Long medical journey of a patient with hepatic echinococcosis: a case report

Long medical journey of a patient with hepatic echinococcosis: a case report | 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 Long medical journey of a patient with hepatic echinococcosis: a case report Bo Qian, Lixin Lou, XiaoHua Li, Peng Zhang, Kaiyu Zhang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8292733/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 Hepatic echinococcosis is uncommon in Northeast China and often presents atypically, leading to misdiagnosis. We report a patient initially misdiagnosed with liver abscess whose prolonged and complicated course highlights the pitfalls in recognising this parasitic disease. A 48-year-old woman from Northeast China was referred after an 18-month odyssey of intermittent right-upper-quadrant pain repeatedly labelled "liver abscess". Multiple percutaneous drains, prolonged antibiotics and eventual sinus formation failed to control the lesion. Contrast CT at our centre raised the suspicion of metastases, whereas subsequent PET-CT favoured chronic infection but could not rule out abscess. However, percutaneous liver biopsy coupled with metagenomic sequencing identified Echinococcus multilocularis, and histopathology further confirmed necrotic granulomatous cysts consistent with a diagnosis of hepatic alveolar echinococcosis. She underwent radical hepatic resection in May 2024 followed by continuous albendazole. Post-operative imaging demonstrated complete removal, with no intra- or extra-hepatic relapse at 3-month follow-up, illustrating the importance of considering parasitic disease in indolent hepatic lesions.This case underscores the importance of including echinococcosis in the differential diagnosis of cystic hepatic lesions even in non-endemic areas of Northeast China. Early serological testing and characteristic imaging review can prevent unnecessary invasive procedures and guide definitive treatment. Hepatic echinococcosis Liver abscess Misdiagnose Figures Figure 1 Figure 2 Background Hepatic echinococcosis (also known as liver hydatid disease) is an infectious disease found worldwide that is mainly caused by Echinococcus granulosus and Echinococcus multilocularis , which cause cystic echinococcosis (CE) and alveolar echinococcosis (AE), respectively[ 1 ]. Adult Echinococcus tapeworms reside in carnivores and lay eggs in their intestines. These eggs are subsequently excreted in the faeces of the carnivores. Humans or intermediate hosts become infected by ingesting these eggs[ 2 ]. Due to its nonspecific clinical and imaging features, hepatic echinococcosis is frequently misdiagnosed as other liver diseases, carrying a high risk of diagnostic error. Moreover, hepatic echinococcosis remains life-threatening after surgery: a large-cohort study documented an 11.7% post-operative mortality rate, with advanced age and right-liver location being independent risk factors and the first 100 days the critical peak for fatal events[ 3 ]. These data underscore the need for greater clinical awareness. We therefore present a patient whose road to diagnosis was long and tortuous, hoping that her story will help clinicians recognise and manage this disease more promptly. Case presentation A 48-year-old woman experienced ongoing dull pain and bloating in the right upper abdomen starting on November 15, 2022, with no identifiable cause. The ultrasound (US) and positron emission tomography-computed tomography (PET-CT) images obtained at the local hospital indicated liver abscess. The patient then went to the Sino-Japanese Friendship Hospital of Jilin University on November 19, 2022. Laboratory tests revealed anaemia (haemoglobin, 87 g/L) and low albumin (34.79 g/L) in the patient. There were no obvious abnormalities in kidney function, coagulation, hepatitis marker, tumour marker, or procalcitonin levels. Liver US revealed 2 hypoechoic masses in the right lobe, which were considered abscesses; the largest mass was 8.0x4.9 cm in size. The patient underwent US-guided percutaneous drainage on November 20, 2022. After the puncture, the pus was cultured, and meropenem was given. No bacteria were found. On November 24, 2022, a doctor punctured a 3.6x2.1 cm hypoechoic mass under the right lobe's dorsal membrane. Three drainage tubes were inserted for pus. Abdominal pain and distension slightly improved—with no major changes in blood work post-punctures. The patient was discharged with tubes on November 29, 2022. Three months later, the patient still experienced mild upper abdominal discomfort and revisited the hospital on March 7, 2023. The results of the laboratory examinations were similar to those of previous studies. Pus culture conducted after admission suggested the presence of Pseudomonas aeruginosa . On March 10th, the doctor removed the central drainage tube under ultrasound guidance while leaving the other two drainage tubes in place. The patient was discharged on March 21 and received antibiotics and supportive symptomatic treatment during the hospitalization period. Only a small amount of pus flowed into the tubes every day. In July 2023, the patient underwent a follow-up ultrasound examination at the hospital, during which the drainage tubes were removed. The traditional Chinese medicine ointment was subsequently applied externally, and the dressing was changed daily, resulting in white pus. In August 2023, during the patient's ultrasound follow-up, sinus echoes were detected on the deep surface of the abdominal wall drainage tube. After a few months, a thumb-sized mass of tissue was detected protruding from the surface of the body at the point of sinus tract formation. The persistent 'liver abscess' led the patient to visit our hospital for further evaluation on April 22, 2024. Outpatient enhanced CT scans revealed multiple liver lesions highly suggestive of metastasis (Fig. 1 B). Her subsequent PET‒CT results suggested a high possibility of infectious lesions, and abscesses were not excluded (Fig. 1 C). To clarify the diagnosis, the patient was admitted to the ward; granulation tissue was observed under the application of a traditional Chinese medicine ointment on the upper right abdomen (Fig. 1 D). The conjunctiva of both eyelids appeared pale, and no obvious abnormalities were found during the subsequent physical examination. The results of the routine blood tests are shown in Table 1 . Given the patient's extensive medical history, we recommended a liver biopsy. After discussion, the patient agreed to undergo ultrasound-guided liver puncture. The puncture point was selected on the upper right abdomen (Fig. 1 E). Four liver tissue samples were obtained; three samples were subjected to pathological examination and acid‒fast staining, while one sample was subjected to DNA and RNA sequencing. The sequencing report identified Echinococcus multilocularis, with a sequence number of 103. Pathological findings revealed granulomatous lesions with extensive coagulative necrosis. Within the necrotic region, a powdery, unstructured, and cortical-like substance formed cysts of varying sizes. No clear germinal layer or scolex was observed. Furthermore, fibrous tissue proliferation was observed around the necrotic area and was accompanied by infiltration of lymphocytes, plasma cells, and a small number of eosinophils. Morphology did not exclude alveolar echinococcosis (Fig. 1 F-G). Postdiagnosis, the patient underwent surgery at Beijing Tsinghua Chang Gung Hospital on May 22, 2024 and experienced no postoperative discomfort. The regular use of albendazole was prescribed postsurgery. Figure 1 A briefly summarizes the patient's long journey of seeking medical treatment. This patients had a complex case of hepatic echinococcosis, with no obvious abnormalities in liver function, and the results of routine blood examination revealed anaemia only (Fig. 2A-F). The liver CT scan results from the patient's reexamination were satisfactory (Fig. 2G-H). The outpatient doctor considered that hepatic hydatid disease may have metastasized to the lungs; therefore, a lung CT scan was performed, which revealed only slight inflammation (Fig. 2I). and degenerated into a gel-like substance. Table 1 Laboratory Data. Variable Reference Range Day 1 Day 5 White-cell count (10 9 /L) 3.5–9.5 5.29 6.55 Differential count (%) Neutrophil 0.40–0.75 0.64 0.73 Lymphocytes 0.20–0.50 0.22 0.17 Monocytes 0.03–0.10 0.09 0.07 Eosinophils 0.004–0.08 0.049 0.029 Basophils 0.00-0.01 0.00 0.00 Red-cell count (10 12 /L) 3.80–5.10 3.97 3.87 Hemoglobin (g/L) 98 115–150 95 Mean corpuscular volume (fl) 82–100 84.1 82.7 Mean corpuscular hemoglobin(pg) 27–34 24.7 24.5 Mean corpuscular hemoglobin concentration (g/L) 316–354 293 297 Platelet count (10 9 /L) 125–350 317 282 Liver function Alkaline phosphatase (U/L) 35.0-100.0 103.6 115.9 Alanine aminotransferase (U/L) 7.0–40.0 8.7 24.4 Aspartate aminotransferase (U/L) 13.0–35.0 17.6 42.2 Albumin(g/L) 40.0–55.0 32.8 29.8 Bilirubin (umol/L) 0.0–21.0 7.2 11.7 Indirect bilirubin (umol/L) 5.0–20.0 4.3 9.8 Direct bilirubin (umol/L) 0.0-6.8 2.9 1.9 Twelve Female Tumor Markers All negative Inflammatory indicators Hypersensitive C-Reactive Protein (mg/L) 0–1.0 13.79 8.17 Procalcitonin (ng/ml) 0.00-0.500 0.012 Erythrocyte sedimentation rate (mm/1h) 0–20 97 Discussion We reported a case of hepatic echinococcosis that was initially misdiagnosed as a liver abscess, thus leading to a prolonged medical journey that lasted 2 years and caused distress to the patient. Previous records revealed that the patient had a liver abscess, but the persistent course of illness led to doubts. The most common manifestations of bacterial liver abscess are fever and abdominal pain. In a study of 178 bacterial liver abscess cases with fever and chills, our patient notably lacked fever[ 4 ]. Studies indicate that diabetes, proton pump inhibitor use, prior liver surgery, liver malignancies, and cholangitis are common risk factors for liver abscesses. Patients with bacterial liver abscess often have elevated WBC counts, anaemia, hypoalbuminaemia, and increased AST, ALT, GGT, and ALP levels[ 5 ]. Our patient lacked the abovementioned risk factors, had normal white blood cell counts, and exhibited no significant abnormalities in liver function. For most patients with bacterial liver abscesses, the pathogen can be identified through pus culture[ 6 ]. During the first hospitalization, the patient's pus cultures were negative. In addition, P. aeruginosa was identified. This opportunistic pathogen, which is commonly detected in medical settings and associated with medical devices such as catheters, is known for biofilm formation[ 7 ]. Therefore, we consider the significance to be minimal. Another challenge in this patient's diagnosis was differentiating liver hydatid disease from malignant tumours, as imaging can sometimes be inconclusive, a challenge also reported in similar cases[ 8 ]. In this patient's case, liver metastasis was considered likely after an enhanced CT scan. However, the absence of typical cancer symptoms, such as weight loss, abnormal tumour marker levels, and no disease progression on imaging over time, casts doubt on this diagnosis. The patient's definitive diagnosis of hepatic echinococcosis hinged on liver biopsy pathology and tissue sequencing, which are necessary when serology is inconclusive. These methods offer definitive diagnostic evidence, which is essential for treatment planning and prognosis assessment[ 9 ]. Despite medical advancements, the fact that liver hydatid disease is sometimes misdiagnosed as other liver conditions highlights the need for clinicians to exercise caution when diagnosing focal liver lesions[ 10 ]. Notably, a small number of patients with hepatic echinococcosis may present with some complications as the initial presentation, such as gastrointestinal bleeding, cholangitis, and fistula[ 11 – 13 ]. Spontaneous external fistula formation is a rare clinical manifestation of liver hydatid disease[ 14 ]. The diagnosis of liver echinococcosis lacks specific laboratory markers; however, some patients present with liver function abnormalities and elevated eosinophil levels[ 15 ]. Imaging examination forms the basis for diagnosing hepatic echinococcosis[ 16 ]. CT has unique advantages in visualizing the location, size, quantity, and other aspects of lesions. For CE, ultrasound remains the preferred imaging technique for staging lesions[ 17 ]. Serological examinations and pathology play important roles in the diagnosis of hepatic echinococcosis[ 18 – 19 ]. Albendazole is the cornerstone of all treatments for liver hydatid disease[ 20 ], and surgery remains an important treatment method[ 9 ]. In addition to traditional radical resection, some emerging surgical methods, including laparoscopic treatment, are gradually being applied and have become increasingly popular in recent years. Laparoscopy offers several advantages, such as minimal invasiveness, mild pain, a short postoperative hospital stay, and fast recovery[ 21 ]. Conclusions Hepatic hydatid disease is relatively rare in Northeast China. This case confirms that hepatic echinococcosis is a highly complex disease, and vigilance should be exercised in daily work for its identification and accurate diagnosis. Declarations Data availability statement The case materials used in this study involve patient privacy and have been de-identified for academic analysis only; thus they are not publicly deposited. Original data may be requested from the corresponding author ( [email protected] ) for legitimate academic purposes, subject to a confidentiality commitment and written authorization. Competing interests statement The authors declare that this study received no funding from commercial agencies or organizations and that they have no financial or non-financial conflicts of interest that could have influenced data collection and analysis, manuscript writing, or the decision to submit the paper. Author Contributions Statement Qian Bo and Lou Lixin were responsible for data collection and drafting the manuscript. Li Xiaohua and Zhang Peng prepared the figures and tables. Zhang Kaiyu revised the manuscript. Consent for publication This case report consists of a retrospective description of routine clinical data only and does not involve any additional interventions or disclosure of patient privacy. Written informed consent was obtained from the patient and his/her legal guardian. References MCMANUS D P, ZHANG W, LI J, et al. Echinococcosis[J]. Lancet,2003 362(9392).1295-1304.doi:10.1016/s0140-6736(03)14573-4 WEN H, VUITTON L, TUXUN T, et al. Echinococcosis: Advances in the 21st Century[J]. Clin Microbiol Rev,2019 32(2).doi:10.1128/cmr.00075-18 MUTLU V, ERZURUMLU K, YıLMAZ K. Multivariate 25-Year Trend Analysis of Mortality Due to Liver Hydatid Cysts[J]. Acta Parasitol,2025 70(6).209.doi:10.1007/s11686-025-01153-5 WANG W J, TAO Z, WU H L. Etiology and clinical manifestations of bacterial liver abscess: A study of 102 cases[J]. Medicine (Baltimore),2018 97(38).e12326.doi:10.1097/md.0000000000012326 MUKTHINUTHALAPATI V, ATTAR B M, PARRA-RODRIGUEZ L, et al. Risk Factors, Management, and Outcomes of Pyogenic Liver Abscess in a US Safety Net Hospital[J]. Dig Dis Sci,2020 65(5).1529-1538.doi:10.1007/s10620-019-05851-9 YIN D, JI C, ZHANG S, et al. Clinical characteristics and management of 1572 patients with pyogenic liver abscess: A 12-year retrospective study[J]. Liver Int,2021 41(4).810-818.doi:10.1111/liv.14760 TUON F F, DANTAS L R, SUSS P H, et al. Pathogenesis of the Pseudomonas aeruginosa Biofilm: A Review[J]. Pathogens,2022 11(3).doi:10.3390/pathogens11030300 ZHU D, ABUDUHELILI A, TULAHONG A, et al. A special case of intrahepatic cholangiocarcinoma misdiagnosed as hepatic cystic echinococcosis[J]. Heliyon,2024 10(15).e35073.doi:10.1016/j.heliyon.2024.e35073 BRESSON-HADNI S, SPAHR L, CHAPPUIS F. Hepatic Alveolar Echinococcosis[J]. Semin Liver Dis,2021 41(3).393-408.doi:10.1055/s-0041-1730925 MAGACHA H M, VEDANTAM V, VEDANTAM N, et al. Liver Hydatid Cyst Masquerading as a Liver Abscess[J]. Cureus,2023 15(1).e34334.doi:10.7759/cureus.34334 ONKA B, BENMOULA F Z, TRAORE W M, et al. A rare case: Spontaneous gastric fistula from a hydatid cyst of the liver[J]. BJR Case Rep,2022 7(6).20210087.doi:10.1259/bjrcr.20210087 ZOUAGHI A, BELLIL N, BEN ABDALLAH K, et al. Case Report: Portal cavernoma related to multiple liver hydatidosis: A rare case of fatal cataclysmic haemorrhage[J]. F1000Res,2021 10.1097.doi:10.12688/f1000research.74012.2 JIANG T, WANG Z, AJI T, et al. ERCP management of acute cholangitis caused by rupture of Echinococcus hepaticus into the biliary tract[J]. J Minim Access Surg,2023 19(4).498-503.doi:10.4103/jmas.jmas_219_22 JAYANT K, AGRAWAL S, AGARWAL R, et al. Spontaneous external fistula: the rarest presentation of hydatid cyst[J]. BMJ Case Rep,2014 2014.doi:10.1136/bcr-2014-203784 CHRISTODOULIDIS G, SAMARA A A, DIAMANTIS A, et al. Reaching the Challenging Diagnosis of Complicated Liver Hydatid Disease: A Single Institution's Experience from an Endemic Area[J]. Medicina (Kaunas),2021 57(11).doi:10.3390/medicina57111210 BOTEZATU C, MASTALIER B, PATRASCU T. Hepatic hydatid cyst - diagnose and treatment algorithm[J]. J Med Life,2018 11(3).203-209.doi:10.25122/jml-2018-0045 CALAME P, WECK M, BUSSE-COTE A, et al. Role of the radiologist in the diagnosis and management of the two forms of hepatic echinococcosis[J]. Insights Imaging,2022 13(1).68.doi:10.1186/s13244-022-01190-y LIU L S, GUO W P, WANG Y F, et al. [Hepatic echinococcus granulosus: a clinicopathological analysis of thirteen cases][J]. Zhonghua Bing Li Xue Za Zhi,2021 50(6).650-654.doi:10.3760/cma.j.cn112151-20210202-00119 MAHAJAN S, THAPAR S, KHILLAN V, et al. Comparative Evaluation of Echinococcus Serology with Cytology for the Diagnosis of Hepatic Hydatid Disease[J]. J Lab Physicians,2020 12(2).98-102.doi:10.1055/s-0040-1716460 BHALLA V P, PAUL S, KLAR E. Hydatid Disease of the Liver[J]. Visc Med,2023 39(5).112-120.doi:10.1159/000533807 ZAHARIE F, VALEAN D, ZAHARIE R, et al. Surgical management of hydatid cyst disease of the liver: An improvement from our previous experience?[J]. World J Gastrointest Surg,2023 15(5).847-858.doi:10.4240/wjgs.v15.i5.847 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. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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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-8292733","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":561834353,"identity":"8e8a367b-46ea-49e9-be50-c8df3b57775c","order_by":0,"name":"Bo Qian","email":"","orcid":"","institution":"The First Hospital of Jilin University","correspondingAuthor":false,"prefix":"","firstName":"Bo","middleName":"","lastName":"Qian","suffix":""},{"id":561834354,"identity":"d1984965-b4c1-4297-b87d-619c4f9a6e7b","order_by":1,"name":"Lixin Lou","email":"","orcid":"","institution":"The First Hospital of Jilin 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The enhanced scan reveals enhanced edges, but no dilation of the intrahepatic bile ducts is observed. Additionally, the liver exhibits a circular low-density shadow, measuring approximately 0.4 cm in diameter with a CT value of 16 HU. \u003cstrong\u003eFig 1C\u003c/strong\u003e: Patient's Liver PET-CT Images \u0026nbsp;Imaging findings revealed multiple nodules and low-density masses in the liver, with increased uptake at the margins measuring approximately 7.8 cm × 4.5 cm. The maximum SUV value is 13.3, and the CT value is 50.5 HU. \u003cstrong\u003eFig 1D\u003c/strong\u003e:\u003cstrong\u003e \u003c/strong\u003eUpon admission for physical examination, granulation tissue was observed protruding from the body surface in the abdomen, covered by a black substance derived from traditional Chinese medicine ingredients \u003cstrong\u003eFig 1E\u003c/strong\u003e: The arrow points to the liver puncture point. \u003cstrong\u003eFig 1F-G\u003c/strong\u003e: HE Staining of Liver Tissue Sections The pink area indicates necrosis. The light pink or transparent white, parallel layered structure, indicated by the arrow, is a partial residual structure of the parasite. The parasite's body has died and degenerated into a gel-like substance\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8292733/v1/c0a539d1a8b4fd8ce5cf709f.png"},{"id":98777971,"identity":"bed36013-d024-4c2f-ba58-274a602f423e","added_by":"auto","created_at":"2025-12-22 12:28:45","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":407093,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA-D \u003c/strong\u003e:\u003cstrong\u003e \u003c/strong\u003eLiver Function Throughout the Patient's Illness, Measured in U/L \u0026nbsp;\u003cstrong\u003eFig 2E\u003c/strong\u003e: White Blood Cell Count at Disease Onset, Measured in 10^9/L \u003cstrong\u003eFig 2F\u003c/strong\u003e: Hemoglobin levels in the patient during the onset of the disease, measured in g/L \u0026nbsp;\u003cstrong\u003eFig 2G-H\u003c/strong\u003e: Patient's Liver Plain Scan Image Re-examined on July 2, 2024 \u003cstrong\u003eFig 2I\u003c/strong\u003e: Patient's lung plain CT scan examined on July 2, 2024.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8292733/v1/cf62acba4c6debc8f1f351f9.png"},{"id":107317540,"identity":"3f6adaea-411a-4ea2-9eaf-840cd5079bad","added_by":"auto","created_at":"2026-04-20 09:58:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1278358,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8292733/v1/2660748b-1f5d-42a2-a0f8-26f17904fd2d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Long medical journey of a patient with hepatic echinococcosis: a case report","fulltext":[{"header":"Background","content":"\u003cp\u003eHepatic echinococcosis (also known as liver hydatid disease) is an infectious disease found worldwide that is mainly caused by \u003cem\u003eEchinococcus granulosus\u003c/em\u003e and \u003cem\u003eEchinococcus multilocularis\u003c/em\u003e, which cause cystic echinococcosis (CE) and alveolar echinococcosis (AE), respectively[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Adult Echinococcus tapeworms reside in carnivores and lay eggs in their intestines. These eggs are subsequently excreted in the faeces of the carnivores. Humans or intermediate hosts become infected by ingesting these eggs[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Due to its nonspecific clinical and imaging features, hepatic echinococcosis is frequently misdiagnosed as other liver diseases, carrying a high risk of diagnostic error. Moreover, hepatic echinococcosis remains life-threatening after surgery: a large-cohort study documented an 11.7% post-operative mortality rate, with advanced age and right-liver location being independent risk factors and the first 100 days the critical peak for fatal events[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. These data underscore the need for greater clinical awareness. We therefore present a patient whose road to diagnosis was long and tortuous, hoping that her story will help clinicians recognise and manage this disease more promptly.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eA 48-year-old woman experienced ongoing dull pain and bloating in the right upper abdomen starting on November 15, 2022, with no identifiable cause. The ultrasound (US) and positron emission tomography-computed tomography (PET-CT) images obtained at the local hospital indicated liver abscess. The patient then went to the Sino-Japanese Friendship Hospital of Jilin University on November 19, 2022. Laboratory tests revealed anaemia (haemoglobin, 87 g/L) and low albumin (34.79 g/L) in the patient. There were no obvious abnormalities in kidney function, coagulation, hepatitis marker, tumour marker, or procalcitonin levels. Liver US revealed 2 hypoechoic masses in the right lobe, which were considered abscesses; the largest mass was 8.0x4.9 cm in size. The patient underwent US-guided percutaneous drainage on November 20, 2022. After the puncture, the pus was cultured, and meropenem was given. No bacteria were found. On November 24, 2022, a doctor punctured a 3.6x2.1 cm hypoechoic mass under the right lobe\u0026apos;s dorsal membrane. Three drainage tubes were inserted for pus. Abdominal pain and distension slightly improved\u0026mdash;with no major changes in blood work post-punctures. The patient was discharged with tubes on November 29, 2022.\u003c/p\u003e\n\u003cp\u003eThree months later, the patient still experienced mild upper abdominal discomfort and revisited the hospital on March 7, 2023. The results of the laboratory examinations were similar to those of previous studies. Pus culture conducted after admission suggested the presence of \u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e. On March 10th, the doctor removed the central drainage tube under ultrasound guidance while leaving the other two drainage tubes in place. The patient was discharged on March 21 and received antibiotics and supportive symptomatic treatment during the hospitalization period. Only a small amount of pus flowed into the tubes every day. In July 2023, the patient underwent a follow-up ultrasound examination at the hospital, during which the drainage tubes were removed. The traditional Chinese medicine ointment was subsequently applied externally, and the dressing was changed daily, resulting in white pus. In August 2023, during the patient\u0026apos;s ultrasound follow-up, sinus echoes were detected on the deep surface of the abdominal wall drainage tube. After a few months, a thumb-sized mass of tissue was detected protruding from the surface of the body at the point of sinus tract formation.\u003c/p\u003e\n\u003cp\u003eThe persistent \u0026apos;liver abscess\u0026apos; led the patient to visit our hospital for further evaluation on April 22, 2024. Outpatient enhanced CT scans revealed multiple liver lesions highly suggestive of metastasis (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003eB). Her subsequent PET‒CT results suggested a high possibility of infectious lesions, and abscesses were not excluded (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003eC). To clarify the diagnosis, the patient was admitted to the ward; granulation tissue was observed under the application of a traditional Chinese medicine ointment on the upper right abdomen (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003eD). The conjunctiva of both eyelids appeared pale, and no obvious abnormalities were found during the subsequent physical examination. The results of the routine blood tests are shown in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. Given the patient\u0026apos;s extensive medical history, we recommended a liver biopsy. After discussion, the patient agreed to undergo ultrasound-guided liver puncture. The puncture point was selected on the upper right abdomen (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003eE). Four liver tissue samples were obtained; three samples were subjected to pathological examination and acid‒fast staining, while one sample was subjected to DNA and RNA sequencing. The sequencing report identified Echinococcus multilocularis, with a sequence number of 103. Pathological findings revealed granulomatous lesions with extensive coagulative necrosis. Within the necrotic region, a powdery, unstructured, and cortical-like substance formed cysts of varying sizes. No clear germinal layer or scolex was observed. Furthermore, fibrous tissue proliferation was observed around the necrotic area and was accompanied by infiltration of lymphocytes, plasma cells, and a small number of eosinophils. Morphology did not exclude alveolar echinococcosis (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003eF-G). Postdiagnosis, the patient underwent surgery at Beijing Tsinghua Chang Gung Hospital on May 22, 2024 and experienced no postoperative discomfort. The regular use of albendazole was prescribed postsurgery. Figure \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003eA briefly summarizes the patient\u0026apos;s long journey of seeking medical treatment.\u003c/p\u003e\n\u003cp\u003eThis patients had a complex case of hepatic echinococcosis, with no obvious abnormalities in liver function, and the results of routine blood examination revealed anaemia only (Fig. 2A-F). The liver CT scan results from the patient\u0026apos;s reexamination were satisfactory (Fig. 2G-H). The outpatient doctor considered that hepatic hydatid disease may have metastasized to the lungs; therefore, a lung CT scan was performed, which revealed only slight inflammation (Fig. 2I). and degenerated into a gel-like substance.\u003c/p\u003e\n \u003ctable id=\"Tab1\" border=\"1\" class=\"fr-table-selection-hover\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eLaboratory Data.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eReference Range\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDay 1\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDay 5\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWhite-cell count (10\u003csup\u003e9\u003c/sup\u003e/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.5\u0026ndash;9.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.55\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDifferential count (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNeutrophil\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.40\u0026ndash;0.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.73\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLymphocytes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.20\u0026ndash;0.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.17\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMonocytes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.03\u0026ndash;0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEosinophils\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.004\u0026ndash;0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.049\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.029\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBasophils\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.00-0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRed-cell count (10\u003csup\u003e12\u003c/sup\u003e/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.80\u0026ndash;5.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.87\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHemoglobin (g/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e115\u0026ndash;150\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e95\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMean corpuscular volume (fl)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e82\u0026ndash;100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e84.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e82.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMean corpuscular hemoglobin(pg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27\u0026ndash;34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMean corpuscular hemoglobin\u003c/p\u003e\n \u003cp\u003econcentration (g/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e316\u0026ndash;354\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e293\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e297\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePlatelet count (10\u003csup\u003e9\u003c/sup\u003e/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e125\u0026ndash;350\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e317\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e282\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLiver function\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAlkaline phosphatase (U/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35.0-100.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e103.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e115.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAlanine aminotransferase (U/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.0\u0026ndash;40.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAspartate aminotransferase (U/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.0\u0026ndash;35.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAlbumin(g/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40.0\u0026ndash;55.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBilirubin (umol/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.0\u0026ndash;21.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIndirect bilirubin (umol/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.0\u0026ndash;20.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDirect bilirubin (umol/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.0-6.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTwelve Female Tumor Markers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAll negative\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInflammatory indicators\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHypersensitive C-Reactive Protein \u0026nbsp;(mg/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u0026ndash;1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.17\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eProcalcitonin (ng/ml)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.00-0.500\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.012\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eErythrocyte sedimentation rate (mm/1h)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u0026ndash;20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe reported a case of hepatic echinococcosis that was initially misdiagnosed as a liver abscess, thus leading to a prolonged medical journey that lasted 2 years and caused distress to the patient. Previous records revealed that the patient had a liver abscess, but the persistent course of illness led to doubts. The most common manifestations of bacterial liver abscess are fever and abdominal pain. In a study of 178 bacterial liver abscess cases with fever and chills, our patient notably lacked fever[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Studies indicate that diabetes, proton pump inhibitor use, prior liver surgery, liver malignancies, and cholangitis are common risk factors for liver abscesses. Patients with bacterial liver abscess often have elevated WBC counts, anaemia, hypoalbuminaemia, and increased AST, ALT, GGT, and ALP levels[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Our patient lacked the abovementioned risk factors, had normal white blood cell counts, and exhibited no significant abnormalities in liver function. For most patients with bacterial liver abscesses, the pathogen can be identified through pus culture[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. During the first hospitalization, the patient's pus cultures were negative. In addition, \u003cem\u003eP. aeruginosa\u003c/em\u003e was identified. This opportunistic pathogen, which is commonly detected in medical settings and associated with medical devices such as catheters, is known for biofilm formation[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Therefore, we consider the significance to be minimal.\u003c/p\u003e \u003cp\u003eAnother challenge in this patient's diagnosis was differentiating liver hydatid disease from malignant tumours, as imaging can sometimes be inconclusive, a challenge also reported in similar cases[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In this patient's case, liver metastasis was considered likely after an enhanced CT scan. However, the absence of typical cancer symptoms, such as weight loss, abnormal tumour marker levels, and no disease progression on imaging over time, casts doubt on this diagnosis. The patient's definitive diagnosis of hepatic echinococcosis hinged on liver biopsy pathology and tissue sequencing, which are necessary when serology is inconclusive. These methods offer definitive diagnostic evidence, which is essential for treatment planning and prognosis assessment[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite medical advancements, the fact that liver hydatid disease is sometimes misdiagnosed as other liver conditions highlights the need for clinicians to exercise caution when diagnosing focal liver lesions[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Notably, a small number of patients with hepatic echinococcosis may present with some complications as the initial presentation, such as gastrointestinal bleeding, cholangitis, and fistula[\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Spontaneous external fistula formation is a rare clinical manifestation of liver hydatid disease[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe diagnosis of liver echinococcosis lacks specific laboratory markers; however, some patients present with liver function abnormalities and elevated eosinophil levels[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Imaging examination forms the basis for diagnosing hepatic echinococcosis[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. CT has unique advantages in visualizing the location, size, quantity, and other aspects of lesions. For CE, ultrasound remains the preferred imaging technique for staging lesions[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Serological examinations and pathology play important roles in the diagnosis of hepatic echinococcosis[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Albendazole is the cornerstone of all treatments for liver hydatid disease[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], and surgery remains an important treatment method[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In addition to traditional radical resection, some emerging surgical methods, including laparoscopic treatment, are gradually being applied and have become increasingly popular in recent years. Laparoscopy offers several advantages, such as minimal invasiveness, mild pain, a short postoperative hospital stay, and fast recovery[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eHepatic hydatid disease is relatively rare in Northeast China. This case confirms that hepatic echinococcosis is a highly complex disease, and vigilance should be exercised in daily work for its identification and accurate diagnosis.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData availability statement \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe case materials used in this study involve patient privacy and have been de-identified for academic analysis only; thus they are not publicly deposited. Original data may be requested from the corresponding author ([email protected]) for legitimate academic purposes, subject to a confidentiality commitment and written authorization.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that this study received no funding from commercial agencies or organizations and that they have no financial or non-financial conflicts of interest that could have influenced data collection and analysis, manuscript writing, or the decision to submit the paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions Statement \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eQian Bo and Lou Lixin were responsible for data collection and drafting the manuscript. Li Xiaohua and Zhang Peng prepared the figures and tables. Zhang Kaiyu revised the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis case report consists of a retrospective description of routine clinical data only and does not involve any additional interventions or disclosure of patient privacy. Written informed consent was obtained from the patient and his/her legal guardian.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMCMANUS D P, ZHANG W, LI J, et al. Echinococcosis[J]. Lancet,2003 362(9392).1295-1304.doi:10.1016/s0140-6736(03)14573-4\u003c/li\u003e\n\u003cli\u003eWEN H, VUITTON L, TUXUN T, et al. Echinococcosis: Advances in the 21st Century[J]. Clin Microbiol Rev,2019 32(2).doi:10.1128/cmr.00075-18\u003c/li\u003e\n\u003cli\u003eMUTLU V, ERZURUMLU K, YıLMAZ K. Multivariate 25-Year Trend Analysis of Mortality Due to Liver Hydatid Cysts[J]. Acta Parasitol,2025 70(6).209.doi:10.1007/s11686-025-01153-5\u003c/li\u003e\n\u003cli\u003eWANG W J, TAO Z, WU H L. Etiology and clinical manifestations of bacterial liver abscess: A study of 102 cases[J]. Medicine (Baltimore),2018 97(38).e12326.doi:10.1097/md.0000000000012326\u003c/li\u003e\n\u003cli\u003eMUKTHINUTHALAPATI V, ATTAR B M, PARRA-RODRIGUEZ L, et al. Risk Factors, Management, and Outcomes of Pyogenic Liver Abscess in a US Safety Net Hospital[J]. Dig Dis Sci,2020 65(5).1529-1538.doi:10.1007/s10620-019-05851-9\u003c/li\u003e\n\u003cli\u003eYIN D, JI C, ZHANG S, et al. Clinical characteristics and management of 1572 patients with pyogenic liver abscess: A 12-year retrospective study[J]. Liver Int,2021 41(4).810-818.doi:10.1111/liv.14760\u003c/li\u003e\n\u003cli\u003eTUON F F, DANTAS L R, SUSS P H, et al. Pathogenesis of the Pseudomonas aeruginosa Biofilm: A Review[J]. Pathogens,2022 11(3).doi:10.3390/pathogens11030300\u003c/li\u003e\n\u003cli\u003eZHU D, ABUDUHELILI A, TULAHONG A, et al. A special case of intrahepatic cholangiocarcinoma misdiagnosed as hepatic cystic echinococcosis[J]. Heliyon,2024 10(15).e35073.doi:10.1016/j.heliyon.2024.e35073\u003c/li\u003e\n\u003cli\u003eBRESSON-HADNI S, SPAHR L, CHAPPUIS F. Hepatic Alveolar Echinococcosis[J]. Semin Liver Dis,2021 41(3).393-408.doi:10.1055/s-0041-1730925\u003c/li\u003e\n\u003cli\u003eMAGACHA H M, VEDANTAM V, VEDANTAM N, et al. Liver Hydatid Cyst Masquerading as a Liver Abscess[J]. Cureus,2023 15(1).e34334.doi:10.7759/cureus.34334\u003c/li\u003e\n\u003cli\u003eONKA B, BENMOULA F Z, TRAORE W M, et al. A rare case: Spontaneous gastric fistula from a hydatid cyst of the liver[J]. BJR Case Rep,2022 7(6).20210087.doi:10.1259/bjrcr.20210087\u003c/li\u003e\n\u003cli\u003eZOUAGHI A, BELLIL N, BEN ABDALLAH K, et al. Case Report: Portal cavernoma related to multiple liver hydatidosis: A rare case of fatal cataclysmic haemorrhage[J]. F1000Res,2021 10.1097.doi:10.12688/f1000research.74012.2\u003c/li\u003e\n\u003cli\u003eJIANG T, WANG Z, AJI T, et al. ERCP management of acute cholangitis caused by rupture of Echinococcus hepaticus into the biliary tract[J]. J Minim Access Surg,2023 19(4).498-503.doi:10.4103/jmas.jmas_219_22\u003c/li\u003e\n\u003cli\u003eJAYANT K, AGRAWAL S, AGARWAL R, et al. Spontaneous external fistula: the rarest presentation of hydatid cyst[J]. BMJ Case Rep,2014 2014.doi:10.1136/bcr-2014-203784\u003c/li\u003e\n\u003cli\u003eCHRISTODOULIDIS G, SAMARA A A, DIAMANTIS A, et al. Reaching the Challenging Diagnosis of Complicated Liver Hydatid Disease: A Single Institution\u0026apos;s Experience from an Endemic Area[J]. Medicina (Kaunas),2021 57(11).doi:10.3390/medicina57111210\u003c/li\u003e\n\u003cli\u003eBOTEZATU C, MASTALIER B, PATRASCU T. Hepatic hydatid cyst - diagnose and treatment algorithm[J]. J Med Life,2018 11(3).203-209.doi:10.25122/jml-2018-0045\u003c/li\u003e\n\u003cli\u003eCALAME P, WECK M, BUSSE-COTE A, et al. Role of the radiologist in the diagnosis and management of the two forms of hepatic echinococcosis[J]. Insights Imaging,2022 13(1).68.doi:10.1186/s13244-022-01190-y\u003c/li\u003e\n\u003cli\u003eLIU L S, GUO W P, WANG Y F, et al. [Hepatic echinococcus granulosus: a clinicopathological analysis of thirteen cases][J]. Zhonghua Bing Li Xue Za Zhi,2021 50(6).650-654.doi:10.3760/cma.j.cn112151-20210202-00119\u003c/li\u003e\n\u003cli\u003eMAHAJAN S, THAPAR S, KHILLAN V, et al. Comparative Evaluation of Echinococcus Serology with Cytology for the Diagnosis of Hepatic Hydatid Disease[J]. J Lab Physicians,2020 12(2).98-102.doi:10.1055/s-0040-1716460\u003c/li\u003e\n\u003cli\u003eBHALLA V P, PAUL S, KLAR E. Hydatid Disease of the Liver[J]. Visc Med,2023 39(5).112-120.doi:10.1159/000533807\u003c/li\u003e\n\u003cli\u003eZAHARIE F, VALEAN D, ZAHARIE R, et al. Surgical management of hydatid cyst disease of the liver: An improvement from our previous experience?[J]. World J Gastrointest Surg,2023 15(5).847-858.doi:10.4240/wjgs.v15.i5.847\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"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},"keywords":"Hepatic echinococcosis, Liver abscess, Misdiagnose","lastPublishedDoi":"10.21203/rs.3.rs-8292733/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8292733/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eHepatic echinococcosis is uncommon in Northeast China and often presents atypically, leading to misdiagnosis. We report a patient initially misdiagnosed with liver abscess whose prolonged and complicated course highlights the pitfalls in recognising this parasitic disease. A 48-year-old woman from Northeast China was referred after an 18-month odyssey of intermittent right-upper-quadrant pain repeatedly labelled \"liver abscess\". Multiple percutaneous drains, prolonged antibiotics and eventual sinus formation failed to control the lesion. Contrast CT at our centre raised the suspicion of metastases, whereas subsequent PET-CT favoured chronic infection but could not rule out abscess. However, percutaneous liver biopsy coupled with metagenomic sequencing identified Echinococcus multilocularis, and histopathology further confirmed necrotic granulomatous cysts consistent with a diagnosis of hepatic alveolar echinococcosis. She underwent radical hepatic resection in May 2024 followed by continuous albendazole. Post-operative imaging demonstrated complete removal, with no intra- or extra-hepatic relapse at 3-month follow-up, illustrating the importance of considering parasitic disease in indolent hepatic lesions.This case underscores the importance of including echinococcosis in the differential diagnosis of cystic hepatic lesions even in non-endemic areas of Northeast China. Early serological testing and characteristic imaging review can prevent unnecessary invasive procedures and guide definitive treatment.\u003c/p\u003e","manuscriptTitle":"Long medical journey of a patient with hepatic echinococcosis: a case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-22 09:57:05","doi":"10.21203/rs.3.rs-8292733/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":"6f74d894-33d3-4ab3-a831-e267ae53d0b7","owner":[],"postedDate":"December 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-20T09:57:21+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-22 09:57:05","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8292733","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8292733","identity":"rs-8292733","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}