Monitored medico-surgical approach to the treatment of cystic hydatidosis.

Monitored medico-surgical approach to the treatment of cystic hydatidosis* G.N. Awar,1 R.M. Matossian,2 H. Radwan,3 & G.A. Meshefedjian4 Significant improvements in the health of patients with chronic multifocal abdominal hydatidosis, leading to recovery, have been observed after combined medico-surgical treatment. The benefits of massive surgical removal of cysts, accompanied by effective doses of albendazole, were assessed by the clinical, radiological, and immunological responses of individual patients. Variations in the levels of specific classes of immunoglobulins and circulating immunocomplexes provided additional measures of the state of host response and the persistence of parasitic activity. Introduction For over 50 years the consensus of opinion has been that surgical intervention is the only effective way of treating human cystic hydatidosis caused by Echino- coccus granulosus (1). Numerous reports have appeared about the advantages of various operative techniques and approaches to patient management (2, 3). However, despite evident advances in tech- nology, a significant proportion (10-15%) of indi- viduals fail to recover, owing to the inaccessibility of their lesions or chronic host tissue reactions (4, 5). The introduction of effective chemotherapy with benzimidazole derivatives has recently pro- vided fresh hopes for persistent cases of hydatidosis (6-8). However, this has created concern about the proper selection of patients for chemotherapy, and the subsequent provision of adequate, standard criteria to assess progress or recovery at the early stages of, during the course of, and after therapy (9-12). Since the antigenic activity induced by E. granulosus can be detected by analysing the host immune response, we have developed a monitoring system to determine variations in the specific IgG and IgM and circulating immunocomplexes in pa- tients. The results obtained can be used to gauge the progress of patients still under treatment (13 and R.M. Matossian et al., unpublished results, 1991). In this article we present the selected case histories of six patients with complicated abdominal hydatidosis for whom immunological monitoring * From the American University of Beirut, Beirut, Lebanon. Instructor, Department of Internal Medicine. 2 Professor and Chairman, Department of Microbiology. Re- quests for reprints should be sent to this author. 3 Student. 4 Instructor, Faculty of Health Sciences. Reprint No. 5198 was valuable in choosing an adequate form of therapy, and which led to improved clinical status or cure. Materials and methods Patient selection and management Six patients (1 male and 5 females, aged 15-45 years) with multifocal abdominal hydatidosis were selected at random for the study from a group undergoing combined albendazole therapy and sur- gery. At the start of the study each patient under- went a complete physical examination. Also blood samples were taken at intervals for differential counts, biochemical investigations (SGOT, SGPT), and serology. Urine analysis was routine. An ultra- sound radiograph or ultrasound computed tomo- graph was made initially and whenever needed thereafter. The patients received albendazole tablets (10-14 mg/kg body weight per day) in cycles of 6 weeks separated by drug-free intervals of 4 weeks or longer. Serum samples were obtained generally at monthly visits and were stored at -20 'C. Whole hydatid cyst fluid (HCF) antigen, which had previously been tested for high potency, was obtained from single cysts of ovine or human origin. Samples (5 ml) were stored at -20 'C. Indirect haemagglutination (IHA) tests were carried out following the method described by Matossian et al. (13). Latex agglutination tests for rheumatoid factor in serum were performed using a commercially available reagent (Rapid-Tex RF, Behring). Enzyme immunoassays Specific antibodies. Anti-echinococcus antibodies were assayed in human sera using a peroxidase micro-ELISA (enzyme-linked immunosorbent as- say) described by Craig (15) and modified by Matossian et al. (13). Bulletin of the World Health Organization, 69(4): 477-482 (1991) © World Health Organization 1991 477 G.N. Awar et al. Specific immunocomplexes. These were assayed in whole human sera using a capture antibody method described by Craig (15). The procedure was similar to that followed for the detection of specific anti- bodies, except that the wells of the microassay plates were sensitized with sheep serum containing anti- HCF antibodies (kihdly provided by Dr P. Craig). The cut-off point for the discrimination of positive and negative sera was taken to be twice the absorbance of the mean of a negative serum pool (3 donors) tested in triplicate. All sera from individual patients were tested simultaneously and in triplicate (13). Results Table 1 shows the salient clinical data and progress of the six patients throughout their medico-surgical management, while details of their sequential im- mune responses are contained in Table 2. The patients' case histories are described in the Annex. All patients were negative for rheumatoid factor. Progress of patients All patients received albendazole therapy, and five underwent surgical intervention immediately before chemotherapy. Repeat surgery was carried out on two patients (B2, B4). For one patient (B6) chemo- therapy was the only mode of treatment. Two patients (Bi, B6) had previously undergone com- bined medico-surgical treatment; one (B4) had received mebendazole but no surgery; and another (B3) had had surgery at three intervals. Two patients retained postoperative residual cysts, while for four, cyst rupture and spillage occurred during surgery. The outcome of chemotherapy was favourable for all patients; they became active, their local symptoms decreased, and their appetite and weight increased. Small cysts (3 cm) disappeared from the liver (Bi, B2), spleen (Bi), and peritoneum (B6) after two cycles of treatment. On the basis of the clinical and radiological findings, five patients re- covered at the end of their follow-up periods (9-33 months; average, 21 months): three had no demon- strable cysts, one (Bi) had shrunken cysts, while for another (B6) clinical improvement was observed, despite the presence of residual cysts. Albendazole was well tolerated by all the patients. Complaints were few and consisted of malaise, gastrointestinal discomfort, and mild head- ache. No fever, allergic manifestations, or hair loss occurred, and there were no instances of leukope- nia, anaemia, or thrombocytopenia. Borderline levels of transaminase occurred transiently in four patients. One patient exhibited an increased SGPT level, which subsided after reduction of the daily dose of albendazole. The results of the urine analyses were normal for all patients. The results of the sequential analysis of serum samples for all six patients (Table 2) show that IgG immunoglobulins remained at high levels for long periods; however, a significant decline in haemag- glutination antibody titres (patients Bi, B3, and B5) indicated recovery as opposed to persistent illness (patients B2, B4, and B6). The IgG ELISA titres were more plateau-like with spectrophotometric absorbances ranging from 0.94 to 1.88 (control, 0.5 ± 0.25). There was an initial absence of antigenic activity for three patients (Bi, B2, B4), and at the end of the follow-up period all six exhibited zero antigenic activity. Evidence for transient production Table 1: Salient clinical features of the six study patients with abdominal hydatidosis Past Location No. of ABZ No. of Sex/age therapy/ of the courses/ Repeat months Case (years) surgerya lesionb Surgery months surgery follow-up Progress Bl (S.J.) M/45 MEB/yes L, S, K, P, Pe Yes 4/11 No 32 Recovered, few residual cysts B2(R.D.) F/15 No/no L, S, P, Pe Yes 5/12 Yes 23 Recovered, no cysts B3(N.Z.) F/25 No/yes L, K Yes 4/10 No 13 Recovered, no cysts B4(I.S.) F/22 MEB/no L, S, P, Pe Yes 3/10 Yes 22 Recovered, no cysts B5(M.F.) F/16 No/no L Yes 3/9 No 20 Recovered, no cysts B6(A.E.) F/25 MEB, L, S, P, Pe No 4/9 No 13 Improved, resi- ABZ/yes dual cysts a MEB = mebendazole; ABZ= albendazole. L = liver; S = spleen; K = kidney; P = peritoneum; Pe = pelvis. WHO Bulletin OMS. Vol 69 1991.478 Medico-surgical approach to cystic hydatidosis Table 2: Results of the sequential testing of patient serum samples for haemagglutination (HA), IgG and IgM antibodies, and circulating IgG and IgM immunocomplexes IgGa Day HA titres (absorbance) AAa,b Case B1 (S.J.) 1cd, 104C 166 211c, 299C 365 458, 590, 615 672, 761, 816, 830 837 Case B2 (R.D.) .cd, 69c 132C 207C 317C 357, 398, 476, 511, 512d, 525 595 Case B3 (N.Z) 1 cd 76C 167C 249C 332 Case B4 (1.S.) 1d, 172 355,c 371, 461,c 537Cd 558 573 593 Case B5 (M.F.) 1d, 12b 160b, 230b 292 312, 472 Case B6 (A.E.) ld, 49 77d 150d 227d, 255 269, 311 20480 1280 640 320 160 80 20 81 920 40960 20480 5120 10240 20480 81 920 20480 10240 2560 1280 5120 10240 5120 20480 10240 1.70, 1.55 1.49 1.37, 1.25 1.11 1.13, 1.18, 1.02 1.00, 1.05, 1.00, 1.00 0.94 1.70, 1.61 1.56 1.54 1.51 1.55, 1.52, 1.54, 1.55, 1.56, 1.55 1.57 1.75 1.72 1.70 1.70 1.67 1.84, 1.73 1.78, 1.83, 1.82, 1.80 1.70 1.82 1.70 20480 5120 2560 1280 163840 81 920 20480 10240 20480 1.62, 1.70 1.53, 1.56 1.43 1.35, 1.34 1.88, 1.88 1.85 1.90 1.87, 1.85 1.83, 1.79 a Data correspond to the sequence of days shown in the first column. b AA = antigenic activity. A = IgM antibodies; B = IgG immunocomplexes; C = IgM immunocomplexes; 0 = no antigenic activity. c Indicates the day when a course of chemotherapy began. ' Surgical intervention. of IgM antibody was available for four patients (B3, B4, B5, B6). This may have been due to surgical intervention (B4), chemotherapy (B6), or both (B3, B5). IgG immunocomplexes were detected in four patients undergoing chemotherapy. The disappear- ance of these immunocomplexes was associated with a reduction in the production of antigens, leading to recovery (Bi, B2, B5, and B6). However, high IgG antibody levels also occurred, indicating residual cysts in the absence of IgG immunocomplexes (B2, B4). IgM complexes, which occurred transiently in patient B 1, suggest antigenic multiplicity. Discussion The merits of clear-cut surgical intervention for simple cases of hydatid disease are well recognized (3). On the other hand, "inoperable" patients with WHO Bulletin OMS. Vol 69 1991. 0, 0 B BC, 0 0 0, 0, 0 0, 0, 0, 0 0 0, 0 B 0 0 0, 0, 0, 0, 0, 0 0 A 0 0 0 0 0, 0 0, 0, 0, 0 0 A 0 AB 0, 0 0 0, 0 A B 0 0, 0 0, 0 479 G.N. Awar et al. chronic cystic hydatidosis, who usually comprise 10-15% of the natural or surgical outcome of the disease, require additional sympathy and reassur- ance to face greater risks, undergo major expenses, and retain some hope for new treatments to alleviate their condition. In recent years the beneficial out- come of chemotherapy with soluble benzimidazole compounds has been encouraging. The results range, however, from recovery for up to 30% of cases, to maintenance of the status quo for about 50% of chronic patients (10-12, 16-20). Present trends in therapy have tended to initiate combined medico-surgical approaches simultaneously or at closely spaced intervals (7, 21, 22). The combined medico-surgical approach offers distinct advantages. Thus, delayed healing and the increased probability of ruptured cysts, two condi- tions induced primarily by the chemotherapy, may be relieved by surgery. Chemotherapy readily allows the diffusion of the excretory-secretory products of the metacestode into the periparasitic tissues and circulation (13, 23). These can produce local inflam- matory reactions ranging from immune evasion to marked cellular infiltration and fibrosis (23). On the other hand, antigenaemia may affect the immune response by inhibiting T-cell activity, liberation of interleukins (IL-1, IL-2), and complement (C3) action (14). The amount of antigen in the circulation may be related to the total surface area of cysts that constitute the overall infection load. Hence, a patient with a greater surface area of cysts may have a poorer chance of healing and a greater risk of developing a ruptured cyst. The reduction of the total volume of cysts by operative intervention can be considered to be useful in the healing process and may prevent rupture. Constantly monitoring the patients can assist in predicting and controlling these events. The accelerated healing among the study patients may be attributed to the massive early removal of multiple cysts. Monitoring for antigenic activity can reveal the possible causes of failure in both the surgical and medical approaches to hydatid therapy. In this way, it can be determined, for example, whether cyst rupture during surgery has resulted in the seeding of protoscoleces. Also the effect of chemotherapy on inaccessible residual cysts can be monitored. Previously, criteria for assessing progress in the chemotherapy of cystic hydatidosis have been based on clinical and functional changes in the general health of the patient and on radiologically moni- tored cyst dimensions (10-12). These criteria have frequently been inconclusive and may require a prolonged period of observation. In contrast, the results of the present study show that a prompt response of the specific antibodies and immunocom- plexes signals drug-induced antigenic activity on the cyst membranes. The reduction of immunoglobulin levels induced by the antigenic activity appears to indicate a decrease in parasitic stimulus or a greater potential of the reticuloendothelial system to re- move circulating complexes. The eventual reduction in the level of HA antibodies is indicative of a maintained healing process leading to cure. Acknowledgements Thanks are due to SmithKline Beecham, England, for a gift of albendazole tablets, and to Wellcome Reagents, Becken- ham, Kent, for providing diagnostic reagents. Financial sup- port by the Lebanese Council for Scientific Research is deeply appreciated. The discussions with Dr P. Craig and his gift of sheep antihydatid test serum were vital for the study. Resume Approche medico-chirurgicale surveillee du traitement de l'hydatidose kystique Des ameliorations importantes conduisant a la gueri- son ont e observees chez des malades atteints d'hydatidose abdominale multifocale chronique, apres traitement m6dico-chirurgical. Les avantages d'une ablation chirurgicale massive des kystes, asso- ciee a des doses efficaces d'albendazole, ont e evalues par la reponse clinique, radiologique et im- munologique de malades etudies individuellement. Les variations des taux d'immunoglobulines specifi- ques et des immuncomplexes circulants ont permis des evaluations supplementaires de la reponse de I'hote et de l'ventuelle persistance d'une activite parasitaire. References 1. Albendazole: worms and hydatid disease. Lancet, 2: 675-676 (1984). 2. Saidi, F. Surgery of hydatid disease. Philadelphia, Saunders, 1976. 3. Jidejian, Y.D. Hydatid disease. Syracuse, NY, Syra- cuse University Press, 1979. 4. Mottaghian, H. & Saidi, F. Post-operative recurrence of hydatid disease. British journal of surgery, 65: 237-242 (1978). 5. Matossian, R.M. & Araj, G.F. Serologic evidence of the post-operative persistence of hydatid cysts in man. Journal of hygiene, 75: 333-340 (1975). 6. Morris, D.L. Chemotherapy of hydatid disease. Journal of antimicrobial chemotherapy, 2: 494-496 (1983). 480 WHO Bulletin OMS. Vol 691991. Medico-surgical approach to cystic hydatidosis 7. Morris, D.L. et al. Albendazole-objective evidence of response in human hydatid disease. Journal of the American Medical Association, 253: 2053-2057 (1985). 8. Saimot, A.G. et al. Albendazole as a potential treat- ment for human hydatidosis. Lancet, 2: 652-656 (1983). 9. Eckert, J. Prospects for the treatment of the metaces- tode stage of echinococcus. In: Thompson, R.C.A., ed. The biology of echinococcus and hydatid disease. Lon- don, Allen & Unwin, 1986, pp. 250-284. 10. Davis, A. et al. Multicentre clinical trials of benzimid- azolecarbamates in human echinococcosis. Bulletin of the World Health Organization, 64: 383-388 (1986). 11. Davis, A. et al. Multicentre clinical trials of benzimid- azolecarbamates in human cystic echinococcosis (phase 2). Bulletin of the World Health Organization, 67: 503-508 (1989). 12. Horton, R.J. Chemotherapy of echinococcus infection in man with albendazole. Transactions of the Royal Soci- ety of Tropical Medicine and Hygiene, 83: 97-102 (1989). 13. Matossian, R.M. et al. Host response in human hydati- dosis. IIl. Immunoglobulin class of reactive antibodies in diagnosis. Helminthologia, 28: 41-47 (1991). 14. Lightowlers, M.W. & Rickard, M.D. Excretory-secre- tory products of helminth parasites: effects on host immune responses. Parasitology, 96: S123-S166 (1988). 15. Craig, P.S. Detection of specific circulating antigen, immune complexes and antibodies in human hydatido- sis from Turkana (Kenya) and Great Britain by enzyme immunoassay. Parasite immunology, 8: 171-188 (1986). 16. Schantz, P.M. Effective medical treatment for hydatid disease? Journal of the American Medical Association, 253: 2095-2097 (1985). 17. Woodtli, W. et al. Effect of plasma mebendazole con- centrations in the treatment of human echinococcosis. Transactions of the Royal Society of Tropical Medicine and Hygiene, 34: 754-760 (1985). 18. Okelo, G.B.A. Hydatid disease: research and control in Turkana. Ill. Albendazole in the treatment of inoperable hydatid disease in Kenya-a report of 12 cases. Trans- actions of the Royal Society of Tropical Medicine and Hygiene, 80: 193-195 (1986). 19. Todorov, T. et al. Albendazole treatment of human cystic echinococcosis. Transactions of the Royal Society of Tropical Medicine and Hygiene, 82: 453-459 (1988). 20. Golematis, B. et al. Albendazole in the conservative management of multiple hydatid disease. Mount Sinai joumal of medicine, 56: 53-55 (1989). 21. Morris, D.L. Pre-operative albendazole therapy for hy- datid cyst. British journal of surgery, 74: 805-806 (1987). 22. Morris, D.L. & Taylor, D.H. Optimal timing of post- operative albendazole prophylaxis in E. granulosus. Annals of tropical medicine and parasitology, 82: 65-66 (1988). 23. Mufarrij, A.A. et al. Host response in human hydatido- sis. II. Comparative histopathology of hepatic and pul- monary hydatid adventitias. Helminthologia, 27: 279-290 (1990). Annex Case histories of the study patients Case B1 (S.J.), 45 years old, male. Recurrent hydati- dosis involving the liver, spleen, kidneys, perito- neum, and pelvis, diagnosed by ultrasound scan- ning. Surgical removal of multiple visible cysts; some left in situ. Four cycles of chemotherapy. Cyst disappearance was first observed after 2 months. Small, shrunken cysts were still visible after 32 months. Recovery uneventful. Case B2 (R.D.), 15 years old, female. Extensive hyda- tidosis of the liver, spleen, omentum, peritoneum, and pelvis, diagnosed by computed tomography scan. Surgical removal of multiple visible cysts; others left in situ. Chemotherapy started: after two cycles, small hepatic cysts disappeared, a large (15-cm diameter) cyst persisted for 17 months and was removed by surgery. Patient became active and symptom-free early in treatment. Radiography ne- gative after 23 months. Recovery uneventful. Case B3 (N.Z.), 25 years old, female. Recurrent hydatidosis involving the liver and right kidney, diagnosed by ultrasound scan. Earlier history of ruptured abdominal cyst. Surgical removal of all visible cysts. Four cycles of chemotherapy given as prophylactic for possible invisible cysts resulting from rupture. Radiography negative after 13 months. Recovery uneventful. Case B4 (I.S.), 22 years old, female. Extensive hydati- dosis of the liver, spleen, peritoneum and pelvis, diagnosed by computed tomography scan. Surgical removal of multiple visible cysts; some left in situ. Three cycles of chemotherapy given over 18 months because of poor attendance. Patient became active and symptom-free. Residual cysts persisted and needed a second operative removal after 18 months; they were sterile for protoscoleces. Radiography became negative after 22 months. Recovery un- eventful. Case B5 (M.F.), 16 years old, female. Acute cholangi- tis secondary to intrabiliary rupture of a large hepatic hydatid cyst. Cholecystectomy and surgical removal of two associated cysts. Three cycles of therapy were given as prophylaxis. Radiography negative after 20 months. Recovery uneventful. Case B6 (A.E.), 25 years old, female. Extensive re- current hydatidosis of the liver, spleen, omentum, peritoneum and pelvis; diagnosed by ultrasound WHO Bulletin OMS. Vol 69 1991. 481 G.N. Awar et al. scan. No surgery undertaken. Chemotherapy started and four cycles were given. Multiple small peri- toneal cysts disappeared after 3 months (2 cycles); others decreased markedly in size. Residual cysts visible by radiography after 13 months. Condition stable. WHO Bulletin OMS. Vol 69 1991.482