Case Report: Case report: Hepatic and  pulmonary echinococcosis with reactivated tuberculosis

Introduction

Echinococcosis is a disease that primarily affects developing nations with poor medical infrastructure, where cohabitation with domesticated animals is common.¹ It poses distinct difficulties because of the complicated nature of its diagnosis and treatment; moreover, it can metastasize similarly to cancer due to its elevated recurrence rate after therapy.²

The simultaneous presence of tuberculosis (TB) and hydatid disease in a person with a healthy immune system is a very uncommon situation. Due to the overlapping symptoms and complications associated with both conditions, accurately diagnosing individuals who are coinfected can be challenging.³ Many factors may influence the co-infection of TB and parasitic diseases, including sociodemographic factors related to gender and age, underlying diseases, and residency in co-endemic areas with a higher prevalence of M. tuberculosis and parasitic infection.⁴ Further research into the immunological interactions between the two diseases is needed, with the hope of improving therapeutic strategies.

Case report

Due to the conflict in Khartoum, a 45-year-old woman was compelled to relocate to Sinnar, Sudan, an area known for its abundance of domestic animals such as sheep, dogs, and goats. After two months of residence, she began experiencing symptoms of shortness of breath, chronic cough, and weight loss. The patient presented with fever and was found to have an erythrocyte sedimentation rate (ESR) of 130 mm per hour, a C-reactive protein level of 88 mg per liter, and a white blood cell count of 33750 per cubic millimeter with 88% neutrophils ( Table 1). A lung abscess was detected on her chest X-ray, leading to empyema, pneumothorax, and pleural effusion in the right lung ( Figure 1A). Additionally, an unidentified round-shaped lesion was observed in the left lung ( Figure 1A). Due to the limited resources in the area, including a lack of radiologists, technicians, and reliable power supply, physicians diagnosed the patient clinically with pulmonary tuberculosis and this was further confirmed by sputum analysis yielding acid fast bacilli. The appropriate treatment was initiated, including intravenous antibiotics and chest tube insertion for draining the empyema. She was discharged with anti-tuberculous medication and advised to return for a follow-up in two weeks.

Figure 1. (A) Antero-posterior CXR shows a round-shaped mass in the left lower lung lobe, “Asterix” Right lung showing pneumothorax “white arrow” and air-fluid level obscuring the right costophrenic angle “black arrow.” (B) Contrast enhanced Axial CT showing a solitary thin-walled cystic lesion at segments II and IV measuring 6.8 cm by 5.3 cm by 4.3 cm “Arrow”. No wall or septa enhancement. (C) Non-enhanced Coronal CT showing right lung loculated pneumothorax in the previous chest tube insertion “Arrow” with adjacent pleural thickening. A large, well-defined cystic lesion in the apical segment of the left lower lung lobe measuring 6.5 cm by 5.7 cm “Asterix” with thin wall. The lack of consolidation, cavitation and tree-in-bud appearance rouled out TB and pointed towards hydatid cyst.

The patient was readmitted due to upper abdominal fullness and a palpable mass in the liver. Abdominopelvic ultrasound indicated the presence of a cystic lesion in the left liver lobe, which was further confirmed by computed tomography showing a solitary thin-walled cystic lesion at segments two and four ( Figure 1B). Evaluation of chest Computed tomography (CT) revealed loculated pneumothorax, round lung collapse, and adjacent pleural thickening ( Figure 1C). The left lung lesion was suspected to be hydatid in origin due to its well-defined cystic appearance with a thin wall and lack of consolidation. Unlike TB lesions which typically presents with cavitation, fibrosis or tree-in-bud patterns. Moreover, the elevated ESR and WBCs supported active systemic inflammation rather than malignancy and collected with either TB or hydatid disease. A test using enzyme-linked immunosorbent assay revealed an anti-echinococcus IgG antibody index of 16.8 in the patient’s serum supporting the diagnosis of Echinococcosis, as well as reactivation of pulmonary Tuberculosis. Albendazole was administered at a dose of 400 mg twice daily for 3 months. Liver function tests (AST, ALT) was monitored throughout therapy to detect signs of hepatotoxicity, and no significant effects were observed. A partial pericystectomy was performed via open laparotomy as the cyst was located centrally and closely associated with vascular structures. The procedure included evacuation of the cyst contents, sterilization of the cavity and omentoplasty. Anesthesia was carefully tailored, close intraoperative monitoring and optimization with nutritional support was required. The patient tolerated the procedure well with no significant intraoperative complications reported. A follow-up ultrasound showed no signs of recurrence. The possibility of pleural decortication was considered to facilitate lung re-expansion.

Discussion

We reported a case of co-infection with Echinococcosis and TB, this combination of Echinococcosis and reactivated TB is definitely a diagnostic challenge and requires comprehensive diagnostic strategies in endemic areas.⁵ Overlapping clinical manifestations include cough and systemic symptoms which would render the differential diagnosis very extensive with the aid of imaging and microbiological investigations.⁶ Immunosuppressive effects due to parasitic infections are one of the predisposing factors for the reactivation of TB.⁷ Patients with risk factors for immunodeficiency conditions or those taking immunosuppressive drugs have a greater risk of opportunistic infection or coexistence. Co-infections should always be considered by physicians and investigated in those whose symptoms are resistant to treatment.⁴

Mycobacterium TB is controlled through Th1-type immunity (IFN-γ, TNF-α), whereas Echinococcus granulosus-induced hydatid disease induces Th2-type immunity (IL-4, IL-10, PGE2) which inhibits Th1 immunity and compromises control of TB.⁸ This immunological interplay between hydatid disease and TB can cause the re-activation of latent TB because these infections initiate alternative patterns of immunity.

Furthermore, hydatid infection modulates the mesenchymal stem cells (MSCs), down-expressing pro-inflammatory mediators (IL-6, NOS2/NO) and chemokines (MCP-1, CXCL1), and expressing anti-inflammatory mediators like COX2/PGE2.⁹ It therefore induces an immunosuppressive environment that destabilizes the granulomas of TB, inhibits macrophage activation and remodels cellular metabolism to enhance latent TB reactivation.

Many Civilians in Sudan suffer from malnutrition due to the ongoing war there which started in 2023, malnutrition heightens the likelihood of contracting tuberculosis (TB) and can lead to the reactivation of dormant pulmonary TB. Conversely, TB is known to contribute to malnutrition. Assessing the nutritional health and anemia of patients with active tuberculosis is a crucial aspect of managing the disease.¹⁰

Treatment should be done for both the infections simultaneously, keeping drug interactions and their adverse effects in mind: Albendazole-a benzimidazole acting against Echinococcosis¹¹ and standard ATT given for TB. Monitoring for hepatotoxicity is an important issue in view of hepatic involvement and drug interaction.¹²

The medical imaging modalities provide the keystones to diagnose the hydatid cysts. Among all, first line diagnosis, differential diagnosis, staging, establishing the role in interventional management, and follow-up is given by high-resolution ultrasound imaging. Unenhanced CT is useful where or when the ultrasound is unsatisfactory, as may be seen with chest and brain hydatid cysts, detection of calcification, and in obese patients.¹³ These modalities delivery may further deteriorate and become unavailable, especially in war-torn areas. Areas affected by conflict usually face a lack of radiologists and equipment, a situation worsened by violent events. This is contrary to the increasing need for radiology services during such conflicts.¹⁴ Which in turn makes confirming the diagnosis more difficult.

This case brings into consideration the importance of recognition of co-infection in the endemic regions. Interdisciplinary management and vigilant follow-up may result in successful clinical outcomes therapeutically. Further research in immunological interplay between these two infections could provide better therapeutic approaches.