Diagnostic Dilemma in the Preoperative Differential Diagnosis of Recurrent Hepatic Echinococcosis with a Concomitant Pancreatic Cystic Lesion: A Case Report

Diagnostic Dilemma in the Preoperative Differential Diagnosis of Recurrent Hepatic Echinococcosis with a Concomitant Pancreatic Cystic Lesion: 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 Diagnostic Dilemma in the Preoperative Differential Diagnosis of Recurrent Hepatic Echinococcosis with a Concomitant Pancreatic Cystic Lesion: A Case Report Jiangkun Nie, Yameng Chen, Yindi Du, Qian Zhao This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9189492/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background Cystic echinococcosis (CE) is a zoonotic parasitic disease caused by the larval stage of Echinococcus granulosus. The liver is the organ most commonly affected, whereas pancreatic involvement is extremely rare. When a patient with recurrent hepatic CE also presents with a pancreatic cystic lesion, accurate preoperative diagnosis can be difficult because the imaging findings may overlap. Case presentation: A 36-year-old woman with a history of surgery for hepatic hydatid disease presented with intermittent right upper abdominal pain for 1 month. Serologic testing was positive for Echinococcus granulosus IgG. Imaging showed multiple hepatic cystic echinococcosis lesions classified as CE2, CE4, and CE5, together with a 16 mm cystic lesion in the body of the pancreas. The pancreatic lesion had a well-defined border, showed no contrast enhancement, and could not be clearly characterized before surgery. Pancreatic echinococcosis therefore could not be excluded. The patient underwent right hepatectomy, common bile duct exploration, and cholecystectomy. During surgery, the pancreatic lesion was examined, but it did not show typical features of hydatid disease. Pancreatic echinococcosis was considered unlikely, and no pancreatic resection was performed. Postoperative pathology confirmed hepatic cystic echinococcosis. The patient recovered well, and follow-up CT at 1 month showed reduced postoperative inflammatory changes in the surgical area, while the pancreatic cystic lesion remained stable in size without significant change. Conclusions In endemic areas, careful differential diagnosis is essential when recurrent hepatic cystic echinococcosis is accompanied by a pancreatic cystic lesion. In this setting, intraoperative assessment combined with postoperative imaging follow-up may support safe clinical management while helping to avoid unnecessary pancreatic resection. cystic echinococcosis hepatic echinococcosis pancreatic cystic lesion diagnostic challenge imaging-based differential diagnosis Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Background Cystic echinococcosis (CE) is a chronic parasitic disease caused by infection with the larval stage of Echinococcus granulosus. It is endemic in pastoral regions worldwide and is mainly found in western China, particularly in Qinghai, Xinjiang, and Tibet [ 1 ]. The liver is the organ most commonly affected, accounting for approximately 60%–75% of all cases [ 2 ]. Surgery remains the preferred treatment for cystic echinococcosis [ 3 ]. However, recurrence can still occur after surgery, with reported rates ranging from 2% to 25% [ 4 ]. Possible reasons include missed or residual lesions, intraoperative spillage of cyst fluid, and insufficient antiparasitic treatment during the perioperative period. When recurrent hepatic CE coexists with an incidentally detected pancreatic cystic lesion, it can be difficult to determine whether the pancreatic lesion represents secondary echinococcal spread or an unrelated benign cyst, such as a retention cyst or serous cyst. This distinction becomes even more challenging when serologic testing is positive and imaging findings are not specific. However, reports describing recurrent hepatic CE accompanied by a pancreatic cystic lesion are extremely rare, and the optimal diagnostic strategy for such presentations remains unclear. Here, we report a case of recurrent hepatic CE with a concomitant pancreatic cystic lesion. Preoperative imaging raised strong suspicion for pancreatic echinococcosis, but the lesion could not be definitively characterized due to the limitations of currently available diagnostic methods. By describing the diagnostic process and clinical management of this case, we aim to highlight the key challenges in this setting and provide practical information for clinicians. Case presentation A 36-year-old woman presented to the Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hospital of Qinghai University, in January 2026 with intermittent dull pain in the right upper abdomen for 1 month. She had undergone surgery for hepatic hydatid disease at the same hospital 15 years earlier, but details of her postoperative follow-up were unavailable. The patient had lived long term in Chengbei District, Xining, Qinghai Province, and reported a history of animal contact. She had no history of pancreatitis, diabetes, smoking, or alcohol use. On admission, her vital signs were stable. Physical examination showed mild tenderness in the right upper abdomen without rebound tenderness or guarding. No jaundice was observed, and the remainder of the examination was unremarkable. Laboratory testing showed mild anemia, with a hemoglobin level of 108 g/L, and hypoalbuminemia, with a serum albumin level of 32.5 g/L. Liver and renal function, serum amylase, lipase, blood glucose, and electrolytes were within normal ranges. Serologic tests for hepatitis B, hepatitis C, HIV, and syphilis were negative. Enzyme-linked immunosorbent assay showed positive Echinococcus granulosus-specific IgG antibodies. Imaging studies were then performed. Hepatobiliary and pancreatic ultrasonography demonstrated multiple cystic lesions in the liver, consistent with cystic echinococcosis, predominantly CE2 lesions with daughter cysts. Contrast-enhanced upper abdominal CT showed a giant cystic lesion in the right hepatic lobe, measuring approximately 13 × 10 × 18 cm, with multiple daughter cysts, consistent with CE2 disease, as well as a CE5 lesion in the hepatic dome. A 16 mm cystic low-density lesion was also identified in the pancreatic body; it had a well-defined margin and showed no enhancement on contrast imaging (Fig. 1 a, 1 b). Further evaluation with contrast-enhanced whole-abdomen MRI showed hepatic lesions consistent with CE2 and CE4 disease. The right hepatic duct and common hepatic duct were closely adjacent to the right hepatic lesion, but no intrahepatic or extrahepatic bile duct dilatation was seen. The cystic lesion in the pancreatic body showed long T1 and long T2 signal intensity, without enhancement or diffusion restriction, and pancreatic echinococcosis could not be excluded (Fig. 1 c, 1 d). Based on the patient’s medical history, epidemiologic background, laboratory findings, and imaging results, the preoperative diagnoses were as follows: recurrent hepatic cystic echinococcosis (CE2/CE4/CE5), cholelithiasis with chronic cholecystitis, and a cystic lesion in the pancreatic body of uncertain nature, with pancreatic echinococcosis and a simple pancreatic cyst both considered in the differential diagnosis. Before surgery, the patient received nutritional support to improve anemia and hypoalbuminemia. Three-dimensional liver reconstruction was performed to clarify the relationship between the hepatic lesion and adjacent vessels (Fig. 2 ), and multidisciplinary discussion was undertaken to optimize perioperative safety. After adequate preoperative preparation, the patient underwent right hepatectomy, cholecystectomy, and common bile duct exploration through a reverse L-shaped incision under general anesthesia on January 16, 2026. During the operation, the cystic lesion in the pancreatic body was also examined. However, no typical features of hydatid disease, such as an outer capsule or daughter cysts, were identified. Pancreatic echinococcosis was therefore considered unlikely at that time. Because the lesion was small and showed no evidence of invasive behavior, no pancreatic resection was performed, and postoperative imaging follow-up was recommended (Fig. 3 ). The operation was completed without intraoperative complications. The patient recovered from anesthesia uneventfully and was transferred safely back to the ward. Postoperatively, she received anti-infective treatment, liver-protective therapy, and nutritional support. During recovery, she developed a right pleural effusion and underwent thoracentesis with catheter drainage on January 23, 2026, which relieved her symptoms. She was discharged in stable condition on January 26, 2026. Postoperative pathology showed echinococcal cyst wall tissue in the right hepatic specimen, with fibrosis and chronic inflammatory changes, consistent with hepatic cystic echinococcosis (Fig. 4 ). The gallbladder specimen showed acute and chronic cholecystitis with focal glandular hyperplasia. At 1-month follow-up after discharge, abdominal CT showed decreased postoperative inflammatory changes in the surgical area. The cystic lesion in the pancreatic body remained stable at approximately 16 mm × 11 mm, with no significant change compared with the preoperative findings, and no inflammatory exudation was seen around the pancreas, suggesting short-term stability of the lesion (Fig. 5 ). Written informed consent was obtained from the patient for publication of her clinical information and imaging findings Discussion This case highlights the diagnostic challenge encountered when a pancreatic cystic lesion is detected in a patient with recurrent hepatic cystic echinococcosis in an endemic area. In such situations, distinguishing pancreatic echinococcosis from other cystic pancreatic lesions based solely on imaging findings may be extremely difficult. The differential diagnosis of pancreatic cystic lesions is broad and includes both non-neoplastic conditions, such as pseudocysts, and a range of cystic neoplasms. When a hydatid cyst lacks typical imaging features, its appearance may overlap with these entities, which makes accurate preoperative characterization particularly difficult [ 8 – 10 ]. At present, multimodal imaging, including ultrasonography, CT, and MRI, remains the basis for the diagnosis and staging of cystic echinococcosis and helps guide treatment according to the WHO-IWGE classification (CE1–CE5) [ 7 ]. Even so, currently available imaging methods are not always sufficiently sensitive or specific to define the nature of an indeterminate pancreatic cystic lesion before surgery, as seen in this case. Primary pancreatic hydatid disease is extremely uncommon, accounting for less than 1% of all hydatid infections[ 11 ], which further complicates the preoperative diagnostic process. Serologic testing can provide useful supportive evidence, but the results must be interpreted carefully in relation to lesion site and stage. In extrahepatic disease, serologic sensitivity is lower, and anti-Echinococcus granulosus IgG may remain positive for years after surgery or medical treatment. As a result, a single positive IgG result cannot reliably indicate biological activity and is also of limited value for determining the exact anatomical location of disease [ 5 – 6 ]. Although percutaneous biopsy could theoretically provide histologic confirmation, it is generally not used as a routine diagnostic approach in patients with suspected echinococcosis because leakage of cyst fluid may trigger allergic reactions or parasite dissemination [ 7 ]. This limitation further narrows the available options for preoperative diagnosis. In the present case, priority was given to treatment of the hepatic echinococcal lesions, while the pancreatic cystic lesion was assessed during the same operation. If intraoperative findings had supported pancreatic hydatid disease, cyst excision or pancreatic resection could have been considered. However, the lesion did not show typical hydatid features at surgery. Because it was small and showed no evidence of invasive behavior, no pancreatic procedure was performed, and postoperative imaging follow-up was recommended instead. This approach offered two advantages. First, it avoided unnecessary pancreatic resection and its potential complications. Second, it allowed continued assessment of the lesion over time through imaging surveillance. The 1-month follow-up CT showed that the pancreatic lesion remained stable, with no significant change in size and no inflammatory changes around the pancreas, which supports a cautious follow-up strategy in the short term. This case suggests that, in endemic areas, clinicians should keep a broad differential diagnosis when a patient with cystic echinococcosis also has a pancreatic cystic lesion. Such lesions should not be assumed to represent secondary echinococcal spread without sufficient evidence. When imaging findings are atypical and there are no clear signs of malignancy, close radiologic follow-up may be a safer and more reasonable management strategy. In summary, we report a case of recurrent hepatic cystic echinococcosis with a concomitant pancreatic cystic lesion that created a significant preoperative diagnostic challenge. Intraoperative assessment and short-term postoperative follow-up suggested that the pancreatic lesion had relatively stable biological behavior and did not support active or progressive disease at that stage. However, because follow-up remains limited and no pathologic diagnosis of the pancreatic lesion is available, continued long-term imaging surveillance is still required to clarify its nature and evolution. Abbreviations CE Cystic echinococcosis CT Computed tomography ELISA Enzyme-linked immunosorbent assay MRI Magnetic resonance imaging MRCP Magnetic resonance cholangiopancreatography US Ultrasonography Declarations Ethics approval and consent to participate Ethical approval was not required for this case report according to the institutional policies of the Affiliated Hospital of Qinghai University. The study was conducted in accordance with the principles of the Declaration of Helsinki. Written informed consent was obtained from the patient. Consent for publication Written informed consent was obtained from the patient for publication of this case report and the accompanying images. Funding No funding was received for this study. Author Contribution NJ and CY designed the study. DY collected the clinical data. NJ participated in the surgery. NJ and CY drafted the manuscript. All authors read and approved the final version of the manuscript. NJ and CY contributed equally to this work. ZQ supervised the study and provided final approval of the version to be published. Correspondence: Qian Zhao ( [email protected] ). Acknowledgement The authors would like to thank the patient for providing consent for publication. We also thank the staff of the Department of Hepatobiliary and Pancreatic Surgery and the Department of Pathology, Affiliated Hospital of Qinghai University, for their support in clinical management and data collection. Data Availability All data generated or analyzed during this study are included in this published article. The original imaging and pathology records are available from the corresponding author on reasonable request. References Tuerxun K, Abudoumijiti A, Yusupu Z, et al. Untargeted metabolomics reveals postoperative metabolic dynamics in hepatic cystic echinococcosis patients. Immunobiology. 2025;230(4):153099. Simforoosh N, Rabani S, Dadpour M, Torabi A. Large seminal vesicle hydatid cyst in a young male: A case report with technical modification approach. Int J Surg Case Rep. 2024;124:110350. Ezzatkhah F, Khalaf AK, Mahmoudvand H. Copper nanoparticles: Biosynthesis, characterization, and protoscolicidal effects alone and combined with albendazole against hydatid cyst protoscoleces. Biomed Pharmacother. 2021;136:111257. Zhao ZM, Yin ZZ, Meng Y, et al. Successful robotic radical resection of hepatic echinococcosis located in posterosuperior liver segments. World J Gastroenterol. 2020;26(21):2831–8. Sarkari B, Rezaei Z. Immunodiagnosis of human hydatid disease: Where do we stand? World J Methodol. 2015;5(4):185–95. Kronenberg PA, Deibel A, Gottstein B, et al. Serological Assays for Alveolar and Cystic Echinococcosis—A Comparative Multi-Test Study in Switzerland and Kyrgyzstan. Pathogens. 2022;11(5):518. Brunetti E, Kern P, Vuitton DA. Writing Panel for the WHO-IWGE. Expert consensus for the diagnosis and treatment of cystic and alveolar echinococcosis in humans. Acta Trop. 2010;114(1):1–16. Kothiya PK, Gupta V, Sarawagi R, et al. Isolated primary hydatid cyst of the pancreas: Management challenges of a cystic masquerade. Ann Hepatobiliary Pancreat Surg. 2022;26(4):401–6. Kim YH, Saini S, Sahani D, et al. Imaging diagnosis of cystic pancreatic lesions: pseudocyst versus nonpseudocyst. Radiographics. 2005;25(3):671–85. Morana G, Ciet P, Venturini S. Cystic pancreatic lesions: MR imaging findings and management. Insights Imaging. 2021;12(1):115. Jajal V, Nag H. A Pancreatic Hydatid Cysts Causing Recurrent Acute Pancreatitis Mimicking a Pancreatic Pseudocyst: A Case Report. Cureus. 2023;15(3):e36402. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 18 May, 2026 Reviewers agreed at journal 17 Apr, 2026 Reviewers invited by journal 15 Apr, 2026 Editor invited by journal 26 Mar, 2026 Editor assigned by journal 26 Mar, 2026 Submission checks completed at journal 26 Mar, 2026 First submitted to journal 22 Mar, 2026 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. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-9189492","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":624720167,"identity":"3e2f00c8-e224-4cfa-a02c-4880333ed090","order_by":0,"name":"Jiangkun Nie","email":"","orcid":"","institution":"Qinghai University","correspondingAuthor":false,"prefix":"","firstName":"Jiangkun","middleName":"","lastName":"Nie","suffix":""},{"id":624720168,"identity":"da44c16f-b613-4237-9fad-7c03679316f8","order_by":1,"name":"Yameng Chen","email":"","orcid":"","institution":"Qinghai University","correspondingAuthor":false,"prefix":"","firstName":"Yameng","middleName":"","lastName":"Chen","suffix":""},{"id":624720169,"identity":"581a1b84-61f5-4ae0-8fcc-e79e2fcf0c15","order_by":2,"name":"Yindi Du","email":"","orcid":"","institution":"Qinghai University","correspondingAuthor":false,"prefix":"","firstName":"Yindi","middleName":"","lastName":"Du","suffix":""},{"id":624720170,"identity":"f2c06b02-36c2-4d02-b282-ebb2c6a24b33","order_by":3,"name":"Qian Zhao","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyklEQVRIiWNgGAWjYBAC+/uPDz5I/PePh5+9gVg9B9KSDT6wHZCR7DlAtJYcM8EZbAdsDG4kEKmDseGMGTMPzx0ehpuPN95gqLGJJqiFmbGt7DGPxDMextlpxRYMx9JyGwhpYWNm3m7MY8DMwyydYybB2HCYsBYeNgYzaZ4EZh42yTNEapHgYTGTnHHgMA+PBA+RWgwk2JINPjakAXUA/ZJAjF8MJJiBUdlgY29//PDGGx9qbAhrQdWeQIpyiBZSdYyCUTAKRsHIAACmFzwUDteb0AAAAABJRU5ErkJggg==","orcid":"","institution":"Qinghai University Affiliated Hospital","correspondingAuthor":true,"prefix":"","firstName":"Qian","middleName":"","lastName":"Zhao","suffix":""}],"badges":[],"createdAt":"2026-03-22 06:53:44","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9189492/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9189492/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107618463,"identity":"c19a678d-9f64-4aa7-9475-17758969001e","added_by":"auto","created_at":"2026-04-23 09:25:29","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":265405,"visible":true,"origin":"","legend":"\u003cp\u003ePreoperative imaging findings. (a) Plain CT scan shows a large cystic mass in the right hepatic lobe containing multiple daughter cysts, presenting the typical \"cyst within a cyst\" sign (white arrow). (b) Contrast-enhanced CT reveals a well-defined, non-enhancing cystic lesion in the pancreatic body (white arrow). (c) MRI T2-weighted image shows a hyperintense cystic lesion in the pancreatic body (white arrow). (d) Contrast-enhanced MRI shows no enhancement of the lesion (white arrow).\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-9189492/v1/e1188dabdb0d021f89655419.png"},{"id":107618441,"identity":"ce6ad703-05d4-48ee-912e-1edc93149963","added_by":"auto","created_at":"2026-04-23 09:25:26","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":119646,"visible":true,"origin":"","legend":"\u003cp\u003eThree-dimensional reconstruction of the liver, illustrating the spatial relationship between the hepatic lesion and adjacent vessels.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-9189492/v1/85f7dc111efca43a2a8f438a.png"},{"id":107618459,"identity":"3f52ca7b-8a8b-4941-b1de-0e4c40b96ecd","added_by":"auto","created_at":"2026-04-23 09:25:28","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":204941,"visible":true,"origin":"","legend":"\u003cp\u003eIntraoperative photograph showing exposure of the pancreatic body. The cystic lesion (white arrow) has a smooth wall and lacks the characteristic outer capsule of a hydatid cyst.\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-9189492/v1/49f9f99a17bbb03e489a1d19.png"},{"id":107618560,"identity":"d95e735a-f6fa-4dc1-83d7-c7ed80b43a06","added_by":"auto","created_at":"2026-04-23 09:25:46","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":506175,"visible":true,"origin":"","legend":"\u003cp\u003eHistopathological examination of the hepatic lesion (hematoxylin and eosin stain). The image shows fibrotic cyst wall tissue with amorphous necrotic material on the inner aspect. The interstitium contains scattered acute and chronic inflammatory cell infiltration, along with vascular proliferation, dilation, congestion, and hemorrhage. Surrounding liver tissue is present. These findings are consistent with hepatic cystic echinococcosis.\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-9189492/v1/1d9e6ea935900dc2a5a0ecb5.png"},{"id":107618430,"identity":"578b781e-2398-4948-b418-091d7ffc65c1","added_by":"auto","created_at":"2026-04-23 09:25:18","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":146143,"visible":true,"origin":"","legend":"\u003cp\u003eFollow-up CT at one month postoperatively. The cystic lesion in the pancreatic body (white arrow) remains stable in size and appearance compared to preoperative imaging, with no peripancreatic inflammatory changes.\u003c/p\u003e","description":"","filename":"floatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-9189492/v1/b64d34543f99ff144c3e0b58.png"},{"id":107618927,"identity":"f7200c6c-477d-4349-bcc9-b291331540e9","added_by":"auto","created_at":"2026-04-23 09:26:46","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1467297,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9189492/v1/71e42739-2c5b-492d-af6a-cb4f9863c9f9.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Diagnostic Dilemma in the Preoperative Differential Diagnosis of Recurrent Hepatic Echinococcosis with a Concomitant Pancreatic Cystic Lesion: A Case Report","fulltext":[{"header":"Background","content":"\u003cp\u003eCystic echinococcosis (CE) is a chronic parasitic disease caused by infection with the larval stage of Echinococcus granulosus. It is endemic in pastoral regions worldwide and is mainly found in western China, particularly in Qinghai, Xinjiang, and Tibet [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The liver is the organ most commonly affected, accounting for approximately 60%\u0026ndash;75% of all cases [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSurgery remains the preferred treatment for cystic echinococcosis [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. However, recurrence can still occur after surgery, with reported rates ranging from 2% to 25% [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Possible reasons include missed or residual lesions, intraoperative spillage of cyst fluid, and insufficient antiparasitic treatment during the perioperative period.\u003c/p\u003e \u003cp\u003eWhen recurrent hepatic CE coexists with an incidentally detected pancreatic cystic lesion, it can be difficult to determine whether the pancreatic lesion represents secondary echinococcal spread or an unrelated benign cyst, such as a retention cyst or serous cyst. This distinction becomes even more challenging when serologic testing is positive and imaging findings are not specific.\u003c/p\u003e \u003cp\u003eHowever, reports describing recurrent hepatic CE accompanied by a pancreatic cystic lesion are extremely rare, and the optimal diagnostic strategy for such presentations remains unclear. Here, we report a case of recurrent hepatic CE with a concomitant pancreatic cystic lesion. Preoperative imaging raised strong suspicion for pancreatic echinococcosis, but the lesion could not be definitively characterized due to the limitations of currently available diagnostic methods. By describing the diagnostic process and clinical management of this case, we aim to highlight the key challenges in this setting and provide practical information for clinicians.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eA 36-year-old woman presented to the Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hospital of Qinghai University, in January 2026 with intermittent dull pain in the right upper abdomen for 1 month. She had undergone surgery for hepatic hydatid disease at the same hospital 15 years earlier, but details of her postoperative follow-up were unavailable.\u003c/p\u003e \u003cp\u003eThe patient had lived long term in Chengbei District, Xining, Qinghai Province, and reported a history of animal contact. She had no history of pancreatitis, diabetes, smoking, or alcohol use. On admission, her vital signs were stable. Physical examination showed mild tenderness in the right upper abdomen without rebound tenderness or guarding. No jaundice was observed, and the remainder of the examination was unremarkable.\u003c/p\u003e \u003cp\u003eLaboratory testing showed mild anemia, with a hemoglobin level of 108 g/L, and hypoalbuminemia, with a serum albumin level of 32.5 g/L. Liver and renal function, serum amylase, lipase, blood glucose, and electrolytes were within normal ranges. Serologic tests for hepatitis B, hepatitis C, HIV, and syphilis were negative. Enzyme-linked immunosorbent assay showed positive Echinococcus granulosus-specific IgG antibodies.\u003c/p\u003e \u003cp\u003eImaging studies were then performed. Hepatobiliary and pancreatic ultrasonography demonstrated multiple cystic lesions in the liver, consistent with cystic echinococcosis, predominantly CE2 lesions with daughter cysts. Contrast-enhanced upper abdominal CT showed a giant cystic lesion in the right hepatic lobe, measuring approximately 13 \u0026times; 10 \u0026times; 18 cm, with multiple daughter cysts, consistent with CE2 disease, as well as a CE5 lesion in the hepatic dome. A 16 mm cystic low-density lesion was also identified in the pancreatic body; it had a well-defined margin and showed no enhancement on contrast imaging (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ea, \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eb).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFurther evaluation with contrast-enhanced whole-abdomen MRI showed hepatic lesions consistent with CE2 and CE4 disease. The right hepatic duct and common hepatic duct were closely adjacent to the right hepatic lesion, but no intrahepatic or extrahepatic bile duct dilatation was seen. The cystic lesion in the pancreatic body showed long T1 and long T2 signal intensity, without enhancement or diffusion restriction, and pancreatic echinococcosis could not be excluded (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ec, \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ed).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eBased on the patient\u0026rsquo;s medical history, epidemiologic background, laboratory findings, and imaging results, the preoperative diagnoses were as follows: recurrent hepatic cystic echinococcosis (CE2/CE4/CE5), cholelithiasis with chronic cholecystitis, and a cystic lesion in the pancreatic body of uncertain nature, with pancreatic echinococcosis and a simple pancreatic cyst both considered in the differential diagnosis.\u003c/p\u003e \u003cp\u003eBefore surgery, the patient received nutritional support to improve anemia and hypoalbuminemia. Three-dimensional liver reconstruction was performed to clarify the relationship between the hepatic lesion and adjacent vessels (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), and multidisciplinary discussion was undertaken to optimize perioperative safety.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAfter adequate preoperative preparation, the patient underwent right hepatectomy, cholecystectomy, and common bile duct exploration through a reverse L-shaped incision under general anesthesia on January 16, 2026. During the operation, the cystic lesion in the pancreatic body was also examined. However, no typical features of hydatid disease, such as an outer capsule or daughter cysts, were identified. Pancreatic echinococcosis was therefore considered unlikely at that time. Because the lesion was small and showed no evidence of invasive behavior, no pancreatic resection was performed, and postoperative imaging follow-up was recommended (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe operation was completed without intraoperative complications. The patient recovered from anesthesia uneventfully and was transferred safely back to the ward. Postoperatively, she received anti-infective treatment, liver-protective therapy, and nutritional support. During recovery, she developed a right pleural effusion and underwent thoracentesis with catheter drainage on January 23, 2026, which relieved her symptoms. She was discharged in stable condition on January 26, 2026.\u003c/p\u003e \u003cp\u003ePostoperative pathology showed echinococcal cyst wall tissue in the right hepatic specimen, with fibrosis and chronic inflammatory changes, consistent with hepatic cystic echinococcosis (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The gallbladder specimen showed acute and chronic cholecystitis with focal glandular hyperplasia.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAt 1-month follow-up after discharge, abdominal CT showed decreased postoperative inflammatory changes in the surgical area. The cystic lesion in the pancreatic body remained stable at approximately 16 mm \u0026times; 11 mm, with no significant change compared with the preoperative findings, and no inflammatory exudation was seen around the pancreas, suggesting short-term stability of the lesion (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e Written informed consent was obtained from the patient for publication of her clinical information and imaging findings\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis case highlights the diagnostic challenge encountered when a pancreatic cystic lesion is detected in a patient with recurrent hepatic cystic echinococcosis in an endemic area. In such situations, distinguishing pancreatic echinococcosis from other cystic pancreatic lesions based solely on imaging findings may be extremely difficult. The differential diagnosis of pancreatic cystic lesions is broad and includes both non-neoplastic conditions, such as pseudocysts, and a range of cystic neoplasms. When a hydatid cyst lacks typical imaging features, its appearance may overlap with these entities, which makes accurate preoperative characterization particularly difficult [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAt present, multimodal imaging, including ultrasonography, CT, and MRI, remains the basis for the diagnosis and staging of cystic echinococcosis and helps guide treatment according to the WHO-IWGE classification (CE1\u0026ndash;CE5) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Even so, currently available imaging methods are not always sufficiently sensitive or specific to define the nature of an indeterminate pancreatic cystic lesion before surgery, as seen in this case. Primary pancreatic hydatid disease is extremely uncommon, accounting for less than 1% of all hydatid infections[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], which further complicates the preoperative diagnostic process.\u003c/p\u003e \u003cp\u003eSerologic testing can provide useful supportive evidence, but the results must be interpreted carefully in relation to lesion site and stage. In extrahepatic disease, serologic sensitivity is lower, and anti-Echinococcus granulosus IgG may remain positive for years after surgery or medical treatment. As a result, a single positive IgG result cannot reliably indicate biological activity and is also of limited value for determining the exact anatomical location of disease [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough percutaneous biopsy could theoretically provide histologic confirmation, it is generally not used as a routine diagnostic approach in patients with suspected echinococcosis because leakage of cyst fluid may trigger allergic reactions or parasite dissemination [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This limitation further narrows the available options for preoperative diagnosis.\u003c/p\u003e \u003cp\u003eIn the present case, priority was given to treatment of the hepatic echinococcal lesions, while the pancreatic cystic lesion was assessed during the same operation. If intraoperative findings had supported pancreatic hydatid disease, cyst excision or pancreatic resection could have been considered. However, the lesion did not show typical hydatid features at surgery. Because it was small and showed no evidence of invasive behavior, no pancreatic procedure was performed, and postoperative imaging follow-up was recommended instead.\u003c/p\u003e \u003cp\u003eThis approach offered two advantages. First, it avoided unnecessary pancreatic resection and its potential complications. Second, it allowed continued assessment of the lesion over time through imaging surveillance. The 1-month follow-up CT showed that the pancreatic lesion remained stable, with no significant change in size and no inflammatory changes around the pancreas, which supports a cautious follow-up strategy in the short term.\u003c/p\u003e \u003cp\u003eThis case suggests that, in endemic areas, clinicians should keep a broad differential diagnosis when a patient with cystic echinococcosis also has a pancreatic cystic lesion. Such lesions should not be assumed to represent secondary echinococcal spread without sufficient evidence. When imaging findings are atypical and there are no clear signs of malignancy, close radiologic follow-up may be a safer and more reasonable management strategy.\u003c/p\u003e \u003cp\u003eIn summary, we report a case of recurrent hepatic cystic echinococcosis with a concomitant pancreatic cystic lesion that created a significant preoperative diagnostic challenge. Intraoperative assessment and short-term postoperative follow-up suggested that the pancreatic lesion had relatively stable biological behavior and did not support active or progressive disease at that stage. However, because follow-up remains limited and no pathologic diagnosis of the pancreatic lesion is available, continued long-term imaging surveillance is still required to clarify its nature and evolution.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCystic echinococcosis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eComputed tomography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eELISA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEnzyme-linked immunosorbent assay\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMRI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMagnetic resonance imaging\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMRCP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMagnetic resonance cholangiopancreatography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eUS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eUltrasonography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e \u003cp\u003eEthical approval was not required for this case report according to the institutional policies of the Affiliated Hospital of Qinghai University. The study was conducted in accordance with the principles of the Declaration of Helsinki. Written informed consent was obtained from the patient.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003e Written informed consent was obtained from the patient for publication of this case report and the accompanying images.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eNo funding was received for this study.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eNJ and CY designed the study. DY collected the clinical data. NJ participated in the surgery. NJ and CY drafted the manuscript. All authors read and approved the final version of the manuscript. NJ and CY contributed equally to this work. ZQ supervised the study and provided final approval of the version to be published. Correspondence: Qian Zhao ([email protected]).\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003e The authors would like to thank the patient for providing consent for publication. We also thank the staff of the Department of Hepatobiliary and Pancreatic Surgery and the Department of Pathology, Affiliated Hospital of Qinghai University, for their support in clinical management and data collection.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eAll data generated or analyzed during this study are included in this published article. The original imaging and pathology records are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eTuerxun K, Abudoumijiti A, Yusupu Z, et al. Untargeted metabolomics reveals postoperative metabolic dynamics in hepatic cystic echinococcosis patients. Immunobiology. 2025;230(4):153099.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSimforoosh N, Rabani S, Dadpour M, Torabi A. Large seminal vesicle hydatid cyst in a young male: A case report with technical modification approach. Int J Surg Case Rep. 2024;124:110350.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEzzatkhah F, Khalaf AK, Mahmoudvand H. Copper nanoparticles: Biosynthesis, characterization, and protoscolicidal effects alone and combined with albendazole against hydatid cyst protoscoleces. Biomed Pharmacother. 2021;136:111257.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhao ZM, Yin ZZ, Meng Y, et al. Successful robotic radical resection of hepatic echinococcosis located in posterosuperior liver segments. World J Gastroenterol. 2020;26(21):2831\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSarkari B, Rezaei Z. Immunodiagnosis of human hydatid disease: Where do we stand? World J Methodol. 2015;5(4):185\u0026ndash;95.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKronenberg PA, Deibel A, Gottstein B, et al. Serological Assays for Alveolar and Cystic Echinococcosis\u0026mdash;A Comparative Multi-Test Study in Switzerland and Kyrgyzstan. Pathogens. 2022;11(5):518.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrunetti E, Kern P, Vuitton DA. Writing Panel for the WHO-IWGE. Expert consensus for the diagnosis and treatment of cystic and alveolar echinococcosis in humans. Acta Trop. 2010;114(1):1\u0026ndash;16.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKothiya PK, Gupta V, Sarawagi R, et al. Isolated primary hydatid cyst of the pancreas: Management challenges of a cystic masquerade. Ann Hepatobiliary Pancreat Surg. 2022;26(4):401\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim YH, Saini S, Sahani D, et al. Imaging diagnosis of cystic pancreatic lesions: pseudocyst versus nonpseudocyst. Radiographics. 2005;25(3):671\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMorana G, Ciet P, Venturini S. Cystic pancreatic lesions: MR imaging findings and management. Insights Imaging. 2021;12(1):115.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJajal V, Nag H. A Pancreatic Hydatid Cysts Causing Recurrent Acute Pancreatitis Mimicking a Pancreatic Pseudocyst: A Case Report. Cureus. 2023;15(3):e36402.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"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":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"cystic echinococcosis, hepatic echinococcosis, pancreatic cystic lesion, diagnostic challenge, imaging-based differential diagnosis","lastPublishedDoi":"10.21203/rs.3.rs-9189492/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9189492/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eCystic echinococcosis (CE) is a zoonotic parasitic disease caused by the larval stage of Echinococcus granulosus. The liver is the organ most commonly affected, whereas pancreatic involvement is extremely rare. When a patient with recurrent hepatic CE also presents with a pancreatic cystic lesion, accurate preoperative diagnosis can be difficult because the imaging findings may overlap.\u003c/p\u003e\u003ch2\u003eCase presentation:\u003c/h2\u003e \u003cp\u003eA 36-year-old woman with a history of surgery for hepatic hydatid disease presented with intermittent right upper abdominal pain for 1 month. Serologic testing was positive for Echinococcus granulosus IgG. Imaging showed multiple hepatic cystic echinococcosis lesions classified as CE2, CE4, and CE5, together with a 16 mm cystic lesion in the body of the pancreas. The pancreatic lesion had a well-defined border, showed no contrast enhancement, and could not be clearly characterized before surgery. Pancreatic echinococcosis therefore could not be excluded. The patient underwent right hepatectomy, common bile duct exploration, and cholecystectomy. During surgery, the pancreatic lesion was examined, but it did not show typical features of hydatid disease. Pancreatic echinococcosis was considered unlikely, and no pancreatic resection was performed. Postoperative pathology confirmed hepatic cystic echinococcosis. The patient recovered well, and follow-up CT at 1 month showed reduced postoperative inflammatory changes in the surgical area, while the pancreatic cystic lesion remained stable in size without significant change.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eIn endemic areas, careful differential diagnosis is essential when recurrent hepatic cystic echinococcosis is accompanied by a pancreatic cystic lesion. In this setting, intraoperative assessment combined with postoperative imaging follow-up may support safe clinical management while helping to avoid unnecessary pancreatic resection.\u003c/p\u003e","manuscriptTitle":"Diagnostic Dilemma in the Preoperative Differential Diagnosis of Recurrent Hepatic Echinococcosis with a Concomitant Pancreatic Cystic Lesion: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-23 09:23:51","doi":"10.21203/rs.3.rs-9189492/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-18T21:29:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"44609864783976231711302560189709859001","date":"2026-04-17T06:18:36+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-15T08:18:57+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-26T17:02:44+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-26T11:58:45+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-26T11:57:44+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Infectious Diseases","date":"2026-03-22T06:38:34+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"70ba58d3-1d1d-42c4-9bbe-a14c7915df36","owner":[],"postedDate":"April 23rd, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-18T21:29:00+00:00","index":43,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-23T09:23:55+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-23 09:23:51","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9189492","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9189492","identity":"rs-9189492","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}