Case report ： A case misdiagnosed as cystic echinococcosis in alveolar echinococcosis

Case report ： A case misdiagnosed as cystic echinococcosis in alveolar echinococcosis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Case report ： A case misdiagnosed as cystic echinococcosis in alveolar echinococcosis HongYu Zhao, JunJie Cai, JingJing Wang, Ying Zhou, Zhan Wang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4115688/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Echinococcosis is one of the most common parasitic diseases among humans and animals worldwide, with the most prominent in the northwest region of China. According to different types of infected larvae, it can be divided into cystic echinococcosis and alveolar echinococcosis. Both types of infected organs are most common in the liver. Here we report a 49 years old female patient with hepatic cystic echinococcosis who was initially misdiagnosed as hepatic cystic echinococcosis (CE1) due to her imaging findings being very similar to those of cystic echinococcosis. After further examination and literature review, we were ultimately diagnosed with hepatic alveolar echinococcosis (P4), which was confirmed by surgery and postoperative pathology. In the article, we use MRI and MRCP as recommendations for distinguishing the two, which can efficiently help us distinguish them and avoid misdiagnosis. Presentation: We report a 49 year old female patient residing in an area with a high incidence of hydatid disease. She was admitted with the chief complaint of "persistent swelling and pain in the upper right abdomen for more than half a month". Prior to admission, the abdominal CT result diagnosed her with hepatic cystic echinococcosis CE1 type, which was a huge liver mass of 13.5cm * 13cm * 14cm. After admission, a comprehensive MRI and MRCP imaging examination was performed, and the results were different from CT. The diagnosis was P4 stage cystic cystic echinococcosis in the right lobe of the liver. Through literature review and general practice discussions, we ultimately diagnosed with P4 type of cystic cystic echinococcosis in the right lobe of the liver, and actively prepared for surgery. Due to the large size of the patient's liver lesion, the risk of surgery was assessed to be high. We first performed percutaneous liver puncture under ultrasound to drain the cystic fluid of the lesion. After the lesion collapsed, we finally performed a right hemihepatectomy. The surgery went smoothly and the patient recovered well, and was discharged as scheduled. After intraoperative and postoperative pathological diagnosis, it was confirmed that our diagnosis and treatment were correct and misdiagnosis was avoided. Conclusion when faced with difficult to distinguish AE and CE, MRI and MRCP may be the best choices to solve the problem, as they can effectively avoid misdiagnosis. Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Background Hydatid disease is a prevalent zoonotic parasitic infection in regions such as East Africa, Central Asia, and Northwestern China. It encompasses cystic echinococcosis (CE) and alveolar echinococcosis (AE), caused by the larvae of the fine-grained tapeworm and the multi-chambered tapeworm, respectively[1]. Both AE and CE can impact various organs throughout the body, with the liver being the most commonly affected[2]. Although both are chronic conditions[3], they present distinct clinical manifestations, courses, and prognoses[4]. CE is a disabling disease primarily characterized by space-occupying effects and organ damage, leading to symptoms like hepatomegaly and upper abdominal discomfort. In contrast, AE resembles an infiltrative tumor, with the potential to invade adjacent organs or metastasize to organs like the lungs and brain, akin to malignant tumors, resulting in a poorer prognosis[5]. Misdiagnosis is possible when AE exhibits some CE characteristics, leading to differences in treatment and prognosis[2, 6], incorrect treatment methods may have irreversible consequences for patients. This case presents a rare instance of hepatic AE with features resembling hepatic CE, causing a potential misdiagnosis based on CT imaging as hepatic CE. However, surgical and pathological findings confirmed the diagnosis of hepatic AE. Through an extensive analysis and discussion of relevant literature, we aim to enhance clinicians' ability to differentiate between AE and CE, minimizing the risk of misdiagnosis. Case presentation The patient, a 49-year-old female residing in Yushu Prefecture, Qinghai Province—a region with a high prevalence of hydatid disease in China—was admitted with a chief complaint of persistent right upper abdominal pain lasting over two weeks. The onset of this pain occurred without an apparent cause half a month prior to admission. The pain is continuous, tolerable, and unaccompanied by nausea, vomiting, or diarrhea, and there is no reported fever. The patient has a history of close contact with cattle, sheep, and dogs, as well as the consumption of raw beef and mutton. Physical examination revealed tenderness in the right upper abdomen, suspicion of a positive Murphy's sign, and no rebound tenderness. No jaundice was observed in the skin, mucous membranes, or sclera. Following admission, comprehensive examinations were conducted. Assessments of the patient's liver, kidney, and heart functions, blood routine, and coagulation revealed no significant abnormalities. The serological test for echinococcal IgG antibodies returned positive. Subsequently, abdominal color Doppler ultrasound, abdominal three-phase CT, abdominal MRI, and MRCP were performed. The abdominal color Doppler ultrasound revealed a large, round cystic mass in the liver, measuring approximately 13.5 cm x 13 cm x 14 cm. The internal echo exhibited relative hypoechogenicity, with discernible dense dot-like echoes. The morphology displayed regularity, clear boundaries, and close association with the middle hepatic vein, as depicted in Figure 1a. Short rod-like blood flow signals surrounded it, accompanied by a dense microvascular signal, as illustrated in Figure 1b. CT images indicated an unenhanced, round, cystic density lesion in the right lobe of the patient's liver, with well-defined boundaries and dimensions of approximately 13.5 cm x 11.2 cm x 16.2 cm. Due to cyst compression, the right hepatic vein was not visible, and the middle hepatic vein appeared indistinct, as demonstrated in Figure 1c. The CT image report diagnosed the condition as hepatic right lobe cystic echinococcosis (CE1). Descriptions from MRI and MRCP revealed a well-defined circular lesion in the right lobe of the liver, measuring approximately 17 cm x 13 cm x 11 cm, with a long T1 and long T2 signal. On DWI, it exhibited a high signal, while on ADC, a low signal. The lesion's edge displayed a low signal, with visible small- vesicle (clearly depicted in MRCP). Contrast-enhanced scanning showed mild enhancement at the lesion's edge, accompanied by dilation of the bile duct in the right lobe of the liver, as illustrated in Figure 1e. The MRI and MRCP images diagnosed the condition as hepatic right lobe cystic vesicular echinococcosis (P4). Additionally, CT imaging revealed a blurry and irregular cyst towards the lower pole, surrounded by evident widespread calcification. In contrast to the continuous arc-shaped calcified lesions seen in CE5, these calcifications were scattered, discontinuous, and densely distributed, as shown in Figure 1c. Considering the comprehensive examination results and clinical manifestations, the final diagnosis is deemed to be hepatic right lobe cystic vesicular echinococcosis (P4). Upon subsequent re-examination of liver CT, as depicted in Figure 3, it was noted that the degree of collapse of the cyst was minimal and did not meet the anticipated outcome. This was attributed to the suboptimal placement of the drainage tube, resulting in the retention of a significant portion of cystic fluid under the influence of gravity. To achieve the desired therapeutic effect, on the 13th day of the patient's admission, the drainage tube was repositioned to the optimal location under ultrasound guidance. Four days post-drainage, ultrasound re-examination was conducted, as illustrated in Figure 4. In the second ultrasound image, compared to the initial one, the cystic lesion in the liver had collapsed, measuring approximately 9 cm x 6 cm x 4 cm. The internal echo had increased compared to the previous state, the boundary was clearly distinguishable, the middle hepatic vein was visible, and scattered microvascular signals were observed around it. The previously distorted middle hepatic vein, compressed in the initial stages, was now distinctly visible. This indicated the successful achievement of the expected outcome in the first stage of treatment. Consequently, a decision was made to schedule a right hepatic lobe enlargement resection surgery for the patient. To ensure the smooth progress of the surgery, three-dimensional reconstruction of the liver was performed, as presented in Figure 5, to assess the residual liver volume and prognosis. Following the exclusion of surgery-related contraindications, the surgery was conducted on the 18th day of the patient's admission. Intraoperative specimens are displayed in Figure 6, and postoperative pathology is depicted in Figure 7. The patient was confirmed to have hepatic cystic echinococcosis (P3 stage). Post-discharge, the patient was advised to continue taking albendazole. Three months postoperatively, a telephone follow-up revealed that the patient's general condition remained good, with no specific discomfort reported. As shown in Figure 1, before the patient's admission puncture, the patient underwent ultrasound, CT, and MRI examinations, revealing a large cystic mass in the right lobe of the liver involving segments V, VI, VII, and VIII. As shown in Figure 2, drainage of milky and slightly bloody cystic fluid can be observed. As shown in Figure 3, CT and MRI reexamination after the patient's large right lobe liver mass puncture revealed that the collapse of the cyst was minimal. We consider this to be due to the suboptimal placement of the drainage tube, resulting in the retention of a significant portion of cystic fluid under the influence of gravity. Under the guidance of ultrasound, we repositioned the drainage tube. After continued drainage for 4 days, we performed a follow-up ultrasound examination, revealing significant collapse of the cyst, with most of the cystic fluid drained. On ultrasound, the previously compressed and deformed hepatic middle vein was now clearly visible. Figure 5 shows the three-dimensional reconstruction of the patient's liver: Patient weight: 55 kg, Height: 145 cm, Body Surface Area (BSA): 1.46; Standard liver volume: LV = 613 * BSA^(1.56) + 162.8 = 1057.78 cm^3; Actual liver volume: 2764.80 cm^3 Residual liver compared to standard liver: 81.718%. As shown in Figure 6, the patient underwent open right hemihepatectomy after comprehensive preoperative preparation and exclusion of surgery-related contraindications. The resected right hemi-liver and gallbladder were sent for pathological examination. The pathological image shows normal liver tissue in the upper layer, inflammatory cell infiltration in the middle layer, and scattered germinal layer and stratum corneum in the lower layer of AE lesions. Discussion Cystic Echinococcosis (CE) and Alveolar Echinococcosis (AE) are predominantly prevalent in East Africa, Central Asia, the Middle East, and western China, representing frequently overlooked tropical diseases prone to misdiagnosis[7, 8]. The presented case originates from the northwestern region of Qinghai Province in China, specifically Yushu Tibetan Autonomous Prefecture. Situated on the Qinghai-Tibet Plateau, this area is characterized by vast landscapes and a sparse population, with the majority of households relying on animal husbandry as a primary source of income. Increased contact with animals such as cattle, sheep, and dogs elevates the probability of contracting echinococcosis. Qinghai Province stands as a significant endemic region for cystic echinococcosis, with an average incidence rate of approximately 0.13% (6,138/4,813,070) [9]. In this case report, after a comprehensive physical examination upon admission, it was found that the patient only had symptoms of compression of the liver and surrounding organs caused by liver occupying lesions such as right upper abdominal tenderness and mild rebound pain. Notably absent were the more typical late-stage symptoms of hepatic AE, such as jaundice, ascites, portal hypertension, or secondary organ metastases resulting from liver function impairment and cirrhosis[5]. The clinical presentation leaned more towards CE. In the early stages of CE, most infections are asymptomatic[10], and only in the later stages does the presence of a large hepatic cyst due to echinococcal pressure manifest as a sense of fullness and distension in the upper abdomen[5]. After completing relevant tests, including assessments of patient liver and kidney function, no indicators of liver function impairment or other abnormal findings were observed, except for a positive result in the serological cystic echinococcus IgG antibody. Although serological testing is one of the diagnostic criteria for AE and CE, it is insufficient to distinguish between the two[2]. However, CT imaging revealed a single non-enhanced round cystic low-density shadow in the right lobe of the liver, with an intact cyst wall and clear demarcation from surrounding tissues, consistent with the CT imaging characteristics of Cystic Echinococcosis Type 1(CE1)[11]. The CT imaging report diagnosed it as hepaticCE1. According to the WHO-IWGE classification for Cystic Echinococcosis cysts by ultrasound, this lesion appeared as a single regular round cyst with lower internal echoes and some denser dot-like echoes, exhibiting a regular morphology with clear and distinguishable boundaries, resembling the characteristics of a CE1[11]. Due to the atypical imaging and overall presentation of this case, which did not align with the conventional features of AE, there was a misdiagnosis in the CT imaging. However, following the completion of MRI and MRCP imaging examinations, we ultimately confirmed the diagnosis as Alveolar Echinococcosis. After improving MRI and magnetic resonance cholangiopancreatography (MRCP), through careful observation, we can see the characteristic imaging manifestations of AE at the edge of the lesion - small vesicles, which are extracellular vesicles. Extracellular vesicles (EVs) refer to vesicular bodies with a double-layer membrane structure that detach from the surface of the cell membrane or are secreted by cells[11-13]. Initially regarded as cellular waste, extracellular vesicles garnered little attention, being considered "garbage" ejected from cells until recent years. It has gradually come to light that these minute vesicles harbor a wealth of biologically active substances, including proteins, nucleic acids, and lipids, playing pivotal roles in cellular material and information transfer[14]. Extracellular vesicles are now acknowledged as crucial carriers with intercellular communication functions, participating in host-parasite interactions. Mounting evidence suggests that parasites release EVs during the pathogen-host interaction, supporting their survival. Studies demonstrate that EVs released by the Echinococcus multilocularis tapeworm modulate cytokine expression in macrophages and the LPS/TLR4 pathway[15]. Characteristic radiological manifestations of AE, small cysts, exhibit high signals on T2-weighted imaging (T2WI), best visualized on MRCP[13, 16]. Typically located at the lesion's edge, small cysts display a scattered distribution, as depicted in Figure 8. On MRI, AE demonstrates infiltrative growth with a rough and less smooth periphery, distinguishing it from cystic echinococcosis (CE), as illustrated in Figure 9. Therefore, solely relying on ultrasound, CT imaging, and clinical presentations is insufficient for distinguishing CE from AE. MRI and MRCP should be considered as more compelling imaging evidence for differentiation[17, 18], particularly for less experienced clinical and radiology practitioners, significantly enhancing their ability to distinguish between AE and CE. As shown in Figure 8, there are scattered high signal small vesicles around the hydatid lesions under MRCP。 In the management of hepatic alveolar echinococcosis (AE), when the primary lesion is completely resectable, and liver function is well-preserved, partial hepatectomy stands as the sole curative treatment[19]. However, if the surgical risk deems complete lesion resection unsafe, percutaneous intervention becomes a viable option to avert complications. Following percutaneous drainage and reduction of the necrotic cavity, it may render the initially unfeasible curative resection possible. In this particular case, the surgical risk was initially deemed high, and curative surgery was not feasible before percutaneous intervention. Yet, after percutaneous liver cyst puncture and drainage of cystic fluid, the collapse of the hydatid necrotic cavity created conditions conducive to curative surgery. Subsequent to performing three-dimensional liver reconstruction for the patient, the planned surgical approach extended to right hepatectomy, resulting in a residual liver to standard liver volume ratio of 81.718%. This indicated a diminished probability of postoperative liver failure and enhanced postoperative liver function recovery for the patient. Consequently, the surgery proceeded as scheduled, with a streamlined surgical process. Postoperatively, we submitted the specimen for pathological examination, and the pathological diagnosis confirmed hepatic alveolar echinococcosis, validating the accuracy of our diagnosis and treatment approach. The patient experienced a successful postoperative recovery and was discharged as planned. Conclusion Whether it is alveolar echinococcosis (AE) or cystic echinococcosis (CE), their primary treatment goals encompass the complete elimination of parasites and the prevention of recurrence, ultimately reducing patient mortality[20]. To attain this objective, it is crucial to clearly ascertain whether the hydatid patient presents a vesicular or cystic type. However, during the initial differentiation between the two, we encountered a paucity of reference literature. Misdiagnosing AE as CE can lead to irreversible harm to the patient, potentially missing the optimal treatment window and risking lives. In this instance, the characteristic manifestations in MRI and MRCP assisted us in avoiding misdiagnosing AE. Therefore, in clinical practice, when confronted with challenges in distinguishing between AE and CE, MRI and MRCP may indeed emerge as the optimal choices to resolve this dilemma. Declarations Patient consent The case reports and images involved in the publication of this case have obtained the patient's written consent. If necessary, a copy of the written consent can be provided. Author contribution Hongyu Zhao：data collection and writing and contributor Junjie Cai：interpretation and revision Jingjing Wang：data collection Ying Zhou：guidance Zhan Wang(Corresponding author)：Design and guidance Guarantor Zhan Wang Funding The Department of Science and Technology in Qinghai Province, China (2021-ZJ-963Q); National Natural Science Foundation of China (82160131). Availability of data and materials The data that support the findings of this study are available on request from the corresponding author, upon reasonable request. Declaration of competing Interest The authors of the following names certify that they have no financial interest or involvement in any organization or entity (such as remuneration; educational funding, participation in spokespersons, institutions, members, employment, consulting, equity or other benefits; and expert testimony or patent licensing arrangements) or non-financial interest (such as personal or professional relationships, relationships, knowledge or beliefs) in the subject matter or materials discussed in this manuscript. Acknowledgements Thank The Department of Science and Technology in Qinghai Province, China (2021-ZJ-963Q); National Natural Science Foundation of China (82160131)for funding. References McManus DP, Gray DJ, Zhang W, Yang Y: Diagnosis, treatment, and management of echinococcosis . BMJ : British Medical Journal 2012, 344 :e3866. Brunetti E, Kern P, Vuitton DA: Expert consensus for the diagnosis and treatment of cystic and alveolar echinococcosis in humans . Acta tropica 2010, 114 (1):1-16. Kern P, Da Silva AM, Akhan O, Müllhaupt B, Vizcaychipi K, Budke C, Vuitton D: The echinococcoses: diagnosis, clinical management and burden of disease . Advances in parasitology 2017, 96 :259-369. Stojkovic M, Junghanss T: Cystic and alveolar echinococcosis . Handbook of clinical neurology 2013, 114 :327-334. Zhang Yanling, Wu Zhaohan: Practical Surgery. 3rd Edition: Practical Surgery. 3rd Edition; 2012. Wen H, Vuitton L, Tuxun T, Li J, Vuitton DA, Zhang W, McManus DP: Echinococcosis: advances in the 21st century . Clinical microbiology reviews 2019, 32 (2):10.1128/cmr. 00075-00018. Deplazes P, Rinaldi L, Rojas CA, Torgerson P, Harandi MF, Romig T, Antolova D, Schurer J, Lahmar S, Cringoli G: Global distribution of alveolar and cystic echinococcosis . Advances in parasitology 2017, 95 :315-493. Budke CM, Casulli A, Kern P, Vuitton DA: Cystic and alveolar echinococcosis: Successes and continuing challenges . PLoS neglected tropical diseases 2017, 11 (4):e0005477. Kui Yan, Xue Chuizhao, Wang Xu, Liu Baixue, Wang Ying, Wang Liying, Yang Shijie, Han Shuai, Wu Weiping, Xiao Ning: Progress in the Prevention and Treatment of Echinococcosis in China in 2021. Chinese Journal of Parasitology and Parasitic Diseases, 2023, 41(2):142-148. Woolsey ID, Miller AL: Echinococcus granulosus sensu lato and Echinococcus multilocularis: A review . Research in veterinary science 2021, 135 :517-522. Stojkovic M, Rosenberger K, Kauczor H-U, Junghanss T, Hosch W: Diagnosing and staging of cystic echinococcosis: how do CT and MRI perform in comparison to ultrasound? PLoS neglected tropical diseases 2012, 6 (10):e1880. Liu W, Delabrousse É, Blagosklonov O, Wang J, Zeng H, Jiang Y, Wang J, Qin Y, Vuitton DA, Wen H: Innovation in hepatic alveolar echinococcosis imaging: best use of old tools, and necessary evaluation of new ones . Parasite 2014, 21 . 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Bresson-Hadni S, Delabrousse E, Blagosklonov O, Bartholomot B, Koch S, Miguet J-P, Mantion GA, Vuitton DA: Imaging aspects and non-surgical interventional treatment in human alveolar echinococcosis . Parasitology international 2006, 55 :S267-S272. Kamiyama T: Recent advances in surgical strategies for alveolar echinococcosis of the liver . Surgery today 2020, 50 (11):1360-1367. Nunnari G, Pinzone MR, Gruttadauria S, Celesia BM, Madeddu G, Malaguarnera G, Pavone P, Cappellani A, Cacopardo B: Hepatic echinococcosis: clinical and therapeutic aspects . World journal of gastroenterology: WJG 2012, 18 (13):1448. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4115688","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":286834875,"identity":"3fea7df7-aadb-49d1-8215-cc04fbe5532c","order_by":0,"name":"HongYu Zhao","email":"","orcid":"","institution":"Qinghai University Medical College","correspondingAuthor":false,"prefix":"","firstName":"HongYu","middleName":"","lastName":"Zhao","suffix":""},{"id":286834876,"identity":"65a5bffa-6573-4c16-a39d-e7fd7e552007","order_by":1,"name":"JunJie Cai","email":"","orcid":"","institution":"Qinghai University Medical College","correspondingAuthor":false,"prefix":"","firstName":"JunJie","middleName":"","lastName":"Cai","suffix":""},{"id":286834877,"identity":"cf36c149-3b41-4415-8732-386b93e2ab82","order_by":2,"name":"JingJing Wang","email":"","orcid":"","institution":"Qinghai University Affiliated Hospital","correspondingAuthor":false,"prefix":"","firstName":"JingJing","middleName":"","lastName":"Wang","suffix":""},{"id":286834878,"identity":"5f26a53a-3b49-4161-9027-f116ab33b8a8","order_by":3,"name":"Ying Zhou","email":"","orcid":"","institution":"Qinghai University Affiliated Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ying","middleName":"","lastName":"Zhou","suffix":""},{"id":286834879,"identity":"d5f0550a-65cb-4492-921b-286527b6315b","order_by":4,"name":"Zhan Wang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAArElEQVRIiWNgGAWjYDAC5gMMHxgMJOTY2NsPEKmFLYFxBkOFhTEfz5kEUrScqUicJ+FgQJwOg2PMB5t52yTS2yQYEhh+VGwjRgtbIkhLbpt04wHGnjO3idByv8f8MViLzIEEZsY2YrQc4zEEO4xNIsGABC08ZyQSiNciCfRL45wKCcM2YCAfJMovfMAQa3hjUCcv395+8MGPCiK0oIADJKofBaNgFIyCUYALAADrqTpJRAqaxwAAAABJRU5ErkJggg==","orcid":"","institution":"Qinghai University Affiliated Hospital","correspondingAuthor":true,"prefix":"","firstName":"Zhan","middleName":"","lastName":"Wang","suffix":""}],"badges":[],"createdAt":"2024-03-17 06:30:26","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4115688/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4115688/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":54106846,"identity":"717128e4-cfb0-4c1b-85ec-178f433e260d","added_by":"auto","created_at":"2024-04-04 17:25:13","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":372065,"visible":true,"origin":"","legend":"\u003cp\u003e① Compressed deformation of the hepatic middle vein\u003c/p\u003e\n\u003cp\u003e② Echinococcal lesion\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4115688/v1/0bd61a4e7576185c114cd0f6.jpg"},{"id":54106866,"identity":"9a440001-84c6-42fb-bdcf-1b3654a5ff87","added_by":"auto","created_at":"2024-04-04 17:25:14","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":42522,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4115688/v1/1f8f93599e8a490d00669c79.jpg"},{"id":54106870,"identity":"2db61f05-e38d-4842-ab2d-7cbbbb22df3a","added_by":"auto","created_at":"2024-04-04 17:25:15","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":49655,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4115688/v1/ea4b7478dae8ac693fdf5e7f.jpg"},{"id":54106848,"identity":"3ac5cef9-6083-408f-a4e8-da9e2ff53196","added_by":"auto","created_at":"2024-04-04 17:25:14","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":90062,"visible":true,"origin":"","legend":"\u003cp\u003e①. Collapsed echinococcal lesion\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e②.Restored hepatic middle vein\u003c/p\u003e","description":"","filename":"4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4115688/v1/61f412efae2992fa3705bdcd.jpg"},{"id":54106871,"identity":"e23a341c-d8da-483d-97f4-bd9688f1baae","added_by":"auto","created_at":"2024-04-04 17:25:15","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":50428,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version\u003c/p\u003e","description":"","filename":"5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4115688/v1/5665c3fdbc296adce504bc5c.jpg"},{"id":54106847,"identity":"ecb76a36-bb62-49df-b7f9-3c92bd704fa5","added_by":"auto","created_at":"2024-04-04 17:25:13","extension":"jpg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":88537,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version\u003c/p\u003e","description":"","filename":"6.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4115688/v1/a466f66a9483c880368fba6f.jpg"},{"id":54106868,"identity":"0e6eb3d7-a076-4f2a-b953-2431e3af5f13","added_by":"auto","created_at":"2024-04-04 17:25:15","extension":"jpg","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":186322,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version\u003c/p\u003e","description":"","filename":"7.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4115688/v1/82e31ad84c98a5ad8afbf7d2.jpg"},{"id":54106849,"identity":"430ebca1-0058-4e99-891f-16303b8c35b1","added_by":"auto","created_at":"2024-04-04 17:25:14","extension":"jpg","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":72597,"visible":true,"origin":"","legend":"\u003cp\u003e① small vesicle\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e②Hydatid lesion\u003c/p\u003e","description":"","filename":"8.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4115688/v1/4c9100109cee5021e1e6fe46.jpg"},{"id":54106867,"identity":"897733f8-dc10-4877-a5e4-95168634f82a","added_by":"auto","created_at":"2024-04-04 17:25:14","extension":"jpg","order_by":9,"title":"Figure 9","display":"","copyAsset":false,"role":"figure","size":128870,"visible":true,"origin":"","legend":"\u003cp\u003ea：Hepatic cystic cystic echinococcosis（P4)\u003c/p\u003e\n\u003cp\u003eb：hepatic cystic echinococcosis（CE1）\u003c/p\u003e","description":"","filename":"9.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4115688/v1/d6d3dea43143a806abbb4c9b.jpg"},{"id":54371989,"identity":"507415c2-954a-42fa-a5c2-cfa352da9d6e","added_by":"auto","created_at":"2024-04-09 13:17:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1063939,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4115688/v1/ffadf86a-6a33-4c59-9907-6966e80494c2.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Case report ： A case misdiagnosed as cystic echinococcosis in alveolar echinococcosis","fulltext":[{"header":"Background","content":"\u003cp\u003eHydatid disease is a prevalent zoonotic parasitic infection in regions such as East Africa, Central Asia, and Northwestern China. It encompasses cystic echinococcosis (CE) and alveolar echinococcosis (AE), caused by the larvae of the fine-grained tapeworm and the multi-chambered tapeworm, respectively[1]. Both AE and CE can impact various organs throughout the body, with the liver being the most commonly affected[2]. Although both are chronic conditions[3], they present distinct clinical manifestations, courses, and prognoses[4]. CE is a disabling disease primarily characterized by space-occupying effects and organ damage, leading to symptoms like hepatomegaly and upper abdominal discomfort. In contrast, AE resembles an infiltrative tumor, with the potential to invade adjacent organs or metastasize to organs like the lungs and brain, akin to malignant tumors, resulting in a poorer prognosis[5]. Misdiagnosis is possible when AE exhibits some CE characteristics, leading to differences in treatment and prognosis[2, 6], incorrect treatment methods may have irreversible consequences for patients. This case presents a rare instance of hepatic AE with features resembling hepatic CE, causing a potential misdiagnosis based on CT imaging as hepatic CE. However, surgical and pathological findings confirmed the diagnosis of hepatic AE. Through an extensive analysis and discussion of relevant literature, we aim to enhance clinicians' ability to differentiate between AE and CE, minimizing the risk of misdiagnosis.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eThe patient, a 49-year-old female residing in Yushu Prefecture, Qinghai Province\u0026mdash;a region with a high prevalence of hydatid disease in China\u0026mdash;was admitted with a chief complaint of persistent right upper abdominal pain lasting over two weeks. The onset of this pain occurred without an apparent cause half a month prior to admission. The pain is continuous, tolerable, and unaccompanied by nausea, vomiting, or diarrhea, and there is no reported fever. The patient has a history of close contact with cattle, sheep, and dogs, as well as the consumption of raw beef and mutton. Physical examination revealed tenderness in the right upper abdomen, suspicion of a positive Murphy\u0026apos;s sign, and no rebound tenderness. No jaundice was observed in the skin, mucous membranes, or sclera.\u003c/p\u003e\n\u003cp\u003eFollowing admission, comprehensive examinations were conducted. Assessments of the patient\u0026apos;s liver, kidney, and heart functions, blood routine, and coagulation revealed no significant abnormalities. The serological test for echinococcal IgG antibodies returned positive. Subsequently, abdominal color Doppler ultrasound, abdominal three-phase CT, abdominal MRI, and MRCP were performed. The abdominal color Doppler ultrasound revealed a large, round cystic mass in the liver, measuring approximately 13.5 cm x 13 cm x 14 cm. The internal echo exhibited relative hypoechogenicity, with discernible dense dot-like echoes. The morphology displayed regularity, clear boundaries, and close association with the middle hepatic vein, as depicted in Figure 1a. Short rod-like blood flow signals surrounded it, accompanied by a dense microvascular signal, as illustrated in Figure 1b. CT images indicated an unenhanced, round, cystic density lesion in the right lobe of the patient\u0026apos;s liver, with well-defined boundaries and dimensions of approximately 13.5 cm x 11.2 cm x 16.2 cm. Due to cyst compression, the right hepatic vein was not visible, and the middle hepatic vein appeared indistinct, as demonstrated in Figure 1c. The CT image report diagnosed the condition as hepatic right lobe cystic echinococcosis (CE1).\u003c/p\u003e\n\u003cp\u003eDescriptions from MRI and MRCP revealed a well-defined circular lesion in the right lobe of the liver, measuring approximately 17 cm x 13 cm x 11 cm, with a long T1 and long T2 signal. On DWI, it exhibited a high signal, while on ADC, a low signal. The lesion\u0026apos;s edge displayed a low signal, with visible small- vesicle (clearly depicted in MRCP). Contrast-enhanced scanning showed mild enhancement at the lesion\u0026apos;s edge, accompanied by dilation of the bile duct in the right lobe of the liver, as illustrated in Figure 1e. The MRI and MRCP images diagnosed the condition as hepatic right lobe cystic vesicular echinococcosis (P4). Additionally, CT imaging revealed a blurry and irregular cyst towards the lower pole, surrounded by evident widespread calcification. In contrast to the continuous arc-shaped calcified lesions seen in CE5, these calcifications were scattered, discontinuous, and densely distributed, as shown in Figure 1c. Considering the comprehensive examination results and clinical manifestations, the final diagnosis is deemed to be hepatic right lobe cystic vesicular echinococcosis (P4).\u003c/p\u003e\n\u003cp\u003eUpon subsequent re-examination of liver CT, as depicted in Figure 3, it was noted that the degree of collapse of the cyst was minimal and did not meet the anticipated outcome. This was attributed to the suboptimal placement of the drainage tube, resulting in the retention of a significant portion of cystic fluid under the influence of gravity. To achieve the desired therapeutic effect, on the 13th day of the patient\u0026apos;s admission, the drainage tube was repositioned to the optimal location under ultrasound guidance. Four days post-drainage, ultrasound re-examination was conducted, as illustrated in Figure 4. In the second ultrasound image, compared to the initial one, the cystic lesion in the liver had collapsed, measuring approximately 9 cm x 6 cm x 4 cm. The internal echo had increased compared to the previous state, the boundary was clearly distinguishable, the middle hepatic vein was visible, and scattered microvascular signals were observed around it. The previously distorted middle hepatic vein, compressed in the initial stages, was now distinctly visible. This indicated the successful achievement of the expected outcome in the first stage of treatment. Consequently, a decision was made to schedule a right hepatic lobe enlargement resection surgery for the patient. To ensure the smooth progress of the surgery, three-dimensional reconstruction of the liver was performed, as presented in Figure 5, to assess the residual liver volume and prognosis. Following the exclusion of surgery-related contraindications, the surgery was conducted on the 18th day of the patient\u0026apos;s admission. Intraoperative specimens are displayed in Figure 6, and postoperative pathology is depicted in Figure 7. The patient was confirmed to have hepatic cystic echinococcosis (P3 stage). Post-discharge, the patient was advised to continue taking albendazole. Three months postoperatively, a telephone follow-up revealed that the patient\u0026apos;s general condition remained good, with no specific discomfort reported.\u003c/p\u003e\n\u003cp\u003eAs shown in Figure 1, before the patient\u0026apos;s admission puncture, the patient underwent ultrasound, CT, and MRI examinations, revealing a large cystic mass in the right lobe of the liver involving segments V, VI, VII, and VIII.\u003c/p\u003e\n\u003cp\u003eAs shown in Figure 2, drainage of milky and slightly bloody cystic fluid can be observed.\u003c/p\u003e\n\u003cp\u003eAs shown in Figure 3, CT and MRI reexamination after the patient\u0026apos;s large right lobe liver mass puncture revealed that the collapse of the cyst was minimal. We consider this to be due to the suboptimal placement of the drainage tube, resulting in the retention of a significant portion of cystic fluid under the influence of gravity.\u003c/p\u003e\n\u003cp\u003eUnder the guidance of ultrasound, we repositioned the drainage tube. After continued drainage for 4 days, we performed a follow-up ultrasound examination, revealing significant collapse of the cyst, with most of the cystic fluid drained. On ultrasound, the previously compressed and deformed hepatic middle vein was now clearly visible.\u003c/p\u003e\n\u003cp\u003eFigure 5 shows the three-dimensional reconstruction of the patient\u0026apos;s liver:\u003c/p\u003e\n\u003cp\u003ePatient weight: 55 kg, Height: 145 cm, Body Surface Area (BSA): 1.46; Standard liver volume: LV = 613 * BSA^(1.56) + 162.8 = 1057.78 cm^3; Actual liver volume: 2764.80 cm^3 Residual liver compared to standard liver: 81.718%.\u003c/p\u003e\n\u003cp\u003eAs shown in Figure 6, the patient underwent open right hemihepatectomy after comprehensive preoperative preparation and exclusion of surgery-related contraindications. The resected right hemi-liver and gallbladder were sent for pathological examination.\u003c/p\u003e\n\u003cp\u003eThe pathological image shows normal liver tissue in the upper layer, inflammatory cell infiltration in the middle layer, and scattered germinal layer and stratum corneum in the lower layer of AE lesions.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eCystic Echinococcosis (CE) and Alveolar Echinococcosis (AE) are predominantly prevalent in East Africa, Central Asia, the Middle East, and western China, representing frequently overlooked tropical diseases prone to misdiagnosis[7, 8]. The presented case originates from the northwestern region of Qinghai Province in China, specifically Yushu Tibetan Autonomous Prefecture. Situated on the Qinghai-Tibet Plateau, this area is characterized by vast landscapes and a sparse population, with the majority of households relying on animal husbandry as a primary source of income. Increased contact with animals such as cattle, sheep, and dogs elevates the probability of contracting echinococcosis. Qinghai Province stands as a significant endemic region for cystic echinococcosis, with an average incidence rate of approximately 0.13% (6,138/4,813,070)\u0026nbsp;[9].\u003c/p\u003e\n\u003cp\u003eIn this case report, after a comprehensive physical examination upon admission, it was found that the patient only had symptoms of compression of the liver and surrounding organs caused by liver occupying lesions such as right upper abdominal tenderness and mild rebound pain. Notably absent were the more typical late-stage symptoms of hepatic AE, such as jaundice, ascites, portal hypertension, or secondary organ metastases resulting from liver function impairment and cirrhosis[5]. The clinical presentation leaned more towards CE. In the early stages of CE, most infections are asymptomatic[10], and only in the later stages does the presence of a large hepatic cyst due to echinococcal pressure manifest as a sense of fullness and distension in the upper abdomen[5]. After completing relevant tests, including assessments of patient liver and kidney function, no indicators of liver function impairment or other abnormal findings were observed, except for a positive result in the serological cystic echinococcus IgG antibody. Although serological testing is one of the diagnostic criteria for AE and CE, it is insufficient to distinguish between the two[2]. However, CT imaging revealed a single non-enhanced round cystic low-density shadow in the right lobe of the liver, with an intact cyst wall and clear demarcation from surrounding tissues, consistent with the CT imaging characteristics of Cystic Echinococcosis Type 1(CE1)[11]. The CT imaging report diagnosed it as hepaticCE1. According to the WHO-IWGE classification for Cystic Echinococcosis cysts by ultrasound, this lesion appeared as a single regular round cyst with lower internal echoes and some denser dot-like echoes, exhibiting a regular morphology with clear and distinguishable boundaries, resembling the characteristics of a CE1[11]. Due to the atypical imaging and overall presentation of this case, which did not align with the conventional features of AE, there was a misdiagnosis in the CT imaging. However, following the completion of MRI and MRCP imaging examinations, we ultimately confirmed the diagnosis as Alveolar Echinococcosis.\u003c/p\u003e\n\u003cp\u003eAfter improving MRI and magnetic resonance cholangiopancreatography (MRCP), through careful observation, we can see the characteristic imaging manifestations of AE at the edge of the lesion - small vesicles, which are extracellular vesicles. Extracellular vesicles (EVs) refer to vesicular bodies with a double-layer membrane structure that detach from the surface of the cell membrane or are secreted by cells[11-13]. Initially regarded as cellular waste, extracellular vesicles garnered little attention, being considered \u0026quot;garbage\u0026quot; ejected from cells until recent years. It has gradually come to light that these minute vesicles harbor a wealth of biologically active substances, including proteins, nucleic acids, and lipids, playing pivotal roles in cellular material and information transfer[14]. Extracellular vesicles are now acknowledged as crucial carriers with intercellular communication functions, participating in host-parasite interactions. Mounting evidence suggests that parasites release EVs during the pathogen-host interaction, supporting their survival. Studies demonstrate that EVs released by the Echinococcus multilocularis tapeworm modulate cytokine expression in macrophages and the LPS/TLR4 pathway[15]. Characteristic radiological manifestations of AE, small cysts, exhibit high signals on T2-weighted imaging (T2WI), best visualized on MRCP[13, 16]. Typically located at the lesion\u0026apos;s edge, small cysts display a scattered distribution, as depicted in Figure 8. On MRI, AE demonstrates infiltrative growth with a rough and less smooth periphery, distinguishing it from cystic echinococcosis (CE), as illustrated in Figure 9. Therefore, solely relying on ultrasound, CT imaging, and clinical presentations is insufficient for distinguishing CE from AE. MRI and MRCP should be considered as more compelling imaging evidence for differentiation[17, 18], particularly for less experienced clinical and radiology practitioners, significantly enhancing their ability to distinguish between AE and CE.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAs shown in Figure 8, there are scattered high signal small vesicles around the hydatid lesions under MRCP。\u003c/p\u003e\n\u003cp\u003eIn the management of hepatic alveolar echinococcosis (AE), when the primary lesion is completely resectable, and liver function is well-preserved, partial hepatectomy stands as the sole curative treatment[19]. However, if the surgical risk deems complete lesion resection unsafe, percutaneous intervention becomes a viable option to avert complications. Following percutaneous drainage and reduction of the necrotic cavity, it may render the initially unfeasible curative resection possible. In this particular case, the surgical risk was initially deemed high, and curative surgery was not feasible before percutaneous intervention. Yet, after percutaneous liver cyst puncture and drainage of cystic fluid, the collapse of the hydatid necrotic cavity created conditions conducive to curative surgery. Subsequent to performing three-dimensional liver reconstruction for the patient, the planned surgical approach extended to right hepatectomy, resulting in a residual liver to standard liver volume ratio of 81.718%. This indicated a diminished probability of postoperative liver failure and enhanced postoperative liver function recovery for the patient. Consequently, the surgery proceeded as scheduled, with a streamlined surgical process. Postoperatively, we submitted the specimen for pathological examination, and the pathological diagnosis confirmed hepatic alveolar echinococcosis, validating the accuracy of our diagnosis and treatment approach. The patient experienced a successful postoperative recovery and was discharged as planned.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWhether it is alveolar echinococcosis (AE) or cystic echinococcosis (CE), their primary treatment goals encompass the complete elimination of parasites and the prevention of recurrence, ultimately reducing patient mortality[20]. To attain this objective, it is crucial to clearly ascertain whether the hydatid patient presents a vesicular or cystic type. However, during the initial differentiation between the two, we encountered a paucity of reference literature. Misdiagnosing AE as CE can lead to irreversible harm to the patient, potentially missing the optimal treatment window and risking lives. In this instance, the characteristic manifestations in MRI and MRCP assisted us in avoiding misdiagnosing AE. Therefore, in clinical practice, when confronted with challenges in distinguishing between AE and CE, MRI and MRCP may indeed emerge as the optimal choices to resolve this dilemma.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003ePatient consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe case reports and images involved in the publication of this case have obtained the patient\u0026apos;s written consent. If necessary, a copy of the written consent can be provided.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHongyu Zhao：data collection and writing and contributor\u003c/p\u003e\n\u003cp\u003eJunjie Cai：interpretation and revision\u003c/p\u003e\n\u003cp\u003eJingjing Wang：data collection\u003c/p\u003e\n\u003cp\u003eYing Zhou：guidance\u003c/p\u003e\n\u003cp\u003eZhan Wang(Corresponding author)：Design and guidance\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGuarantor\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eZhan Wang\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Department of Science and Technology in Qinghai Province, China (2021-ZJ-963Q); National Natural Science Foundation of China (82160131).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available on request from the corresponding author, upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of competing Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors of the following names certify that they have no financial interest or involvement in any organization or entity (such as remuneration; educational funding, participation in spokespersons, institutions, members, employment, consulting, equity or other benefits; and expert testimony or patent licensing arrangements) or non-financial interest (such as personal or professional relationships, relationships, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThank The Department of Science and Technology in Qinghai Province, China (2021-ZJ-963Q); National Natural Science Foundation of China (82160131)for funding.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMcManus DP, Gray DJ, Zhang W, Yang Y: \u003cstrong\u003eDiagnosis, treatment, and management of echinococcosis\u003c/strong\u003e. \u003cem\u003eBMJ : British Medical Journal \u003c/em\u003e2012, \u003cstrong\u003e344\u003c/strong\u003e:e3866.\u003c/li\u003e\n\u003cli\u003eBrunetti E, Kern P, Vuitton DA: \u003cstrong\u003eExpert consensus for the diagnosis and treatment of cystic and alveolar echinococcosis in humans\u003c/strong\u003e. \u003cem\u003eActa tropica \u003c/em\u003e2010, \u003cstrong\u003e114\u003c/strong\u003e(1):1-16.\u003c/li\u003e\n\u003cli\u003eKern P, Da Silva AM, Akhan O, M\u0026uuml;llhaupt B, Vizcaychipi K, Budke C, Vuitton D: \u003cstrong\u003eThe echinococcoses: diagnosis, clinical management and burden of disease\u003c/strong\u003e. \u003cem\u003eAdvances in parasitology \u003c/em\u003e2017, \u003cstrong\u003e96\u003c/strong\u003e:259-369.\u003c/li\u003e\n\u003cli\u003eStojkovic M, Junghanss T: \u003cstrong\u003eCystic and alveolar echinococcosis\u003c/strong\u003e. \u003cem\u003eHandbook of clinical neurology \u003c/em\u003e2013, \u003cstrong\u003e114\u003c/strong\u003e:327-334.\u003c/li\u003e\n\u003cli\u003eZhang Yanling, Wu Zhaohan: Practical Surgery. 3rd Edition: Practical Surgery. 3rd Edition; 2012.\u003c/li\u003e\n\u003cli\u003eWen H, Vuitton L, Tuxun T, Li J, Vuitton DA, Zhang W, McManus DP: \u003cstrong\u003eEchinococcosis: advances in the 21st century\u003c/strong\u003e. \u003cem\u003eClinical microbiology reviews \u003c/em\u003e2019, \u003cstrong\u003e32\u003c/strong\u003e(2):10.1128/cmr. 00075-00018.\u003c/li\u003e\n\u003cli\u003eDeplazes P, Rinaldi L, Rojas CA, Torgerson P, Harandi MF, Romig T, Antolova D, Schurer J, Lahmar S, Cringoli G: \u003cstrong\u003eGlobal distribution of alveolar and cystic echinococcosis\u003c/strong\u003e. \u003cem\u003eAdvances in parasitology \u003c/em\u003e2017, \u003cstrong\u003e95\u003c/strong\u003e:315-493.\u003c/li\u003e\n\u003cli\u003eBudke CM, Casulli A, Kern P, Vuitton DA: \u003cstrong\u003eCystic and alveolar echinococcosis: Successes and continuing challenges\u003c/strong\u003e. \u003cem\u003ePLoS neglected tropical diseases \u003c/em\u003e2017, \u003cstrong\u003e11\u003c/strong\u003e(4):e0005477.\u003c/li\u003e\n\u003cli\u003eKui Yan, Xue Chuizhao, Wang Xu, Liu Baixue, Wang Ying, Wang Liying, Yang Shijie, Han Shuai, Wu Weiping, Xiao Ning: Progress in the Prevention and Treatment of Echinococcosis in China in 2021. 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According to different types of infected larvae, it can be divided into cystic echinococcosis and alveolar echinococcosis. Both types of infected organs are most common in the liver. Here we report a 49 years old female patient with hepatic cystic echinococcosis who was initially misdiagnosed as hepatic cystic echinococcosis (CE1) due to her imaging findings being very similar to those of cystic echinococcosis. After further examination and literature review, we were ultimately diagnosed with hepatic alveolar echinococcosis (P4), which was confirmed by surgery and postoperative pathology. In the article, we use MRI and MRCP as recommendations for distinguishing the two, which can efficiently help us distinguish them and avoid misdiagnosis.\u003c/p\u003e\u003ch2\u003ePresentation:\u003c/h2\u003e \u003cp\u003eWe report a 49 year old female patient residing in an area with a high incidence of hydatid disease. She was admitted with the chief complaint of \"persistent swelling and pain in the upper right abdomen for more than half a month\". Prior to admission, the abdominal CT result diagnosed her with hepatic cystic echinococcosis CE1 type, which was a huge liver mass of 13.5cm * 13cm * 14cm. After admission, a comprehensive MRI and MRCP imaging examination was performed, and the results were different from CT. The diagnosis was P4 stage cystic cystic echinococcosis in the right lobe of the liver. Through literature review and general practice discussions, we ultimately diagnosed with P4 type of cystic cystic echinococcosis in the right lobe of the liver, and actively prepared for surgery. Due to the large size of the patient's liver lesion, the risk of surgery was assessed to be high. We first performed percutaneous liver puncture under ultrasound to drain the cystic fluid of the lesion. After the lesion collapsed, we finally performed a right hemihepatectomy. The surgery went smoothly and the patient recovered well, and was discharged as scheduled. After intraoperative and postoperative pathological diagnosis, it was confirmed that our diagnosis and treatment were correct and misdiagnosis was avoided.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003ewhen faced with difficult to distinguish AE and CE, MRI and MRCP may be the best choices to solve the problem, as they can effectively avoid misdiagnosis.\u003c/p\u003e","manuscriptTitle":"Case report ： A case misdiagnosed as cystic echinococcosis in alveolar echinococcosis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-04 17:25:08","doi":"10.21203/rs.3.rs-4115688/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"dba72a43-b6d0-410a-853a-a68d829d60c7","owner":[],"postedDate":"April 4th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-04-09T13:09:35+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-04 17:25:08","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4115688","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4115688","identity":"rs-4115688","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}