Skip to main content

Advertisement

SpringerLink
Log in

Hepatic infestation of Echinococcus multilocularis with extension to regional lymph nodes

  • Original Article
  • Published:
Langenbeck's Archives of Surgery Aims and scope Submit manuscript

Abstract

Objective

The objective of this paper is to prove lymph node infestation by Echinococcus multilocularis and provide evidence for systematic lymph node dissection in curative resections for alveolar echinococcosis (AE).

Background

Human AE is a life threatening parasitic condition, usually caused by an intrahepatic infiltrative and destructive growth of the larvae E. multilocularis. WHO guidelines provide radical hepatic resection for curative treatment. However, the current norms do not consider dissection of regional lymph nodes. No report to date has visualized concurrent lymph node infestation.

Methods

Radical excision of infested liver including regional lymph nodes with subsequent histological examination was carried out in a patient suffering from AE. The literature was reviewed and a revised state-of-the-art treatment of AE deduced.

Results

Upon inspection the liver displayed macroscopic features of AE, in contrast to the regional lymph nodes which appeared unsuspicious. Further histological analysis confirmed regional lymph node infestation of E. multilocularis.

Conclusions

This is the first publication on histological evidence of E. multilocularis in regional hepatic lymph nodes, and thus, demonstrating dissemination from the liver. Since AE can spread through lymphatic drainage, even without causing macroscopic conspicuity, resection should not be resumed to the liver tissue only, but rather to consider the routine removal of regional lymph nodes as well. Omission of lymph node dissection can leave behind parasitic tissue and surgical procedures erroneously judged as curative.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. Kern P, Bardonnet K, Renner E, Auer H, Pawlowski Z, Ammann RW, Vuitton DA, Kern P (2003) European echinococcosis registry: human alveolar echinococcosis, Europe, 1982–2000. Emerg Infect Dis 9:343–349

    PubMed  Google Scholar 

  2. Urdiales-Viedma M, Martos-Padilla S, Nogales-Fernandez F, Lopez-Yevenes A (1984) Lymph node changes in echinococcosis. Arch Pathol Lab Med 108:528

    PubMed  CAS  Google Scholar 

  3. Reuter S, Seitz HM, Kern P, Junghanss T (2000) Extrahepatic alveolar echinococcosis without liver involvement: a rare manifestation. Infection 28:187–192. doi:10.1007/s150100050079

    Article  PubMed  CAS  Google Scholar 

  4. Uchino J, Sato N (1993) Alveolar echinococcosis of the Liver. Hokkaido University Medical Library Series Vol.30. INSS: 0385-6089. Hokkaido University School of Medicine, Sapporo, Japan

  5. Reuter S, Buck A, Manfras B, Kratzer W, Seitz HM, Darge K, Reske SN, Kern P (2004) Structured treatment interruption in patients with alveolar echinococcosis. Hepatology 39:509–517. doi:10.1002/hep. 20078

    Article  PubMed  Google Scholar 

  6. Kern P, Wen H, Sato N, Vuitton DA, Gruener B, Shao Y, Delabrousse E, Kratzer W, Bresson-Hadni S (2006) WHO classification of alveolar echinococcosis: principles and application. Parasitol Int 55(Suppl):S283–S287. doi:10.1016/j.parint.2005.11.041

    Article  PubMed  Google Scholar 

  7. Kadry Z, Renner EC, Bachmann LM, Attigah N, Renner EL, Ammann RW, Clavien PA (2005) Evaluation of treatment and long-term follow-up in patients with hepatic alveolar echinococcosis. Br J Surg 92:1110–1116. doi:10.1002/bjs.4998

    Article  PubMed  CAS  Google Scholar 

  8. Craig P (2003) Echinococcus multilocularis. Curr Opin Infect Dis 16:437–444. doi:10.1097/00001432-200310000-00010

    Article  PubMed  Google Scholar 

  9. Lethbridge RC (1980) The biology of the oncosphere of cyclophyllidean cestodes. Helminthological Abstr A49:59–72

    Google Scholar 

  10. Uchino J, Sato N, Nakajima Y, Matsushita M, Takahashi M, Une Y (1993) XI. Treatment. In: Uchino J, Sato N (eds) Alveolar Echinococcosis of the Liver. Hokkaido University Medical Library Series, vol. 30. INSS: 0385–6089. Hokkaido University School of Medicine, Sapporo, Japan, pp 137–149

    Google Scholar 

  11. Eckert J, Thompson RC, Mehlhorn H (1983) Proliferation and metastases formation of larval Echinococcus multilocularis. I. Animal model, macroscopical and histological findings. Z Parasitenkd 69:737–748. doi:10.1007/BF00927423

    Article  PubMed  CAS  Google Scholar 

  12. Drolshammer I, Wiesmann E, Eckert J (1973) Human echinococcosis in Switzerland during the years 1956–1969. Schweiz Med Wochenschr 103:1386–1392

    PubMed  CAS  Google Scholar 

  13. Mehlhorn H, Eckert J, Thompson RC (1983) Proliferation and metastases formation of larval Echinococcus multilocularis. II. Ultrastructural investigations. Z Parasitenkd 69:749–763. doi:10.1007/BF00927424

    Article  PubMed  CAS  Google Scholar 

  14. Reuter M, Kreshchenko N (2004) Flatworm asexual multiplication implicates stem cells and regeneration. Can J Zool 82:334–356. doi:10.1139/z03-219

    Article  Google Scholar 

  15. Spiliotis M, Lechner S, Tappe D, Scheller C, Krohne G, Brehm K (2008) Transient transfection of Echinococcus multilocularis primary cells and complete in vitro regeneration of metacestode vesicles. Int J Parasitol 38:1025–1039. doi:10.1016/j.ijpara.2007.11.002

    Article  PubMed  CAS  Google Scholar 

  16. Matsuhisa T (1996) The mechanism of distant metastases of alveolar hydatid disease. Hokkaido Igaku Zasshi 71:369–376

    PubMed  CAS  Google Scholar 

  17. Atkins D, Best D, Briss PA, Eccles M, Falck-Ytter Y, Flottorp S, Guyatt GH, Harbour RT, Haugh MC, Henry D, Hill S, Jaeschke R, Leng G, Liberati A, Magrini N, Mason J, Middleton P, Mrukowicz J, O'Connell D, Oxman AD, Phillips B, Schunemann HJ, Edejer TT, Varonen H, Vist GE, Williams JW Jr, Zaza S (2004) Grading quality of evidence and strength of recommendations. BMJ 328:1490–1494. doi:10.1136/bmj.328.7454.1490

    Article  PubMed  Google Scholar 

  18. WHO/OIE (2001) Manual on echinococcosis in humans and animals: a public health problem of global concern. World Organisation for Animal Health and World Health Organisation, Paris, France

    Google Scholar 

  19. Ammann RW, Eckert J (1996) Cestodes; Echinococcus. Gastroenterol Clin North Am 25:655–689. doi:10.1016/S0889-8553(05) 70268-5

    Article  PubMed  CAS  Google Scholar 

  20. WHO Informal Working Group on Echinococcosis (1996) Guidelines for treatment of cystic and alveolar echinococcosis in humans. Bull World Health Organ 74:231–242

    Google Scholar 

  21. Bresson-Hadni S, Humbert P, Paintaud G, Auer H, Lenys D, Laurent R, Vuitton DA, Miguet JP (1996) Skin localization of alveolar echinococcosis of the liver. J Am Acad Dermatol 34:873–877. doi:10.1016/S0190-9622(96) 90068-7

    Article  PubMed  CAS  Google Scholar 

  22. Ambo M, Adachi K, Ohkawara A (1999) Postoperative alveolar hydatid disease with cutaneous-subcutaneous involvement. J Dermatol 26:343–347

    PubMed  CAS  Google Scholar 

  23. Reuter S, Buck A, Grebe O, Nussle-Kugele K, Kern P, Manfras BJ (2003) Salvage treatment with amphotericin B in progressive human alveolar echinococcosis. Antimicrob Agents Chemother 47:3586–3591. doi:10.1128/AAC.47.11.3586-3591.2003

    Article  PubMed  CAS  Google Scholar 

  24. Senturk H, Mert A, Ersavasti G, Tabak F, Akdogan M, Ulualp K (1998) Bronchobiliary fistula due to alveolar hydatid disease: report of three cases. Am J Gastroenterol 93:2248–2253

    PubMed  CAS  Google Scholar 

  25. Huang J, Wu YM, Liang PC, Lee PH (2004) Alveolar hydatid disease causing total occlusion of the inferior vena cava. J Formos Med Assoc 103:633–636

    PubMed  Google Scholar 

  26. Wilson JF, Rausch RL, Wilson FR (1995) Alveolar hydatid disease. Review of the surgical experience in 42 cases of active disease among Alaskan Eskimos. Ann Surg 221:315–323. doi:10.1097/00000658-199503000-00015

    Article  PubMed  CAS  Google Scholar 

Download references

Acknowledgments

The authors thank D. Kocot and R.S. Reske, Department of Nuclear Medicine, University of Ulm, Ulm, Germany for contributing the FDG-PET-CT images.

The patient agreed to publication and gave written consent.

Author information

Authors and Affiliations

  1. Department of Surgery, Division of General Surgery, University of Alberta, Edmonton, Alberta, Canada

    Klaus Buttenschoen

  2. General, Visceral, and Transplantation Surgery, University Hospital and Surgical Center, Ulm, Germany

    Klaus Buttenschoen

  3. Comprehensive Infectious Diseases Center, Division of Infectious Diseases and Clinical Immunology, University Hospital and Medical Center, Ulm, Germany

    Peter Kern & Stefan Reuter

  4. Department of Pathology, University of Ulm, Ulm, Germany

    Thomas F. E. Barth

  5. Comprehensive Infectious Diseases Center (CIDC), Division of Infectious Diseases and Clinical Immunology, University Hospital and Medical Center, Albert-Einstein-Allee 23, 89081, Ulm, Germany

    Peter Kern

Authors
  1. Klaus Buttenschoen
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Peter Kern
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Stefan Reuter
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Thomas F. E. Barth
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Peter Kern.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Buttenschoen, K., Kern, P., Reuter, S. et al. Hepatic infestation of Echinococcus multilocularis with extension to regional lymph nodes. Langenbecks Arch Surg 394, 699–704 (2009). https://doi.org/10.1007/s00423-009-0481-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00423-009-0481-0

Keywords

Search

Navigation