[Pulmonary Echinococcosis: Surgical Aspects]. / Pulmonale Echinokokkose: chirurgische Aspekte.

Pulmonary cystic echinococcosis is a very rare disease in Germany. It is caused by the larvae of the dog tapeworm (echinococcus granulosus). The liver is the most affected organ, followed by the lungs. Surgery remains the main therapeutic approach for pulmonary CE. Whenever possible, parenchyma-preserving lung surgery should be preferred over anatomic lung resections. To ensure best therapeutic results, surgery needs to be performed under precise consideration of important infectiological aspects and patients should be treated in specialised centres based on interdisciplinary consensus. In addition to surgical aspects, this review summarises special infectiological features of this disease, which are crucial to the surgical approach.

Epidemiology and clinical features of cystic hydatidosis in Western Sicily: a ten-year review.

AIM: To assess retrospectively the epidemiological and clinical aspects of cystic echinococcosis (CE) and to evaluate follow-up and response to treatment in patients affected by CE. METHODS: From January 2000 to December 2010, all patients affected by CE at the Infectious Diseases Units of the University of Catania and of Basilotta Hospital in Nicosia-Enna, were enrolled as participants in the study. Epidemiological, clinical and laboratory data were collected for each patient. Diagnosis of CE was performed using clinical imaging and laboratory parameters. Response to treatment was categorized as follows: "cure" as the disappearance or complete calcification of cyst/s; "improvement" as a reduction in the diameter and/or number of existing cysts; and "impairment" as an increase in the diameter and/or number of existing cyst/s and the onset of relapses (i.e., the onset of new cyst/s and an increase in the diameter of previously existing cyst/s and/or complications. Immunoglobulin E (IgE) titers and eosinophil percentages were evaluated at diagnosis, at six months after the initiation of treatment and again in the case of relapse. Hyper-eosinophilia was defined as an eosinophil percentage of ≥ 6%. RESULTS: Thirty-two patients were diagnosed with CE in our Unit during the research period, with a male-female ratio of 2:1. At the time of diagnosis, 40% of patients presented a single CE cyst. Sixty percent showed multi-organ involvement. The liver-lung localization ratio was 2:1. Patients below the age of 50 at diagnosis were more likely to have multiple cysts (73.7% vs 35.5%, P < 0.05). Regarding treatment, 30 patients were treated medically and 16 surgically. Fourteen patients were treated both medically and surgically. Relapses were seen to be less frequent in patients treated with albendazole before and after surgery. Complete cure or an improvement was achieved in 23 patients. Impairment was observed in one patient. Two patients showed no improvement. Relapses were more frequent in those patients treated before 2005. At diagnosis, 71% of patients were positive for specific CE IgE, and 56.3% showed an eosinophil percentage of ≥ 6%. Patients who were diagnosed with hyper-eosinophilia developed complications more frequently than the other patients, but did not suffer relapses. CONCLUSION: On the basis of our results, we propose cystic echinococcosis screening for family members of patients, appropriate pre- and post-surgery treatment and the assessment of anti-echinococcus IgE titer or eosinophil percentage as a therapy response marker in settings with limited resources.

[Echinococcosis: the threat of the urban fox]. / Echinococcose: la menace du renard urbain.

The incidence of alveolar echinococcosis in Switzerland is on the rise, probably due to the proliferation of foxes observed between 1980 and 1995 in both urban and rural areas. This is nevertheless a rare disease as humans are not a natural host for the parasite. Hepatic tumor-like lesions discovered during a workup for jaundice or abdominal pain is the most frequent mode of presentation. In the presence of typical radiological features (echography, CT-Scan, MRI), diagnostic confirmation can be made by serology. If diagnosis remains doubtful, a biopsy of the lesion with histopathological examination and PCR is indicated. Curative radical surgery is possible in only 25 to 35% of cases. In non-operable cases, long standing antiparasitic therapy allows to stop the progression of lesions.

The impact of globalisation on the distribution of Echinococcus multilocularis.

In the past three decades, Echinococcus multilocularis, the cause of human alveolar echinococcosis, has been reported in several new countries both in definitive hosts (canids) as well as in people. Unless treated, infection with this cestode in people is fatal. In previously endemic countries throughout the Northern Hemisphere, geographic ranges and human and animal prevalence levels seem to be increasing. Anthropogenic influences, including increased globalisation of animals and animal products, and altered human/animal interfaces are thought to play a vital role in the global emergence of this pathogenic cestode. Molecular epidemiological techniques are a useful tool for detecting and tracing introductions, and differentiating these from range expansions.

Disease awareness and knowledge in caregivers of children who had surgery for cystic hydatid disease in Lima, Peru.

Cystic hydatid disease (CHD) is a common cause of lung and liver disease worldwide. Despite Peru being highly endemic, information about the level of knowledge is scarce and poor. A telephone survey was applied to assess the knowledge in the caregivers of patients treated for CHD at a paediatric hospital at Lima, Peru. Of the 26 contacted families, only 5 (20%) answered correctly all seven questions. A higher education degree was associated with correct answers (P = 0.002). Most respondents (17, 65%) incorrectly identified the etiologic agent and mode of transmission. Lact of knowledge is likely a major contributor to maintain the endemicity of disease in Peru.

[Pulmonary hydatid disease in childhood: a case report]. / Idatidosi polmonare in età infantile: descrizione di un caso clinico.

Echinococcosis/hydatidosis is a parasitic zoonosis caused in humans by the larval stage of the Echinococcus granulosus cestode. Although notification of infestation is required, there are no reliable data on the prevalence of this parasitosis among humans in Italy. This zoonosis was first reported in ancient times (Hippocrates, fourth century BC) and since then many cases of echinococcosis/hydatidosis have been described. Currently, it is considered one of the main parasitoses affecting animals bred for income and one of the most important parasitic zoonoses. We present the clinical case of a three-year-old child, living in Palermo with a dog in his house, who came to our observation for dyspnea occurring after physical exercise. Diagnosis of echinococcosis was performed on the operating table and by histological examination. The case presented is special in its manifestation from a clinical point of view, because the young patient experienced multiple injuries only to lungs, without involvement of other organs and, although the left lung cysts appeared fissured on the operating table, our patient never presented immunoallergic disorders.

The first finding of Echinococcus multilocularis in dogs in Slovakia: an emerging risk for spreading of infection.

Alveolar echinococcosis, caused by the metacestode Echinococcus multilocularis, is a zoonosis of public health significance. Apart from red foxes, other carnivore species can also serve as definitive hosts of this parasite. This study aimed to determine the occurrence of E. multilocularis in dogs in the Slovak Republic and identify risk factors for acquiring the infection. Out of 289 dogs examined, E. multilocularis was detected in eight samples (2.8%). Positive results were observed in shepherd dogs (12.5%), guard dogs (7.1%), hunting dogs (2.4%) and in one dog with unknown usage (2.5%). Catching rodents and feeding with raw viscera were confirmed to be the most important risk factors for E. multilocularis infection. On the contrary, the way of dog use, frequency of going to the rural areas, the age and gender of animals seem not to be risk factors for infection. No significant association was observed between the positivity of dogs coming from high endemic or non-endemic regions. This is the first report of E. multilocularis in dogs in the Slovak Republic that confirms substantial contribution of dogs to the transmission of the tapeworm in this territory and urges the necessity of prophylactic measures for dog owners.

[Alveolar echinococcosis: a disease comparable to a slow growing cancer]. / L'échinococcose alvéolaire: une maladie comparable à un cancer du foie à marche lente.

Alveolar echinococcosis, a parasitic disease due to the larval stage of the cestode Echinococcus multilocularis, is initially located in the liver in 97% of cases. Progression is very slow and the disease remains silent for many years. The developing larva behaves like a slow-growing liver tumor that gradually invades the liver parenchyma, vessels and bile ducts. Marked granulomatosis around the larva, and the subsequent strong reactive fibrosis, contribute to the severity of the disease. Gradual extension to adjacent organs and distant metastases due to haematogenous spread can also occur. Purely extrahepatic alveolar echinococcosis is rare, but physicians in endemic areas should be aware of this possibility. Diagnostic methods have dramatically improved over the past twenty years. The clinical presentation used to be similar to that of liver cancer, with slowly progressivejaundice (due to involvement of the hilum), huge, hard and irregular hepatomegaly, and a chronic Budd-Chiari syndrome due to hepatic vein involvement. Currently, with extensive use of abdominal ultrasonography, alveolar echinococcosis is commonly diagnosed when still asymptomatic. Alveolar echinococcosis may also be revealed by a complication, such as cholangitis due to communication between the parasite mass and the lumen of a bile duct or to pigment stones accumulating above a parasitic biliary stenosis; liver abscess related to centro-parasitic necrosis; or hematemesis due to esophagal varices in case of portal vein involvement. Metastases, especially in the lungs, reveal the disease in 5% of cases.

The prevalence, organ distribution and fertility of cystic echinoccosis in feral pigs in tropical North Queensland, Australia.

An investigation was carried out to study the prevalence of Echinococcus granulosus hydatidosis in feral pigs (Sus domesticus) in the Charters Towers region of tropical North Queensland. Data were collected from a total of 238 carcasses, which were hunted and shot in the Burdekin River catchment area. Organs of the abdominal, thoracic, and pelvic cavities were examined for the presence of hydatid cysts. In the laboratory, cysts and hydatid cyst fluids were examined under a stereoscopic binocular microscope and a compound microscope. An overall prevalence of E. granulosus hydatid cysts in feral pigs was found to be 31.1%. There was no significant difference in either sex or age between infected and non-infected feral pigs. The predilection sites of cysts were livers (23%) and lungs (62%), with more cysts in lungs (252) than livers (48). The ratio of livers to lungs infected with fertile cysts was 1:4 compared to 1:8 sterile cysts. The overall fertility of cysts was 70.1%. The percentage of fertile cysts in liver and lung was 79.2% and 68.7%, respectively. The diameter of fertile cysts ranged from 15 to over 60 mm. There was no significant difference in size between fertile and non-fertile cysts in lungs. The high prevalence rate and fertility of cysts in feral pigs confirm that feral pigs can take part in the sylvatic cycle of the parasite in the region. The public health significance of this observation is potentially very important.

Echinococcus granulosus in northern Queensland. 1. Prevalence in cattle.

OBJECTIVE: To determine the prevalence and geographical distribution of hydatidosis and investigate factors that might be expected to influence the prevalence of hydatids in cattle in Queensland north of the Tropic of Capricorn. To determine the effect of natural levels of infection on carcase weight and subsequent economic loss. PROCEDURE: An abattoir survey conducted in 1981 provided information on the distribution, prevalence and viability of hydatid cysts in cattle from all shires north of the Tropic of Capricorn in Queensland. Livers, lungs and spleens from 10,382 cattle were palpated at abattoirs in Cairns, Townsville and Rockhampton to detect hydatid cysts. Prevalence of infection in cattle in each shire was estimated from results of the abattoir study together with reports of infection in a further 22,185 cattle obtained from abattoir records. Linear modelling was used to define the effect of geographical origin, age, breed and sex on prevalence of infection. Differences in the weights of carcases between infected and non-infected cattle of the same age, sex, breed and property of origin were examined. The economic loss to the beef industry in the region surveyed was estimated. RESULTS: Cattle infected with hydatids originated almost entirely from regions to the east of the Great Dividing Range. The mean prevalence inside this zone was 28% compared with 3% in other areas. Viable protoscoleces were found in 0.7% of cysts. Geographical origin and age of the cattle were the most significant factors influencing prevalence. Infection with hydatids had no effect on carcase weight. Economic loss was limited to that associated with condemnations of organs at meat inspection, estimated to be 0.5 million dollars per annum in 1981 and 6 million dollars in 2004. The distribution of hydatids in Queensland north of the Tropic of Capricorn corresponded most closely with the distribution of small wallabies such as Macropus dorsalis (black-striped wallaby), M parryi (whiptail wallaby) and M rufogriseus (red-necked wallaby). CONCLUSIONS: It was concluded that cattle are not an important part of maintaining the life-cycle of E granulosus in Queensland north of the Tropic of Capricorn. Within the endemic zone, which is almost all to the east of the Great Dividing Range, the local pattern of bovine echinococcosis is most likely to be determined by the presence or absence of small species of wallaby such as M dorsalis, M parryi and M rufogriseus.

Echinococcus multilocularis--a zoonosis of anthropogenic environments?

Transmission of the fox tapeworm Echinococcus multilocularis, the causative agent of human alveolar echinococcosis, is known to depend on various environmental factors which are subject to human influence. Epidemiological data suggest that in most endemic regions anthropogenic landscape changes (e.g. deforestation and agricultural practices) have led to more favourable conditions for the parasite's animal hosts, especially arvicolid rodents, thereby increasing the risk for parasite transmission and human disease. Examples are the conversion of forests or crop fields into meadows and pastures in Europe, China and North America, and overgrazing of natural grassland in central Asia. Other anthropogenic factors include interference with host population densities by wildlife disease control, changing hunting pressure and provision of new habitats, e.g. in urban areas. Domestic dogs may, under certain conditions, get involved in the otherwise largely wildlife-based transmission, and thereby greatly increase the infection pressure to humans. The introduction of neozootic host species may increase transmission, or even initiate the parasite's life-cycle in previously non-endemic regions. Lastly, the parasite itself may be accidentally introduced into non-endemic areas, if suitable host populations are present (e.g. in northern Japan).

Socioeconomic and behavior risk factors of human alveolar echinococcosis in Tibetan communities in Sichuan, People's Republic of China.

Data from two cross-sectional investigations on 7,138 subjects were used to explore risk factors of human alveolar echinococcosis (AE) in Tibetan communities. The overall human AE prevalence was 3.1% (223 of 7,138), females had a higher prevalence (3.6%, 132 of 3,713) than males (2.7%, 91 of 3,425; P = 0.011), and herdsmen had a higher prevalence (5.2%, 154 of 2,955) than farmers (1.8%, 12 of 661; P < 0.001) and urban populations (2.1%, 49 of 2,360; P < 0.001). Age in all populations, number of dogs kept, fox skin ownership in farmers, not preventing flies from landing on food in herdsmen, using open streams as drinking water sources, and playing with dogs in urban populations were statistically significant risk factors. The results suggest that AE is highly endemic in the eastern Tibetan plateau, in Sichuan Province, the role of the dog is important for human infection, and other factors associated with environmental contamination may vary according to structure and practices of communities.

Echinococcus multilocularis in red foxes (Vulpes vulpes) of the Italian Alpine region: is there a focus of autochthonous transmission?

Alveolar echinococcosis, caused by the metacestode of Echinococcus multilocularis, is a zoonosis with a wider distribution area than described in the past. Fox populations living in the Alpine regions of Italy had been considered free from this parasite until 2002, when two infected foxes (Vulpes vulpes) were detected in the Bolzano province (Trentino Alto Adige region) near the Austrian border. The aim of this work was to evaluate the prevalence of infection in red fox populations from five Italian regions. A modified nested PCR analysis was used to detect E. multilocularis DNA in faecal samples. Amplicons were confirmed by sequencing. Of 500 faecal samples from foxes shot in Valle d'Aosta (n=57), Liguria (n=44), Lombardy (n=102), Veneto (n=56), and Trentino Alto Adige (n=241) regions, 24 animals, all from the Trentino Alto Adige region, were found positive. Twenty-two positive animals originated from the Bolzano province and two positive animals from the Trento province. Several localities of the Bolzano province, in which positive foxes were detected, are the same as those where alveolar echinococcosis had been described in humans in the second half of the 19th century, suggesting an old endemicity for the investigated area, which is adjacent to endemic areas of Austria. Therefore, the question arises if we are observing an increase and expansion of foci, or if the new records are due to the more sensitive and specific methods used to detect the worm DNA.

Transmission dynamics of the Echinococcus granulosus sheep-dog strain (G1 genotype) in camels in Tunisia.

Cystic echinococcosis, caused by Echinococcus granulosus, is highly endemic in North Africa and the Middle East. This paper examines the abundance and prevalence of infection of E. granulosus in camels in Tunisia. No cysts were found in 103 camels from Kébili, whilst 19 of 188 camels from Benguerden (10.1%) were infected. Of the cysts found 95% were considered fertile with the presence of protoscolices and 80% of protoscolices were considered viable by their ability to exclude aqueous eosin. Molecular techniques were used on cyst material from camels and this demonstrated that the study animals were infected with the G1 sheep strain of E. granulosus. Observed data were fitted to a mathematical model by maximum likelihood techniques to define the parameters and their confidence limits and the negative binomial distribution was used to define the error variance in the observed data. The infection pressure to camels was somewhat lower in comparison to sheep reported in an earlier study. However, because camels are much longer-lived animals, the results of the model fit suggested that older camels have a relatively high prevalence rate, reaching a most likely value of 32% at age 15 years. This could represent an important source of transmission to dogs and hence indirectly to man of this zonotic strain. In common with similar studies on other species, there was no evidence of parasite-induced immunity in camels.

Combined eco-epidemiological and molecular biology approaches to assess Echinococcus granulosus transmission to humans in Mauritania: occurrence of the 'camel' strain and human cystic echinococcosis.

Mauritania lies between West-Central Africa where human cystic echinococcosis (CE) is considered extremely rare and West Maghreb where CE accounts for a real public health problem. Until 1992, Mauritania was considered as human CE-free even through CE seemed well known in livestock. In 1992, the introduction of ultrasonography led to the diagnosis of the first human CE cases. In 1997, a veterinary study revealed that dogs living around Nouakchott were commonly infected by Echinococcus granulosus. To assess E. granulosus transmission and to identify the most relevant animal reservoir responsible for human CE emerging in Mauritania, a simultaneous eco-epidemiological and molecular biology approach was performed. The fieldwork included sample collection and investigation of relationship between intermediate hosts, definitive hosts and humans. Typing of E. granulosus strains was performed using comparison of polymerase chain reaction (PCR)-amplified DNA sequences with one nuclear (BG 1/3) and 2 mitochondrial (COI, NDI) targets. Results show that the 'camel' strain is actually infectious to humans and circulates between intermediate hosts including camels and cattle. It is suggested that preventive measures at slaughtering places could reduce human contamination.

[Epidemiology and systematics of cystic and alveolar hydatid disease]. / Epidemiologie und Systematik der cystischen und alveolären Echinokokkose.

Echinococcus multilocularis, a small tapeworm in foxes, has gained considerable public attention owing to its wide distribution in central Europe. Conversely, diagnosis and treatment of the disease have been significantly improved in recent years. Consequently, the incidence among human populations has remained stable and relatively low for many decades. In southern Germany, France (Franche Comté and Doubs), Austria and Switzerland, the annual incidence ranges between 0.02 and 1.4 new cases per 100,000 inhabitants. The relevance of human AE refers to the high lethality of the untreated disease. Therapy consists predominantly of radical surgery followed by continuous, long-term chemotherapy using albendazole (or mebendazole). The action of chemotherapy alone is parasitostatic rather than parasitocidal; nevertheless, clinical improvement is observed in > 80 % of such cases, including a significantly improved prognosis. Diagnosis relies predominantly on imaging procedures and serology. Immunodiagnosis must be performed early, especially when a preclinical diagnosis is desired upon exposure to infection. Thus, in the framework of seroepidemiological studies, first-time evidence was obtained about the phenomenon of natural resistance in non-diseased persons. This raised the question of a potential immunogenetic predisposition in certain infected persons. E. granulosus (cystic hydatid disease) is practically non-existent as autochthonous infection in central Europe now. Most clinical cases of E. granulosus infections are thus observed among persons who have immigrated from - predominantly - the mediterranean basin.

Domestic pets as risk factors for alveolar hydatid disease in Austria.

To identify the risk of pet ownership (i.e., cats and dogs) for alveolar echinococcosis caused by Echinococcus multilocularis, the habits and activities of 21 patients (histologic confirmation or positive serology with corresponding evidence on an ultrasonogram, radiograph, or computed tomography scan) in Austria during the period 1967-1997 were compared with the habits and activities of 84 controls matched by sex, age, and residence. Cat ownership (odds ratio (OR) = 6.47, 95% confidence interval (CI) 1.54-27.29) and hunting (OR = 7.83, 95% CI 1.16-52.77) were independent risk factors associated with alveolar hydatid disease. The study is not in agreement with the hypothesis that eating mushrooms or certain wild berries which grow near the ground are the main risk factors for acquiring this disease. No other behavior patterns or activities studied were identified as risk factors.

Alveolar hydatidosis (Echinococcus multilocularis) in a captive rhesus monkey (Macaca mulatta) in Germany.

A naturally occurring E. multilocularis infection in an 11-year-old female rhesus monkey is described. The infection most probably was acquired from foxes of the Göttingen area through contaminated branches or foliage taken from the nearby forest. The most severely affected organs were the liver and the lung, A limited serological survey using the Em2plus ELISA revealed 5 more animals which so far remain clinically healthy as possibly infected.