eMedicine Specialties > Infectious Diseases > Parasitic Infections

Echinococcosis

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
Contributor Information and Disclosures

Updated: Jan 5, 2010

Introduction

Background

Infection with the larval form of Echinococcus multilocularis causes alveolar echinococcosis (AE). The infection behaves as a slow-growing malignant tumor. Initially, it is located in the liver and then may spread to any other organ through metastases. Without appropriate therapeutic management, the infection is lethal.

Echinococci are platyhelminths of the cestode genus. The parasitic cycle of the organism involves definitive hosts and intermediate hosts, each harboring different stages of the parasite life cycle.

Carnivores are the definitive hosts for the adult form of the parasite, which is an intestinal worm also termed taenia. Numerous (ie, tens to thousands) adult worms that average 2-5 mm in length live in the small bowel of carnivores (taeniasis) and are attached to the small bowel mucosa by hooks and suckers. After 25-40 days, the worm's last gravid segment, each containing hundreds of microscopic eggs (6-hooked oncospheres or hexacanth embryos, 30-40 mm in diameter), detaches from the nonfertile segments. The egg-containing segments are then dispersed through the feces of the carnivore.

Various species act as intermediate hosts, serving the larval form of the parasite (ie, metacestode). The metacestode is a continuously growing tumorlike polycystic mass that is not clearly separated from host tissues. The larval-stage parasite is composed of vesicles that become fertile by producing a form termed the protoscolex, which is able to recreate the adult worm in the definitive host. The protoscoleces that fill the vesicles transform into adult worms once ingested into the intestine of the carnivore host.

The cycle of E multilocularis in Europe is predominantly sylvatic, involving red foxes (see image below) as definitive hosts and rodents as intermediate hosts. In some countries, dogs and cats have been identified as definitive hosts; however, all definitive host species acquire the infection from the sylvatic cycle by consuming rodents infected with metacestodes of E multilocularis. In Alaska and in the People's Republic of China, the domestic cycle, involving family or stray dogs, is particularly important.

Foxes are the definitive hosts of the cestode <em...

Foxes are the definitive hosts of the cestode Echinococcus multilocularis. Courtesy of Dominique A. Vuitton, MD, PhD.

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Foxes are the definitive hosts of the cestode <em...

Foxes are the definitive hosts of the cestode Echinococcus multilocularis. Courtesy of Dominique A. Vuitton, MD, PhD.


E multilocularis eggs, which are the infectious agents for humans, are dispersed in the environment via the feces of carnivores. The eggs may contaminate various types of food, including fruits and vegetables collected from gardens or infected meadows, and drinking water. An oncosphere membrane protects Echinococcus eggs, making them extremely tolerant of environmental conditions. E multilocularis eggs may remain infectious at temperatures ranging from -30°C to +60°C. They are easily destroyed by heat but may survive months or years at low temperatures, especially if they are protected against drying. Freezing the eggs at -20°C does not affect their infectious potency.

Simultaneous occurrence of both alveolar echinococcosis and cystic echinococcosis resulting from Echinococcus granulosus infection is extremely rare but has occurred in endemic areas where both species are present in the environment (eg, western China).

Pathophysiology

Alveolar echinococcosis is a chronic disease with a presymptomatic stage that may last for years before signs and symptoms develop. The variability of the signs and symptoms depends on the location of the lesions (see image below), which may develop in the liver and/or in various organs or tissues, especially the lungs, brain, and bones.

Macroscopic aspect of alveolar echinococcosis les...

Macroscopic aspect of alveolar echinococcosis lesions in the liver. Courtesy of Bernadette Kantelip, MD.

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Macroscopic aspect of alveolar echinococcosis les...

Macroscopic aspect of alveolar echinococcosis lesions in the liver. Courtesy of Bernadette Kantelip, MD.


E multilocularis larvae grow as tumorlike buds that transform into multiple vesicles filled with fluid and, in 15% of cases, with protoscoleces. The parasitic vesicles are lined with a germinal layer and a laminated layer, which are immediately surrounded by an exuberant granulomatous response generated by the host's immune system. This reaction has two main consequences, fibrosis and necrosis (see image below). Both reactions protect the host against larval growth but may also be deleterious.

Fibrosis in alveolar echinococcosis is extremely active from the beginning of the infection. Irreversible acellular fibrosis composed of cross-linked collagens ensues and isolates the parasitic lesions from the host but also compresses and obstructs major vessels and bile ducts. Noncaseous necrosis in the center of the lesions may be superinfected by bacteria and fungi, possibly leading to complications (eg, liver abscesses, septicemia).

Ultrasonographic, CT scan, and perioperative aspe...

Ultrasonographic, CT scan, and perioperative aspect of a typical lesion of alveolar echinococcosis with central necrosis. Courtesy of Jean-Philippe Miguet, MD.

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Ultrasonographic, CT scan, and perioperative aspe...

Ultrasonographic, CT scan, and perioperative aspect of a typical lesion of alveolar echinococcosis with central necrosis. Courtesy of Jean-Philippe Miguet, MD.


Similar to several other parasitic diseases, alveolar echinococcosis appears as a polar disease (as defined in leprosy). The ability of the organism to infect a host and the severity of disease once successfully inoculated depend on the receptivity of the host (ie, host immune defenses).

Mass screenings prove that abortive forms (see image below) exist and may occur in most cases, explaining the relatively low prevalence of this disease. Experimental studies in infected mice and immunologic studies in humans reveal the importance of cell-mediated immunity in the control of larval growth. Immune responses, characterized by a helper T cell TH 1 profile of cytokine secretion, can kill the larvae, thus protecting the host. The progressive forms of the disease are characterized by a TH 2 profile consisting of increased interleukin (IL)–10, transforming growth factor (TGF)–beta, and IL-5 secretion.

Sonogram of an abortive form of alveolar echinoco...

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.

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Sonogram of an abortive form of alveolar echinoco...

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.


Frequency

United States

Foxes infected with E multilocularis are present in most of the northern and central states. The organism has been observed in all or parts of 11 contiguous states and 3 adjacent Canadian provinces in an area centered by southern Manitoba and North Dakota. However, only 2 cases involving humans living in this area have been described since the beginning of the 20th century. Transport of infected foxes from endemic areas to eastern and southern states for hunting purposes could create new areas at risk of becoming endemic. In Alaska, alveolar echinococcosis is observed in Eskimos, especially on St. Lawrence Island, where 30 of 53 cases were diagnosed in Alaska from 1947-1990.

International

Alveolar echinococcosis occurs only in the northern hemisphere, in geographically limited foci (endemic areas) of west-central Europe, Turkey, most areas of the former Soviet Union, Iran, Iraq, western and central China, and northern Japan (Hokkaido Island). If considering only at-risk rural populations in regions in central Europe that are endemic for alveolar echinococcosis, the incidence is 1-20 cases per 100,000 persons per year, despite an overall country prevalence that may be very low. In endemic foci of China, prevalence averages 5% but may reach 10% in villages with specific risk factors. The prevalence of E multilocularis infection in foxes is 15-70% in endemic areas.

Recent trends are related to increasing percentages of infected foxes and increased distribution of those foxes. The presence of infected foxes in large cities of Europe and northern Japan is now well documented; 10% (in city centers) to 50% (in the suburbs) may be found in cities of the European endemic areas (such as Zurich or Geneva in Switzerland, Stuttgart in Germany, or Nancy in France). This and a newly recognized trend of infection in dogs and cats in endemic areas in Europe may lead to major changes in the human populations at risk in the near future.

Mortality/Morbidity

Untreated alveolar echinococcosis is usually fatal. The survival rate at 5 years in untreated patients averages 40%. Therapeutic approaches that have been developed since the early 1980s have markedly improved the prognosis of the disease. The actuarial survival rate at 5 years was 88% in a series of 80 patients observed from 1983-1993.

  • Major complications leading to death include biliary obstruction with bacterial and/or fungal superinfections (eg, cholangitis, septicemia), secondary biliary cirrhosis, bleeding from esophageal or duodenal varices due to portal hypertension, Budd-Chiari disease, obstruction of the vena cava, and complications of heart, lung, or brain metastases (see image below).

  • Brain metastasis of alveolar echinococcosis. Cour...

    Brain metastasis of alveolar echinococcosis. Courtesy of Jean-Philippe Miguet, MD.

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    Brain metastasis of alveolar echinococcosis. Cour...

    Brain metastasis of alveolar echinococcosis. Courtesy of Jean-Philippe Miguet, MD.

  • Alveolar echinococcosis may markedly impair patients' quality of life, and the economic costs associated with treatment are high because the disease is chronic and requires life-long treatment and follow-up care.
  • The outcome of treatment is unpredictable; however, since the beginning of the 1980s, a combination of surgery, interventional radiology, and benzimidazole treatment has improved patient survival rates and quality of life. In developed countries, earlier diagnosis and well-managed treatment have improved average life expectancy at diagnosis from 3 years in the 1970s to 20 years in 2005.

Race

No known racial predilection exists; however, the genetic background, including human lymphocyte antigen (HLA) characteristics, linked to the intensity and/or to the TH 1/TH 2 balance of the patient's immune response may be associated with the occurrence and/or severity of the disease.

Sex

Older reports indicate a male predilection for infection; however, these reports are not accurate. In endemic areas in Europe, the male-to-female ratio is approximately equal. In the endemic areas of China, women are affected more commonly than men. Sex differences in prevalence seem to reflect epidemiologic rather than strictly sex-related risk factors, such as caring for dogs in central China. However, the influence of slightly impaired immune defenses resulting from repeated pregnancies cannot be excluded.

Age

The typical age at onset is 55 years. However, mass screenings have identified symptomatic and asymptomatic infections in patients ranging in age from 6 years to elderly persons.

Clinical

History

The presenting symptoms below are from two series of patients diagnosed in the same hospital in eastern France in the 1970s and 1980s. Other series confirm these figures.

  • Vague abdominal (right upper quadrant) pain is the most common presenting symptom (30%) and can last for years before lesions develop.
  • Jaundice, which was the most common presenting symptom before the 1980s, is observed in 25% of cases. Progressive gradual cancerlike onset of jaundice is observed in most cases that involve symptomatic cholestasis. Intermittent jaundice may also be associated with acute right upper quadrant pain when parasitic material migrates through the common bile duct.
  • Hepatomegaly is observed in 16% of cases.
  • In the presence of bacterial superinfection, fever and chills may accompany gallstonelike symptoms. Fever and chills may also evoke liver abscess due to superinfection in the central periparasitic necrosis.
  • Various symptoms, ranging from dyspnea and bile sputum to seizures and stroke, as well as bone pain or skin tumor, may be the presenting symptoms of a secondary location or metastasis of the parasitic lesions (approximately 10% of cases).

Physical

  • The most frequent clinical finding is hepatomegaly, which may be found in patients who are otherwise asymptomatic. An enlarged left liver lobe due to liver regeneration in the course of a lesion on the right lobe may be found only during palpation of the epigastrium.
  • Splenomegaly is present only in cases complicated by portal hypertension or those that involve spleen metastasis.
  • Ascites and dilated periumbilical veins are rare.
  • Caval collateral circulation between the inferior and superior vena cava may develop on the abdominal and thoracic skin in cases in which the hepatic veins and vena cava are obstructed.
  • Other physical symptoms are dictated by the location of metastatic lesions.
  • A significant number of patients undergoing diagnostic analysis are asymptomatic. Patients may present by chance (eg, at surgery, during ultrasonographic examination for another reason) or during mass screening performed in an endemic area.

Causes

Alveolar echinococcosis is a zoonosis. In nature, humans and other animals share the infection, which results in various factors that allow the parasite to complete its life cycle. Contact with the infectious form of the cestode (ie, oncosphere or egg) depends on human behavior and cultural habits. This explains why the disease is encountered in limited geographic areas. Changes in the environment, possibly related to economic or political decisions, and changes in behavior may be partially responsible for changes in the potential for humans to be exposed to the parasite. In general, humans are not susceptible hosts for infection with E multilocularis. In fact, genetic and immunologic aspects are also involved and may modify the overall prevalence of the disease in humans of a given endemic area.

  • Geographic factors
    • Prevalence rates vary enormously (between 1 per 100,000 and 1 per 10 population) within the recognized distribution range of E multilocularis.
    • In most regions, environmental features that favor the parasite cycle include hilly landscapes, cool and rainy climates, and pastures for cattle breeding.
    • One factor that is key to the presence of the parasite is the abundance of suitable intermediate hosts. The occurrence and population size of these species depends on the presence of unplowed grassland (eg, pastures, meadows), which is the type of landscape most typical in mountainous regions with a cool climate where intensive agriculture is not feasible.
    • A correlation between E multilocularis prevalence in foxes and population densities of rodent species (suitable intermediate hosts) has been demonstrated in France and between the prevalence in dogs and population densities of rodent or small lagomorph species in China. In addition, the number of human cases correlates well with the existence of a cyclic pattern of high densities of rodents. In Europe, high rodent population densities appear to occur only in areas without plowed fields and with permanent meadows or pastures for cow breeding.
    • The appearance of infected foxes in large cities, the overall increase in infected foxes in Europe and northern Japan, and the transport of infected foxes to new areas in the United States also increase the risk of human infection.
    • Although rodents, especially voles (see image below), or small lagomorphs (eg, Ochotona species) are the normal intermediate hosts of E multilocularis in nature, various accidental hosts with a larval disease similar to that observed in humans have been described in cattle, pigs, boars, hares, horses, monkeys, and apes.

    • <em>Microtus larvalis</em> (common vole) is one o...

      Microtus larvalis (common vole) is one of the most common intermediate hosts of Echinococcus multilocularis in Europe. Courtesy of Patrick Giraudoux, PhD.

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      <em>Microtus larvalis</em> (common vole) is one o...

      Microtus larvalis (common vole) is one of the most common intermediate hosts of Echinococcus multilocularis in Europe. Courtesy of Patrick Giraudoux, PhD.

  • Political factors
    • The European Economic Community agricultural policies that favored cow breeding for cheese-making on middle-altitude plateaus of the Jura and Alps mountain ranges since the 1960s may have led to particular changes of the landscape that are more favorable to alveolar echinococcosis development.
    • Similar landscape changes in central China (eg, deforestation) have led to high rodent population densities and an increase in cases of alveolar echinococcosis. In addition, on the Tibetan plateau, changes in land use, especially by fencing common pastures, may have increased the contamination risk by increasing the population of a small mammal, Ochotona curzoniae, which serves as intermediate host in this area.
    • Alveolar echinococcosis epidemiology is a striking example of unexpected public health consequences resulting from political or economic environmental decisions.
  • Human behavioral factors
    • Regional cultural behaviors, such as collecting wild berries or vegetables and harvesting vegetables from open kitchen gardens, put rural populations at risk. In Asia, closer contact with dogs may be responsible for the higher prevalence in women.
    • Other behaviors that promote infection in human populations include hiking, hunting, and consumption of organic food.
  • Genetic factors
    • A multicenter study of the HLA groups of patients with alveolar echinococcosis in France, Germany, and Switzerland suggests that HLA DR 11 is associated with protection against E multilocularis infection in humans, HLA DP 0401 is associated with susceptibility, and HLA B8, DR3, and DQ2 are associated with severe forms of infection. TAP polymorphism is also associated with alveolar echinococcosis occurrence and severity.
    • Similar results involving other HLA groups (because of ethnic differences) have also been observed in China.
    • Risk factors for alveolar echinococcosis include an agricultural occupation and a prolonged stay in an endemic area. Family cases are uncommon; however, a cluster of family cases was discovered in central China and may be due to common exposure combined with genetic characteristics of these families.
    • Minor genetic differences between strains within the species E multilocularis may be recognized using mitochondrial and nuclear DNA sequencing. However, these genetic differences do not seem to greatly influence infectious and growth potential of the larva.
  • Immunologic factors
    • Various states of immunosuppression (eg, HIV infection, organ transplantation, chronic autoimmune or malignant disease treated with immunosuppressive drugs, pregnancy) are associated with a faster progression of alveolar echinococcosis.
    • Because these immunosuppressed populations are increasing, especially the patient population treated with immunosuppressants, echinococcosis is currently observed more and more frequently as an opportunistic disease.

More on Echinococcosis

Overview: Echinococcosis
Differential Diagnoses & Workup: Echinococcosis
Treatment & Medication: Echinococcosis
Follow-up: Echinococcosis
Multimedia: Echinococcosis
References
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Further Reading

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Keywords

echinococcosis, alveolar hydatid disease, multilocular echinococcosis, Echinococcus multilocularis infection, E multilocularis infection, Echinococcus granulosus infection, E granulosus infection, alveolar echinococcosis, AE, echinococci, platyhelminths, cestode, parasites, intestinal worms, taenia, taeniasis, metacestode

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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.

Medical Editor

John M Leedom, MD, Professor of Medicine, Keck School of Medicine, University of Southern California; Chief, Division of Infectious Diseases, Department of Internal Medicine, Los Angeles County, University of Southern California Medical Center
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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

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

CME Editor

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.

 
 
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