Cystic Echinococcosis in Arad County,Romania

Abstract

Cystic echinococcosis (CE) is a major parasitosis in Romania, a country where in the past at least one person from 45.5% of its localities underwent surgery for this disease. This survey aimed to provide new epidemiological and clinical data regarding human cases of CE in a western Romanian county. We have retrospectively investigated the medical records of the patients with CE hospitalized during the period of 2004–2010 in the surgical sections of Arad County. A total of 79 patients aged 5–88 years (mean age: 35.9±20.1 years) were diagnosed with CE during the study period. The average yearly incidence was 2.4 cases per 100,000 inhabitants, and the majority of the patients (29.1%) were aged 0–19 years. Most of the adult cases (≥18 years) were people with limited formal education (laborers) (45.6%). The analysis for trend showed an overall decrease in the affected persons over the study period (R ²=0.66, p=0.026). Hepatic localizations of the hydatid cysts predominated within the study group (73.4%). Only 21.5% of the diseased presented complications and the mean length of hospital stay was 16.2±10.9 days. Eosinophilia of at least 10% of the leukocyte value occurred in 14% of cases and leukocytosis was noticed in 24.1% of patients. Although the rates of CE cases have decreased in Arad County (Romania), this parasitic disease continues to be a concern for public health services and requires the implementation of more stringent prophylactic measures.

Introduction

C ystic echinococcosis (CE) is a parasitic zoonosis caused by Echinococcus granulosus, with the highest prevalence in temperate countries (Cox et al. 2007). Beside south-western and eastern Europe, considered as endemic regions for the E. granulosus complex (Sotiraki and Chaligiannis 2010), the disease is also widespread in the southern part of South America, the Mediterranean basin, the Middle East, southern and central areas of the former Soviet Union, central Asia, India, Nepal, China, Australia, and different parts of Africa (Cox et al. 2007). As it has been previously shown, CE is a major parasitosis in Romania, a country where in the past at least one person from 45.5% of its localities underwent surgery for this disease (Neghina et al. 2010).

The aim of this short communication is to provide new epidemiological and clinical data regarding human cases of CE in a western Romanian county.

Patients and Methods

We have retrospectively investigated the medical records of patients with CE hospitalized during the period of 2004–2010 in the surgical sections of Arad County. The following information was abstracted for each case according to a fixed protocol: registration number, age, sex, address, date and length of hospitalization, occupation, organ involvement, complications, routine laboratory tests, and outcome. The disease was confirmed in each patient by imagistic techniques (ultrasonography, computed tomography, magnetic resonance, or radiography) and serology (detection of specific anti-Echinococcus antibodies using ELISA).

Statistical analysis was performed using the software package SPSS version 17.0 for Windows (SPSS, Inc., Chicago, IL). Descriptive statistics (percentage, mean±standard deviation) were calculated for each variable as appropriate. The chi-square test (with Yates' correction for continuity) was used for the comparison of two proportions (from independent samples) expressed as a percentage. Trends over time for the number of the infected persons were determined by linear regression analysis. A p-value of less than 0.05 was regarded as statistically significant.

Results and Discussion

During the period of 2004–2010, a total of 79 patients aged 5–88 years (mean age: 35.9±20.1 years) were hospitalized in Arad County (see Supplementary Fig. S1 for geographical localization; Supplementary Data are available online at www.liebertonline.com/vbz) for CE. Similar mean age of the study group was also reported by other studies (Pierangeli et al. 2007, Bellil et al. 2009, Gonlugur et al. 2009, Mumtaz et al. 2009). The yearly average incidence (cases per 100,000 inhabitants) of 2.4 does not significantly vary from the value of 3 (p=0.86) reported in the same county during an earlier period (1985–1997) (Iacobiciu 1999). Similarly, a study performed during the same period (2004–2010) in Timis, a neighboring county, revealed an incidence of 3.8 cases (Calma et al. 2011) (p=0.87). The subgroup analyses showed the following incidence rates: 2.2 in male versus 2.6 in female and 2.4 in urban versus 2.5 in rural inhabitants. Adults (≥18 years) accounted for 72.2% of cases. The main epidemiological and clinical characteristics as well as the routine laboratory test results of the study group are presented in Table 1. The distribution of the adult patients according to their professional status showed the predominance of people with limited formal education (laborers) (45.6%) similar to findings from Timis County (49.4%) (Calma et al. 2011). The majority of the cases were diagnosed in summer and autumn (30.4%), but the number of hospital admissions registered a peak in January (12 cases) (Supplementary Fig. S2). The analysis for trend showed an overall decrease in the number of affected persons over the study period (R ²=0.66, p=0.026) (Fig. 1) and this may be explained by the implementation of more rigorous sanitary measures following the country's integration into the European Union (January 1, 2007). Hepatic localization of the hydatid cysts predominated within the study group (73.4%), similar to most surveys (Pierangeli et al. 2007, Ahmadi and Hamidi 2008, Gonlugur et al. 2009, Conchedda et al. 2010, Calma et al. 2011) (range of p-values: 0.65–0.94), but it was lower than that reported by Moreno et al. (2009) (97%, p=0.009) in Valencia, Spain. Only 21.5% of the diseased presented complications, similar to the value reported by Moreno et al. (2009) (30.3%, p=0.45) and Botrugno et al. (2010) (26.3%, p=0.73). On the other hand, only 8.8% of the cases from Timis County were complicated (Calma et al. 2011). The rupture of the cyst in the main biliary ducts was the most frequent complication (64.7%), comparable to the results of the study conducted by Botrugno et al. (2010) (50%, p=0.73). The mean hospitalization period was 16.2±10.9 days (comparable to the data presented by Conchedda et al. (2010) for ordinary admissions), with most of the cases (32.9%) staying in the hospital between 15 and 29 days. The mean eosinophil counts, leukocyte counts, and erythrocyte sedimentation rate (ESR) were 4.6%±4.4% (range: 1–24), 8534.8±2860.3 cells/mm³ (range: 4000–22,300), and 24.9±29.3 mm/h (range: 1–140), respectively. The values of the aforementioned blood tests ranged within normal limits in most of the patients. Eosinophilia of at least 10% of the leukocyte value occurred in 14% of cases, similar to a study from Hamedan, Iran (17%, p=0.67) (Ahmadi and Hamidi 2008). Leukocytosis occurred in 24.1% of cases, a similar percentage to that found by Ozyurtkan and Balci (2010) (37.5%, p=0.19). The outcome was favorable in all patients.

FIG. 1.

Number of cystic echinococcosis (CE) cases per year in Arad County, Romania, 2004–2010.

Table 1.

Epidemiological, Clinical, and Laboratory Characteristics of the Study Group

Characteristic	Distribution	No. of cases	Total cases ^a (%)
Age group (years)	0–19	23	29.1
	20–29	5	6.3
	30–39	16	20.3
	40–49	14	17.7
	50–59	11	13.9
	60–69	6	7.6
	≥70	4	5.1
Occupation^b	Laborers	26	45.6
	Retired	13	22.8
	Unemployed	3	5.3
	Freelancers	7	12.3
	Intellectuals & office workers	8	14.0
Season	Spring	12	15.2
	Summer	24	30.4
	Autumn	24	30.4
	Winter	19	24.1
Cyst localization	Liver	58	73.4
	Lung	11	13.9
	Kidney	3	3.8
	Spleen	2	2.5
	Liver & spleen	2	2.5
	Liver & kidney	1	1.3
	Liver, lung & kidney	1	1.3
	Liver & biliary tract	1	1.3
Complications	None	62	78.5
	Rupture	11	13.9
	Liver abscess	4	5.1
	Diaphragmatic abscess	1	1.3
	Super infections (without other specification)	1	1.3
Length of hospitalization (days)	1–7	21	26.6
	8–14	22	27.8
	15–29	26	32.9
	≥30	10	12.7
Eosinophil counts (% of leukocytes)^c	0–4.9 (normal)	52	65.8
	5–9.9	8	10.1
	10–19.9	10	12.7
	20–29.9	1	1.3
Leukocyte counts (cells/mm³)	≤9999 (normal)	60	75.9
	10,000–19,999	18	22.8
	≥20,000	1	1.3
Erythrocyte sedimentation rate (mm/h)^d	0–10 (normal)	27	34.2
	11–20	16	20.3
	≥21	24	30.4

Seventy-nine cases unless otherwise specified.

Fifty-seven cases—adult patients only (≥18 years old).

Seventy-one cases.

Sixty-seven cases.

Although the rates of CE cases have decreased in Arad County, Romania, during the period of 2004–2010, this parasitic disease continues to be a concern for public health services and requires the implementation of more stringent prophylactic measures.

Footnotes

Acknowledgments

The authors are grateful to Eng. Petru Calma for his technical assistance in collecting and computing the data and to Prof. Ioan Iacobiciu for his bibliographical support and useful advices in preparing the manuscript.

Disclosure Statement

No competing financial interests exist.

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