver and lung hydatid cysts complicated with bronchobiliary fistulae. Surgery was performed, and bronchobiliary fistulae were diagnosed intraoperatively. Lobectomy was done on the lobe, which was chronically infected. Symptoms resolved after surgery in both cases. Green-colored sputum in a patient with a history of echinococcosis should raise the physician's attention to the probability of a connection between the bronchial tree and the biliary tract. Surgery in advanced cases is a suitable therapeutic option.

Muscular hydatid cyst in Iran: A case report

INTRODUCTION AND IMPORTANCE

Hydatid disease, caused by the larval stage of Echinococcus granulosus, is a common parasitic infection of humans and herbivores. Although livers and lungs are the most commonly affected organ, hydatid cysts may develop in any body part. Primary muscular hydatid cyst is extremely rare.

CASE PRESENTATION

We reported the case of a 40-year-old-woman with the presentation of a soft, mobile, and non-tender lump in the dorsal part of her left upper arm (triceps brachii), which emerged one year ago. Her past medical history was unremarkable. The arm sonography revealed a single uniloculated cystic mass (6.5 cm × 5.5 cm) with a thick wall containing cystic lesions. It suggested the diagnosis of echinococcosis. The patient underwent surgery, and the hydatid cyst was excised. Histopathological examination confirmed hydatidosis.

CLINICAL DISCUSSION

Hydatid cysts occur rarely (about 4 %) in muscles even in endemic regions. The study is the first case of hydatidosis found in triceps brachii in Fars province, Iran. In endemic regions, considering the hydatid cyst possibility is very important because it presents with many diversities. As it clinically presents a painless slow-growing mass, may be misdiagnosed with benign soft tissue tumors.

CONCLUSION

Although muscular hydatidosis is extremely rare, it should be considered a differential diagnosis of any growing subcutaneous or muscular masses or tumors. Imaging modalities and blood tests are highly relevant for diagnosis. Surgical excision, a choice of treatment, should be done with cautions and is combined with anthelmintic therapy to reduce the risk of recurrence.

Isolated greater omentum solid mass, a rare manifestation of hydatid disease; A Case Report and Review of Literature

Background

Echinococcus granulosus causes hydatid disease, which is found in various countries of the world, including Iran. The liver and lungs are prevalent involved structures in hydatid disease. One of the least common sites in hydatid disease seems to be the omentum. Seven cases of mesenteric, diaphragmatic, omental, pelvic, and retroperitoneal hydatid cysts have been reported in Iran within last 20 years. The appearance of hydatid disease as a primary mass in the greater omentum without hepatic involvement is very rare and no similar case was introduced in Iran in our searches.

Case Presentation

Our patient was a 33-year-old woman who underwent a diagnostic laparoscopy due to abdominal pain and an abdominal mass. During laparoscopy, there was a solid mass with a size of about 10 × 5 cm in the greater omentum that was resected. The histopathological examination of the mass showed the hydatid disease.

Conclusion

The hydatid cyst can appear anywhere on the body, and no part of the body is guarded. Since these uncommon locations often cause nonspecific symptoms, the hydatid cyst should be included in the differential diagnosing of omental cysts, particularly in endemic countries like Iran.

Necrotizing autoimmune myositis following coronavirus disease 2019 infection: a case report

BACKGROUND

Severe acute respiratory syndrome coronavirus 2 may be associated with late-onset necrotizing myositis, mimicking autoimmune inflammatory myositis; however, the exact underlying pathogenesis of severe acute respiratory syndrome coronavirus 2-induced myositis is still unclear.

CASE PRESENTATION

Herein, we report a rare case of necrotizing autoimmune myositis in a 67-year-old middle eastern male following coronavirus disease 2019 infection, who presented with muscle weakness. The patient had positive anti-NXP2. The diagnosis of necrotizing autoimmune myositis was made according to muscle weakness, increased liver enzymes, electromyography and nerve conduction velocity results, and muscle biopsy. The patient underwent a full malignancy evaluation, which was unremarkable, and was discharged in relatively well condition with a daily dose of 1 mg/kg prednisolone and azathioprine 150 mg (2 mg/kg).

CONCLUSION

Our report highlights the already known possible protracted sequence of coronavirus disease 2019 infection and the potential for delayed-onset necrotizing myositis.

Serosurvey of Cystic Echinococcosis and Related Risk Factors for Infection in Fars Province, Southern Iran: A Population-Based Study

Cystic echinococcosis (CE) is a common zoonotic infection in all provinces of Iran, especially in areas where people live on agriculture and animal husbandry. The current cross-sectional population-based study is aimed at determining the seroprevalence of CE in Kavar County, Fars province, southern Iran. Blood samples were collected from 1500 individuals (749 males and 751 females). Anti-hydatid cyst antibodies were detected, using a recombinant B8/1 antigen of Echinococcus graunlosus in an ELISA system. Multivariate logistic regression analysis was used to find out the independent risk factor for CE seropositivity. Anti-hydatid cyst antibodies were detected in the sera of 131 out of 1500 participants, corresponding to a seroprevalence rate of 8.73%. With a statistically significant difference (p < 0.05), the seroprevalence of hydatid cyst in males and females was 5% and 7%, respectively. Differences in the seropositivity of hydatid cysts were also statistically significant by occupation (p < 0.05). The seroprevalence of hydatid cyst was significantly higher in the age group of 35-45 years than in other age groups (p < 0.05). Multivariate logistic regression showed that only age was associated with seropositivity to CE (OR = 2.23, 95% CI: 1.33-3.72). Moreover, there was a statistically significant association between seropositivity to hydatid cysts and underlying diseases such as hypertension (p = 0.049) and fatty liver (p = 0.048). The findings of this study indicate that the seroprevalence rate of CE is relatively high in the Fars province, southern Iran, and this high rate of infection is mainly linked to people's jobs and lifestyles.

Human Cystic Echinococcosis in Lebanon: A Retrospective Study and Molecular Epidemiology

Purpose

Human cystic echinococcosis (CE) is a zoonotic parasitic disease that constitutes a public health challenge and a socio-economic burden in endemic areas worldwide. No specific surveillance system of CE infections in humans exists in Lebanon. The incidence and trends over time have not been documented. The current study aimed to assess the demographic and epidemiologic features of human CE surgical cases over a 14-year period in the five main regions of Lebanon.

Methods

From 2005 to 2018, a total of 894 surgically confirmed cases of hydatidosis were recorded from five anatomy and pathology laboratories.

Results

The mean annual surgical incidence was 1.23/100,000 inhabitants. Over the span of these years, the incidence increased from 0.53 to 1.94 cases/100,000 inhabitants in 2005 and 2018, respectively. CE is present in Lebanon with an uneven distribution from one region to the other with higher prevalence in Bekaa (29.0%), a rural area where sheep raising is widespread. Human CE cases were more common in females (60.1%) than in males (39.9%) and a high burden of infection was reported for the age group of 30–39 years. Besides, 66.7% of the cases expressed only liver complications whereas, 20.5% showed predilection towards lungs. The 7.8% of cases presented cysts in other organs, and 1.3% showed multiple localizations. Additionally, predominant involvement of Echinococcus granulosus sensu stricto was recorded in human infections. Comparison of Echinococcus granulosus s.s. populations from different Mediterranean countries also revealed high gene flow among this region and sharing of alleles.

Conclusion

The current study is a step forward to fill the gap of knowledge for the hydatidosis in Lebanon where the lack of epidemiological data and control measures have resulted in higher incidence of human CE.

Graphic Abstract

Echinococcus granulosus sensu stricto G1 is the predominant genotype in human and livestock isolates from Turkey and Iran, based on mitochondrial nad5 gene differentiation

BACKGROUND

Different genotypes of Echinococcus granulosus sensu stricto (s.s.) isolated from livestock and humans have been identified based on cox1 and nad1 genomic fragments. The present study was performed to differentiate the G1/G3 genotypes of Echinococcus granulosus (s.s.) isolated from humans and livestock (sheep and cattle) from Azerbaijan in northwestern Iran, Fars Province in southern Iran, and Van province in Eastern Turkey, using the nad5 gene fragment as a suitable marker to distinguish these two genotypes.

METHODS

A total of 60 pathologically confirmed human hydatid cysts and 90 hydatid cyst samples from livestock were collected from Turkey and Iran. PCR was performed on all of the samples, targeting the nad5 gene. Based on PCR product quality, host type, and the geographical area where the samples were obtained, 36 of the samples were sequenced and were used in the phylogenetic analysis.

RESULTS

Out of 36 evaluated samples, 26 (72.2%) samples belonged to G1, and 10 (27.8%) samples belonged to the G3 genotype. Out of 21 samples from Turkey, 16 (76.2%) were G1 and 5 (23.8%) were G3, while out of 15 samples from Iran, 10 (66.7%) were G1 and 5 (33.3%) were the G3 genotype. None of the samples isolated from humans in Iran or from sheep in Turkey were G3. Overall, between the two countries, 18.18% of E. granulosus isolates in cattle, 41.66% of isolates in sheep, and 23.07% of human samples were identified as G3, and the others as the G1 genotype. The G3 genotype was not detected in human samples from Iran or sheep samples from Turkey.

CONCLUSION

The findings of the study revealed that the G1 genotype of E. granulosus s.s. is the predominant genotype in humans and livestock, both in Turkey and Iran. The ratio of the E. granulosus s.s. G1 to G3 genotype was 3.2 in Turkey and 2 in Iran. The study also further confirmed that the nad5 gene properly differentiated the G1/G3 isolates of E. granulosus from both humans and livestock.

Echinococcoses in Iran, Turkey, and Pakistan: Old Diseases in the New Millennium

Echinococcosis is considered a cosmopolitan zoonosis caused by different species of small taeniid tapeworms of the genus Echinococcus and is regarded as a neglected zoonosis. Cystic and alveolar echinococcoses are endemic diseases of Tibetan, Pamir, and Iranian plateaus. All of the countries within the Iranian plateau are affected by echinococcosis. Pakistan, Turkey, and Iran are the three most populous countries of the region, in which echinococcosis is highly endemic. The three neighboring countries share strong cultural and socioeconomic ties. The present study aimed to provide a broad review of the status of cystic and alveolar echinococcosis, summarizing the current knowledge about geographical distribution, molecular epidemiology, and transmission dynamics of Echinococcus granulosus sensu lato and Echinococcus multilocularis in this region. Additionally, we aimed to understand disease burden and risk factors as basic requirements for establishing a surveillance system and planning prevention and control programs. A considerable body of information is available on different aspects of echinococcosis in this region; however, several information and research gaps need to be filled before planning control programs. None of the countries in the region have an elaborate echinococcosis control program. Effective control programs require multi/intersectoral coordination within a One Health approach with a long-term political and administrative commitment and enhanced international collaboration among the three countries.

Cystic Echinococcosis: Knowledge, Attitude, and Practices (KAP) among Surgically Operated Cases in Fars Province, Southern Iran

Introduction

Cystic echinococcosis (CE) is a neglected zoonotic disease caused by Echinococcus granulosus with major health and economic burden. The information on how the community members perceive the disease is crucial in order to recommend an effective preventive and control plan. The current study is aimed at finding out knowledge, attitude, and practices (KAP) of surgically operated cases of hydatid cyst in educational hospitals of Shiraz in Fars Province, southern Iran, toward the CE.

Methods

A cross-sectional survey was conducted among 180 CE patients who underwent surgery due to CE. Using a well-designed questionnaire, a telephone-based survey was carried out to collect the data. The contents of the questionnaire included basic personal information and questions related to the participants' knowledge, attitude, and behavioral patterns toward CE. Univariate and then multivariate linear regression analyses were used to identify factors associated with the KAP. Unstandardized regression coefficients (β) and odds ratios (ORs) and their 95% confidence intervals (CIs) were used to quantify the associations between variables and KAP.

Results

A total of 180 CE patients with a mean age of 35.64 (±17.59) years were recruited. The mean score of participant's knowledge was 8.7 (SD = 2.8, range: 0-17), whereas these scores were 1.3 (SD = 0.7, range 0-2) for attitude and 1.2 (SD = 1.0, range 0-4) for practice. Findings of the study demonstrated that 20 of the participants (11.1%) had good knowledge towards CE, 82 (45.6%) demonstrated a positive attitude, and 57 (47.5%) without having dogs demonstrated a good practice towards CE (score = 2/2), while from 60 dog owners, only 7 (11.6%) participants demonstrated good practice (score 3 and 4/4). Factors that were associated with knowledge were age (OR = −0.49, P value = 0.001) and educational level (OR = 0.668, P value = 0.001), where higher age was associated with lower knowledge and also higher educational levels were associated with higher knowledge regarding hydatid cyst. Regarding attitude, only living location had a significant association with participants' attitude where those who were living in urban areas demonstrating a more positive attitude towards CE (OR = 0.261, P value = 0.022). The practice of the participants was grouped into dog owners and participants with no dogs, in which among participants who did not own a dog, those living in urban areas demonstrating weaker practice towards CE (OR = −0.491, P value>0.001). Moreover, a lack of counseling of patients after the surgery on how to prevent reinfection was noticed.

Conclusion

Findings of the study revealed that the CE patients in southern Iran had poor knowledge and attitude toward the disease, and their practice may help in maintaining the disease in the community. Health education is highly needed to increase community awareness and to prevent and control this neglected parasitic infection in the area.