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Cystic echinococcosis (CE) is a major parasitosis in Romania, a country where in the past at least one person from 45.5% of its localities underwent surgery for this disease. This survey aimed to provide new epidemiological and clinical data regarding human cases of CE in a western Romanian county. We have retrospectively investigated the medical records of the patients with CE hospitalized during the period of 2004-2010 in the surgical sections of Arad County. A total of 79 patients aged 5-88 years (mean age: 35.9±20.1 years) were diagnosed with CE during the study period. The average yearly incidence was 2.4 cases per 100,000 inhabitants, and the majority of the patients (29.1%) were aged 0-19 years. Most of the adult cases (≥18 years) were people with limited formal education (laborers) (45.6%). The analysis for trend showed an overall decrease in the affected persons over the study period (R(2)=0.66, p=0.026). Hepatic localizations of the hydatid cysts predominated within the study group (73.4%). Only 21.5% of the diseased presented complications and the mean length of hospital stay was 16.2±10.9 days. Eosinophilia of at least 10% of the leukocyte value occurred in 14% of cases and leukocytosis was noticed in 24.1% of patients. Although the rates of CE cases have decreased in Arad County (Romania), this parasitic disease continues to be a concern for public health services and requires the implementation of more stringent prophylactic measures.

Background: An increasing number of publications are suggesting that galectin-3 (Gal-3) and soluble cadherin fragments, such as E-cadherin (sE-CAD) and N-cadherin (sN-CAD), may be considered as cancer markers. Despite the promising results of the studies, there are no data concerning their levels in the plasma of echinococcosis patients. In most cases, echinoccocosis affects the liver, and its symptoms and disease course are very similar to those of liver cancer. The aim of the present study was to observe whether echinococcosis affects the concentration of soluble sN-CAD, sE-CAD fragments and Gal-3 in plasma and to determine which of them could be considered reliable liver cancer markers for further research., Methods: The concentrations of sN-CAD, sE-CAD and Gal-3 in the EDTA plasma of patients suffering from echinococcosis (N = 20), liver cancers (N = 10) and healthy subjects (N = 20) were measured using the ELISA method., Results: The plasma concentration of sE-CAD was lower (p = 0.0381), and that of Gal-3 higher (p = 0.0288), in echinococcosis than in the healthy group. However, only the concentration of sE-CAD differed significantly among the three analysed groups. In echinococcosis there was a correlation between the sE-CAD and CRP levels (rs = 0.79; p = 0.0066) as well as a correlation between the sE-CAD level and the number of leukocytes (rs = 0.65; p = 0.0210) in the blood., Conclusions: Echinococcosis affects the concentration of soluble sE-CAD fragments and Gal-3 in plasma. sE-CAD can be considered as a marker for differentiation between liver cancer and echinoccocossis, a parasitic liver disease similar in symptoms. Further study is required to confirm these preliminary results., Virtual Slides: The virtual slide(s) for this article can be found here:http://www.diagnosticpathology.diagnomx.eu/vs/2115657402650448.

Objective: Our aim was to evaluate the contribution of diffusion-weighted imaging to the differentiation of hydatid cysts (HCs) from the simple cysts and to the identification of the HC subtypes., Materials and Methods: A total of 37 patients were included in this retrospective study. Fifty of these patients had diagnosed liver cysts (28 HCs and 22 simple cysts) of at least 1 cm in size. All of the cysts were examined with sonography and magnetic resonance imaging, and the HCs were classified according to the World Health Organization criteria., Results: Twenty-eight of the total 50 cysts were HCs, and 22 were simple cysts. When the apparent diffusion coefficient (ADC) values of all HCs were compared with the ADC values of the simple cysts, a statistically significant relationship was found (P=.001). The optimal ADC threshold value was established as 2.5 s/mm(2). The sensitivity, specificity, positive predictive value, negative predictive value and accuracy rates were 60%, 95%, 94%, 65% and 76%, respectively., Conclusion: Diffusion-weighted imaging-magnetic resonance imaging is a considerably helpful technique for differentiating between HCs and simple cysts and for differentiating between HC subtypes., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Introduction: In humans, alveolar echinococcosis (AE) of the liver is caused by canine tapeworm called Echinococcus multilocularis. The disease is most prevalent in the northern hemisphere and in the eastern part of Turkey., Objectives: The aim of the study was to review the natural history of AE and its clinical and radiological features., Patients and Methods: The retrospective study involved 23 patients (10 men, 13 women), aged 34-75 years with AE who had been referred to our liver disease clinic in the past 4 years. Only patients with pathologically proven AE were included in the study. The sociodemographic, clinical, and radiological features of AE were also evaluated., Results: The main laboratory characteristics of AE included mild eosinophilic leukocytosis with hypergammaglobulinemia, elevated C-reactive protein levels, near-normal liver transaminases, and increased levels of cholestatic enzymes and immunoglobulin E. Eight patients (35%) had hepatitis B e antigen-negative hepatitis B infection. Budd-Chiari syndrome was identified in 3 of 23 patients (13%). Eighty-three percent of the patients had a seropositive test result for AE, and approximately one-third of the patients had distant metastasis. Surgical treatment was administered in 4 patients. Four patients died due to complications during follow-up., Conclusions: Patients with AE have numerous complications and advanced disease at the time of diagnosis. The clinical picture of AE comprises a number of hepatic and extrahepatic disturbances related both to destructive and mass effects of the tapeworm.

To investigate the usefulness of serum cytokine dosage in the clinical management of cystic echinococcosis (CE), we analyzed serum levels of Th1 and Th2 cytokines in patients with hepatic CE in different cyst stages, CE1-2 (active), CE3a-3b (transitional), and CE4-5 (inactive). Ex vivo assessment of Th1 (IFN-γ) and Th2 (IL-4, IL-13, and IL-10) cytokines in sera was carried out using ELISA. IL-10 was undetectable in all serum samples of patients and controls, while a few sera contained measurable amounts of IFN-γ, IL-4, and IL-13. No statistically significant difference was found between the percentages of positive samples for each cytokine and the different groups analyzed (patients/controls, stage, number, location, and size of the cyst, serology, and sex of patients), with the exception of the association of IL-4 and IL-13 with the cyst stage. Overall, this investigation showed many limits of serum cytokine dosage as a marker of biological activity of echinococcal cysts. Because of low sensitivity and lack of specificity of this test, we believe that other ways to evaluate ex vivo biological activity of the cysts should be explored.

Introduction: Surgery remains the basic treatment of hepatic hydatid cyst (HHC). However, it is associated with significant morbidity. The aim of our study was to evaluate mortality and morbidity of surgery of the HHC and to highlight the risk factors., Methods: A retrospective study was conducted from January 1, 1996 to December 31, 2006. 391 patients hospitalized for HHC and operated in the Department of General Surgery "A" of the Rabta Hospital in Tunis, Tunisia., Results: The overall mortality rate was 0.7% while the overall morbidity rate was 20.4%. About 16.6% suffered from specific complications, while 3.8% suffered from non-specific complications. Predictors of morbidity in a univariate analysis included cysts larger than 9 cm, dome cysts, cysts with bilious contents, type II, III, IV or V on ultrasound classification, fissured cysts and intrabiliary rupture of hepatic hydatid cyst. The multivariate study consisted of independent predictors of disease at the site of the liver dome, the cysto-biliary fistula and intrabiliary rupture of hepatic hydatid cyst, Conclusion: The hepatic hydatid cyst of the dome and the existence of preoperative complications in particular intrabiliary rupture of hepatic hydatid cyst are the main factors of morbidity. A better understanding of these factors allows the surgeon to choose the appropiate surgical technique that is associated with less morbidity.

Gastroenteropancreatic neuroendocrine tumors and their metastases have an inconsistent appearance with only a small percentage of lesions appearing as cystic masses in computed tomography (CT) and magnetic resonance imaging (MRI) and can therefore be mistaken as benign or infectious lesions, leading to a false diagnosis with delayed and inadequate treatment. We report a patient with upper abdominal pain lasting for several months, caused by a huge cystic neuroendocrine carcinoma of the liver which was mistakenly interpreted as an echinococcus cyst and present the findings in the initial CT and the subsequently performed MRI under application of hepatocyte specific contrast material, which led to distinct differential diagnoses and therefore had a capacious impact on the therapeutic strategy.

Objective: To observe the inhibitive effect on invasive growth and metastasis of Echinococcus multilocularis by exogenous anti-osteopontin (OPN) antibody., Methods: 180 gerbils were infected with 20% E. multilocularis suspension (approximately 400 protoscoleces in 0.1 ml per gerbil) through abdominal opening injection in liver, and then divided into model group, experiment group and control group. Experiment group and control group each with 60 gerbils were injected via the tail vein with 0.15 ml of anti-OPN antibody (1:32) and rabbit serum, respectively. All gerbils in the two groups received injections, with 2-day interval for the first seven injections, and then at 7-day interval for the remaining injections. Model group were without any treatment. The three groups were subdivided into six groups each with 10 gerbils. The gerbils from each group were sacrificed on day 1, 20, 40, 60, 80, and 100 after infection, respectively. Hepatic echinococcus cyst and metastasis tissue were observed. The expression of OPN was measured by immunohistochemistry staining (SP method). Serum samples were collected at 100 d post-infection, and the content of OPN in sera was measured by ELISA., Results: There were no significant difference in cyst weight and metastatic rate of thoracic lymph node among the three groups at 1, 20, 40, 60, and 80d post-infection (P > 0.05), while at 100 d postinfection, cyst weight and metastatic rate of thoracic lymph node in experiment group [(7.28 +/- 0.38) g, 20%] were lower than that of control group [(9.70 +/- 0.61) g, 70%] and model group [(932 +/- 0.73) g, 70%] (P < ). Expression of OPN was found at different levels in echinococcus cysts. OPN was located in the cytoplasm, and mainly distributed in the germinal layer. The OPN positive expression levels were not significantly different between experiment group and other groups on day 1, 20, 40, 60, and 80 afer infection ( >0 . 05). At 100d post-infection, OPN positive expression rate and serum OPN content in experimental group [20% and (30.90 +/- 2.25) ng/.l micro respectively] was lower than that of control group [80% and (41.03.2 +/- 76) nWng/micro and model group [80% and (42.39 +/- 2.85) nWng/micro (PdL < 0.)., Conclusion: Anti-osteopontin antibody can reduce OPN concentration in hepatic echinococcus cyst and serum, and inhibit the invasive growth and metastasis of E. multilocularis.

Hydatid cyst disease remains a considerable public health problem, especially in pastoral and farming regions. Although the spleen is the third most commonly affected organ after the liver and lungs, splenic hydatid cyst is an uncommon entity even in areas that are endemic for echinococcosis. The recurrence rate after surgical therapy of the liver hydatid cyst is reported as 6.8-22.3 percent. Recurrences most frequently occur in the liver. Extrahepatic recurrences occur in the lung or peritoneum and the serosa of the abdominal organs. Splenic recurrence of liver hydatid cyst has not previously been reported. The most common surgical therapy is splenectomy, and the other option is spleen preserving surgery. We report the first case of recurrent splenic hydatid cyst in the spleen and liver synchronously after surgical therapy for liver hydatid disease. The patient was treated with liver resection and spleen preserving surgery.

Background: Human alveolar echinococcosis (AE) is caused by the accidental ingestion of the eggs of the fox tapeworm Echinococcus multilocularis. AE occurs frequently in rural western China due to the poor levels of hygiene, the close contact of people with dogs, and the lack of appropriate facilities for the correct and rapid diagnosis of the disease., Findings: We describe a case of a patient with hepatic AE, and AE metastases of the brain. She was mistakenly diagnosed with suspected undifferentiated metastatic cancer of the liver and brain, and with a pulmonary bacterial infection, but was subsequently correctly diagnosed during a follow-up field survey for echinococcosis. The diagnosis of brain AE was confirmed by pathological examination of tissue biopsies removed during neurosurgery. We also briefly describe other symptomatic and asymptomatic AE cases, identified by chance, likely due to the inadequate facilities available in rural communities in China for AE diagnosis and management, since the rapid and accurate diagnosis of metastatic AE requires a high level of expertise in the appropriate diagnostic procedures., Conclusions: This report highlights the necessity for an upgrade in the diagnosis, treatment, prevention and control of AE in rural China.

Study Background: Hydatid disease of the liver is endemic in India and is a common health problem. Although various treatment options have been described ranging from pharmacotherapy to radiological interventions and surgical procedures (both conservative and radical), the best treatment option in an individual case continues to be debated., Methods: We did a retrospective analysis of patients with hydatid disease of the liver who were managed at our centre between January 2000 and December 2009. All cysts were classified as per the Gharbi's classification. The various treatment options used to treat hydatid cysts of the liver included percutaneous aspiration, injection and reaspiration (PAIR) or PAIR with drainage (PAIR-D) and surgery (both conservative and radical). The immediate and long-term outcomes following such management were analysed., Results: During the study period, 128 patients with hydatid cyst of the liver were managed with PAIR/PAIR-D (n = 52), radical/excisional surgery (n = 61) and conservative surgery (n = 33). In ten patients, the PAIR procedure was abandoned due to either bile or pultaceous material aspirated after the initial puncture and these patients subsequently underwent surgical management. The PAIR was unsuccessful in eight of the 42 patients in whom it was attempted and these subsequently underwent surgery. The mean intraoperative blood loss and the duration of surgery were comparable in patients who underwent either conservative or radical surgery (p = 0.35 and 0.19, respectively). Postoperative bile leaks and cavity abscesses were significantly higher in patients who underwent conservative surgery (p = 0.032 and p  = 0.001, respectively). Five patients (one following a radical operation and four following a conservative surgery, p = 0.05) developed recurrence in a mean follow-up period of 28 months and these were managed medically., Conclusion: Several treatment options are available for the management of hydatid disease of the liver and the treatment modality chosen should be tailored to the individual patient. While percutaneous drainage (with PAIR/PAIR-D) is reserved for more favourable cases of type I and II cysts, the others are best managed surgically. Complete excision (cystopericstectomy or resection) of the hydatid cyst is the preferred approach and 61 of the 94 patients who were managed surgically were suitable for it. Although excisional surgery minimizes the risk of long-term recurrence and cavity-related complications, it may be hazardous in cysts located close to major biliovascular channels. In these cases (considering that it is benign disease), a drainage operation is preferable. Both conservative and radical surgery can be safely performed laparoscopically.

Background: Alveolar echinococcosis (AE) is a disease in human and animals, and the cure rate is unsatisfactory. This study aimed to investigate the curative efficacy of different doses of locally applied radiotherapy on alveolar echinococcosis in rats., Methods: Rats infected with Echinococcus multilocularis were randomly divided into 4 groups of 15 rats each: low-, middle-, and high-irradiation groups and a control group. Rats in the control group underwent no treatment, while rats in the irradiation groups received 6-MeV radiotherapy at 20 Gy/8 f, 40 Gy/8 f, and 60 Gy/8 f respectively, once every 3 days for a total of 8 times. One month after radiotherapy, wet weight and AE vesicle inhibitory rate were detected in rats of each group. Histopathologic and ultrastructural observations of tissues with AE lesions were performed., Results: In the treatment groups, an obvious inhibitory effect was found in AE rats; the inhibitory rates were 50%, 72%, and 82%, respectively. There were also statistical differences in pathological changes and average wet weight of the lesions compared with the control group (P < 0.05). In the treatment groups, injuries of various degrees were found in the ultrastructure of the laminated and germinal layers in the capsular wall of AE, and injury was most severe in the high-dose group., Conclusion: Radiotherapy has a dose-dependent inhibitory effect on the growth of AE.

Background: hepatic hydatid disease (HHD) is still an important health problem in certain areas of Spain where it is endemic. The treatment of HHD is usually surgical but certain patients are found to be ineligible after assessment for surgery (asymptomatic disease, comorbidity, patient refusal, or other)., Material and Methods: description of patients assessed in the Department of Surgery for hepatic hydatid disease., Results: in a group of 70 patients with HHD, 27 patients were not treated surgically (mean age: 72.7 years [range: 47-97], 14 women [51.8%]). The number of cysts presented by these patients was 33, with 1.22 cyst/patient (range: 1-4). The cyst size was 5.5 cm (range: 2.1-12.5 cm). The cysts, according to the WHO classification, were CE1: 3 patients, CE3B: 5 patients, CE4: 10 patients and CE5: 9 patients. The form of presentation was: symptomatic in 9 patients, although only 6 were attributable to HHD (22%) and asymptomatic in 18 patients. In these cases, imaging was performed for study of tumor extension in 6 patients and diverse medical reasons in 12. Only two therapeutic interventions were performed: endoscopic retrograde cholangiopancreatography (ERCP) with insertion of a bile duct stent, and puncture-aspiration-injection-re-aspiration (PAIR), both in patients who did not wish to undergo surgery.Ten patients had surgical indications: CE1 (3 patients), CE3B (5 patients), CE4 (1 patient), and CE5 (1 patient). The reasons why the patients did not undergo surgical treatment were: refusal (9 patients) and advanced neoplasm (1 patient). Surgery was judged necessary in 5 patients. In the mean follow-up period of 17 months (range: 1-37), no surgery was performed., Conclusions: there were various causes for not performing surgical intervention of HHD after medical evaluation: asymptomatic patients, older patients, patients with multiple pathologies and oncologic patients. Usually, they were patients who voluntarily chose not to undergo surgery.

Background: Although the computer tomography (CT) or magnetic resonance imaging (MRI) findings of alveolar echinococcosis (AE) have been well documented, the consecutive imaging changes of this disease in each PNM stage (parasite lesion, neighboring organ invasion, metastases) were not described accurately. The aim of this study was to analyze the correlation between imaging type and PNM stage and diameter of AE lesions, and to explore the development features of this disease., Methods: A total of 87 patients with AE were examined using CT and MRI before medical management. Imaging features including the maximum diameter, calcification pattern, and imaging type of lesion were retrospectively assessed. The correlation of imaging type with PNM stage, diameter and calcification pattern was analyzed., Results: Lesions (n=111) in 87 patients were divided into three types based on imaging characteristics; solid type (33.3%, 37/111, a solid lesion without liquid necrosis or only small patches of necrosis), mixed type (41.4%, 46/111, solid component surrounding large and/or irregular liquid necrosis area), and pseudo-cystic type (25.2%, 28/111, large cyst without visible solid component). Lesion calcification in the alveolar echinococcosis was categorized into three patterns; mild calcification (45.1%, 50/111, i.e. inconspicuous calcification or punctuate scattered calcification), moderate calcification (46.8%, 52/111, coastline calcification located at the periphery of the lesion, with or without the central dot-calcification) and abundant calcification (8.1%, 9/111, large calcified deposits). Significant differences were found between pseudo-cystic type and other two types in PNM stage, maximum diameter and calcification (P <0.05), but there was no significant difference between solid type and mixed type in those mentioned aspects (P >0.05). No correlation was observed between calcification patterns and maximum diameter (P >0.05)., Conclusions: Solid and mixed type lesions showed some similarities during the course of the disease and accounted for the major form of advanced AE. Pseudo-cystic type represented neither earlier nor advanced stage of AE, but a special presentation during AE development.

Liver transplantation (LT) is currently contraindicated in patients with residual or metastatic alveolar echinococcosis (AE) lesions. We evaluated the long-term course of such patients who underwent LT and were subsequently treated with benzimidazoles. Clinical, imaging, serological, and therapeutic data were collected from 5 patients with residual/recurrent AE lesions who survived for more than 15 years. Since 2004, [(18) F]-2-fluoro-2-deoxyglucose (FDG)-positron emission tomography (PET) images were available, and the levels of serum antibodies (Abs) against Echinococcus multilocularis-recombinant antigens were evaluated. Median survival time after LT was 21 years. These patients were from a prospective cohort of 23 patients with AE who underwent LT: 5 of 8 patients with residual/recurrent AE and 4 of 9 patients without residual/recurrent AE were alive in September 2009. High doses of immunosuppressive drugs, the late introduction of therapy with benzimidazoles, its withdrawal due to side effects, and nonadherence to this therapy adversely affected the prognosis. Anti-Em2(plus) and anti-rEm18 Ab levels and standard FDG-PET enabled the efficacy of therapy on the growth of EA lesions to be assessed. However, meaningful variations in Ab levels were observed below diagnostic cutoff values; and in monitoring AE lesions, images of FDG uptake taken 3 hours after its injection were more sensitive than images obtained 1 hour after its injection. In conclusion, benzimidazoles can control residual/recurrent AE lesions after LT. Using anti-rEm18 or anti-Em2(plus) Ab levels and the delayed acquisition of FDG-PET images can improve the functional assessment of disease activity. The potential recurrence of disease, especially in patients with residual or metastatic AE lesions, should not be regarded as a contraindication to LT when AE is considered to be lethal in the short term., (Copyright © 2011 American Association for the Study of Liver Diseases.)

Background/aims: Hydatid disease is a concealed parasite illness that spreads over all organs and tissues. It is a difficult and widespread invasive illness which occupies a special place in pathology of hepato-billious tract., Methodology: This study includes analysis of 103 patients operated from liver hydatidosis during a 15 year period., Results: Ratio between female and male patients was 2:1, with a female predominance. The patient's age ranged from 19 to 65 years old, i.e. they were still capable of working, with an average age of 47 years. The patient's were mostly housewives, farmers and cattle breeders (71 or 68.9%). The most frequent method we used was pericystectomy with omentoplastics applied in (51 or 49.5%) cases, then pericystectomy with drainage applied in (31 or 30.1%) cases, followed by extirpation of the cyst applied in (11 or 10.7%) cases, liver resection was performed in only (7 or 6.8%) cases, marsupielisation was performed in (3 or 2.9%) cases, but out of necessity. The most frequently used approaches were the right subcostal ones, medial and Orh's cut - (95 or 92.2%) cases. Postoperative complications occurred in (39 or 37.9%) cases. Lethal result occurred in (2 or 1.9%) cases., Conclusions: Our opinion is that a total cystopericystectomy with omentoplastics, which is a method of choice, decreases hospitalization period and complications.

Alveolar echinococcosis (AE) of human being caused by Echinococcus multilocularis is a rare but important zoonosis especially in tempered zones of middle Europe and Northern America with endemic character in many countries. Due to the long incubation period, various clinical manifestations, critical prognosis, and outcome AE presents a serious and severe disease. The primary focus of infection is usually the liver. Although secondary affection of visceral organs is possible extrahepatic AE is highly uncommon. Moreover, the involvement of bone and muscle presents with an even lower incidence. In the literature numerous cases on hepatic AE have been reported. However, extrahepatic AE involving bones and/or muscles was described very rarely. We report a case of an 80-year-old man with primary extrahepatic alveolar Echinococcosis of the lumbar spine and the psoas muscle. The etiology, diagnosis, differential diagnoses, treatment options and outcome of this rare disease are discussed in context with the current literature.

Apical lung opacity was diagnosed in an asymptomatic 30 year-old woman native of Central African Republic by routine chest X-ray. CT scan demonstrated an excavated pulmonary mass and revealed a simple hepatic cyst. Tuberculosis was suspected but mycobacterial cultures remained negative. Three months later, ultrasonography showed septations within the hepatic lesion suggestive of cystic echinococcosis. The detection of seric anti-Echinococcus antibodies was positive. Hepatic and pulmonary cysts were removed surgically and association with three-month course of albendazole resulted in a favorable outcome. Cystic echinococcosis is exceptional in Central Africa and to our knowledge never reported from the Central African Republic., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Objective: To investigate the expression and distribution of osteopontin (OPN) in Echinococcus multilocularis cyst, and explore the role of OPN in the metastasis of hepatic E. multilocularis infection., Methods: Forty gerbils were infected with 20% E. multilocularis suspension (0.1 ml per gerbil) through abdominal opening injection in liver. Gerbils were sacrificed at 100 days postinfection for observing the growth and metastasis of hepatic echinococcus cyst. The liver, hepatic echinococcus cyst and metastasis tissue were observed on HE stain; the expression of OPN were measured by immunohistochemistry staining (SP method)., Results: E. multilocularis were spread over the liver and abdominal cavity. Expression of OPN was found at different degree in echinococcus cysts. The positive expression rate of OPN in echinococcus cysts was 70% (28/40). OPN was mainly distributed in the germinal layer, inflammatory cells and some liver cells. 60% (24/40) occurred thoracic lymph node metastases. The OPN expression rate in hepatic echinococcus cysts with thoracic lymph node metastases (83%, 20/24) was significantly higher than that of hepatic echinococcus cysts without thoracic lymph node metastases (50%, 8/16) (P < 0.05). The positive expression of OPN in lymph node metastases (92%, 22/24) was higher than that of hepatic echinococcus cyst (70%, 28/40) (P < 0.05)., Conclusion: Osteopontin mainly distributes in the germinal layer of hepatic echinococcus cyst and inflammatory cells, which might be involved in metastasis of hepatic E. multilocularis infection.

Aim: To determine the efficacy and success of percutaneous aspiration irrigation and reaspiration (PAIR) in the management of hepatic hydatidosis., Methods: Twenty-six patients with 32 hepatic hydatid cysts had PAIR. Twenty-two patients received at least 2 wk of drug therapy before the procedure was carried out to reduce the risk of recurrence from spillage during the procedure. The procedure was performed under local anesthesia with a 19-gauge 20 cm long needle, the cyst was punctured, cystic content (approximately 30 mL) was aspirated by a 12-14 F pigtail catheter and aspirated fluids were sent for analysis. Once the cyst was almost empty, two-thirds of the net amount of material aspirated was replaced by hypertonic saline and left in the cavity for about 30 min, with the catheter left in place for reaspiration of most of the fluid. When the amount of fluid drained was less than 10 mL per 24 h, the drainage catheter was removed., Results: All 32 cysts showed evidence of immediate collapse after completion of the procedure, and before discharge from hospital, ultrasound examination showed fluid reaccumulation in all cysts. Serial follow-up showed a progressive decrease in the size and change in the appearance of cysts. To confirm the sterility of these cystic cavities, seven cysts were reaspirated on average 3 mo after the procedure. Investigations revealed no viable scolices., Conclusion: PAIR using hypertonic saline is very effective and safe with proper precautions.

A lesional study on human hydatidosis (localization, fertility of cysts, protoscolex viability, and histological structure) focused on 63 human hydatid cysts from patients operated at CHN of Nouakchott was conducted during the period 1997-2007. The authors report the following results: the annual surgical incidence rate was in the order of 1.2% per 100,000 inhabitants. The lung was the primary localization of cyst (52%) followed by the liver (33%), spleen (4%), brain (3%), heart (2%), breasts (2%), kidney (2%), diaphragm (1%), and peritoneum (1%). The pulmonary cysts were larger and more fertile (76%) with protoscoleces also more viable (70%) compared with liver cysts (67-62%). The histology of hydatid cysts revealed in most cases a histological structure consistent with that described in the literature: thick cuticle, membrane proligeous, and capsules visible.

We analyze the clinical data and the possible methods for diagnostics of liver echinococcosis. The most common clinical manifestations are: burden, dull or colic pain in right hypochondrium, hepatomegaly plus. Against this clinical picture available eosinophilia is indicative sign in the diagnostic process; echography is binding method in the study. Establish the possibilities of each diagnostic method individually and in combination. It is recommended that the application of ultrasound in combination with the immunological method, which combined in 9/10 of the patients decided to avoid diagnosis and diagnostic polipragmatic approach. The other, considerably more expensive and radiological overdosing methods must be applied in exceptional cases. In every manifestation of allergy must be investigation to exclude the echinococcosis. We highly recommended the introduction in Bulgaria of screening methods for early detection of disease and timely treatment.

Secondary hydatidosis is an important problem encountered during the surgical treatment of hydatid cysts. This study describes an experimental model of secondary hydatidosis by cyst inoculation, used to explore whether simultaneous inoculation of protoscolocidal agents could prevent secondary hydatidosis. Fertile cyst fluid was injected into the pleural space of rabbits alone (group 1, n = 8), and in combination with 2% albendazole solution (group 2, n = 8), 20% hypertonic saline (group 3, n = 8) or 10% povidone-iodine (group 4, n = 8). Computed tomography imaging of the thorax, indirect haemagglutination (IHA) titres and eosinophil counts were used to determine cyst development. After 16 months, three control rabbits had pneumothorax, seven had cysts and four had parenchymal nodules. Histopathological investigation of nodules revealed 87.5% cyst formation. Pleural thickening was observed in rabbits from all groups. Cyst formation rates, IHA titres and eosinophilia counts were higher in group 1 than in groups 2-4. This study demonstrated the experimental formation of secondary hydatidosis and found that topical protoscolocidal agents were beneficial in preventing cyst recurrence.

Purpose: The purpose of this study is to identify the role of diffusion-weighted magnetic resonance imaging (DW-MRI) in the classification of liver hydatid cysts (HCs) and their differentiation from simple cysts and liver abscesses., Materials and Methods: Twenty-two patients that were sent to our department with preliminary diagnoses of HCs or abscess were included in the study. Thirty lesions were evaluated. MRI included T1-weighted fast gradient echo, T2-weighted half-Fourier acquisition single-shot turbo spin echo, and DW single-shot echo planar pulse sequencing (b, 0, 50, and 1000 s/mm²). The apparent diffusion coefficient (ADC) values (mm²/s) of the HCs, abscesses, and simple cysts were calculated., Results: No statistically significant difference was found between the ADC values of type 1 and 3 (P > 0.05) HCs and of simple cysts and type 1 HCs (P > 0.05). The ADC values of abscesses were significantly lower than those of type 1 and type 3 HCs, and simple cysts. No statistically significant difference was found between the ADC values of abscesses and type 4 HCs (P > 0.05). Type 4 lesions exhibited significantly lower ADC values in comparison to type 1 and 3 HCs., Conclusion: DW-MRI helps differentiate type 4 lesions from other cysts and can distinguish abscesses from hydatid cysts other than type 4 as well as from simple cysts. Type 1 HCs cannot be differentiated from simple cysts using ADC values alone, and type 4 lesions are indistinguishable from abscesses.

Hepatobiliary cystadenoma is a rare tumor which is difficult to diagnose before surgery and pathologic examination. Herein we present the case of a 32-year-old woman from an endemic area for hydatid cysts who presented with the impression of hydatid cyst of the liver, which was completely resected. Histopathologic examination revealed a mucinous hepatic cystadenoma with ovarian-like stroma. She had an uneventful postoperative course and now, after one year, she is doing well.

Echinococcus multilocularis is a tapeworm with zoonotic potential that is common in the northern hemisphere. Its natural definitive hosts are foxes and other canids and its intermediate hosts are rodents. Other mammalian species, including man, can become infected and develop infiltrative, tumour-like lesions that particularly affect the liver. The present study characterizes the relatively rare lesions of alveolar echinococcosis in 10 dogs. Metacestodes in these dogs frequently contained no protoscolices and were thus sterile. Metacestodes were surrounded by fibrous tissue intermixed with inflammatory cells comprising variable numbers of macrophages, T and B lymphocytes, and plasma cells, as well as neutrophils and/or eosinophils. These lesions resemble those observed in man and are in contrast to those observed in the natural intermediate hosts, which have less fibrosis and more protoscolices., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Purpose of Review: Human alveolar echinococcosis is caused by the larval stage of Echinococcus multilocularis, occurring in at least 42 countries of the northern hemisphere. Recent studies in Europe and Asia have shown that the endemic area of E. multilocularis is larger than previously known and the parasite has regionally expanded from rural to urban areas. Diagnosis of alveolar echinococcosis is supported by results from imaging studies, histopathology and/or nucleic acid detection, and serology. The present review summarizes current understanding of clinical features, knowledge on appropriate treatment, and discusses ways to improve standards of care., Recent Findings: High prevalences of this deadly disease have been discovered in surveys in parts of China. Clinical manifestations, diagnostic tools and the burden of disease were described, and are based on high case numbers. In Europe, excellent tools have been introduced, which improve disease management. Long-term observations in Switzerland provide an optimistic view, as the infection can be well controlled, if patients are cared for in specialized centres. An expert consensus summarizes the current recommendation for diagnosis and treatment of alveolar echinococcosis by the Informal Working Group on Echinococcosis of the WHO., Summary: Diagnosis and treatment of alveolar echinococcosis remains a challenge for clinicians. The updated WHO-recommendations aim to support decisions on diagnosis and treatment of alveolar echinococcosis. Anti-infective therapy is the backbone of treatment; surgery should be restricted to patients at an early stage of the disease. For the majority of cases continuous chemoprophylaxis with benzimidazoles is cost-effective and leads to a good quality of life for patients with this chronic disease.

Background and Aims: Hydatid disease is still a major health problem in sheep-raising areas. Surgery remains the basic treatment for liver hydatid cyst (LHC). However, recurrences can occur after all therapies. Surgery for recurrence of LHC becomes technically more difficult with higher rate of morbidity and mortality. The aim of this study was to determine perfective factors associated to hepatic recurrence after LHC surgery and to propose and discuss postoperative follow-up schedules., Methods: It is a retrospective cohort study of 672 patients with LHC treated at the surgery department "A" at Ibn Sina University Hospital, Rabat, Morocco, from January 1990 to December 2004. Recurrence rates have been analyzed by the Kaplan-Meier method for patients undergoing surgery., Results: Fifty-six patients (8.5%) had LHC recurrence after surgery. There were 34 females (60.7%) and 22 males (39.3%). Median duration of recurrence's diagnosis was 24 months (interquartile range: 10-48 months). Recurrence's risk was 2.3% +/- 0.6% at 1 year and 9.1% +/- 1.3% at the 10th year. The history of LHC (hazard ratio, 2; 95% confidential interval, 1.13-3.59) and three cysts or more (hazard ratio, 3.8; 95% confidential interval, 2.07-6.98) was an independent risk factor for recurrence., Conclusion: We think that the surgeon's practice and experience are the most important to success the surgical treatment. It prevents complications and recurrences.

Aim: To evaluate the predisposing factors for peritoneal perforation and intrabiliary rupture and the effects of these complications on surgical outcome in liver hydatid disease., Methods: A total of 372 patients with liver hydatid cysts who had undergone surgical treatment were evaluated retrospectively. Twenty eight patients with peritoneal perforation, 93 patients with spontaneous intrabiliary perforation, and 251 patients with noncomplicated hydatid cysts were treated in our clinics., Results: When the predisposing factors for complications were evaluated, younger age, superficial position, and larger cyst dimensions (P < 0.05; range, 0.001-0.017) increased peritoneal perforation rates. It was shown that older age increased cyst dimensions, and presence of multiple and bilobar cysts increased intrabiliary rupture rates (P < 0.05; range, 0.001-0.028). Partial pericystectomy and drainage was the most frequent surgical procedure in all groups (71.6%). The incidence of post-operative complications in the peritoneal perforated group, in the intrabiliary ruptured group, and in the noncomplicated group was 25%, 16.1% and 5.5%, respectively. When compared, complication rates were significantly different (P = 0.002). When length of hospital stay was compared, there was no significant difference between the groups (P > 0.05). The overall recurrence rate was 3.8% (14 patients), but there was not any statistical difference among the patient groups (P = 0.13). The early postoperative mortality rate was 1.1%., Conclusion: In peritoneally perforated and intrabiliary ruptured cases, the most important steps are irrigation of the peritoneal cavity and clearance of the cystic material from the biliary tree.

Purpose: To evaluate the value of conventional and diffusion-weighted (DW) magnetic resonance imaging (MRI) in the diagnosis of extrahepatic hydatid cysts., Materials and Methods: Forty-one extrahepatic hydatid cysts (12 renal, 6 pulmonary, 5 peritoneal, 4 bone, 3 soft tissue, 3 pancreatic, 2 splenic, 2 retroperitoneal, 1 adrenal, 1 scrotal, 1 diaphragmatic, and 1 cardiac) were included in this retrospective study. After a series of routine conventional MRI, DW imaging was performed using a breath-hold, single-shot, echo-planar, spin echo sequence with three b factors (0, 500 and 1,000 s/mm(2)), and apparent diffusion coefficient (ADC) maps were created. On DW trace images, signal intensity of the cysts was visually compared to the signal intensity of the muscle with the use of a 3-point scale: 0, isointense; 1, moderately hyperintense; 2, significantly hyperintense. For quantitative evaluation, signal intensity ratio and ADC of the cystic lesions were calculated., Results: On conventional MR images, all but 3 patients had concomitant liver involvement. Three of them were disseminated. On DW trace images (b = 1,000 s/mm(2)), most hydatid cysts (86%) were hyperintense, while five hydatid cysts (14%) were isointense. Quantitatively, the mean ADC of the hydatid cysts was 2.8 x 10(-3) +/- 0.5 mm(2)/s., Conclusion: DW imaging may help in the differential diagnosis of extrahepatic hydatid cysts.

Objective: Solitary necrotic nodule of the liver (SNNL) is a rare lesion and accepted as a benign entity. The aim of this study is to investigate the possible causes for the development of solitary necrotic nodules., Methods: Twenty-two retrospective solitary necrotic nodule specimens were examined to evaluate histologic features. The clinical records of these patients were reviewed, and clinical data were obtained for all patients., Results: Histologically, 17 of the 22 nodules were necrotic with surrounding fibrosis, and the remaining five nodules were completely fibrotic. Four of the 22 cases were found to have specific lesions within the nodules which may put light on the pathogenesis. Foci of metastatic carcinoma were identified in two of these four cases, and cuticle fragments of the hydatid cyst were identified in the other two cases. Clinical data showed that half of the cases with solitary necrotic nodule have an associated malignancy mainly involving the gastrointestinal system., Conclusions: SNNL is not always benign. The possible causes of this lesion include parasites and metastatic tumors. It is important to identify the minute foci of metastatic carcinoma for the appropriate management of this lesion.

Aim: To compare the efficacy and safety of radical and conservative surgical interventions for liver hydatid disease., Methods: The study comprised 59 patients in two groups who had undergone radical and conservative surgical procedures for liver hydatid disease in our department between 2004 and 2009. Preoperative diagnostic tools, medical treatments, demographic and clinical characteristics, postoperative follow-up, and recurrence were compared in both groups., Results: This non-randomized retrospective study included 59 patients who had undergone liver hydatid disease surgery. The radical technique was used in 18 patients (mean age: 42.1 +/- 13.5 years, seven male, 11 female), and the conservative technique was used in 41 patients (mean age: 43.5 +/- 13.9 years, 17 male, 24 female). The follow-up period ranged from 3 to 58 mo. Although operative time was significantly shorter in the conservative group (P < 0.001), recurrence was significantly reduced in the radical group (P = 0.045). No statistically significant differences were found in terms of hospitalization duration, cyst count and size, location, postoperative complications, scolicidal solution usage, or follow-up duration between the two groups., Conclusion: The more effective method for preventing postoperative recurrence is radical surgery. Endoscopic retrograde cholangiopancreatography for bile leakage in the early postoperative period may decrease the requirement for repeat surgery.

Alveolar echinococcosis cases diagnosed histopathologically in 2002, 2006, 2007, and 2009 in Ulaanbaatar, Mongolia were reconfirmed by evaluating the cytochrome c oxidase subunit I gene of mitochondrial DNA. The most recent three cases using paraffin-embedded and ethanol-fixed specimens revealed that one was of the "Asian" haplotype, whereas two others were of the "Inner Mongolian" type. All patients were born in the western provinces of Mongolia, they never resided outside of Mongolia, and they were given a preliminary diagnosis of malignant hepatic tumor or abscess. The most recent two cases were also confirmed serologically to be active alveolar echinococcosis.

A research has been conducted studying the enzyme system of the liver using biopsy material of the organ taken during the operation from patients with echinococcosis and an experiment with infantile white mice. It is proved reduction of the activity of the alkaline and acid phosphatase as well as of the glycogen along with their progressive reduction during the disease progression. Compared with the other researches--histological and by electronic microscope, etc.--there are proved great hepatic damages due to the echinococcosis that have caused change of the treatment tactics: large preoperative period, including reconstructions of the glycogenic depot in the organ, gentle to the liver anesthesia, exact postoperative reanimation. Very good results have been obtained concerning the postoperative complications and operative mortality: observing the developed acute liver insufficiency--in the past the mortality has been 27.60% throughout 2.49% of the operated patients; after those measures the acute liver insufficiency after this kind of operation is seen just once (0.40% of the patients) and the mortality is 0.

Hydatid disease most commonly affects the liver and lungs but no organ is immune. Splenic hydatid cyst is a rare clinical entity. Although the patients are usually asymptomatic, the disease may present with secondary infection, adhesion to adjacent organs with fistulisation or rupture into abdominal cavity. We present a 67 year old women with splenic hydatid cyst. Severe adhesions and tumorlike growth were found in the retroperitoneal region. To our knowledge, retroperitoneal invasion with a splenic hydatid cyst is a very rare clinical condition. Total splenectomy was performed without complication.

There are few reports regarding the use of liver grafts with multiple large cysts in living donor liver transplantation. A 40-year-old woman who was diagnosed with Wilson's disease underwent living donor left liver transplantation; the donor was her 67-year-old mother. The liver graft had multiple large cysts, with a maximum diameter of 9 cm. At donor hepatectomy, the largest cyst and one small cyst were fenestrated, because they were located in the left paramedian sector; the other cysts were left intact. After transplantation, the liver graft exhibited good function with no cyst-related complications, such as hemorrhage, infection, or rupture, despite slight enlargement of the cysts. Thus, a liver graft with multiple large cysts is transplantable. However, the necessity of treating large cysts remains debatable.

Introduction: In some cases of multicystic forms of liver echinococcal disease, the advanced method for treatment of cystic echinococcosis faces great problems relating to the final outcome of the treatment., Case Report: In May 2005, a computerized tomography of the abdomen obtained in a 27-year-old female patient with abdominal pain revealed more than 20 echinococcal cysts measuring up to 6.7 cm in both lobes of the liver. Laboratory analyses found the value of eosinophils 6.8%, gamma globulins 29.9%, immunoglobulin E 29 600 IU/mL and the indirect hemagglutination for echinococcosis 1:8,196. The treatment started in December that year with the continuous administration of a daily dose of 800 mg (14.5 mg/kg body weight) of albendazole, but it was terminated two months later due to high serum transaminases values. By the end of 2006, the largest cyst detected in the left lobe of the liver had a diameter of 5.7 cm and the one in the right lobe of the liver measured 4.1 cm. There were lesions of germinative membrane found on both cysts. Six months later, praziquantel at daily dose of 2,500 mg (45.3 mg/kg body waight) was introduced into the therapy, but the treatment was terminated after eight days because of the development of exanthema. The computerized tomography of the abdomen obtained in February 2008 revealed the presence of a large number of echinococcal cysts in the liver. The largest among those cysts measured 3.5 cm while calcifications of the cyst walls were observed on some of them. None of the remaining therapeutic options for further treatmetnt of echinococcal disease could be applied., Conclusion: The presented case confirms medical therapy as the only option for the treatment of some forms of cystic echinococcosis. Benzimidazole carbamates (albendazole, mebendazole) and praziquantel are only efficacious antihelminitics currently available, and when they have to be withdrawn due to serious adverse affects, futher treatment of a patient with liver multicystic echinococcosis is impossible. Because of that there is a need to search for new and more efficient drugs for the treatment of ehinococcal disease.

In this study, we report the imaging findings in two Japanese monkeys (Macaca fuscata) diagnosed with alveolar echinococcosis. Both monkeys were treated with albendazole for 10 years, without surgery. Radiography, computed tomography, and contrast-enhanced ultrasonography were performed under general anesthesia. This is the first report on contrast-enhanced ultrasonographic imaging for alveolar echinococcosis wherein perflubutane was used as the contrast medium. The findings of the imaging analyses were similar to those reported for alveolar echinococcosis in humans, such as snowflake sign and worm-eaten sign. In addition, the serology correlated well with the imaging data in these two monkeys. Therefore, we propose that the imaging findings of alveolar echinococcosis in nonhuman primates may be used to accumulate data on this condition in human alveolar echinococcosis.

Alveolar echinococcosis (AE) is a rare but potentially serious zoonosis for which an early diagnosis is of primary importance. We report the first observation of AE in a cardiac transplant patient infected by hepatitis C virus. He first presented with a single asymptomatic hepatic nodule. The liver biopsy showed an epithelioid granuloma with necrosis. We review the clinical features, diagnosis and outcome of this disease in immunocompromised hosts. In immunocompromised patients living in areas endemic for Echinococcus multilocularis, AE should be included in the differential diagnosis of tumor like lesions of the liver.

Aim: To evaluate radiofrequency thermal ablation (RTA) for treatment of cystic echinococcosis in animal models (explanted organs)., Methods: Infected livers and lungs from slaughtered animals, 10 bovine and two ovine, were collected. Cysts were photographed, and their volume, cyst content, germinal layer adhesion status, wall calcification and presence of daughter or adjacent cysts were evaluated by ultrasound. Some cysts were treated with RTA at 150 W, 80 degrees C, 7 min. Temperature was monitored inside and outside the cyst. A second needle was placed inside the cyst for pressure stabilization. After treatment, all cysts were sectioned and examined by histology. Cysts were defined as alive if a preserved germinal layer at histology was evident, and as successfully treated if the germinal layer was necrotic., Results: The subjects of the study were 17 cysts (nine hepatic and eight pulmonary), who were treated with RTA. Pathology showed 100% success rate in both hepatic (9/9) and lung cysts (8/8); immediate volume reduction of at least 65%; layer of host tissue necrosis outside the cyst, with average extension of 0.64 cm for liver and 1.57 cm for lung; and endocyst attached to the pericystium both in hepatic and lung cysts with small and focal de novo endocyst detachment in just 3/9 hepatic cysts., Conclusion: RTA appears to be very effective in killing hydatid cysts of explanted liver and lung. Bile duct and bronchial wall necrosis, persistence of endocyst attached to pericystium, should help avoid or greatly decrease in vivo post-treatment fistula occurrence and consequent overlapping complications that are common after surgery or percutaneous aspiration, injection and reaspiration. In vivo studies are required to confirm and validate this new therapeutic approach.

Echinococcosis is a cyclozoonosis characterized by cystic lesions usually situated inside or outside the liver. We discuss the case of a 77-year-old woman with a recurrent hydatidosis with a cyst arising from the liver, growing through the lateral right abdomen wall, and reaching the subcutaneous tissue of the lumbar region. In the literature, rare subcutaneous or muscular localizations of hydatid cysts are described, however, there is no mention of a cyst growing over the abdominal wall muscles, shaped like an hourglass, partially in the liver and partially in the subcutaneous tissue, as in our case. We have not found any pathogenetic explanation for this growth pattern which is not typical of the biological behaviour of a hydatid cyst.