Echinococcosis Follow-up

  • Author: Dominique A Vuitton, MD, PhD; Chief Editor: Burke A Cunha, MD   more...
 
Updated: Oct 20, 2011
 

Further Inpatient Care

  • Follow the usual rules for postoperative management of liver surgery (or of any other indicated surgical or interventional radiology procedures).
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Further Outpatient Care

  • Follow-up schedule
    • Because of the risk of recurrence, regular follow-up examinations are mandatory (eg, ultrasonographic examination, drug adverse effect monitoring), even after radical surgery.
    • Depending on the severity of the case, an experienced physician (with a permanent link to a reference center) must observe the patient every 3, 6, or 12 months. The WHO-Collaborating Center for the Prevention and Treatment of Human Echinococcosis and the WHO-Informal Working Group on Echinococcosis may be contacted at ccoms@chu-besancon.fr.
  • Drug availability and monitoring
    • Depending on the country, MBZ and/or ABZ at the recommended dosage may or may not be authorized or easily available. See regulations for availability.
    • In view of the large individual variations in the systemic availability of benzimidazole drugs, measure patients' plasma concentrations. If the techniques are available locally, measure concentrations at the beginning of treatment (after 4 wk of continuous treatment) and every 6 months during long-term treatment, especially in patients with cholestasis or hepatocellular disturbances.
    • Measuring MBZ and ABZ sulfoxide may be difficult because this test is performed only in highly specialized pharmacology laboratories; their list is available through ccoms@chu-besancon.fr.
  • Decision to stop chemotherapy: After several years of treatment, if serology findings using very specific antigens (eg, Em2+ or Em18) have become negative and CT scanning shows massive calcification of the lesions, the decision of drug withdrawal may be made. The final decision is based on the morpho-PET (PET-CT or PET-RMI) images; absence of any FDG uptake 3 hours after injection supports withdrawal. Careful follow-up is necessary because recurrence may occur despite apparently inactive lesions. Persistently negative PET findings should be confirmed 3 months after withdrawal, then yearly for 10 years.
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Inpatient & Outpatient Medications

  • Prescription includes MBZ or ABZ at the recommended dosage and blood sampling at recommended intervals to monitor adverse effects.
  • In cases that involve bacterial or fungal superinfection, administer antimicrobial drugs according to the usual rules of treatment for cholangitis, liver abscess, or septicemia.
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Transfer

  • Transfer the patient to a hospital with expertise in major hepatic surgery and, preferably, to a reference center familiar with this rare disease. Any physician under the guidance of a reference center specialist may institute follow-up care.
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Deterrence/Prevention

  • Humans
    • No known drug prophylaxis for echinococcosis exists.
    • Prevention is hampered by incomplete knowledge of the actual mode of contamination in most endemic areas, but basic advice is to avoid touching foxes and to avoid eating uncooked fruits or vegetables collected from fields.
    • A vaccine prepared using a recombinant antigen protein has been successfully used to prevent E granulosus larval infection in sheep and E multilocularis in experimental rodents. The potential efficacy and cost-to-benefit ratio of this vaccine in humans are questionable.
  • Animal hosts
    • Regularly treating dogs and baiting of foxes with praziquantel in Alaska and rural Germany and China has shown encouraging preliminary results. Baiting urban foxes with praziquantel is currently performed in Germany, Switzerland, and France and should be considered by health authorities in endemic areas where infected foxes are present in cities.
    • Repeated and prolonged treatment is required, which leads to logistic and financial concerns.
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Complications

  • Complications related to obstruction or invasion of bile ducts or hepatic vessels
    • Obstructive jaundice
    • Cholangitis
    • Intrahepatic gallstones
    • Secondary biliary cirrhosis
    • Portal vein thrombosis
    • Portal hypertension resulting in esophageal variceal bleeding
    • Hypersplenism with anemia and thrombocytopenia
    • Budd-Chiari disease
    • Vena cava obstruction
  • Complications related to invasion of neighboring organs and tissues
    • Adrenal or kidney dysfunction
    • Small bowel obstruction
    • Gastric perforation
    • Skin tumorlike lesions (see image below)Skin metastasis of alveolar echinococcosis. CourteSkin metastasis of alveolar echinococcosis. Courtesy of Solange Bresson-Hadni, MD, PhD.
    • Right atrium parasitic thrombus
    • Pulmonary embolism
    • Communication between bile ducts and bronchi leading to bilious sputum
  • Complications related to distant metastases
    • Lung dysfunction (multiple metastases)
    • Focal cerebral disorders (eg, seizures, hemiparesis, aphasia)
    • Tumorlike bone lesions and fracture
    • Miscellaneous and anecdotal complications related to rare locations
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Prognosis

  • The prognosis of echinococcosis has improved markedly during the past 20 years because of earlier diagnoses, better management, and medical treatment with benzimidazoles.
  • In a French series of 117 patients, the actuarial survival rate at 5 years improved from 67% in patients diagnosed from 1972-1982 to 88% in patients diagnosed from 1983-1993. The ages of patients were comparable in both series. Of the 34 deaths with a clearly identified cause in this series of 117 patients, 28 were related to the parasitic disease and/or its treatment; however, this ratio is currently rapidly decreasing.
  • In a Swiss series of 155 patients, for an average 54-year-old patient diagnosed in 1970, the life expectancy was estimated to be reduced by 18.2 for men and 21.3 years for women. By 2005, this was reduced to approximately 3.5 and 2.6 years, respectively.
  • Patients undergoing radical surgery typically have a better outcome, whereas older patients have a poorer prognosis than younger patients.
  • Costs of treatment in Western Europe amount to approximately US $160,000 per patient. Assuming the improved life expectancy of patients is due to modern treatment, the cost per disability-adjusted life years (DALY) saved is approximately US $8,800.
  • Patients who receive transplants have a 5-year survival rate of 46%; in 1 per 6 of such patients, the survival rate exceeded 20 years.
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Patient Education

  • Regularly emphasize the importance of treatment compliance, which for some patients may be life long. In addition, inform patients that their medications are better absorbed when taken with a fatty meal.
  • Stress the importance of regular follow-up care and good cooperation between the family care physician and a reference center.
  • Despite the rarity of family-clustered cases, consider offering serology and/or liver ultrasonographic examinations to family members and relatives who share the same risk factors and immunogenetic background as the patient.
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Contributor Information and Disclosures
Author

Dominique A Vuitton, MD, PhD  Coordinator of International Affairs, WHO Collaborating Center for Prevention and Treatment of Echinococcosis, Professor Emeritus in Clinical Immunology, University of Franche-Comté, Besançon, France

Dominique A Vuitton, MD, PhD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology

Disclosure: Nothing to disclose.

Specialty Editor Board

John M Leedom, MD  Professor Emeritus of Medicine, Keck School of Medicine of the University of Southern California

John M Leedom, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, American Society for Microbiology, Infectious Diseases Society of America, International AIDS Society, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

John W King, MD  Professor of Medicine, Chief, Section of Infectious Diseases, Director, Viral Therapeutics Clinics for Hepatitis, Louisiana State University Health Sciences Center; Consultant in Infectious Diseases, Overton Brooks Veterans Affairs Medical Center

John W King, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Federation for Medical Research, American Society for Microbiology, Association of Subspecialty Professors, Infectious Diseases Society of America, and Sigma Xi

Disclosure: emedicine $50.00 Author of chapter; MERCK None Other

Eleftherios Mylonakis, MD  Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital

Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD  Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital

Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Additional Contributors

Thanks to all colleagues who are actively working within the framework of the WHO-Collaborating Centre for Prevention and Treatment of Human Echinococcosis, and more generally within the framework of the WHO-Informal Working Group on Echinococcosis.

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Foxes are the definitive hosts of the cestode Echinococcus multilocularis. Courtesy of Dominique A. Vuitton, MD, PhD.
Macroscopic aspect of alveolar echinococcosis lesions in the liver. Courtesy of Bernadette Kantelip, MD.
Ultrasonographic, CT scan, and perioperative aspect of a typical lesion of alveolar echinococcosis with central necrosis. Courtesy of Jean-Philippe Miguet, MD.
Microtus larvalis (common vole) is one of the most common intermediate hosts of Echinococcus multilocularis in Europe. Courtesy of Patrick Giraudoux, PhD.
Sonogram of a typical form of alveolar echinococcosis of the liver, discovered at a screening in China. Courtesy of Dominique A. Vuitton, MD, PhD; Brigitte Bartholomot, MD; and Philip S. Craig, PhD.
Sonogram of an abortive form of alveolar echinococcosis of the liver, discovered at a screening in China. Courtesy of Dominique A. Vuitton, MD, PhD; Brigitte Bartholomot, MD; and Philip S. Craig, PhD.
Pathognomonic aspect of alveolar echinococcosis lesions invading the adrenal gland (resembling a honeycomb) that shows a necrotic area in the contiguous left liver lesion; MRI showing multiple parasitic cysts smaller than 1 cm in diameter appearing in high signal intensity on T2-weighted sequence. Courtesy of Brigitte Bartholomot, MD.
Brain metastasis of alveolar echinococcosis. Courtesy of Jean-Philippe Miguet, MD.
Skin metastasis of alveolar echinococcosis. Courtesy of Solange Bresson-Hadni, MD, PhD.
Histologic features of alveolar echinococcosis vesicles and periparasitic granuloma in humans, periodic acid-Schiff staining of the laminated layer. Courtesy of Bernadette Kantelip, MD.
Fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT scan aspect of active alveolar echinococcosis. White-yellow colors show a very high FDG uptake due to the periparasitic granulomatous infiltration and/or active germinal layer of Echinococcus multilocularis, and green-gray colors show the absence of the FDG uptake by inactive parasitic lesions (mostly necrotic). Courtesy of Solange Bresson-Hadni, MD, PhD, and Oleg Blagosklonov, MD, PhD.
Fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT scan aspect of inactive alveolar echinococcosis. No abnormal FDG uptake by the parasitic lesions after several years of albendazole treatment. Courtesy of Solange Bresson-Hadni, MD, PhD, and Oleg Blagosklonov, MD, PhD.
 
 
 
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