F1000ResearchF1000Research2046-1402F1000 Research LimitedLondon, UK10.12688/f1000research.158097.2Case ReportArticlesCase Report: Case report: Hepatic and pulmonary echinococcosis with reactivated tuberculosis
[version 2; peer review: 2 approved with reservations, 1 not approved]
MohamedYousifResourcesSupervisionValidationWriting – Original Draft PreparationWriting – Review & Editinghttps://orcid.org/0009-0002-6415-866Xa1ArbabSohaibVisualizationWriting – Review & Editing2MohamedAliSupervisionWriting – Review & Editing3
Department of Radiology, University of Khartoum Faculty of Medicine, Khartoum, Khartoum, Sudan
Department of internal medicine, University of Khartoum Faculty of Medicine, Khartoum, Khartoum, Sudan
Department of internal medicine, Rochester general hospital, Rochester, New York, USAValyvxly@gmail.com
The co-infection of Pulmonary Tuberculosis (TB) and hydatid disease is rare. Diagnosis and treatment of this co-infection may be challenging as both diseases present with overlapping clinical manifestations, especially in war zones where the health system is destroyed. We are reporting a 45-year-old female police officer transferred to Sinnar Sudan due to ongoing conflict. She was admitted with chronic cough, shortness of breath, and weight loss. The preliminary diagnosis of pulmonary TB was made based on chest X-ray examination and sputum analysis. Further imaging showed cystic lesions in both the liver and the lungs, and thus a diagnosis of Echinococcosis was made. Surgical intervention was done successfully followed by the courses of Albendazole and anti-TB medication. The clinical condition of the patient improved, with the disappearance of all symptoms. This case represents the diagnostic dilemma of dual infections in the areas of their endemicity because of the symptomatology overlap that might occur and result in an erroneous diagnosis. It does demand an appropriate diagnostic approach, thus, with advanced imaging applications, and once more, emphasizes the interdisciplinary attitude in its treatment for the best possible result.
EchinococcosisTuberculosisCo-infectionHepatic cystsPulmonary cystsReactivation.The author(s) declared that no grants were involved in supporting this work.Amendments from Version 1
This revised edition presents some clinical clarifications and improvements. It specifies the nature of hepatic surgery (partial cystectomy) and incorporates crucial anaesthetic considerations along with details on postoperative care. From a radiological standpoint, the manuscript outlines definitive criteria to differentiate hydatid cysts from tuberculosis lesions, thereby enhancing diagnostic precision. It provides particular information regarding albendazole treatment and the monitoring of liver function tests. The discussion has been broadened to address the potential immunological link between hydatid disease and the reactivation of tuberculosis. These additions provide clinical insights alongside the practical advantages of the manuscript.
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.
Showing the patient laboratory investigation and reference ranges.
Parameter
Patient value
Reference range
Total WBCs
33.57 x 10
9/μL
4.5-11 x 10
9/μL
Lymphocytes %
06%
20-40%
Neutrophils %
88%
50-70%
Eosinophils %
08%
02-06%
Total RBCs
4.1 x 10
6/μL
4.5-6 x 10
6/μL
Hb count
10.7 g/dL
12-15 g/dL
Platelets count
747 x 10
3/μL
150-450 x 10
3/μL
Blood urea
32 mg/dL
10-50 mg/dL
Serum creatinine
0.9 mg/dL
0.7-1.4 mg/dL
C-reactive protein
88 mg/L
< 6 mg/L
ESR
130 mm/h
5-20 mm/h
ALT
21 IU/L
> 41 IU/L
Serum Albumin
2.8 g/dL
3.8-5.1 g/dL
Anti-Echinococcus IgG
16.8 IV
> 11 IV
RBG
135 mg/dL
70-180 mg/dL
(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 Echinococcosis
11 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.
Consent to publication
Written informed consent was obtained from the patient for publication of this case report and accompanying images.
Underlying data
No data are associated with this article.
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673570710.5256/f1000research.180566.r383200Reviewer response for version 2ChaariZied1Refereehttps://orcid.org/0000-0002-4006-4055
Department of Thoracic and Cardiovascular Surgery, Universite de Sfax, Sfax, Sfax, Tunisia
Competing interests: No competing interests were disclosed.
This case report highlights an uncommon but clinically significant co-infection of pulmonary tuberculosis and echinococcosis. It is timely and relevant for regions facing endemic burdens of both diseases.
However, while the case content is compelling, the manuscript requires improvements in referencing consistency, medical accuracy, and structural coherence.
Otherwise, some points should be listed:
Introduction section: emphasize the objectives of this case and the specificity of this case.
Case Report: make this part more precise and reduce repetition. Also, the case was not well explained, and pathology management is not-well based. It would be better if from the beginning, a CT or abdominal ultrasound was made, to show associated liver cyst which will make easier to identify the pathology and the association of both infections/
Discussion Section: especially immunology and public health implications. This part needs more precision according to the different physiopathology and the cause of this combined infection case!!
Standardize references and enrich them with current immunology and parasitology literature.
Refine scientific writing: use shorter, clearer sentences and remove colloquial expressions.
Add a conclusion section and if appropriate, list any limitations.
Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes?
Yes
Is the case presented with sufficient detail to be useful for other practitioners?
No
Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment?
Partly
Is the background of the case’s history and progression described in sufficient detail?
Partly
Reviewer Expertise:
Lung hydatidosis and pulmonary infections / Lung surgery
I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above.
10.5256/f1000research.180566.r379745Reviewer response for version 2UlasAli Bilal1Refereehttps://orcid.org/0000-0003-3880-2423
Department of Thoracic Surgery, Ataturk University, Erzurum, Turkey
Competing interests: No competing interests were disclosed.
Based on my review of the revised manuscript and responses to reviewers, I believe the authors have made significant improvements and addressed most of the key concerns raised during the peer review process.
The authors have provided much-needed clarification on the surgical procedure (open partial pericystectomy), anesthetic considerations, albendazole treatment duration and monitoring, and radiological criteria for differentiating hydatid cysts from TB lesions. They've also expanded the discussion on immunological interactions between the two infections and clarified laboratory reference ranges.
However, a few minor points could still be improved:
While the authors mention nutritional support, it would be helpful to specify exactly how malnutrition was assessed and managed in this patient. For example, were any standardized nutritional assessment tools used?
The discussion could briefly mention potential long-term follow-up strategies for such complex cases, especially given the resource-limited setting.
It would be valuable to include a brief comment on how conflict situations specifically impact the management of such co-infections beyond just limited resources such as patient transportation issues, interrupted treatment courses.
The authors might consider adding a sentence or two about the psychological impact of managing such complex conditions in war-torn areas, both for patients and healthcare providers.
Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes?
Partly
Is the case presented with sufficient detail to be useful for other practitioners?
Partly
Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment?
Partly
Is the background of the case’s history and progression described in sufficient detail?
Partly
Reviewer Expertise:
Thoracic Surgery
I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.
10.5256/f1000research.173644.r370084Reviewer response for version 1UlasAli Bilal1Refereehttps://orcid.org/0000-0003-3880-2423
Department of Thoracic Surgery, Ataturk University, Erzurum, Turkey
Competing interests: No competing interests were disclosed.
Firstly, thank you for submitting your interesting and clinically significant case report. The report touches upon a rare co-infection scenario involving hepatic and pulmonary echinococcosis complicated by reactivated pulmonary tuberculosis in an area affected by conflict, which indeed highlights crucial diagnostic and therapeutic challenges.
Your report highlights a rare yet noteworthy clinical presentation. The co-infection with hydatid disease and tuberculosis is unusual, but highly relevant in conflict zones or resource-limited settings. This makes your case notably interesting and contributes valuable insights, particularly for clinicians working under similar challenging conditions.
You effectively highlight the complexity and diagnostic challenge posed by overlapping symptoms of pulmonary TB and echinococcosis. This underlines the importance of maintaining high suspicion for multiple pathologies in endemic regions. The incorporation of diagnostic imaging, such as CT and ultrasound scans, is commendable and provides clear illustrations of the liver and lung lesions. The discussion acknowledges the practical difficulties clinicians face in war-torn areas, an essential context that adds great value to your report.
I appreciate the detailed presentation of laboratory and radiological findings. However, certain diagnostic procedures and clinical decisions would benefit from further explanation. Below, I'll walk you through some points that might help strengthen your paper.
Could you please elaborate on the specific surgical procedure used for hepatic echinococcosis? Was it a percutaneous aspiration or open surgery like cystectomy or hepatic resection? Clarifying whether a complete cystectomy, partial cystectomy, or cyst aspiration was performed would substantially enhance the practical usefulness of your report for surgeons and clinicians in similar settings.
Given the complexity of this patient's conditions like co-infection, systemic inflammation, malnutrition please elaborate on any anesthetic considerations or intraoperative complications encountered, and how they were managed.
In Figure 1(A), you mention a "round-shaped lesion" in the left lung; can you clarify the radiological criteria used to differentiate this lesion as hydatid rather than TB-related? You might consider labeling the images more clearly and distinctly to aid readers unfamiliar with radiology in quickly identifying the pathology described.
How long is the total duration of albendazole therapy? It would also be helpful to know whether liver enzymes or other biochemical parameters were monitored regularly during therapy to detect potential hepatotoxicity.
You might consider expanding slightly on the immunological or pathophysiological interplay between TB and hydatid disease based on existing literature. You could discuss or hypothesize more clearly how echinococcosis might have contributed immunologically to the reactivation of latent tuberculosis.
In Table 1, it might be beneficial to provide some clarification regarding the CRP reference (> 6 mg/L). Could you kindly explain if you intended to indicate a reference "below" 6 mg/L as normal? It would be greatly appreciated if you could clarify this (normal ranges usually indicate "< 6 mg/L" rather than ">6 mg/L").
It may be helpful to readers if you briefly mention the significance of the markedly elevated ESR and white cell count in relation to diagnosis and prognosis.
Discuss how you monitored anemia, nutritional status, or potential malnutrition in relation to TB reactivation, given your mention of these issues as significant contributors to TB reactivation in war-torn areas.
I would greatly appreciate it if you could address the points above, primarily focusing on the surgical and anesthetic aspects, therapy specifics, and clearer radiologic interpretations.
Warm regards,
Your Peer Reviewer
Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes?
Partly
Is the case presented with sufficient detail to be useful for other practitioners?
Partly
Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment?
Partly
Is the background of the case’s history and progression described in sufficient detail?
Partly
Reviewer Expertise:
Thoracic Surgery
I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.
Mohamed YousifUniversity of Khartoum Faculty of Medicine, Khartoum, Khartoum, Sudan
Competing interests: No competing interests were disclosed.
1042025
Dear Reviewer, Thank you very much for your thorough and insightful feedback on our case report. We truly appreciate the time you took to review our manuscript and for your encouraging remarks about the clinical relevance and context of our work. We are grateful for your suggestions and have addressed each of the points you raised as follows: 1. Surgical Procedure: We have clarified that the surgical intervention for hepatic echinococcosis involved a open partial pericystectomy was chosen due to the cyst’s size, location, and resource limitations. 2. Anesthetic Considerations & Intraoperative Complications: Additional details have been included regarding preoperative assessment, anesthetic risk (noting malnutrition and systemic inflammation), and intraoperative management. No major complications occurred, and the patient was managed with close intraoperative monitoring and postoperative supportive care. 3. Radiologic Criteria for Lung Lesion: We have elaborated on the CT findings used to differentiate hydatid cysts from TB lesions, including features like well-defined margins and lack of cavitation. Figure 1 has been updated with clearer labels to guide readers. 4. Albendazole Therapy Duration & Monitoring: The albendazole regimen (400 mg twice daily for 3 months) and the monitoring protocol (including regular liver enzyme tests) have been added to the manuscript to provide a clearer therapeutic context. 5. Immunological Interplay Between TB and Hydatid Disease: We expanded the discussion to include a brief review of the immunological mechanisms by which parasitic infections may alter host immunity and potentially facilitate TB reactivation, referencing relevant literature. 6. CRP Reference Range in Table 1: We corrected the CRP reference to “< 6 mg/L” to avoid confusion and ensure consistency with standard laboratory values. 7. ESR and WBC Significance: A sentence has been added discussing the diagnostic and prognostic relevance of elevated ESR and leukocytosis in the context of systemic infection and inflammation. 8. Anemia and Nutritional Status Monitoring: The manuscript now includes additional information on hemoglobin levels, nutritional support, and our approach to monitoring and managing malnutrition, which we agree is a key factor in TB reactivation, especially in conflict-affected regions. We sincerely thank you once again for your valuable comments, which have significantly improved the quality and clarity of our report. We hope that the revised version meets your expectations and continues to contribute meaningfully to the medical literature. Warm regards, Dr. Yousif Mohamed, On behalf of all co-authors
10.5256/f1000research.173644.r343283Reviewer response for version 1MihetiuAlin1Referee
Faculty of Medicine, County Clinical Emergency Hospital of Sibiu, Lucian Blaga University of Sibiu, Sibiu, Romania
Competing interests: No competing interests were disclosed.
Although a clear causal link cannot be established between hydatid infection and the activation of tuberculosis, the association of these pathologies in the context of a precarious economic framework can still be noted. The decrease in immunity may be due to the demands of the immune mechanisms given by the echinococcus infection, and may predispose to the activation of the tuberculosis disease, but a clear causal link, both physio pathologically and statistically, cannot be affirmed.
Data are needed to detail the type of surgical intervention used in the approach to the hepatic hydatid cyst and the challenges that anesthesia and the postoperative evolution of such a case entail.
Without such details, the article lacks the practical side, it being more of a report with a unique character but without a direct causal link and remains only in the area of a unique association.
Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes?
Partly
Is the case presented with sufficient detail to be useful for other practitioners?
Partly
Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment?
Yes
Is the background of the case’s history and progression described in sufficient detail?
Yes
Reviewer Expertise:
General Surgery, Liver Surgery, Hydatid Abdominal Surgery, Oncological Surgery, Laparoscopy
I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.
Mohamed YousifUniversity of Khartoum Faculty of Medicine, Khartoum, Khartoum, Sudan
Competing interests: No competing interests were disclosed.
1042025
Additionally, we acknowledge your valuable observation regarding the need for clarity on the potential pathophysiological connection between hydatid disease and tuberculosis. We agree that, while the two conditions may co-exist in immunocompromised individuals or in populations affected by poverty and malnutrition, a direct causal relationship cannot be definitively established based on current evidence. We have revised the discussion to better reflect this, emphasizing the association within the broader context of endemic diseases in conflict zones and resource-limited settings. We have also included detailed information about the type of surgical intervention (partial pericystectomy), the intraoperative and anesthetic considerations, and the postoperative course. These additions aim to enhance the practical utility of the report for clinicians who may encounter similar cases, particularly in regions facing limited healthcare resources and high burden of infectious diseases. We sincerely appreciate your emphasis on improving the clinical applicability of the manuscript, and we believe these revisions will strengthen the report both in scientific accuracy and practical value.