317 - Case Series of Echinococcus Infections at Mayo Clinic Florida

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Presenting Author(s)

Eugene P. Harper

Resident physician
Mayo Clinic Florida
Jacksonville, Florida
Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.

Co-Author(s)

JO

Justin Oring

Consultant Physician
Mayo Clinic Florida
Jacksonville, Florida
Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
Harry Ross Powers

Associate Consultant
Mayo Clinic Florida
Jacksonville, Florida
Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
CS

Courtney E. Sherman

Courtney E Sherman, M.D.
Mayo Clinic Florida
Jacksonville, Florida
Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
BW

Benjamin Wilke

Assistant Professor
Mayo Clinic Florida
Jacksonville, Florida
Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
Jane Hata

Associate Director of Clinical Microbiology
Mayo Clinic Florida
Jacksonville, FL
Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
AN

Aziza Nassar

Chair, Department of Laboratory Medicine And Pathology
Mayo Clinic Florida
Jacksonville, Florida
Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
JM

Julio C. Mendez

ID Consultant, Assistant Professor of Medicine
Mayo Clinic Florida
Jacksonville, Florida
Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
CL

Claudia R. Libertin

Consultant
Mayo Clinic, Jacksonville
Jacksonville, Florida
Disclosure: Pfizer, Inc. (Grant/Research Support, Research Grant or Support)

Background: Echinococcus multilocularis is a destructive zoonotic cestode with low human incidence. Hydatid disease classically presents with hepatic or lung involvement with infrequent extrahepatic bone destruction. Diagnosis is challenging due to its latency and mimicry.Fig.1: Case 1 - X-ray imaging of the pelvis shows osseous destruction of the iliac crest secondary to known osteomyelitis status post left ilium debridement.

Fig.2: Case 1 - Magnetic resonance imaging demonstrates extensive osteomyelitis throughout left ilium. Stable scattered focal fluid collections seen throughout the left lower quadrant.

Methods: CASE 1: A 57 year-old Albanian male with diabetes, latent TB, and left iliac lytic lesion presented with 4 weeks of left flank pain and was treated with 6 weeks of IV Ceftriaxone and Flagyl. 2 years later he returned with flank pain and purulent lumbar drainage. Hip x-ray suggested chronic osteomyelitis, with left psoas fluid collections on CT. Bartonella, Q fever, Brucella, HIV, AFB and fungal serologies were negative. Hemipelvis debridement revealed structures concerning for hydatid disease. Echinococcus IgG was equivocal. Histopathology was consistent with Echinococcus multilocularis species, and albendazole was started. On follow-up, he presented with left hip tenderness and toe extensor weakness. Labs showed mild leukocytosis. CT revealed progressive destruction of the left iliac with sacroiliac extension concerning for abscess.
CASE 2: A 36 year-old female presented with lung and liver cysts, progressive dyspnea, and non-productive cough. She lived in Africa, Asia, and Europe and consumed local street food and unpasteurized milk. Hobbies included spelunking and swimming in freshwater lakes. She had exposure to stray animals, but denied bites or scratches. Over 4 years dyspnea progressed to orthopnea. MR abdomen revealed a 10x6x12cm liver cyst and chest CT showed 2 fluid-attenuating lesions in the LLL and RLL, measuring 4.9 x 6.0 cm and 6.8 x 4.3 cm respectively. Echinococcus, Bartonella, Q fever, Brucella, HIV, AFB and fungal serologies were negative. Schistosomiasis serology was equivocal.Fig. 3: Case 2 - MRI abdomen demonstrating 10x6x12cm liver cyst

Fig. 4: Case 2 - Chest CT showed 2 dominant fluid attenuating lesions within the LLL and RLL. The larger lesion in RLL measures 6.8 x 4.3 cm. The left lower lobe lesion measures 4.9 x 6.0 cm.

Results: Patient 1 underwent type I hemipelvectomy. Patient 2 underwent pulmonary segmentectomy and liver lobectomy. Both were continued on albendazole.Fig. 5: Case 1 - Photo taken during debridement of left ileac and hip. Note presence of white cysts discovered intraoperatively.

Fig. 6: Case 1 - Histopathologic slides (H&E stain) demonstrating hooks and scolices consistent with Echinococcus multilocularis. A. Hooklet (100x magnification). B. Hydatid cyst with black-staining structures suggestive of degenerating hooklets. C. Zoomed detail of cyst wall. D. Degenerating hydatid cyst and hooklets.

Conclusion: Equivocal IgG serology does not exclude infection. History and clinical presentation are key to diagnosis, but histopathology remains the gold standard. Hydatid bone infection progresses insidiously and frequently recurs, depending upon excision and debridement. Finally, echinococcosis demands aggressive long-term therapy and surveillance.