Human cystic and alveolar echinococcosis in the Tibet Autonomous Region (TAR), China.

Human cystic echinococcosis (CE) is known to be endemic in the Tibet Autonomous Region (TAR), China; however, there is relatively little data from hospital records or community prevalence studies, and the situation regarding occurrence of human alveolar echinococcosis (AE) is unclear. Here we review the available reports about human echinococcosis in the seven prefectures of TAR. In addition, two pilot studies by mass screening using ultrasound (with serology) were undertaken (2006/7) in Dangxiong County of Lhasa Prefecture (north central TAR) and Dingqing County of Changdu Prefecture (eastern TAR). In Dangxiong County a prevalence of 9.9% (55/557) for human CE was obtained but no human AE cases were detected. By contrast, in Dingqing County (N= 232 persons screened), 11 CE cases (4.7%) and 12 AE cases (5.2%) (including one mixed CE and AE case) were diagnosed by ultrasound. Hospital records and published reports indicated that CE cases were recorded in all of seven prefectures in Tibet Autonomous Region, and AE cases in four prefectures. Incidence rates of human CE were estimated to range from 1.9 to 155 per 100,000 across the seven prefectures of TAR, with a regional incidence of 45.1 per 100,000. Incidence of AE was estimated to be between 0.6 and 2.8 cases per 100,000. Overall for TAR, human AE prevalence appeared relatively low; however, the pilot mass screening in Dingqing in eastern TAR indicated that human AE disease is a potential public health problem, possibly similar to that already well described in Tibetan communities bordering TAR in north-west Sichuan and south-west Qinghai provinces.

Serum sIL-2R, TNF-alpha and IFN-gamma in alveolar echinococcosis.

AIM: to approach the relationship between alveolar echinococcosis (AE) pathology and level of sIL-2R,TNF-alpha and IFN-gamma in sera and the significance of cytokines in development of AE. METHODS: After 23 patients with AE were confirmed by ELISA and ultrasound, their sera were collected and the concentrations of sIL-2R,TNF-alpha and IFN-gamma were detected by double antibody sandwich. Twelve healthy adults served as controls. According to the status of livers of AE patients by ultrasound scanning, they were divided into 4 groups: P(2), P(3), P(4) groups and C group (control). Average of concentrations of sIL-2R,TNF-alpha and IFN-gamma in homologous group was statistically analyzed by both ANOV and Newman-Keuls, respectively. RESULTS: The mean of sIL-2R in P(2) group was 97+/-29, P(3): 226+/-80, P(4): 194+/-23 and control group (111+/-30)X10(3) u/L (P<0.01). The mean of TNF-alpha in P(2) group was 1.12+/-0.20, P(3): 3.67+/-1.96, P(4): 1.30+/-0.25 and control group 0.40+/-0.19 mug/L (P<0.01). The mean of IFN-gamma in P(2) group was 360+/-20, P(3): 486+/-15, P(4): 259+/-19 and control group: 16+/-2 ng/L (P<0.01). Judged by ANOV and Newman-Keuls, the mean concentrations of sIL-2R, TNF-alpha and IFN-gamma had a significant difference among groups. Except for P(2) group, the mean sIL-2R between other groups of AE patients had a significant difference (P<0.05). The mean of TNF-alpha concentration in P(3) group was the highest (P<0.01). The mean of IFN-gamma concentration in all patients was higher than that in control group (P<0.01), but there was no difference between AE groups (P>0.05). CONCLUSION: Low sIL-2R level indicates an early stage of AE or stable status, per contra, a progression stage. Higher level of TNF-alpha might be related to the lesion of liver. The role of single IFN-gamma is limited in immunological defense against AE and it can not fully block pathological progression.

Classification, follow-up and recurrence of hepatic cystic echinococcosis using ultrasound images.

Ultrasound image and morphological structure of hepatic cystic echinococcosis (CE) were analysed in 277 human cases (385 hepatic hydatid cysts). These included 65 CE cases from community surveys carried out between 1995 and 2000 in 3 countries (China, Mongolia and Jordan) and 212 cases from a clinical hospital survey from Xinjiang, China. A new simplified WHO ultrasound classification for human CE was assessed, and considered useful. It is proposed that type, size and number in particular need to be included in the ultrasound classification of hepatic CE. For comparative purposes 6 categories of type were classified in the study as Type 0 to Type 5 (T0-T5): T0, univesicular without pathognomonic signs; T1, univesicular with pathognomonic signs; T2, cysts with sagging or floating laminated membrane; T3, cysts containing daughter cysts; T4, solid mass or mixed cysts; and T5, cysts with partial or full calcifications. This differs from the WHO classification wherein Type T3 cysts (daughter cysts present) are considered a pathological stage to occur in general prior to the sagging or floating membrane (T2) stage. Recurrent hydatid cysts in the liver were also studied based on morphological structures observed directly from surgical intervention. Case follow-up over 1-5 years since endocystectomy in the community surveys indicated 10% (2/10) recurrence of cysts in the residual surgical cavity. Recurrent CE included 2 (2/4) cases after percutaneous treatment.

Application of ultrasound in diagnosis, treatment, epidemiology, public health and control of Echinococcus granulosus and E. multilocularis.

The last 30 years have seen an impressive use of ultrasonography (US) in many fields of veterinary and clinical medicine and the technique is being increasingly applied to a wide variety of parasitic infections including the cestode zoonoses Echinococcus granulosus and E. multilocularis. US provides real-time results which are permanently recordable with a high resolution and diagnostic accuracy. These properties, coupled with the clinical value of the images obtained and the non-invasive nature of the test which is safe, require no special patient preparation time; it is easy to operate and this has resulted in the establishment of US as the diagnostic technique of choice for cystic (CE) and alveolar (AE) echinococcosis. The lack of ionizing radiation and side-effects mean that examination times are not restricted. The hand-held probes facilitate what amounts to a rapid, bloodless non-invasive laparotomy, enabling a search from an infinite number of angles for lesions producing information on their number, size and type of cysts, their location and clinical implications. Such clinical information has facilitated the development of treatment protocols for different cyst types. Less invasive surgical techniques, such as US guidance for PAIR (Puncture, Aspiration, Injection, Re-aspiration), PAIRD (PAIR plus Drainage) or PPDC (Percutaneous Puncture with Drainage and Curettage) are also possible. Longitudinal US studies have facilitated monitoring the effects of the outcome of treatment and chemotherapy. Portable ultrasound scanners which today weigh as little as a few pounds, powered by battery or generators have facilitated the use of the technique in mass community-based screening studies. The majority of these studies have been conducted in remote, low socio-economic areas where there were few, if any, hospitals, veterinary facilities, schools or trained personnel. The surveys led to the discovery of unexpectedly high prevalences of CE and AE in asymptomatic individuals of endemic areas and especially amongst transhumant or nomadic pastoralists living in various parts of the world. Screening for CE and AE is justified as an early diagnosis leads to a better prognosis following treatment. The application of US in field and clinical settings has led to a better understanding of the natural history of CE and AE and to the development of a WHO standardized classification of cyst types for CE. This classification can be used in helping define the treatment options for the different cysts found during the surveys, which in turn can also be used to calculate the public health cost of treating the disease in an endemic community. The case mix revealed can also influence the specificity (particularly proportions of cyst types CE4 and CE5 and cystic lesions--CL) of US as a diagnostic test in a particular setting. Community based US surveys have provided new insights into the public health importance of CE and AE in different endemic settings. By screening whole populations they disclose the true extent of the disease and reveal particular age and sex risk factors. Through the treatment and follow-up of all infected cases found during the mass screening surveys a drastic reduction in the public health impact of the disease in endemic communities can be achieved. Educational impacts of such surveys at the national, community and individual levels for both professional and lay people are beginning to be appreciated. The translation of the information gained into active control programmes remains to be realized. In areas where intermediate hosts, such as sheep and goats, are not slaughtered in large numbers mass US screening surveys to determine the prevalence of CE in livestock has proved possible. Longitudinal studies in such intermediate hosts would reveal changes in prevalence over time, which has been used as a marker for control success in other programmes. Mass US screening surveys in an ongoing control programme in Argentina has demonstrated the early impact of control in the human population and identified breakthroughs in that control programme. Mass US screening surveys must adhere to the highest ethical standards and the outcome of surveys should result in the application of appropriate WHO recommended treatment options for different cyst types. Follow-up strategies have to be in place prior to the implementation of such surveys for all infected individuals who do not require treatment and for all suspected, but not confirmed, cases found during the surveys. The use of US in community screening surveys has revealed the complexity of ethical issues (informed consent, confidentiality, follow-up, detection of lesions that are not the focus of the study etc) and also provided real solutions to providing the most ethical guidelines for the early detection and treatment of CE and AE.

Interactions between landscape changes and host communities can regulate Echinococcus multilocularis transmission.

An area close to the Qinghai-Tibet plateau region and subject to intensive deforestation contains a large focus of human alveolar echinococcosis while sporadic human cases occur in the Doubs region of eastern France. The current review analyses and compares epidemiological and ecological results obtained in both regions. Analysis of rodent species assemblages within quantified rural landscapes in central China and eastern France shows a significant association between host species for the pathogenic helminth Echinococcus multilocularis, with prevalences of human alveolar echinococcosis and with land area under shrubland or grassland. This suggests that at the regional scale landscape can affect human disease distribution through interaction with small mammal communities and their population dynamics. Lidicker's ROMPA hypothesis helps to explain this association and provides a novel explanation of how landscape changes may result in increased risk of a rodent-borne zoonotic disease.

[Clinical target volume for preoperative radiotherapy of rectal cancers]. / Volume-cible anatomoclinique dans la radiothérapie préopératoire des cancers du rectum.

The total mesorectal excision allows the marked increase of the local control rate in rectal cancer. Therefore, the mesorectal space is the usual field for the spread of rectal cancer cells. It could therefore be considered as the clinical target volume in the preoperative plan by the radiation oncologist. We propose to identify the mesorectum on anatomical structures of a treatment-position CT scan.

[Mazabraud syndrome: a case diagnosed with MRI]. / Syndrome de Mazabraud: à propos d'un cas diagnostiqué en IRM.

We report a case of Mazabraud's syndrome diagnosed with MRI in a 40-year-old woman.

Cystic echinococcosis in semi-nomadic pastoral communities in north-west China.

In order to determine the prevalence of human cystic echinococcosis (CE) in semi-nomadic traditional pastoralist groups in north-west China, 2 large community studies were undertaken in Altai and Tacheng Prefectures in 1990/91 and 1995/96, respectively. The Kekergash community (Altai) comprised mainly ethnic Kazakhs, whereas the Narenhebuke community (Tacheng) comprised mainly Mongolians. Populations were screened for CE by abdominal ultrasound scan (US) and serological tests. The total prevalence of confirmed human CE was higher in Narenhebuke (2.7%, 49/1844) than in Kekergash (0.9%, 17/1861; P < 0.01). Within each community there was no significant difference of CE prevalence between the Kazakh and Mongolian groups, although Han Chinese exhibited twice the rate of CE (4.9%) in Narenhebuke compared to the dominant Mongolian population. For each community, human CE prevalence increased with age and there was a greater risk associated with the practice of home slaughter of livestock. Dogs were screened for Echinococcus granulosus infection and re-infection levels using a highly specific coproantigen test. The proportion of dogs with positive coproantigen tests was significantly higher in Narenhebuke (36.0%, 50/139) compared to Kekergash (17.8%, 16/90). In Narenhebuke the re-infection levels of dogs, as determined by coproantigen positivity, were higher in the winter quarters (49.4%, 39/79) compared to the summer quarters (18.3%, 11/60; P < 0.01). Furthermore, coproantigen re-test positivity was 25% at 3 months and 29.2% at 7 months. Highest dog coproantigen positivity was obtained over the winter period.

[Gas-containing gallstones: value of the "Mercedes-Benz" sign at CT examination]. / Gaz au sein de calculs biliaires: intérêt tdm du signe de <>.

Gas-containing gallstones are well-known in vitro. The typical triradiate arrangement of fissures filled with gas, first described on abdominal plain films, was named by Meyers the "Mercedes-Benz" sign. This sign is absent of the recent literature. We report a case where gas was the only CT sign suggesting the presence of gallstones in the gallbladder.

An epidemiological and ecological study of human alveolar echinococcosis transmission in south Gansu, China.

Human alveolar echinococcosis (AE) is usually a rare, highly pathogenic zoonotic disease, transmitted across the northern hemisphere between fox and rodent hosts. In China the first cases were described in 1965; however very few epidemiological studies have been undertaken since. Following identification in 1991 of a serious focus of human AE in south Gansu province, detailed village-based community and ecological studies were carried out between 1994 and 1997. Hepatic ultrasound mass screening with serological testing (five tests) identified 84/2482 new AE cases (3%). An overall prevalence of 4.1% (135/3331) was recorded for the area when previous cases were also included. Based on a seropositive result only, without an ultrasound scan indication, no additional AE cases were identified. Of the evolutive AE cases, 96% were seropositive in at least one test, while up 15-20% of individuals who exhibited hepatic calcified lesions and 12-15% exhibiting hepatic nodular lesions were seropositive for specific Em2 or Em18 antibodies. Village (n=31) human AE prevalence rates varied from 0 to 15.8%. Questionnaire analysis indicated that total number of dogs owned over a period was a risk factor (P<0.006), but not a history of red fox hunting (P>0.6). Rodent ecology studies revealed an association between density indices of voles (Microtus limnophilus) and village AE prevalence rates, on the one hand, and village landscape characterised by a ratio of scrub/grassland to total area above 50% (P<0.005). Long-term transmission of Echinococcus multilocularis and risk of zoonotic infection of south Gansu farmers may be related ultimately to a process of deforestation driven by agriculture. This in turn probably results in creation of optimal peri-domestic habitats for rodents that serve as intermediate host species (such as M. limnophilus) and subsequent development of a peri-domestic cycle involving dogs.

Gallstone ileus: CT findings.

Gallstone ileus is a rare complication of recurrent gallstone cholecystitis. The classic radiographic triad of small bowel obstruction, pneumobilia and ectopic gallstone on abdominal plain radiograph is described with CT imaging. Because of the better resolution of CT compared with abdominal radiography and its recent accession to emergency use, radiologists should be aware of CT findings of gallstone ileus. We report a case in which gallstone ileus was initially diagnosed by CT.

A twenty-year history of alveolar echinococcosis: analysis of a series of 117 patients from eastern France.

OBJECTIVES: Alveolar echinococcosis of the liver is a very rare and severe parasitic disease due to the growth of the larva of Echinococcus multilocularis. The aim of this paper was to describe a 20-year study of the epidemiological, clinical and therapeutic aspects of alveolar echinococcosis in eastern France. DESIGN: One hundred and seventeen consecutive cases, diagnosed and followed in our liver unit, were studied from 1972 to 1993. METHODS: Data from 85 patients followed since 1983 (period B) were compared to data from a first series of 32 patients (period A) collected from 1972 to 1982; 1983 was chosen as the cut-off year because of the numerous changes that occurred in the diagnosis, follow-up and treatment of the disease at this time, in particular the introduction of parasitostatic benzimidazoles. RESULTS: The results of patient follow-up were evaluated in December 1997. The cumulative prevalence was 2.5 per 100,000 persons in period A whereas it reached 6.6 per 100,000 in period B. The annual incidence in period B was 7.3 on average, compared with 2.7 in period A. Twenty-nine per cent of patients from period B were asymptomatic at the time of diagnosis compared with 10% in period A. This change was correlated with less advanced liver lesions, and was related to the extensive use of abdominal ultrasound, and from 1987, serological screening. Curative resections were performed in 24% of the cases in period B versus only 3% in period A. From 1986, liver transplantations were performed in eight patients from period A and 13 patients from period B. In period B, palliative surgery was frequently replaced by radiological non-operative procedures to treat abscesses and jaundice. From 1982, 73 patients received benzimidazoles for a period of time ranging from 4 to 138 months. Stabilization of the lesions was observed in two-thirds of the patients. Episodes of jaundice or digestive haemorrhage due to portal hypertension were 31.5 and 11 times less frequent respectively in patients from period B compared with period A. Actuarial survival at 5 years improved from 67% in period A to 88% in period B in patients of similar age. CONCLUSIONS: Radical changes in the diagnosis and the management of alveolar echinococcosis have occurred during the last decade. Together they have contributed to an improvement in the status of the patients affected by this very severe parasitic disease.

Primary disease recurrence after liver transplantation for alveolar echinococcosis: long-term evaluation in 15 patients.

Between 1986 and 1991, 21 patients received liver grafts in our center for incurable alveolar echinococcosis (AE). The aim of this study was to analyze the long-term results in 15 of these 21 patients who survived more than 1 year after undergoing a liver transplantation (LT). The follow-up, mainly aimed at the diagnosis of recurrence, consisted of repeated radiological and specific immunological investigations. The role of pre- and post-LT benzimidazole (BZM) therapy was also evaluated. Among the 15 patients, 8 patients had a palliative LT related to previously known pulmonary AE metastases and/or inextirpable abdominal parasitic foci. In the 7 remaining patients, LT was considered curative. In June 1998, the mean follow-up duration was 96 months (range: 28-138 months). Five late deaths occurred, 2 of them were directly related to residual AE. A reinfection of the graft was observed in 4 patients. Preoperative BZM therapy seemed useful in preventing or delaying the parasitic recurrence. Post-LT BZM was able to stabilize and even to reduce residual AE. The anti-Em2 enzyme-linked immunosorbent assay (ELISA), which is the standard test used in patient follow-up after partial liver resection for AE, did not appear useful in detecting recurrence here; however, an ELISA, using a crude heterologous antigen (Echinococcus granulosus) allowed early diagnosis of residual AE. In conclusion, primary disease recurrence is not rare after LT for AE. Immunosuppressive therapy may favor larval growth in extrahepatic sites; therefore, an extensive extrahepatic radiological check-up has to be performed before LT. BZM therapy seems to stabilize residual foci. Anti-Eg immunoglobulin G (IgG) follow-up is the most useful test for early diagnosis of parasite recurrence.

[Pseudotumor form of hepatic distomatosis: successful treatment with praziquantel]. / Forme pseudo-tumorale de distomatose hépatique: guérison par le praziquantel.

Human Fasciola hepatica infection is usually discovered either early, during the acute (invasive) phase, or in the advanced phase, which is characterized by biliary complications. We report a case of liver distomatosis with nodular intra-hepatic lesions in a 58-year-old woman. Radiological investigations showed 3 nodular lesions in the VII segment, which were difficult to distinguish from liver metastases or liver abscesses. Distomatosis serology was positive with passive hemagglutination. After a 5-day treatment with praziquantel, clinical symptoms resolved quickly while serological tests became negative. Radiological images slowly decreased to a calcified scar at 13 months. No side-effects were noted. Praziquantel, whose efficacy in the common presentations of liver distomatosis has recently been demonstrated, also seems effective and well tolerated in case of nodular intra-hepatic lesions.

[Percutaneous thoracic sympathectomy under x-ray computed tomographic control in hyperhidrosis and refractory ischemia. Apropos of 17 cases]. / Sympatholyse thoracique percutanée sous contrôle scanographique dans les hyperhidroses et les ischémies rebelles. A propos de 17 cas.

We report our experience with percutaneous thoracic sympathectomy using computed tomography-guided injection of phenol in 17 patients. A total of 24 neurolyses were performed in outpatients. Indications were palmo-plantar hyperhidrosis in 10 patients and severe Raynaud phenomena in 7 cases (Sharp's syndrome = 2. sclerodermia = 3, Raynaud's syndrome = 1, digital arteritis = 1). Conventional treatment had failed in all patients. Cure was obtained in all cases of hyperhidrosis. For the patients with critical ischemia, there was temporary improvement which allowed wound healing, but recurrence was the rule within 6 months on average. Complications included pneumothorax, brachial nevralgia which persisted for 4 months and 3 partial Claude-Bernard-Horner syndromes. This technique is an inexpensive reliable method which can be used in case of contraindications or to avoid certain complications of endoscopic surgery which remains the standard treatment. Percutaneous sympatholysis in thus an interesting simple alternative.

[X-ray computed tomography in purulent pleurisy]. / Apport de la scanographie au cours des pleurésies purulentes.

Complementary CT scan imaging during investigation of 18 cases of empyema showed it to be an essential examination, since it established the diagnosis in all cases, determined possible extension of the infectious process and possible causal lesion, defined the most effective approach for percutaneous drainage and evaluated efficacy of the later.

Computed tomographic demonstration of the posterior pituitary.

From a series of 700 thin, axial, contrast-enhanced CT scans of the sellar region, the posterior lobe of the pituitary was studied. Empty sellae and pituitary lesions larger than 8 mm in diameter were excluded from the study. Of the 320 remaining axial contrast-enhanced CT scans, the posterior lobe of the pituitary was apparent in 124 (39%) as an oval lucency 3-4 mm thick, located medially or paramedially just in front of the dorsum sellae. Normally, the anterior limit of the posterior lobe is always regularly convex forward, but in the presence of a microadenoma of the anterior lobe it may be compressed. The lesser enhancement of the posterior lobe probably correlates with the different volumes of the interstitial spaces in the anterior and in the posterior lobes. The normal picture of the posterior lobe of the pituitary must not be confused with a posteriorly located microadenoma.