Multimodality imaging in diagnosis and management of alveolar echinococcosis: an update

The genetic variation of mitochondrial sequences and pathological differences of Echinococcus multilocularis strains from different continents

Alveolar echinococcosis is a lethal zoonotic disease caused by the fox tapeworm Echinococcus multilocularis. The parasite is widely distributed in the Northern Hemisphere and exhibits low genetic diversity among populations. To compare the differences among four E. multilocularis strains from different geographical locations, namely, Alaska (EM-AK), Japan (EM-JP), Xinjiang (EM-XJ), and Ningxia (EM-NX), their complete mitochondrial (mt) sequences were compared, and their induced pathological lesions were analyzed in mouse models. The complete mt sequence of EM-AK resulted in 0.84%-0.86% variation as compared with the other strains, which had a lower variation. Phylogenetic analysis and parsimony network indicated that EM-AK resulted in 30,000 years of evolutionary distance from the other three strains. EM-AK induced more pathological damage than the other three strains, which was likely to induce more host cell infiltration and acute granuloma in the liver. More importantly, EM-AK produced more protoscoleces than the other three strains, which may impact the transmission dynamics of the parasite. Given the geographical location of four strains, which is far from each other, and also the pathological differences, the strains of E. multilocularis are likely models for addressing the relationship and interfacial immune response between the host and the helminth.IMPORTANCEEchinococcus multilocularis is the causative agent of alveolar echinococcosis, which is considered the most serious parasitic disease in the Northern Hemisphere. There are many genotypes, but the pathogenic and mitochondria sequence and differences are still unclear. Therefore, this study showed both pathological and genetic differences between the four strains of E. multilocularis. EM-AK induced more severe immune responses and especially induced more host cell infiltration, which resulted in more severe granuloma in the liver. EM-JP has metacestode lesions morphologically closer to those of E. granulosus with clear cyst fluid. However, this strain produced much fewer protoscoleces (PSCs). Genetically, EM-AK is more distant from other strains.

Human Alveolar Echinococcosis-A Neglected Zoonotic Disease Requiring Urgent Attention

Alveolar echinococcosis (AE) in humans is caused by the larval (metacestode) stage of Echinococcus multilocularis, commonly known as the 'fox tapeworm'. This disease predominantly targets the liver and has an invasive growth pattern, allowing it to spread to adjacent and distant tissues. Due to its gradual progression and tumour-like characteristics, early diagnosis and prompt intervention are crucial, particularly as there are currently no highly effective vaccines or chemotherapeutics against AE. Current estimates suggest that ~10,500 new infections occur annually worldwide; however, more research is required to refine the prevalence and incidence data for both human and animal hosts in endemic areas of the world. This article discusses the biology of E. multilocularis, outlines aspects of the pathogenesis, diagnosis, treatment, and management of AE, reviews its global distribution, annual incidence, and prevalence, highlights the role of molecular parasitology in advancing therapeutic strategies, and presents recommendations for improving the prevention and control of AE in human populations.

Human alveolar echinococcosis-global, regional, and national annual incidence and prevalence rates

BACKGROUND

Alveolar echinococcosis (AE) of humans is a disease caused by the larval (metacestode) stage of the 'fox tapeworm' Echinococcus multilocularis. AE primarily affects the liver and, like cancer, can spread to surrounding or distant organs. Its slow progression and resemblance to malignant tumours emphasise the critical importance of early detection and intervention, as there is no highly effective vaccine against AE. Although recognised as a neglected disease, there has been no recent, comprehensive review of the distribution, incidence and prevalence of AE in humans around the world.

OBJECTIVES

To estimate the global, regional, and national annual incidence rates and prevalences of human AE in endemic countries.

SOURCES

Incidence and prevalence data were obtained from published articles from 1980 to 2024, accessible via public databases.

CONTENT

This article provides a brief background on E. multilocularis, its biology and impact; reviews the geographic distribution and incidence of AE; and gives a perspective on the prevention and control of this neglected disease in humans.

IMPLICATIONS

The AE burden in humans is substantial and emphasises the need for enhanced public awareness, surveillance, prevention, and control, particularly in under-resourced communities to mitigate the health, economic, and psychological impact of AE.

Advances in Novel Diagnostic Techniques for Alveolar Echinococcosis

Alveolar echinococcosis (AE), caused by the larval stage of the tapeworm Echinococcus multilocularis, is a serious parasitic disease that presents significant health risks and challenges for both patients and healthcare systems. Accurate and timely diagnosis is essential for effective management and improved patient outcomes. This review summarizes the latest diagnostic methods for AE, focusing on serological tests and imaging techniques such as ultrasonography (US), computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography/computed tomography (PET/CT). Each imaging modality has its strengths and limitations in detecting and characterizing AE lesions, such as their location, size, and invasiveness. US is often the first-line method due to its non-invasiveness and cost-effectiveness, but it may have limitations in assessing complex lesions. CT provides detailed anatomical information and is particularly useful for assessing bone involvement and calcification. MRI, with its excellent soft tissue contrast, is superior for delineating the extent of AE lesions and their relationship to adjacent structures. PET/CT combines functional and morphological imaging to provide insights into the metabolic activity of lesions, which is valuable for monitoring treatment response and detecting recurrence. Overall, this review emphasizes the importance of a multifaceted diagnostic approach that combines serological and imaging techniques for accurate and early AE diagnosis, which is crucial for effective management and improved patient outcomes.

Cystic echinococcosis of the liver

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.

Novel miRNA biomarkers for alveolar echinococcosis: sequencing and clinical validation

This study aimed to explore extracellular microRNA derived from Echinococcus multilocularis (EM) in the plasma of patients with alveolar echinococcosis (AE) and assess its potential as a diagnostic biomarker. EM-derived miRNAs were identified in plasma samples from 20 AE patients through miRNA sequencing. Three novel miRNA molecules (emu-miR-novel 1, 2 and 3) were predicted through bioinformatic analysis to elucidate their chromosomal locations, secondary structures and precursor forms. Subsequently, plasma samples from 30 AE patients and 30 controls were utilized to establish an assay via stem-loop reverse transcription PCR, optimizing primers, reaction systems, and conditions to assess cross-reactivity and sensitivity. Clinical validation revealed that emu-miR-novel 1 had the highest diagnostic accuracy, with an area under the curve (AUC) of 0.8994, a P value of less than 0.0001, a sensitivity of 83.3%, and a specificity of 86.7%. Statistically significant differences were observed between the groups for emu-miR-novel 1 (P < 0.05), whereas emu-miR-novel 2 and 3 showed AUC values of 0.7922 and 0.6883, with P values of 0.0001 and 0.012, respectively, indicating no significant difference between groups (P > 0.05). Furthermore, the assay showed no cross-reactivity with samples from 18 common viruses, 4 parasitic infections, and miRNAs from AE sequenced from 8 species, confirming its high specificity. Emu-miR-novel 1 exhibited a sensitivity of 1 femtomolar. Emu-miR-novel 1 holds promise as a key diagnostic tool for AE, offering a novel perspective and approach for disease diagnosis.

Characteristics of the imaging diagnosis of alveolar echinococcosis

Alveolar echinococcosis (AE) primarily manifests in the liver and exhibits characteristics resembling those of slow-growing malignant tumours. Untreated Echinococcus multilocularis infection can be lethal. By infiltrating the vascular systems, biliary tracts, and the hilum of the liver, it might lead to various problems. Due to its ability to infiltrate neighbouring tissues or metastasize to distant organs, AE can often be mistaken for malignancies. We present a concise overview of the epidemiological and pathophysiological characteristics of AE, as well as the clinical manifestations of the disease. This article primarily examines the imaging characteristics of AE using various imaging techniques such as ultrasonography, computed tomography (CT), magnetic resonance imaging, diffusion-weighted imaging, and virtual non-enhanced dual-energy CT. We additionally examined the contribution of radiography in the diagnosis, treatment, and monitoring of the condition.

Clinical value of the semi-quantitative parameters of 18F-fluorodeoxyglucose PET/CT in the classification of hepatic echinococcosis in the Qinghai Tibetan area of China

BACKGROUND

To investigate the value of 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT) semi-quantitative parameters, including the lesion diameter, maximum standardized uptake value (SUVmax), maximum standardized uptake value corrected for lean body mass (SULmax), metabolic lesion volume (MLV), and total lesion glycolysis (TLG), for classifying hepatic echinococcosis.

METHODS

In total, 20 patients with 36 hepatic echinococcosis lesions were included in the study. Overall, these lesions were categorized as hepatic cystic echinococcosis (HCE) or hepatic alveolar echinococcosis (HAE) according to the pathological results. Multiple semi-parameters including the maximum diameter, SUVmax, SULmax, MLV, and TLG were measured to classify HCE and HAE compared with the pathological results. The receiver operator characteristic curve and area under the curve (AUC) of each quantitative parameter were calculated. The Mann-Whitney U test was used to compare data between the two groups.

RESULTS

In total, 12 cystic lesions and 24 alveolar lesions were identified after surgery. There were significant differences in SUV max, SUL max, MLV, and TLG between the HAE and HCE groups (Z =  - 4.70, - 4.77, - 3.36, and - 4.23, respectively, all P < 0.05). There was no significant difference in the maximum lesion diameter between the two groups (Z =  - 0.77, P > 0.05). The best cutoffs of SUV max, SUL max, MLV, and TLG for the differential diagnosis of HAE and HCE were 2.09, 2.67, 27.12, and 18.79, respectively. The AUCs of the four parameters were 0.99, 0.99, 0.85, and 0.94, respectively. The sensitivities were 91.7%, 87.5%, 66.7%, and 85.6%, respectively, and the specificities were 90.1%, 91.7%, 83.3%, and 90.9%, respectively.

CONCLUSION

18F-FDG PET/CT semi-quantitative parameters had significant clinical value in the diagnosis and pathological classification of hepatic echinococcosis and evaluation of clinical treatment.

A Case Series and Literature Review of Alveolar Echinococcosis in Kashmir, India: An Emerging Endemic Zone for Echinococcus multilocularis

A prospective study on 110 patients with echinococcosis at Dr. Khuroo's Medical Clinic, Srinagar, Kashmir, India, from March 2019 to April 2024 identified 12 cases (4 males, 8 females; mean age of 46.58 ± 11.97 years) of Alveolar echinococcosis (AE). Two patients were detected through ultrasound examinations carried out for unrelated causes; one presented with features of liver abscess, and nine had pain in the right upper quadrant for a mean period of 2.2 ± 1.79 years. All had the liver as the primary organ involved, with 15 tumor masses of a mean maximum diameter of 9.22 ± 3.21 cm and volume of 426 ± 374.61 cm3. Tumors placed centrally had invaded vessels and the biliary tract in eight patients, and those placed peripherally had invaded the liver capsule and adjacent organs in nine patients. Histologic examination of liver biopsies or resected organs revealed necrotic lesions, calcifications, and granulomatous inflammation with slender, thin-walled vesicles of bizarre configuration that stained strongly eosinophilic with periodic acid Schiff. Two patients had segmental liver resections; one was treated with liver aspiration, while the other nine with advanced disease received chemotherapy with albendazole along with praziquantel. Patients showed clinical improvement on a median follow-up of 12 months (range 1 to 60 months); however, MRI T2-weighted images and 18F-FDG-PET-CECT scans in two patients showed active disease on follow-up at one and five years, respectively. A systematic review detected 146 cases of AE in India from 1980 to April 2024. Twenty cases were from foreign countries, mostly from Central Asian republics, and 118 (93.65%) of the remaining 126 Indian patients were permanent residents of Kashmir Valley. The disease affected a population of 79,197 residing in 22 villages from 5 border districts of the valley. These villages were either high in or adjacent to the Himalayan mountain range. Disease prevalence in the affected population was 146.47/105 (males 131.53/105 and females 163.18/105) and the incidence was 12.41/105/year (males 11.16/105/year and females 13.81/105/year). Possible causes of the emergence of AE are discussed, and future directions for research to face this challenge arebeen identified.

Two Cases of Disseminated Alveolar Echinococcosis: The Diagnosis, Management, and Differential Considerations for Liver Lesions

Alveolar echinococcosis (AE), caused by Echinococcus multilocularis, is an aggressive and potentially critical infestation that primarily affects the liver and can metastasize to any part of the body. We herein report two cases of echinococcosis, which could be differentiated from malignancy on imaging studies, with infections of the liver and mediastinal lymph nodes, and also associated with systemic disseminated lesions. AE is a very invasive infectious disease, and in order to detect such lesions at an early stage when they are still resectable, it is necessary to understand the characteristic imaging findings and determine the patient's current medical history.

Computed tomography angiography of liver alveococcosis: a case report

BACKGROUND

Alveococcosis, helminthiasis caused by the larvae of Alveococcus multilocularis, is characterized by the formation of parasitic nodes in the liver. This clinical case is a rare occurrence of liver alveococcosis in Uzbekistan.

CASE PRESENTATION

We present a case of a 33-year-old Asian woman from Uzbekistan who complained of discomfort in the epigastric region and right hypochondrium, along with general weakness. She had been experiencing symptoms for 5 months when a routine ultrasound examination revealed a structural formation in the liver. Patient was investigated by using contrast enhanced computed tomography (CT) and diagnosed with liver alveococcosis with multiple lesions. Patient underwent diagnostic laparotomy with obtaining gross specimen, biomaterial was examined microscopically and found that there were small fragments of fibrous tissue determined together with small groups of cystic formations and walls consisted of chitin. Moreover, contrast enhanced CT allowed us to differentiate liver alveococcosis from cavernous hemangioma, hepatocellular carcinoma, and liver metastases from unknown source.

CONCLUSION

Contrast enhanced CT plays a major role in differentially diagnosing liver alveococcosis and makes it the first line method of choice for the consideration of the future treatment and surgical interventions.

Differentiation between cerebral alveolar echinococcosis and brain metastases with radiomics combined machine learning approach

BACKGROUND

Cerebral alveolar echinococcosis (CAE) and brain metastases (BM) share similar in locations and imaging appearance. However, they require distinct treatment approaches, with CAE typically treated with chemotherapy and surgery, while BM is managed with radiotherapy and targeted therapy for the primary malignancy. Accurate diagnosis is crucial due to the divergent treatment strategies.

PURPOSE

This study aims to evaluate the effectiveness of radiomics and machine learning techniques based on magnetic resonance imaging (MRI) to differentiate between CAE and BM.

METHODS

We retrospectively analyzed MRI images of 130 patients (30 CAE and 100 BM) from Xinjiang Medical University First Affiliated Hospital and The First People's Hospital of Kashi Prefecture, between January 2014 and December 2022. The dataset was divided into training (91 cases) and testing (39 cases) sets. Three dimensional tumors were segmented by radiologists from contrast-enhanced T1WI images on open resources software 3D Slicer. Features were extracted on Pyradiomics, further feature reduction was carried out using univariate analysis, correlation analysis, and least absolute shrinkage and selection operator (LASSO). Finally, we built five machine learning models, support vector machine, logistic regression, linear discrimination analysis, k-nearest neighbors classifier, and Gaussian naïve bias and evaluated their performance via several metrics including sensitivity (recall), specificity, positive predictive value (precision), negative predictive value, accuracy and the area under the curve (AUC).

RESULTS

The area under curve (AUC) of support vector classifier (SVC), linear discrimination analysis (LDA), k-nearest neighbors (KNN), and gaussian naïve bias (NB) algorithms in training (testing) sets are 0.99 (0.94), 1.00 (0.87), 0.98 (0.92), 0.97 (0.97), and 0.98 (0.93), respectively. Nested cross-validation demonstrated the robustness and generalizability of the models. Additionally, the calibration plot and decision curve analysis demonstrated the practical usefulness of these models in clinical practice, with lower bias toward different subgroups during decision-making.

CONCLUSION

The combination of radiomics and machine learning approach based on contrast enhanced T1WI images could well distinguish CAE and BM. This approach holds promise in assisting doctors with accurate diagnosis and clinical decision-making.

Can contrast-enhanced ultrasound differentiate the type of hepatic echinococcosis: cystic echinococcosis or alveolar echinococcosis?

BACKGROUND

Hepatic echinococcosis (HE) is a zoonotic disease caused by Echinococcus, and Echinococcus granulosus and E. multilocularis are the most common, causing cystic echinococcosis (CE) and alveolar echinococcosis (AE), respectively. Contrast-enhanced ultrasound (CEUS) is an imaging technique which has been recommended for identifying focal lesions in the liver. However, the effect of CEUS on the differentiation of hepatic echinococcosis type remains unclear.

METHODS

Twenty-five patients with 46 HE lesions confirmed by histopathology in our hospital from December 2019 to May 2022 were reviewed by conventional ultrasound (US) and CEUS examinations, respectively. After US was completed, the CEUS study was performed. A bolus injection of 1.0-1.2 ml of a sulfur hexafluoride-filled microbubble contrast agent (SonoVue^®) was administered. The images and clips of the lesions by US and CEUS were reviewed retrospectively. The lesions detected using US were evaluated including the location, size, morphology, margin, internal echogenicity and the internal Doppler signal. The lesions detected using CEUS were evaluated including the enhancement degree, enhancement pattern and enhancing boundary in different phases. The diagnoses of lesions by US or CEUS were respectively recorded. By taking the histopathology as the gold standard, the paired Chi-square test was performed with statistical software (IBM SPSS; IBM Corp., Armonk, NY, USA), and the results of differentiation of HE type by US and CEUS were statistically analyzed.

RESULTS

A total of 46 lesions were involved in 25 patients, including 10 males (40.0%) and 15 females (60.0%) aged 15-55 (42.9 ± 10.3) years. By histopathology, 24 lesions of nine patients were diagnosed as CE and 22 lesions of 16 patients were diagnosed as AE. Among the 46 HE lesions, compared with histopathological examination, the accuracy rate was 65.2% and 91.3% in US and CEUS findings, respectively. Among the 24 CE lesions, 13 lesions were correctly differentiated by US, and 23 by CEUS. The difference between US and CEUS was statistically significant (Chi-square test, [Formula: see text] = 8.10, df = 23, P < 0.005). Among the total 46 HE lesions, 30 lesions were correctly differentiated by US, and 42 by CEUS. The difference between US and CEUS was statistically significant (Chi-square test, [Formula: see text] = 10.08, df = 45, P < 0.005).

CONCLUSIONS

CEUS is a more effective technique than US for differentiating the type of HE between CE and AE. It could be a reliable tool in the differentiation of HE.

Percutaneous management in hepatic alveolar echinococcosis: A sum of single center experiences and a brief overview of the literature

BACKGROUND

Hepatic alveolar echinococcosis (HAE) is a serious zoonotic infection that affects humans. It may have a tumor-like appearance at times. Percutaneous treatment of HAE patients is extremely relaxing for them. HAE is a significant human zoonotic infection caused by the fox tapeworm Echinococcus Multilocularis larvae. It possesses the characteristics of an invasive tumor-like lesion due to its infiltrative growth pattern and protracted incubation period. The disease is endemic over central Europe, Asia, and North America.

AIM

To characterize HAE patients who were treated percutaneously, their outcomes, and the major technical features of percutaneous treatment in HAE.

METHODS

Patients who were treated with percutaneous cyst drainage and/or percutaneous biliary drainage were included in the study. Uncorrected abnormal coagulation values and solid or non-infected HAE with minor necrotic change were excluded.

RESULTS

Thirty-two patients underwent percutaneous cyst drainage, two patients underwent percutaneous biliary drainage, and four patients underwent percutaneous biliary drainage alone. Interventional radiology is utilized to drain echinococcal necrosis and abscesses within/without the liver, as well as diseased and clogged bile ducts.

CONCLUSION

Percutaneous drainage of cyst contents and/or biliary channels using a minimally invasive technique is a very beneficial. Percutaneous cyst drainage with albendazole therapy improves quality of life in patients who are unable to undergo surgery, even when the mass resolves with long-term treatment.

CT Imaging Findings of Pulmonary Alveolar Echinococcosis

Alveolar echinococcosis is a parasitic infection caused by Echinococcus multilocularis in the metacestode stage. The disease involves the liver in almost all cases, and additionally, lung involvement is accompanied in approximately 13% of the cases. Due to the low incidence of pulmonary alveolar echinococci, there are few case reports of lung involvement in the literature. In this study, computed tomography (CT) findings related to pulmonary involvement in alveolar echinococcosis cases, which have increased worldwide in recent years, were evaluated.

Diagnostic and Management Perspectives in Alveolar Echinococcosis: Review of Literature

Alveolar echinococcosis is a life-threatening zoonotic disease caused by Echinococcus multilocularis. The disease usually primarily involves the liver and shows tumor-like growth. Early diagnosis of alveolar echinococcosis is difficult because the disease is usually asymptomatic in the early stages. Untreated cases are fatal and result in death within 10 years of liver involvement. In the diagnosis of alveolar echinococcosis, the patient's medical history, radiological imaging findings, and serological and histopathological tests are used together. Radiological imaging methods are very important for early diagnosis and differential diagnosis of the disease. In this article, we wanted to review the diagnosis and treatment of alveolar echinococcosis and emphasize the importance of keeping it in mind, especially in cystic lesions of the liver, and the importance of early diagnosis of the disease.

Alveolar and neotropical echinococcosis

The urgency of the problem of human alveolar and neotropic echinococcosis is due to polymorphism and the severity of clinical manifestations. The purpose and result of the work is to summarize the data available in the literature on the etiology, epidemiology, clinic, diagnosis, treatment, prevention of alveolar and neotropic echinococcosis in humans. Conclusion. The causative agent of human alveolar echinococcosis is E. multilocularis, neotropic – E. vogeli, E. oligarthra. The liver and lungs are most often affected, less often other organs of the abdominal cavity, bones, brain, spinal cord, eyes, etc. Diagnostics is carried out on the basis of a complex of clinical, instrumental, serological, molecular genetic studies. Treatment includes surgical removal of parasitic cysts and drug therapy.

The hepato-cardiac disorders in Tibetan residents with hepatic echinococcosis: A case-control echocardiography study

BACKGROUND

Clinical guidelines indicate that chronic highland exposure could induce pulmonary hypertension; chronic hepatic disease may affect cardiac structure and functions. However, the simultaneous impact of hepatic echinococcosis (HE) and chronic highland exposure on cardiac structure and function in Tibetan residents are under-investigated.

METHODS

One hundred and twenty patients with HE, 23 healthy high-altitude migrants with a mean residence time of 7.15 ± 1.12 years, and 46 healthy Tibetan permanent residents were enrolled in this study. All participants received comprehensive transthoracic echocardiography.

RESULTS

High-altitude migrants have a relatively lower pulmonary artery flow velocity (PV) and a slightly higher pulmonary artery mean pressure (PAMP) than the Tibetan permanent residents. Patients with HE presented relatively smaller dimensions of the main pulmonary artery and branches and a bigger right atrium and right ventricular cavity size than the two control groups. PV, PAMP and numbers of detectable tricuspid regurgitation jet velocity (TRJV), right ventricular fractional area change (RV_FAC), tricuspid annular plane systolic excursion (TAPSE), the ratio of tricuspid inflow velocities at early diastole to tricuspid annular early diastolic excursion velocity (RV_E/e') and right ventricular myocardial performance index (RV_MPI) were increased in patients with HE compared to the two control groups. Similarly, decreased LVEF and Impaired left ventricular diastolic function were identified in patients with HE compared to the two control groups.

CONCLUSIONS

Patients with HE presented with impaired biventricular contractile performance and diastolic dysfunction.

One-tube nested MGB Probe Real-time PCR assay for detection of Echinococcus multilocularis infection in plasma cell free DNA

INTRODUCTION

The main objective of this study was to develop a One-tube nested MGB probe real-time PCR Assay for detecting Echinococcus multilocularis infection in human plasma cell free DNA (cfDNA).

METHODS

cfDNA was extracted from 10 E.m.-infected patients using a NucleoSnap DNA Plasma Kit and characterized by genomic sequencing. We designed nested PCR primers and MGB probe for Echinococcus multilocularis detection. The specificity, sensitivity and reproducibility of this assay were analyzed, and its validity was confirmed in 13 early stage clinical samples.

RESULTS

Several Echinococcus multilocularis-specific sequences were detected in the cfDNA of E.m.-infected patients, and CBLO020001206.1 was selected as the candidate sequence. We designed the primers and probe for the one tube nested real-time PCR. No cross-reactions with E.g. were observed. The detection limit was as low as 1 copy for Echinococcus multilocularis. The coefficients of variation were lower than 5% in intra- and inter-assays. 11 out of 13 patients were positive with nested MGB Probe PCR Assay and 3 patients were positive without outer primer in early stage Alveolar Echinococcosis pateints.

CONCLUSION

The one-tube nested MGB probe real-time PCR assay is a simple, rapid, and cost-effective method for detection of Echinococcus multilocularis infection in patients' Plasma DNA.

Prediction of benzimidazole therapy duration with PET/CT in inoperable patients with alveolar echinococcosis

Alveolar echinococcosis is a rare parasitic disease, most frequently affecting the liver, as a slow-growing tumor-like lesion. If inoperable, long-term benzimidazole therapy is required, which is associated with high healthcare costs and occasionally with increased morbidity. The aim of our study was to determine the role ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) in staging of patients with alveolar echinococcosis and to identify quantitative imaging parameters related to patient outcome and/or duration of benzimidazole therapy. In this single-center retrospective cohort study, 47 PET/CT performed for staging in patients with confirmed alveolar echinococcosis were analysed. In 43 patients (91%) benzimidazole therapy was initiated and was successfully stopped after a median of 870 days (766–2517) in 14/43 patients (33%). In inoperable patients, tests for trend of survivor functions displayed clear trends for longer benzimidazole therapy duration (p = 0.05; n = 25), and for longer time intervals to reach non-detectable serum concentration of Em-18 antibodies (p = 0.01, n = 15) across tertiles of SUVratio (maximum standardized uptake value in the echinococcus manifestation compared to normal liver tissue). Hence, in inoperable patients with alveolar echinococcosis, PET/CT performed for staging may predict the duration of benzimidazole therapy.

Massive sympathetic nerve infiltration in advanced hepatic alveolar echinococcosis: a case report and review of the literature

Background

Alveolar echinococcosis is a zoonotic disease that mostly affects the liver, with vascular invasion and a protean clinical symptom. However, no reports of sympathetic nerve infiltration in hepatic alveolar echinococcosis have been reported. Here, we report a case of hepatic alveolar echinococcosis in a 33-year-old man. In this end-stage case, the lesion was heavily involved in the large vessels and biliary tract, and immunohistochemistry also incidentally revealed extensive nerve infiltration in the specimens after surgical treatment. Subsequently, neural classification was identified.

Case presentation

We herein report a case of advanced hepatic alveolar echinococcosis with macrovascular invasion and sympathetic nerve infiltration. In this case, inferior vena cava (IVC), the portal vein and bile duct were infiltrated. Ultimately, according to our experience, ex vivo liver resection and autotransplantation (ELRA) was the optimal treatment way to perform for this unresectable patient. Samples were collected from normal liver tissue, junction tissue and the lesion. Hematoxylin–eosin (HE) staining was used to confirm the diagnosis. Neural infiltration was observed by immunohistochemical staining with protein gene product 9.5 (PGP9.5). Fluorescence colocalization was determined with PGP9.5 and tyrosine hydroxylase (TH). These results suggest that a large amount of sympathetic nerve infiltration occurred at the junction.

Conclusion

This study suggests that advanced hepatic alveolar echinococcosis shows infiltrating growth, often invades the large vessels and biliary ducts, and may be accompanied by sympathetic nerve infiltration.

Role of the radiologist in the diagnosis and management of the two forms of hepatic echinococcosis

Echinococcosis is a parasitic disease caused by two zoonotic tapeworms (cestodes) of the Echinocococcus genus. It can be classified as either alveolar or cystic echinococcosis. Although the two forms differ significantly in terms of imaging findings, they share similarities in terms of management and treatment. In parallel to medical treatment with albendazole (ABZ), and surgery, historically used in these diseases, various imaging-guided interventional procedures have recently emerged (drainage, stenting, or Puncture, aspiration, injection, and reaspiration (PAIR)). These options open up a new range of therapeutic options. As in oncology, multidisciplinary consultation meetings now play a major role in adapted management and patient care in hepatic echinococcosis. Consequently, diagnostic imaging and interventional expertise have brought radiologists to the fore as important members of these multidisciplinary team. The radiologist will need to evaluate parasite activity in both forms of the disease, to guide the choice of the appropriate therapy from among medical treatment, interventional radiology procedures and/or surgical treatment. Knowledge of the specific complications of the two forms of echinococcosis will also help radiologists to discuss the appropriate treatment and management. The aim of this review is to describe the core knowledge that what a radiologist should possess to actively participate in multidisciplinary meetings about hepatic echinococcosis. We discuss the role of imaging, from diagnosis to treatment, in alveolar (AE) and cystic echinococcosis (CE), respectively.

Treatment of Complicated Hepatic Alveolar Echinococcosis Disease With Suspicious Lymph Node Remote Metastasis Near the Inferior Vena Cava-Abdominal Aorta: A Case Report and Literature Review

Echinococcosis is a human-animal parasitic disease caused by Echinococcosis tapeworm larvae in humans. From a global perspective, it is mainly prevalent in the mid-high latitudes of the Northern Hemisphere, and it is a widespread infectious disease. Its form, host and release areas are slightly different. In clinical practice, Echinococcus granulosus (hepatic cystic echinococcosis) is the most common. Its growth mode is swelling growth and its metastasis is more common in implanted metastasis; However, hepatic alveolar echinococcosis (HAE) is rare. It has been reported that HAE can metastasize through the blood or lymph nodes, and its invasive growth pattern is known as “carcinoma”. At this time, it may be accompanied by invasion of the portal vein and inferior vena cava(IVC)or metastasis to distant organs outside the liver (such as lung, brain, lymph nodes). Most patients are in the middle or late stages, making treatment complicated. World Health Organization guidelines recommend radical resection of HAE; However, there is no consensus on lymph node dissection. To date, there have been no reports of cases of HAE accompanied by inferior vena cava-para-abdominal aortic suspected lymph node metastasis and infection. This article reports a clinical case of a complex HAE treated by the surgical method of “middle liver resection + abdominal enlarged lymph node resection + inferior vena cava repair”, and histological examination was performed to illustrate the differences in microscopic pathology of alveolar echinococcosis invading the liver and lymph nodes at different magnifications. This article reviews the relevant literature on HAE and derives the latest treatment methods for HAE to provide a reference for future clinical cases of similar alveolar echinococcosis and maximize the benefits of patients.

Imaging Aspects of Hepatic Alveolar Echinococcosis: Retrospective Findings of a Surgical Center in Turkey

Radiologists should be aware of the findings of alveolar echinococcosis (AE) due to the diagnostic and management value of imaging. We are attempting to define the most common diagnostic imaging findings of liver AE, along with the prevalence and distribution of those findings. The patients' US, CT, and MRI images were reviewed retrospectively. CT images were acquired with and without the administration of contrast medium. The MRI protocol includes T2-weighted images (WI), diffusion (WI), apparent diffusion coefficient (ADC) maps, and pre- and post-contrast T1WIs. The current study included 61 patients. The mean age of the population was 58.2 ± 9.6 years According to Kratzer's categorization (US), 139 lesions (73.1%) were categorized as hailstorm. According to Graeter's classification (CT), 139 (73.1%) lesions were type 1-diffuse infiltrating. The most frequent types were Kodama type 2 and 3 lesions (MRI) (42.6% and 48.7%, accordingly). P2N0M0 was the most frequent subtype. The current study defines the major, characteristic imaging findings of liver AE using US, CT, and MRI. Since US, CT, and MRI have all been utilized to diagnose AE, we believe that a multi-modality classification system is needed. The study's findings may aid radiologists in accurately and timely diagnosing liver AE.

Effectiveness and safety of ultrasound-guided percutaneous microwave ablation for hepatic alveolar echinococcosis

BACKGROUND

Microwave ablation (MWA) is a popular therapy for liver malignant tumor in recent years. Few studies have been conducted on its use in the treatment of hepatic alveolar echinococcosis (HAE). The study aims to evaluate the efficacy and safety of MWA in the treatment of HAE.

METHODS

This study analyzed the data of 45 patients (mean age, 38 ± 2 years; 24 males) diagnosed with HAE and underwent MWA treatment between June 2014 to December 2019. The patients after MWA were examined by CT or MRI [follow-up: 32 months (IQR 23-48.5)] to determine whether the lesions were relapsed and to evaluate the therapeutic effect of MWA. The safety of MWA was evaluated by monitoring postoperative complications. Clinical data, such as patient demographics, imaging features of the lesions, relevant findings of laboratory tests before and after ablation, and information related to ablation, were collected and analyzed. Paired-sample t tests and paired-sample Wilcoxon signed-rank tests were used to compare relevant laboratory indicators before and after MWA.

RESULTS

MWA was applied to 57 HAE lesions in 45 patients. The median size of lesions was 3.42 cm (IQR2.85-4.41). The rate of complete ablation was 100% (57/57). The median follow-up time was 32 months (IQR 23-48.5). The recurrence rate was 13% (6/45), and the median time of recurrence was 22 months. The rate of minor complications was 11.1% (5/45), and there were no major complications and deaths. Compared to preoperative, ALB, RBC, HBG, and PLT were decreased (p < 0.001); ALT, TB, DB, and WBC were increased (p < 0.001); and no statistically difference in PT, APTT, and INR (p > 0.05).

CONCLUSIONS

MWA might be a safe and effective way to cure HAE. Meanwhile, it provides a new option and a new way of thinking about treatment for patients with HAE.

Albendazole reduces hepatic inflammation and endoplasmic reticulum-stress in a mouse model of chronic Echinococcus multilocularis infection

BACKGROUND

Echinococcus multilocularis causes alveolar echinococcosis (AE), a rising zoonotic disease in the northern hemisphere. Treatment of this fatal disease is limited to chemotherapy using benzimidazoles and surgical intervention, with frequent disease recurrence in cases without radical surgery. Elucidating the molecular mechanisms underlying E. multilocularis infections and host-parasite interactions ultimately aids developing novel therapeutic options. This study explored an involvement of unfolded protein response (UPR) and endoplasmic reticulum-stress (ERS) during E. multilocularis infection in mice.

METHODS

E. multilocularis- and mock-infected C57BL/6 mice were subdivided into vehicle, albendazole (ABZ) and anti-programmed death ligand 1 (αPD-L1) treated groups. To mimic a chronic infection, treatments of mice started six weeks post i.p. infection and continued for another eight weeks. Liver tissue was then collected to examine inflammatory cytokines and the expression of UPR- and ERS-related genes.

RESULTS

E. multilocularis infection led to an upregulation of UPR- and ERS-related proteins in the liver, including ATF6, CHOP, GRP78, ERp72, H6PD and calreticulin, whilst PERK and its target eIF2α were not affected, and IRE1α and ATF4 were downregulated. ABZ treatment in E. multilocularis infected mice reversed, or at least tended to reverse, these protein expression changes to levels seen in mock-infected mice. Furthermore, ABZ treatment reversed the elevated levels of interleukin (IL)-1β, IL-6, tumor necrosis factor (TNF)-α and interferon (IFN)-γ in the liver of infected mice. Similar to ABZ, αPD-L1 immune-treatment tended to reverse the increased CHOP and decreased ATF4 and IRE1α expression levels.

CONCLUSIONS AND SIGNIFICANCE

AE caused chronic inflammation, UPR activation and ERS in mice. The E. multilocularis-induced inflammation and consecutive ERS was ameliorated by ABZ and αPD-L1 treatment, indicating their effectiveness to inhibit parasite proliferation and downregulate its activity status. Neither ABZ nor αPD-L1 themselves affected UPR in control mice. Further research is needed to elucidate the link between inflammation, UPR and ERS, and if these pathways offer potential for improved therapies of patients with AE.

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.

Identification of candidate biomarkers of liver hydatid disease via microarray profiling, bioinformatics analysis, and machine learning

Objectives

Liver echinococcosis is a severe zoonotic disease caused by Echinococcus (tapeworm) infection, which is epidemic in the Qinghai region of China. Here, we aimed to explore biomarkers and establish a predictive model for the diagnosis of liver echinococcosis.

Methods

Microarray profiling followed by Gene Ontology and Kyoto Encyclopedia of Genes and Genomes analysis was performed in liver tissue from patients with liver hydatid disease and from healthy controls from the Qinghai region of China. A protein–protein interaction (PPI) network and random forest model were established to identify potential biomarkers and predict the occurrence of liver echinococcosis, respectively.

Results

Microarray profiling identified 1152 differentially expressed genes (DEGs), including 936 upregulated genes and 216 downregulated genes. Several previously unreported biological processes and signaling pathways were identified. The FCGR2B and CTLA4 proteins were identified by the PPI networks and random forest model. The random forest model based on FCGR2B and CTLA4 reliably predicted the occurrence of liver hydatid disease, with an area under the receiver operator characteristic curve of 0.921.

Conclusion

Our findings give new insight into gene expression in patients with liver echinococcosis from the Qinghai region of China, improving our understanding of hepatic hydatid disease.

Hepatic Alveolar Echinococcosis: Predictive Biological Activity Based on Radiomics of MRI

BACKGROUND

To evaluate the role of radiomics based on magnetic resonance imaging (MRI) in the biological activity of hepatic alveolar echinococcosis (HAE).

METHODS

In this study, 90 active and 46 inactive cases of HAE patients were analyzed retrospectively. All the subjects underwent MRI and positron emission tomography computed tomography (PET-CT) before surgery. A total of 1409 three-dimensional radiomics features were extracted from the T2-weighted MR images (T2WI). The inactive group in the training cohort was balanced via the synthetic minority oversampling technique (SMOTE) method. The least absolute shrinkage and selection operator (LASSO) regression method was used for feature selection. The machine learning (ML) classifiers were logistic regression (LR), multilayer perceptron (MLP), and support vector machine (SVM). We used a fivefold cross-validation strategy in the training cohorts. The classification performance of the radiomics signature was evaluated using receiver operating characteristic curve (ROC) analysis in the training and test cohorts.

RESULTS

The radiomics features were significantly associated with the biological activity, and 10 features were selected to construct the radiomics model. The best performance of the radiomics model for the biological activity prediction was obtained by MLP (AUC = 0.830 ± 0.053; accuracy = 0.817; sensitivity = 0.822; specificity = 0.811).

CONCLUSIONS

We developed and validated a radiomics model as an adjunct tool to predict the HAE biological activity by combining T2WI images, which achieved results nearly equal to the PET-CT findings.

Investigating new serological and tissue markers for the follow-up of patients operated for alveolar echinococcosis

AIMS

Alveolar echinococcosis (AE) is characterized by a chronically progressing hepatic injury caused by Echinococcus multilocularis. Surgery presently remains the best curative option. Currently, biological predictive features derived from the resected specimens are not suitable to assess surgery efficacy. The present study was designed to investigate whether a selection of markers measured on the resected specimens exhibits predictive features related to parasite viability, or to a total elimination of the parasite, in addition to serological markers.

METHODS AND RESULTS

In a collaboration between two centres, one in France (Besançon), and one in Switzerland (Bern), samples from 40 AE patients were analysed by microarray and serology techniques, individually. Paired serum samples before and after surgery were obtained for 26 patients. In the sera, a significant decrease in PD-L1 levels was observed after surgery, in addition to anti-Em18 levels. In the liver tissue, low levels of Cluster of Differentiation (CD)-3 were correlated with the absence of serum anti-Em18 after surgery.

CONCLUSION

This study showed PD-L1 is promising as a potential serological marker and further confirmed the performance of anti-Em18 serology. Further studies on a larger cohort are needed to confirm the utility of performing systematically microarray on resected liver tissue.

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

Background

Human alveolar echinococcosis (AE) caused by Echinococcus multilocularis is an underreported, often misdiagnosed and mistreated parasitic disease mainly due to its low incidence. The aim of this study was to describe the epidemiological and clinical characteristics of human AE patients in Hungary for the first time.

Method

Between 2003 and 2018, epidemiological and clinical data of suspected AE patients were collected retrospectively from health database management systems.

Results

This case series included a total of 16 AE patients. The mean age of patients was 53 years (range: 24–78 years). The sex ratio was 1:1. Four patients (25%) revealed no recurrence after radical surgery and adjuvant albendazole (ABZ) therapy. For five patients (31.3%) with unresectable lesions, a stabilization of lesions with ABZ treatment was achieved. In seven patients (43.8%), progression of AE was documented. The mean diagnostic delay was 33 months (range: 1–122 months). Three AE related deaths (fatality rate 18.8%) were recorded.

Conclusions

AE is an emerging infectious disease in Hungary with a high fatality rate since based on our results, almost every fifth AE patient died in the study period. Differential diagnosis and appropriate surgical and medical therapy for AE is an urging challenge for clinicians in Hungary, as well as in some other European countries where E. multilocularis is prevalent.

MR Imaging of the Perihepatic Space

The perihepatic space is frequently involved in a spectrum of diseases, including intrahepatic lesions extending to the liver capsule and disease conditions involving adjacent organs extending to the perihepatic space or spreading thanks to the communication from intraperitoneal or extraperitoneal sites through the hepatic ligaments. Lesions resulting from the dissemination of peritoneal processes may also affect the perihepatic space. Here we discuss how to assess the perihepatic origin of a lesion and describe the magnetic resonance imaging (MRI) features of normal structures and fluids that may be abnormally located in the perihepatic space. We then review and illustrate the MRI findings present in cases of perihepatic infectious, tumor-related, and miscellaneous conditions. Finally, we highlight the value of MRI over computed tomography.

Radiological manifestations of thoracic hydatid cysts: pulmonary and extrapulmonary findings

Hydatid cyst caused by the larval form of Echinococcus is a worldwide zoonosis. The lungs and liver are the most common sites involved. While the lung parenchyma is the most common site within the thorax, it may develop in any extrapulmonary region including the pleural cavity, fissures, mediastinum, heart, vascular structures, chest wall, and diaphragm. Imaging plays a pivotal role not only in the diagnosis of hydatid cyst, but also in the visualization of the extent of involvement and complications. The aim of this pictorial review was to comprehensively describe the imaging findings of thoracic hydatid cyst including pulmonary and very unusual extrapulmonary involvements. An outline is also given for the findings of complications and differential diagnosis of thoracic hydatid cyst.

The spectrum of multimodality imaging findings in hepatic alveolar echinococcosis and the potential role of diffusion-weighted imaging in its characterisation

Purpose

To study the spectrum of imaging findings in hepatic alveolar echinococcosis (HAE) and to evaluate the potential role of diffusion-weighted imaging (DWI) in its characterisation.

Material and methods

Two radiologists with more than seven years of experience retrospectively studied ultrasonography, computed tomography (CT), and magnetic resonance imaging (MRI) findings in 23 histopathologically proven cases of HAE with emphasis on the appearance and extent of disease. DWI characteristics of lesions were noted, and their apparent diffusion values (ADC) were calculated.

Results

Ultrasonography features of HAE included heterogeneous, hyperechoic hepatic mass with or without calcification (n = 20), or heterogeneous mass with solid-cystic appearance (n = 2). CT revealed heterogeneous density infiltrative hepatic mass with no contrast enhancement in 19 patients or thick-walled cystic mass (n = 4). Following Kodama classification one type 1, six type 2, two type 3, eight type 4, and two type 5 lesions were identified on T2-weighted MRI. No enhancement was seen on post-contrast T1-weighted images. Mean ADC values were 1.74 ± 0.48 × 10^-3 mm²/s (range: 1.39 × 10^-3 mm²/s to 2.3 × 10^-3 mm²/s).

Conclusions

HAE by virtue of its infiltrative growth pattern with a tendency to involve biliary, vascular, and extra hepatic structures can be easily misdiagnosed as malignant hepatic neoplasm. Knowledge of varied imaging appearances of HAE is essential to suspect the condition and to make an appropriate diagnosis. Diffusion-weighted imaging is a useful adjunct with relatively high diffusivity (high ADC values) suggesting diagnosis of alveolar hydatid.

Alveolar Echinococcosis in Children

Alveolar echinococcosis (AE) is an infectious zoonotic disease that is caused by Echinococcus multilocularis. The disease is generally identified accidentally because of the long asymptomatic period, has a malignant behaviour, and mainly occurs in the liver. Usually it is diagnosed in adults and is very rare in pediatric patients. We report two cases of AE and 1 differential case between AE and cystic echinococcosis (CE) in children: two of them had lesions in the liver and one had rare extrahepatic presentation of a cyst in the spleen. All our patients received chemotherapy with albendazole because surgical treatment was not recommended. The children were followed-up from 10 to 30 months and no significant improvement was seen. In this report we discuss the difficulties we faced in the treatment and follow-up of these patients. We also review the main clinical manifestations, general diagnostic methods, and treatment options of AE according to the current literature.

Clinical aspects and treatment of alveolar echinococcosis: the current state of knowledge and difficulties in the diagnosis and management of cases in Poland

The aim of the study is to summarize the current state of knowlege in the diagnosis and monitoring of patients with alveolar echinococcosis (AE), using serological tests and imaging techniques, and to present the most recent therapeutic guidelines based on a literature review. The paper discusses the challenges in diagnosing and treating AE encountered in clinical practice in Poland, based on the analysis of medical records of 86 patients with AE, who were hospitalized in the University Centre for Maritime and Tropical Medicine (UCMTM) between 2000 and 2018. In Poland, AE is usually diagnosed at the advanced stage, when optimal, radical surgery is not an option. Diagnosis of AE is often preceded by invasive diagnostic methods, such as biopsy or exploratory laparotomy, which may result in the infection spreading. Pharmacological treatment is associated with potential adverse effects and is a significant financial burden for the patient due to the lack of reimbursement. There is a need to raise the awareness of AE among physicians performing imaging studies and to facilitate access to modern techniques enabling the assessment of the parasitic process.

Isolated Pulmonary Hydatid Cyst: A Rare Presentation in a Young Maasai Boy from Northern Tanzania

Introduction

Hydatidosis is a parasitic manifestation caused by Echinococcus granulosus. It is characterized by cystic lesions in the liver and lungs. Diagnosis is based on typical history and radiological measures.

Case presentation

A four-year-old boy presented with a one-year history of dry cough and difficulty in breathing which was of gradual progression. Computed tomography of the chest revealed a large 11.7 cm × 8.6 cm × 11.0 cm cyst in the right hemithorax. The patient underwent thoracotomy and recovered well post procedure.

Conclusion

This case report highlights that large hydatid cysts can be surgically removed with good outcome and the importance of realizing that the disease is a burden to the public health and is much neglected.

An Imported Case of Disseminated Echinococcosis in Korea

A complicated case of echinococcosis with multiple organ involvement is reported in a 53-year-old businessman who frequently traveled overseas, including China, Russia, and Kazakhstan from 2001 to 2007. The patient was first diagnosed with a large liver cyst during a screening abdomen ultrasonography in 2011, but he did not follow up on the lesion afterwards. Six years later, dizziness, dysarthria, and cough developed, and cystic lesions were found in the brain, liver and lungs. The clinical course was complicated when the patient went through multiple surgeries and inadequate treatment with a short duration of albendazole without a definite diagnosis. The patient visited our hospital for the first time in August 2018 due to worsening symptoms; he was finally diagnosed with echinococcosis using imaging and serologic criteria. He is now on prolonged albendazole treatment (400 mg twice a day) with gradual clinical and radiological improvement. A high index of suspicion is warranted to early diagnose echinococcosis in a patient with a travel history to endemic areas of echinococcosis.

Ultrasound images in hepatic alveolar echinococcosis and clinical stage of the disease

PURPOSE

Hepatic alveolar echinococcosis (AE) is a parasitic disease caused by the larval stage of the tapeworm Echinococcus multilocularis. Ultrasonography is the method of choice in the initial diagnosis of AE. The aim of the study is to present the most frequent sonomorphological patterns of lesions in hepatic AE based on the analysis of ultrasound findings in patients treated for AE at the University Centre of Maritime and Tropical Medicine (UCMMiT; Gdynia, Poland), and to establish whether there is a relationship between the clinical stage of AE and the occurrence of a specific sonomorphological pattern of hepatic lesions.

PATIENTS AND METHODS

We analysed the results of ultrasound examinations of 58 patients hospitalized in the UCMMiT with probable or certain diagnosis of AE. Liver lesions were assessed according to the classification developed by researchers from the University Hospital in Ulm (Germany). Statistical analysis was based on the relationship between the occurrence of a specific sonomorphological pattern of hepatic lesions and the clinical stage of AE.

RESULTS

The most frequently observed patterns of AE lesions in the liver were the hailstorm and the pseudocystic patterns. There was no correlation between the clinical stage of the disease and the ultrasonographic appearance of lesions. There was no statistically significant relationship between the more frequent occurrences of specific ultrasonographic patterns of lesions in the liver and radical or non-radical surgery.

CONCLUSIONS

The ultrasonographic appearance of the lesion in liver AE cannot determine the therapeutic management. Treatment plan should be established based on the PMN classification.

A multiplex PCR for the identification of Echinococcus multilocularis, E. granulosus sensu stricto and E. canadensis that infect human

Echinococcus granulosus sensu stricto (s.s.), Echinococcus multilocularis and Echinococcus canadensis are the common causes of human echinococcosis in China. An accurate species identification tool for human echinococcosis is needed as the treatments and prognosis are different among species. The present work demonstrates a method for the simultaneous detection of these three Echinococcus species based on multiplex polymerase chain reaction (mPCR). Specific primers of this mPCR were designed based on the mitochondrial genes and determined by extensive tests. The method can successfully detect either separated or mixed target species, and generate expected amplicons of distinct size for each species. Sensitivity of the method was tested by serially diluted DNA, showing a detection threshold as less as 0.32 pg for both E. granulosus s.s. and E. canadensis, and 1.6 pg for E. multilocularis. Specificity assessed against 18 other parasites was found to be 100% except weakly cross-react with E. shiquicus. The assay was additionally applied to 69 echinococcosis patients and 38 healthy persons, confirming the high reliability of the method. Thus, the mPCR described here has high application potential for clinical identification purposes, and can further provide a useful tool for evaluation of serology and imaging method.

Alveolar Hydatid

Background

The aim of the present study was to study the different imaging appearances on proven cases of hepatic alveolar hydatid, which is often misdiagnosed as a tumor.

Materials and Methods

We studied ultrasonography, computed tomography, and magnetic resonance imaging findings in 21 histopathologically proven cases of hepatic alveolar hydatid disease over a period of 1½ year. The ultrasonography findings were heterogeneous hyperechoic mass in 14 cases, multilocular cystic mass in 3 cases, and hyperechoic mass with calcification giving dense acoustics in 4 cases. Computed tomography findings were a sheet-like hypodense, infiltrative, nonenhancing mass without biliary or portal encasement or infiltration in 16 cases, biliary infiltration in 4 cases, and portal encasement in 3 cases. The magnetic resonance imaging findings showed that all 21 patients had a characteristic microvesicular appearance of the parasitic mass on T2-weighted images corresponding to the microvesicles demonstrated on histopathology. The portal encasement and biliary infiltration were also demonstrated on magnetic resonance (MR) images.

Conclusions

T2-weighted MR images correlate with the histologic characteristic of the hepatic alveolar hydatid disease. Ultrasonography and computed tomography may help in initial assessment of the extent of the disease, but MR helps in exact diagnosis.

Survey of echinococcoses in southeastern Qinghai Province, China, and serodiagnostic insights of recombinant Echinococcus granulosus antigen B isoforms

Background

Echinococcoses, caused by metacestodes of Echinococcus granulosus (cystic echinococcosis; CE) and E. multilocularis (alveolar echinococcosis; AE), represent major emerging parasitic diseases. These enzootic helminthiases invoke significant public health concerns and social burdens in endemic areas. The diseases are prevalent in the Qinghai-Tibetan Plateau, China, while community-based epidemiological studies have been scarcely reported. We surveyed echinococcosis patients in the southeastern Qinghai Province, China, to better understand the concurrent epidemiological situation in this area.

Methods

During July and August of 2013 and 2014, we screened echinococcosis patients at Yushu and Golog Prefectures, Qinghai Province, China, in a diagnostic campaign. A total of 2856 people (male:female ratio, 1:1.12; mean age, 34.6 years; age range, 6–88 years) were ultrasonographically examined for the presence of hepatic echinococcal cysts. We also collected serum samples from patients and analyzed antibody reactivity against recombinant forms of diverse E. granulosus antigen Bs (rEgAgB1-5) by enzyme-linked immunosorbent assay.

Results

We detected 134 patients whose imaging scans were compatible with CE (115 cases) and AE (20 patients). One patient might have been infected with both CE and AE. The overall incidence was 4.7% (CE, 4.0%; AE, 0.7%). A large proportion (67.5%) of CE patients was diagnosed at active and transitional CE1-CE3 stages in their late 30s. The AE cases were generally detected at advanced stage in patients at early 20s (60%). Analysis of the receiver operating characteristic curve and Youden’s index indicated that rEgAgB2 was the most promising biomarker, followed by rEgAgB3 and rEgAgB1. Overall, sensitivity and specificity of rEgAgB1-3 were 84.5–92.7% and 91.9–94.6%, respectively. rEgAgB4 and 5 showed low sensitivity with high cross-reactivity.

Conclusions

Our results strongly suggest that disability-adjusted life years related to echinococcoses in Qinghai-Tibetan areas might be more serious than previously considered. Control and prevention strategy against CE and AE are highly required in these areas. In addition to ultrasonography, serological tests might provide supportive data. However, serological data should be carefully interpreted for differential diagnosis, especially in areas where both CE and AE are co-endemic.

Electronic supplementary material

The online version of this article (10.1186/s13071-019-3569-6) contains supplementary material, which is available to authorized users.

Hepatic alveolar hydatid disease (Echinococcus multilocularis), a mimic of liver malignancy: a review for the radiologist in non-endemic areas

Alveolar hydatid disease or alveolar echinococcosis (AE) is caused by the parasite Echinococcus multilocularis and is increasingly seen as an imported disease in non-endemic areas such as the UK. It is rare compared to cystic echinococcosis (CE), but like CE commonly affects the liver. AE does have imaging features that can aid in diagnosis, but is often initially misdiagnosed as liver malignancy. It is usually fatal if untreated, underscoring the importance of early diagnosis. This review highlights the role of imaging in AE diagnosis with the broader objective of increasing radiologists' awareness of this unusual, but increasingly prevalent disease.

Doughnut sign of hepatic alveolar echinococcosis on FDG PET/CT: Clinical case report

RATIONALE

A characteristic metabolic finding of hepatic alveolar echinococcosis (HAE) on positron emission tomography/computed tomography (PET/CT) correlates with morphologic features on CT and magnetic resonance imaging (MRI).

PATIENT CONCERNS

A young man from an endemic area was admitted to our hospital due to right upper quadrant pain for 2 months.

DIAGNOSIS

CT and MRI revealed a heterogeneous mass with calcification, consisting of central necrosis and peripheral solid inflammatory tissues. Accordingly, FDG PET/CT demonstrated a characteristic metabolic finding of doughnut sign. Combining the above characteristic imaging features with positive serologic findings, the patient was diagnosed as HAE.

INTERVENTIONS

He then underwent extracorporeal hepatectomy and liver autotransplantation followed by medical treatment of benzimidazoles.

OUTCOMES

He remained asymptomatic without evidence of recurrence at 2-year follow-up.

LESSONS

The characteristic metabolic appearance of HAE on FDG PET/CT, correlated with its morphologic features of CT and MRI, may allow to make accurate diagnoses.

Performance of Magnetic Resonance Susceptibility-Weighted Imaging for Detection of Calcifications in Patients With Hepatic Echinococcosis

OBJECTIVE

We evaluated the performance of susceptibility-weighted imaging (SWI) for identification of hepatic calcifications in alveolar echinococcosis and cystic echinococcosis.

METHODS

The SWI images of 58 lesions in 40 patients (age, 49 ± 14 y) with alveolar echinococcosis (n = 22) or cystic echinococcosis (n = 18) were reviewed for calcifications. First, calcifications were suggested by visual assessment. Second, ratios of minimum intralesional intensity and mean lumbar muscle intensity were recorded. Computed tomography (CT) served as the criterion standard.

RESULTS

Thirty-seven lesions showed calcifications on CT. Susceptibility-weighted imaging provided a sensitivity of 89.2% (95% confidence interval [CI], 50.1-75.7) and a specificity of 57.1% (95% CI, 34.4-77.4) for calcifications detected by visual assessment. Receiver operating characteristic curves demonstrated a sensitivity of 67.6% and a specificity of 85.0% for an intensity ratio of 0.61. A specificity of 100% (95% CI, 80.8-100) and a sensitivity of 84.5% (95% CI, 67.3-93.2) were achieved by SWI for calcifications with a density greater than 184 HU in CT.

CONCLUSIONS

Identification of hepatic calcifications is possible with SWI. Susceptibility-weighted imaging offers the potential to reduce the need for of CT imaging for evaluation of echinococcosis.

Comparison of Intravoxel Incoherent Motion Diffusion-Weighted Magnetic Resonance (MR) Imaging to T1 Mapping in Characterization of Hepatic Alveolar Echinococcosis

BACKGROUND The aim of this study was to compare intravoxel incoherent motion diffusion-weighted magnetic resonance imaging (IVIM DW MRI) to T1 mapping for characterization of hepatic alveolar echinococcosis (HAE). MATERIAL AND METHODS Eighteen HAE patients confirmed by surgery were examined with conventional MRI, IVIM DWI MRI with 10 b values (range: 0-1,000 sec/mm²), and longitudinal relaxation time (T1) mapping. Diffusion coefficient (D), perfusion fraction (f), pseudo-diffusion coefficient (D*), and T1 relaxation time were calculated in solid components, perilesional components, and background liver parenchyma of HAE patients. The correlation between T1 relaxation time and IVIM-derived parameters was assessed by using the Pearson correlation test. RESULTS T1 relaxation times were significantly higher in solid components (820.58±331.24 ms) compared to background components (551.52±182.93 ms) of HAE patients (p<0.05). IVIM-derived D values were significantly higher in solid components (1.30±0.28×10^-3 mm²/sec) compared to perilesional components (0.88±0.28×10^-3 mm²/sec) and background liver parenchyma (0.97±0.27×10^-3 mm²/sec) of liver parenchyma. There were significant differences in f values between solid components (13.70±7.66%), perilesional components (23.59±10.73%) and background liver parenchyma (30.78±10.18%). IVIM derived D* values were significantly lower in solid components (14.32±10.85×10^-3 mm²/sec) than in background liver parenchyma (30.06±15.68×10^-3 mm²/sec). Importantly, IVIM-derived f values were significantly correlated with T1 relaxation time: r=-0.337 (p<0.05). CONCLUSIONS Based on our image comparison, IVIM DWI MRI might be better than T1 mapping, and IVIM-derived f values might be a valuable index for characterization of HAE.