Echinococcosis Hydatid Cyst Workup

  • Author: Enrico Brunetti, MD; Chief Editor: Burke A Cunha, MD   more...
 
Updated: Oct 19, 2011
 

Laboratory Studies

  • Generally, routine laboratory tests do not show specific results.
    • In patients with rupture of the cyst in the biliary tree, marked and transient elevation of cholestatic enzyme levels occurs, often in association with hyperamylasemia and eosinophilia (up to 60%).
    • In most cases, eosinophilia is limited (< 15%) or absent.
  • Cystic echinococcosis is one of the few parasitic infections in which the basis for laboratory diagnosis is primarily serology.[13]
    • Indirect hemagglutination test and enzyme-linked immunosorbent assay are the most widely used methods for detection of anti-Echinococcus antibodies (immunoglobulin G [IgG]).
    • Depending on the test system used and other parameters, approximately 10% of patients with hepatic cysts and 40% with pulmonary cysts do not produce detectable serum IgG antibodies and exhibit false-negative results.
    • Cysts of the brain or eye and calcified cysts often induce no or low antibody titers.
    • Children aged 3-15 years may produce minimal serologic reactions.
  • No standard, highly sensitive, and specific serologic test exists for cystic echinococcosis antibody detection. In specialized laboratories, the arc 5 test or detection of cestode-specific antibodies can be used to exclude cross-reactions caused by noncestode parasites.
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Imaging Studies

  • Radiographic examination is useful for cysts in the lungs, bone, and muscle and for detecting calcified cysts.
  • Ultrasonography is the procedure of choice when making the diagnosis of asymptomatic cystic echinococcosis because it is safe, noninvasive, and relatively inexpensive. Ultrasonography is an imaging technique that uses the reflection of ultrasound waves emitted by a probe on the bodily organs to build images of the organs explored.
    • Any abnormality can be viewed using ultrasonography from an infinite number of angles and positions. Cysts in every part of the abdomen and in muscles can be imaged with ultrasonography.
    • Ultrasonography is useful in longitudinal studies, such as monitoring the response of cysts to treatment and recording cyst growth rate.[14]
    • Ultrasonography has also been used extensively in endemic areas for mass screening, often using portable machines that can work without an electrical distribution system by running on batteries or on a generator.
    • Many authors consider ultrasonographic mass surveys to be the best way to assess prevalence.
  • Various classifications exist of the ultrasonographic picture in cystic echinococcosis, the most widely used still being the one proposed by Gharbi in the early 1980s.[15] In 2003, the World Health Organization Informal Working Group on Echinococcosis (WHO-IWGE) proposed a standardized ultrasound classification based on the active-transitional-inactive status of the cyst as suggested by its sonographic appearance.[16]
  • The standardized classification scheme is intended to promote uniform standards of diagnosis and treatment and may be applied to the clinical treatment of patients as well as to field diagnostic surveys. This classification has important implications for clinical decision-making ad prognosis.[17, 18, 13] CE1 and CE2 are active cysts containing viable protoscolices. CE3 has been subdivided into CE3a (detached endocyst) and CE3b (predominantly solid with daughter cysts). This subdivision is supported by a recent work that used high-field 1 H magnetic resonance spectroscopy to evaluate ex vivo the metabolic profiles of cyst contents.[19] Another paper has shown that, contrary to what previously assumed, calcifications are not limited to CE5 cysts, but are present to a various extent in all cystic stages.[20]
  • Whatever the classification used, general consensus exists about the following:
    • Simple cysts with well-defined borders and uniform anechoic contents are not pathognomonic for echinococcal cysts (nonparasitic cysts have the same appearance).
    • Cysts with a visible split wall inside (floating membrane or water lily sign) are pathognomonic.
    • Septated cysts, or cysts with a honeycomb pattern, are likely to be echinococcal.
    • A solid heterogeneous mass is difficult to differentiate from granulomas or tumors, although calcification suggests echinococcal cyst.
  • Echocardiography may be used to detect cardiac lesions.
  • CT scanning has the advantage of inspecting any organ (lungs cannot be explored with ultrasonography), detecting smaller cysts when located outside the liver, locating cysts precisely, and sometimes differentiating parasitic from nonparasitic cysts. Measurement of cyst density appears to be an additional tool to differentiate parasitic from nonparasitic cysts and for follow-up studies during chemotherapy. However, the cost of CT scanning is prohibitive in several endemic countries.
  • MRI may have some advantages over CT scanning in the evaluation of postsurgical residual lesions, recurrences, and selected extrahepatic infections, such as cardiac infections.[21] It is also superior in identifying changes of the intrahepatic and extrahepatic venous system and in identifying cysto-biliary fistulas.[22]
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Other Tests

  • Endoscopic retrograde cholangiopancreatography may be indicated in patients with cholestatic jaundice. This technique may also be a therapeutic intervention when cysts communicating with the biliary tree can be basketed out.
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Procedures

  • Fine-needle aspiration biopsy of the cyst performed under ultrasonographic guidance, by the transhepatic approach, and under anthelmintic coverage is generally safe and diagnostically useful for differentiation of cystic echinococcosis, malignancy, and abscesses.[23] It may be particularly helpful in cases with no detectable anti-Echinococcus serum antibodies and inconclusive imaging appearance. The hooks are usually numerous and can be found even in bacteriologically infected and/or degenerating cysts. Rostellar hooklets are seen in the image below. Viable scolices (note rostellar hooklets). Viable scolices (note rostellar hooklets).
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Contributor Information and Disclosures
Author

Enrico Brunetti, MD  Assistant Professor, Department of Infectious Diseases, Division of Infectious and Tropical Diseases, University of Pavia, Italy; Staff Physician, Department of Infectious Diseases, IRCCS S Matteo Hospital Foundation, Pavia, Italy

Enrico Brunetti, MD is a member of the following medical societies: American Society of Tropical Medicine and Hygiene and European Society of Clinical Microbiology and Infectious Diseases

Disclosure: Nothing to disclose.

Coauthor(s)

Carlo Filice, MD  Chief of Ultrasound Unit, Associate Professor, Department of Internal Medicine, IRCCS S Matteo Hospital, University of Pavia, Italy

Disclosure: Nothing to disclose.

Specialty Editor Board

Mark R Wallace, MD, FACP, FIDSA  Clinical Professor of Medicine, Florida State University College of Medicine; Head of Infectious Disease Fellowship Program, Orlando Regional Medical Center

Mark R Wallace, MD, FACP, FIDSA is a member of the following medical societies: American College of Physicians, American Medical Association, American Society of Tropical Medicine and Hygiene, and Infectious Diseases Society of America

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.

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WHO Informal Working Group on Echinococcosis standardized ultrasound classification of echinococcal cysts. Image courtesy of World Health Organization (WHO).
CE1 cyst in the right segments of the liver in a young Albanian boy
CE3a echinococcal cyst of the liver. Note the folding endocyst ("waterlily sign") typical of CE3a cysts.
CE3b cyst in the right lobe of the liver. The cyst is predominantly solid with a few daughter cysts
CE4 cyst in the liver. The cyst is completely solid and inactive.
CE3b cyst in the muscles of posterior thigh (scanned with a convex ultrasound probe).
CE4 cysts in the peritoneum in a patient with disseminated echinococcosis (longitudinal scan).
Viable scolices (note rostellar hooklets).
CT scan of peritoneal, disseminated echinococcosis
MR scan of echinococcal cyst in the right psoas muscle, infiltrating the adjacent vertebral body
Ultrasound scan of a CE3b subcutaneous cyst located in the lumbar area. The cyst was the subcutaneous extension of a cyst located in the spine that had been previously operated on.
MR of the spine showing CE involvement of CE3,CE4,CE5 vertebral bodies, spinous processes and subcutaneous tissue (same patient as # )
CT scan showing CE infiltration of vertebral bodies and destruction of left peduncles
 
 
 
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