Echinococcus multilocularis and other zoonotic helminths in red foxes (Vulpes vulpes) from a southern German hotspot for human alveolar echinococcosis.

BACKGROUND: We describe the spatial distribution of Echinococcus multilocularis in its main definitive host, the red fox, and the distribution of human cases of alveolar echinococcosis (AE) within a highly endemic focus in southern Germany (13.7-19.9/100,000 in 1992-2018). Human cases were unequally distributed within the endemicity focus. The purpose of the study was to test whether this is reflected in the small-scale distribution of E. multilocularis in foxes. METHODS: Three areas with contrasting numbers of human cases were selected within the counties of Ravensburg and Alb-Donau, Baden-Württemberg, Germany. From 2018 to 2020, a total of 240 fox carcasses were obtained from traditional hunters in these areas. Carcasses were necropsied and examined for the presence of intestinal helminths. The statistical analysis was performed with SAS version 9.4, and the geo-mapping with QGIS version 3.16.0 Hannover. RESULTS: The prevalence of E. multilocularis in foxes was 44/106 (41.5%) in area I (commune Leutkirch and environs), 30/59 (50.8%) in area II (commune Isny and environs), and 31/75 (41.3%) in area III (commune Ehingen and environs). From 1992 to 2018, a total of nine human cases of alveolar echinococcosis were recorded in area I, five cases were recorded in study area III, and no cases were recorded in area II. No statistically significant differences between the areas were observed (P > 0.05) for intestinal infections with E. multilocularis, and no apparent spatial correlation with the small-scale distribution of human cases was found. Concerning other zoonotic helminths, Toxocara spp. were equally common, with prevalence of 38.7%, 47.4% and 48.0%, respectively, while the frequency of Alaria alata varied among the study areas (0.0-9.4%), probably reflecting the specific habitat requirements for the establishment of its complex life cycle. CONCLUSIONS: Echinococcus multilocularis is highly prevalent in foxes in all the studied areas. The varying number of human AE cases within these areas should therefore be caused by factors other than the intensity of parasite transmission in foxes.

An optimized protocol for isolation of hepatic leukocytes retrieved from murine and NASH liver biopsies.

Immune dysregulation and inflammation by hepatic-resident leukocytes is considered a key step in disease progression of non-alcoholic fatty liver disease and non-alcoholic steatohepatitis toward cirrhosis and hepatocellular carcinoma. Here, we provide a protocol for isolation and characterization of liver-resident immune cells from fine-needle biopsies obtained from a rodent model and humans. We describe steps for isolating leukocytes, cell sorting, and RNA extraction and sequencing. We then detail procedures for low-input mRNA sequencing analyses.

[Diagnostic delaying factors in hepatic alveolar echinococcosis]. / Diagnoseverzögernde Faktoren bei hepatischer alveolärer Echinokokkose.

PURPOSE: The purpose of this study was to analyze the diagnostic workflow of patients with alveolar echinococcosis (AE) and to identify possible diagnosis-delaying factors. METHODS: The number and type of diagnostic procedures of patients diagnosed with alveolar echinococcosis were investigated. The disease history was recorded on the basis of questionnaires, the available findings, and data supplements from the hospital information system (SAP). Statistical analyses were performed using SAS version 9.4 and Microsoft Excel version 16.43. The study population of the cross-sectional study included n = 109 patients with confirmed alveolar echinococcosis. RESULTS: The definitive diagnosis of alveolar echinococcosis of the liver was made at 26.5 ± 65.0 (mean ± standard deviation) months (min - max: 0 - 344, median = 3). The majority of patients were diagnosed because of incidental imaging findings of the liver (n = 74/109 (67.9%)). A total of n = 56/74 (75.7%) of all incidental findings were diagnosed in an outpatient setting, while n = 15/74 (20.3%) of cases were diagnosed during inpatient hospitalization. On average, 1.1 ± 1.2 (0-11, median = 1) ionizing imaging modalities were used for each patient. Contrast-enhanced sonography was received by 0.3 ± 0.5 (0-2, median = 0) patients. Almost all patients (n = 104/109 (95.4%) had at least one suspected hepatic or extrahepatic malignancy at some time. Exclusion of suspected malignancy occurred at a mean of 4.1 ± 16.5 months (0 -133.8, median = 1). CONCLUSIONS: The diagnostic clarification process of AE patients is lengthy and stressful. The psychological burden of a questionable malignant diagnosis is considerable. Early use of contrast-enhanced sonography and, if necessary, puncture of unclear hepatic masses helps to shorten the difficult diagnostic process.

Contrast-enhanced ultrasound (CEUS) in patients with metastasis-like hepatic alveolar echinococcosis: a cohort study.

PURPOSE: Hepatic alveolar echinococcosis (HAE) of the metastasis-like pattern, according to the Echinococcus Ulm classification, is usually discovered as an incidental finding, and the diagnostic differentiation from "true metastases" is difficult. The aim of this study was to investigate whether lesions of the "metastasis-like pattern" in HAE show a typical contrast behavior that can be used for differentiation from metastasis in malignancies. METHODS: This prospective clinical study included 11 patients with histologically confirmed HAE of the metastasis-like pattern (7 female and 4 male; mean age, 57.1 years; mean disease duration, 59.5 months), who had been examined by B-scan sonography and CEUS, from the National Echinococcosis Registry Germany. RESULTS: On contrast-enhanced sonography, 11/11 reference lesions showed annular rim enhancement in the arterial and portal venous phases. Throughout the entire 4-min study period, none of the reference lesions showed central contrast enhancement-i.e., all exhibited a complete "black hole sign". A small central scar was seen in 81.8% of cases. CONCLUSION: In clinically unremarkable patients with incidentally detected metastasis-like lesions of the liver, contrast-enhanced sonographic detection of rim enhancement without central contrast uptake (black hole sign) should be considered evidence supporting a diagnosis of hepatic alveolar echinococcosis with a rare metastasis-like pattern. This can help to differentiate HAE from metastases, especially in high-endemic areas.

Differentiation of hepatic alveolar echinococcosis with a hemangioma-like pattern compared to typical liver hemangioma using contrast-enhanced ultrasound: a pilot study.

PURPOSE: Echinococcus multilocularis infects humans as a false intermediate host, primarily with intrahepatic manifestation. Incorrect diagnostic interpretation of these liver tumors, especially the hemangioma-like pattern, can lead to progressive disease. The aim of the study was to investigate the differentiation of typical hemangioma and a hemangioma-like pattern of E. multilocularis using contrast-enhanced ultrasound (CEUS). METHODS: This prospective clinical pilot study comprised patients with hemangioma (n = 14) and patients with alveolar echinococcosis (AE) and hemangioma-like pattern (n = 7). Inclusion criteria were the detection of a liver lesion according to a hemangioma-like pattern on E. multilocularis Ulm classification-ultrasound (EMUC-US) and "confirmed" or "probable" AE according to WHO case definition. The comparison group had hepatic hemangioma with typical B-scan sonographic morphology. All participants underwent conventional and contrast-enhanced ultrasonography. RESULTS: The patient group comprised five men (71.4%) and two women (28.6%) with a mean average age of 64.1 ± 11.2 years. The patient group with hemangioma comprised nine female subjects (64.3%) and five male subjects (35.7%) with a mean average age of 56.1 ± 12.0 years. Early arterial bulbous ring enhancement (p < 0.0001) and iris diaphragm phenomenon could only be visualized in the patients with hemangioma (p < 0.0001). Furthermore, the patients with hemangioma exhibited hyperenhancement in the late phase (p = 0.0003). In contrast, the patients exhibited typical early arterial rim enhancement (p < 0.0001) and, in the portal venous and late phase, complete or incomplete non-enhancement (black hole sign; p = 0.0004). CONSLUSION: The behavior of hemangioma-like AE lesions and typical liver hemangiomas is significantly different on CEUS. AE should be considered as a possible differential diagnosis, especially in high-endemic areas.

[Spread and Development of Alveolar Echinococcosis in Germany, 1992-2018]. / Untersuchung zur Ausbreitung und Entwicklung der alveolären Echinokokkose in Deutschland, 1992­2018.

GOAL OF THE STUDY: Alveolar echinococcosis (AE) is a rare parasitosis caused by the pathogen Echinococcus multilocularis. There is an increase in the number of cases in many countries. The aim of the study was to investigate the current prevalence and the change in the geographical distribution pattern. METHODOLOGY: Data were collected retrospectively for the period 1992-2018 using the registered cases in the national disease register for AE in Germany. Statistical analysis was performed using the SAS statistical analysis system version 9.4 (SAS Institute, Cary, N.C., USA). RESULTS: The study population of n=569 patients included n=322 (56,59%) women and n=247 (43,40%) men. The mean average age of patients with alveolar echinococcosis at first presentation was 53,90±17,54 years (median: 56,00 years). The Moran's I test statistic showed a positive spatial autocorrelation for the period 1992-2018 corresponding to a heterogeneous distribution of disease cases in Germany (I=0,4165; Z=10,9591, p=0,001). An increase in age- and sex-specific prevalence could be determined for the entire study period (1992-2018). The overall prevalence in the period 1992-2018 was 0,71 cases per 100,000 population. The determination of the prevalence for the period 1992-2018 resulted in 0,31 cases for men and 0,40 cases for women per 100,000 population. In the period 1992-1996, no AE cases had been registered in 11/16 (68,8%) federal states (Berlin, Brandenburg, Bremen, Hamburg, Mecklenburg-Vorpommern, Rheinland-Pfalz, Saarland, Sachsen, Sachsen-Anhalt, Schleswig-Holstein und Thüringen). The evaluation recently shows an increased occurrence of cases in the federal states of Hessen, Rheinland-Pfalz and Nordrhein-Westfalen. CONCLUSIONS: The analysis shows a rise in prevalence and an increasing number of cases outside the classic endemic areas of Baden-Württemberg and Bavaria.

Dog Ownership and Risk for Alveolar Echinococcosis, Germany.

Human alveolar echinococcosis is caused by the parasite Echinococcus multilocularis, and dog ownership has been identified as a risk factor. We sought to specify the factors of dog ownership underlying this risk by conducting a case-control study among dog owners in Germany. The analysis revealed an increased odds ratio of ≈7-fold for dog owners whose dogs roam unattended in fields, 13-fold for dog owners who feed their dogs organic waste daily, 4-fold for dog owners who take their dog to a veterinarian only in case of illness, and 10-fold for dog owners who have never been informed by a veterinarian about the risk for infection. The results highlight the risk for infection associated with various factors of dog ownership and the value of veterinarians informing owners about prevention.

Long-term follow-up of liver alveolar echinococcosis using echinococcosis multilocularis ultrasound classification.

BACKGROUND: When Echinococcus multilocularis infects humans as a false intermediate host, alveolar echinococcosis (AE) usually manifests primarily intrahepatically and is initially asymptomatic. If the disease remains undiagnosed and untreated, progressive growth occurs, reminiscent of malignant tumours. The only curative therapy is complete resection, which is limited to localised stages, and palliative drug therapy is used otherwise. Consequently, early diagnosis and reliable detection of AE lesions are important. For this reason, abdominal ultrasonography, as the most common primary imaging for AE, relies on classification systems. AIM: To investigate how hepatic AE lesion sonomorphology changes over time in the Echinococcosis Multilocularis Ulm Classification (EMUC)-ultrasound (US) classification. METHODS: Based on data from Germany's national echinococcosis database, we evaluated clinical and US imaging data for 59 patients according to the AE case definition in our preliminary retrospective longitudinal study. There had to be at least two liver sonographies ≥ 6 mo apart, ≥ 1 hepatic AE lesion, and complete documentation in all US examinations. The minimum interval between two separately evaluated US examinations was 4 wk. The AE reference lesion was the largest hepatic AE lesion at the time of the first US examination. To classify the sonomorphologic pattern, we used EMUC-US. In addition to classifying the findings of the original US examiner, all reference lesions at each examination time point were assigned EMUC-US patterns in a blinded fashion by two investigators experienced in US diagnosis. Statistical analysis was performed using SAS version 9.4 (SAS Institute Inc., Cary, NC, United Stated). P values < 0.05 were considered statistically significant. RESULTS: The preliminary study included 59 patients, 38 (64.5%) women and 21 (35.6%) men. The mean age at initial diagnosis was 59.9 ± 16.9 years. At the time of initial ultrasonography, a hailstorm pattern was present in 42.4% (25/59) of cases, a hemangioma-like pattern in 16.9% (10/59), a pseudocystic pattern in 15.3% (9/59), and a metastasis-like pattern in 25.4% (15/59). For the hailstorm pattern, the average lesion size was 67.4 ± 26.3 mm. The average lesion size was 113.7 ± 40.8 mm with the pseudocystic pattern and 83.5 ± 27.3 mm with the hemangioma-like pattern. An average lesion size of 21.7 ± 11.0 mm was determined for the metastasis-like pattern. Although the sonomorphologic pattern remained unchanged in 84.7% (50/59) of AE reference lesions, 15.3% (9/59) showed a change over time. A change in pattern was seen exclusively for AE lesions initially classified as hemangioma-like or pseudocystic. A total of 70% (7/10) of AE lesions initially classified as hemangioma-like showed a relevant change in pattern over time, and 85.7% (6/7) of these were secondarily classified as having a hailstorm pattern, with the remainder (1/7; 14.3%) classified as having a pseudocystic pattern. A total of 22.2% (2/9) of AE lesions initially classified as pseudocystic showed a relevant change in pattern over time and were classified as having a hailstorm pattern. For AE lesions initially classified as having a hailstorm or metastatic pattern, no pattern change was evident. All patients with pattern change were on continuous drug therapy with albendazole. CONCLUSION: The sonomorphology of hepatic AE lesions may change over time. The hemangioma-like and pseudocystic patterns are affected.

Comparison of point and two-dimensional shear wave elastography of the spleen in healthy subjects.

BACKGROUND: Few systematic comparative studies of the different methods of physical elastography of the spleen are currently available. AIM: To compare point shear wave and two-dimensional elastography of the spleen considering the anatomical location (upper, hilar, and lower pole). METHODS: As part of a prospective clinical study, healthy volunteers were examined for splenic elasticity using four different ultrasound devices between May 2015 and April 2017. The devices used for point shear wave elastography were from Siemens (S 3000) and Philips (Epiq 7), and those used for two-dimensional shear wave elastography were from GE (Logiq E9) and Toshiba (Aplio 500). In addition, two different software versions (5.0 and 6.0) were evaluated for the Toshiba ultrasound device (Aplio 500). The study consisted of three arms: A, B, and C. RESULTS: In study arm A, 200 subjects were evaluated (78 males and 122 females, mean age 27.9 ± 8.1 years). In study arm B, 113 subjects were evaluated (38 men and 75 women, mean age 26.0 ± 6.3 years). In study arm C, 44 subjects were enrolled. A significant correlation of the shear wave velocities at the upper third of the spleen (r = 0.33088, P < 0.0001) was demonstrated only for the Philips Epiq 7 device compared to the Siemens Acuson S 3000. In comparisons of the other ultrasound devices (GE, Siemens, Toshiba), no comparable results could be obtained for any anatomical position of the spleen. The influencing factors age, gender, and body mass index did not show a clear correlation with the measured shear wave velocities. CONCLUSION: The absolute values of the shear wave elastography measurements of the spleen and the two different elastography methods are not comparable between different manufacturers or models.

[An Update on the Epidemiological Situation of Alveolar Echinococcosis: Recording and Reporting Structures in Austria, Switzerland and Germany]. / Epidemiologisches Update: Aktuelles zur epidemiologischen Situation der alveolären Echinokokkose und deren Erfassungs- und Meldestrukturen in Österreich, der Schweiz und Deutschland.

OBJECTIVE: Alveolar echinococcosis (AE) is a rare disease in Austria, Switzerland and Germany (DACh) caused by an infection with the parasite Echinococcus multilocularis. The aim of the study was to describe differences in the detection and reporting systems of alveolar echinococcosis in Austria, Switzerland and Germany and to describe epidemiological trends. METHODOLOGY: As part of an epidemiological update on 6th September 2019 in Ulm, Germany, experts and representatives discussed differences in the reporting and recording systems as well as the current epidemiological situation. RESULTS: Since 2004, Austria has had an obligation to report suspected cases, diseases and deaths of alveolar echinococcosis by name in accordance with §1 Para. 1 of the Epidemiegesetz 1950 (EpidemieG) and the Ordinance on Notifiable Communicable Diseases. According to §7 Para. 3 of the German Infection Protection Act (IfSG), Germany has also been subject to a reporting obligation since 2001, but not by name. In addition, national registers are available in both countries, which can be used to answer scientific questions. In Switzerland, there is no obligation to report human alveolar echinococcosis since 1997. Efforts are currently being made to implement a national register for alveolar echinococcosis in Switzerland. Despite different reporting and recording systems, a similar epidemiological trend can be observed for DACh. CONCLUSIONS: In Austria, Switzerland and Germany there is a slightly increasing trend of human cases with alveolar echinococcosis. The direct comparability is limited due to different reporting obligations. The structures often do not allow a joint answering of scientific questions concerning diagnostics, treatment and care.

Distribution of alveolar echinococcosis according to environmental and geographical factors in Germany, 1992-2018.

Alveolar echinococcosis (AE) is a rare zoonotic disease caused by the larval stage of Echinococcus multilocularis. Despite its low world-wide prevalence, this disease shows differences in the regional distribution of cases. In the present cohort study, we analyse the distribution of AE according to environmental and geographical factors in Germany. We identified the place of residence of 591 cases of AE from the national database for AE, and georeferenced these localities in the Universal Transverse Mercator coordinate system. Data on elevation, air temperature, precipitation height and land cover were mapped out and correlated with the distribution of cases of disease during the period 1992-2018. Moran's I statistic was used for spatial autocorrelation. Differences in frequency distribution between elevation, air temperature, precipitation height and landscape feature classes were analysed with the Kruskal-Wallis test. With the multiple linear regression analysis, we determined the influences and interactions of geographical and climatic factors on the number of AE cases. The results showed a heterogeneous distribution of AE cases with a higher concentration in southern Germany than in the rest of Germany (I = 0.225517, Z = 35.8182 and p < 0.001). There was a statistically significant difference in frequency distribution between precipitation height, air temperature, elevation and landscape feature classes and AE cases in Germany (p < 0.0001). In regions with higher elevations (505-672 m), moderate average air temperatures (6.0-7.9°C) and higher precipitation rates (701-1000 mm) most AE cases were recorded. It seems, that regions with higher precipitation rates, higher elevations and moderate average air temperatures have a higher infection burden and infection conditions. It is therefore extremely important to generate greater awareness of the disease in these regions, with the aim of recognising potential cases of AE as early as possible and introducing the appropriate therapeutic measures.

Surgery versus conservative drug therapy in alveolar echinococcosis patients in Germany - A health-related quality of life comparison.

Alveolar echinococcosis (AE) is a rare zoonosis caused by the parasite Echinococcus multilocularis. Nothing is known about the health-related quality of life (HRQoL) in patients with AE receiving different types of therapy. Therefore, the aim of the study was to compare HRQoL in patients with AE in Germany depending on their therapeutic regimen namely conservative drug treatment with long-term benzimidazoles versus surgical therapy by resection of the parasitic liver lesions. The 36-Item Short Form Health Survey (SF-36) questionnaire, including other echinococcosis-related questions, was used to measure HRQoL. The SF-36 scales were evaluated according to the algorithms provided by the authors. The statistical analysis was performed with SAS version 9.2. The significance level was set at α = 0.05, p < 0.05 corresponds to statistical significance. The investigated group consisted of conservatively drug treated (n = 30) and patients with curative surgery (n = 25) with confirmed AE. The study was performed at an infectious disease outpatient department from April 2018 to October 2018. The conservatively drug treated patient group consisted of 15 men (50.0%) and 15 women (50.0%) with an average age of 55.7 ±â€¯16.7 years (Median: 59). The surgery group consisted of nine men (36.0%) and 16 women (64.3%) with an average age of 53.3 ±â€¯31.9 years (Median: 54). The physical quality of life of the conservatively drug treated patients did not show any significant differences to the surgical treated group (45.2 ±â€¯11.4 vs. 47.6 ±â€¯9.9; p = 0.4079). There was also no significant difference regarding the mental quality of life between the conservatively drug treated patients, and those treated with curative surgery (45.5 ±â€¯10.6 vs. 47.3 ±â€¯10.8; 0.5206). Nevertheless, there was a slight advantage in the physical and mental scores of the patients treated with surgery. Furthermore, for 13 of the 25 surgically treated patients, some aspects of the HRQoL improved significantly after surgery. The evaluation showed no statistically significant differences in HRQoL in patients with AE dependent on the applied treatment strategy (conservative drug versus curative surgical therapy).

Health-related quality of life in patients with alveolar echinococcosis: a cross-sectional study.

PURPOSE: The Alveolar echinococcosis (AE) is a rare zoonosis caused by the parasite Echinococcus multilocularis. To date, nothing is known about the health-related quality of life (HRQoL) in patients with AE. The aim of the study was to evaluate the HRQoL in patients with AE in comparison of the healthy population. METHODS: We used the 36-Item Short Form Health Survey (SF-36) questionnaire to evaluate the HRQoL. The SF-36 scales have a range of 0-100 (0 represents the worst and 100 the most favourable state of health). SAS Version 9.2 was used for the statistical analysis of AE-cases (n = 30) and the healthy control group (n = 35). RESULTS: The analysis showed that the HRQoL in people with AE is reduced in comparison with the control population. The study group consisted of 15 (50.0%) men and 15 (50.0%) women; the control group of 16 (45.7%) men and 19 (54.3%) women. The mean age was 55.73 ± 16.65 years, while that of the control group was 54.57 ± 15.34 years. The physical quality of life in patients with AE (45.21 ± 11.42) was not significantly less than that of the control group (50.54 ± 10.52); p = 0.0568. Nevertheless, AE-patients show lower SF-36 scores for the physical quality of life. For the mental quality of life, patients with AE had a significantly lower score (45.46 ± 10.57) than the control group (51.57 ± 9.04); p = 0.0154. CONCLUSIONS: The HRQoL in people with AE is reduced in comparison with a control population. Assessment of the physical and mental quality of life in patients with AE may help to evaluate the patient outcome.