Echinococcosis Follow-up

Updated: Apr 06, 2015
  • Author: Dominique A Vuitton, MD, PhD; Chief Editor: Burke A Cunha, MD  more...
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Follow-up

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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Further Inpatient Care

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

If perendoscopic procedures are indicated, perform extensive lavage of the bile ducts and use systematic antibiotic treatment before and after procedure.

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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 are as follows:

  • 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 are as follows:

  • Adrenal or kidney dysfunction
  • Small bowel obstruction
  • Gastric perforation
  • Skin tumorlike lesions (see image below)
    Skin metastasis of alveolar echinococcosis. Courte Skin 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 are as follows:

  • 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. Of the 34 deaths with a clearly identified cause, 28 were related to the parasitic disease and/or its treatment. [4] Currently, in France, the life expectancy in patients with AE does not significantly differ from that in the general population. 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. AE-related mortality is mostly observed in the first 2 years after diagnosis and in symptomatic patients. [4]

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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