Pediatric Echinococcosis Treatment & Management

Updated: Dec 21, 2020
  • Author: Germaine L Defendi, MD, MS, FAAP; Chief Editor: Russell W Steele, MD  more...
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Treatment

Approach Considerations

Four treatment approaches are utilized to treat cystic echinococcosis (CE):

  • Anti-infective drug treatment

  • Surgery

  • Percutaneous treatment of the hydatid cysts with the PAIR ( uncture, spiration, njection, Re-aspiration) technique
  • “Watch and wait”

The treatment approach used is based on the ultrasonographic images of the cyst (along with other imaging studies, if obtained), clinical assessment taking a  stage-specific approach, and health care awareness of available medical infrastructure and human resources.

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Medical Care

Preoperative and postoperative albendazole therapy may benefit patients with echinococcosis. As an alternative to surgical management, a randomized controlled study of albendazole in uncomplicated hepatic hydatid disease in adults concluded that 10 mg/kg/d for 3 months without rest periods was effective and could be tried before surgical intervention. In children, the recommended dose is 15 mg/kg/d for 28 days and is repeated, as necessary.

Early diagnosis and radical (tumor-like) surgery followed by anti-infective prophylaxis with albendazole are key treatment approaches for alveolar echinococcosis (AE). If the lesion is confined, radical surgery offers cure. Unfortunately for many patients, the disease is diagnosed at an advanced stage and is not locally confined. Palliative surgery, either with or without prescribed anti-infective treatment, frequently results in disease relapse. [1] The World Health Organization (WHO) recommends postoperative chemotherapy for 2.5 years after radical surgery for treatment of AE.

Inoperable cases can be treated with albendazole or mebendazole. [14] An overall response rate of 55-79% has been documented, with cure in 29% of cases. Albendazole is the drug of choice because of its greater absorption from the GI tract to achieve higher plasma levels. Mebendazole is poorly absorbed and must be taken at higher doses for several months to attain a therapeutic effect. Albendazole is administered in 3 or more cycles of 400-800 mg twice daily for 4 weeks (adult dose), followed by a 2-week period of rest. If response after 3 cycles of albendazole is not evident, subsequent courses are not likely to be beneficial.

Response to anti-infective therapy is best monitored by serial imaging studies. Another treatment option for disseminated AE disease that fails to respond to standard treatment regimens is nitazoxanide with albendazole (with or without praziquantel) for salvage therapy. [15]

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Surgical Care

Surgery is the treatment of choice for most cases of CE and is usually successful. AE is less amenable to surgery.

Hepatic surgery options include the following:

  • Partial hepatic resection

  • Pericystectomy

  • Cystectomy

In 20% of CE cases, disease recurs despite surgical intervention.

In the past, surgery was the only treatment for removal of echinococcal cysts. Some clinicians have inactivated the fertile cyst with formalin or 30% saline in combination with surgical resection. A potential complication of this procedure is sclerosing cholangitis.

Alternative methods, such as chemotherapy, cyst puncture, and the PAIR (uncture, spiration, njection, e-aspiration) method, are effective treatments for CE. The PAIR method (i.e., puncture the cyst, aspirate fluid, introduce a protoscolicidal agent, then reaspirate) requires concurrent ultrasonographic guidance. [15] Extreme care is essential to prevent spilling hydatid fluid into a body cavity because this may lead to anaphylactic shock. Albendazole therapy may be combined with PAIR from 10 days before to 30 days after the procedure. PAIR is a promising technique, and early large-scale clinical trials have been reassuring. [16]

Surgery remains the most effective treatment approach for hydatid cyst removal and hence, ultimate cure. Some cysts do not cause symptoms and are diagnosed as inactive; these cysts often self-resolve without treatment; hence the “watch and wait” approach. [2]

For hepatic AE, another treatment modality is pericyst radiofrequency ablation. [17] Overall, the treatment of AE is more difficult than for CE and usually requires radical surgery, long-term chemotherapy, or both. Severe cases of AE have led to liver transplantation. [2]

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Consultations

Recommended consultations for patients with echinococcosis include surgeons, infectious diseases specialists, and radiologists with knowledge strength in ultrasonography who have experience in diagnosis and treatment of this parasitic disease.

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Diet

To prevent repeat infections, instruct patients to wash fruits and vegetables thoroughly and to consume only well-cooked meats.

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