NONSURGICAL TREATMENT OF CYSTIC ECHINOCOCCOSIS
Soheila Khazaee*, Mohammad Ismail Motlagh**, Saeed Khazaei***
Department of Infectious disease, **Department of Pediatrics, Ilam Medical University, ***Family Physician, Tehran, Iran.
Address for Correspondence
Dr Soheila Khazaei, Pediatric infectious Diseases, Ministry of Health and Medical Education, Tehran, Iran.
Email
dr.s.khazaee@gmail.com
Indications for chemotherapy of cystic echinococcosis :

Chemotherapy is certainly indicated for inoperable patients with primary lung or liver cysts, those with multiple cysts-specially in multiple organs making operative resection difficult or impossible and patients with peritoneal cysts which usually are multiple and result of secondary echinococcosis. (1) The use chemotherapy alone as the primary treatment of cystic echinococcosis in other patients as suggested by some authors (3,20,26) is not widely accepted because of relatively low and unpredictable cure rate. Chemotherapy also should be considered in patients with relapse of hydatid cyst after surgical treatment because of technical difficulties and relatively high complication rate associated with repeat surgery (27,28). Albendazole is widely used as adjunct pre-and post-operative chemotherapy with both surgery and percutaneous aspiration therapy to reduce incidence of secondary hydatidosis. Pre-operative chemotherapy not only decreases the number of viable protoscoleces, but also results in significant reduction of intracystic pressure, which facilitates surgical removal and percutaneous aspiration (1,28). Different dosages and durations of preoperative chemotherapy have been given in different studies from single dose of drug given 4 hours before procedure (to attain maximum serum concentration at time of procedure) to 1-3 months of preoperative treatment (20,30,31). Although World Health Organization (WHO) recommends preoperative chemotherapy for at least 4 days followed by continuous post-operative treatment for 1 and 3 months for albendazole and mebendazole respectively (1), prospective studies showed that increasing the duration of preoperative chemotherapy significantly increases the percentage of non viable cysts (20,30) and even 3 months of treatment was significantly more effective than 1 month. Combined regimen of albendazole plus praziquantel is also useful as preoperative therapy and apparently was more successful in decreasing the number of viable cysts compared with albendazole alone. (24)

It is shown in animal studies that post-spillage chemotherapy with albendazole for 1-2 weeks may be effective in reducing the implantation of protoscoleces even in the absence of previous chemotherapy (32) but little data on this aspect of treatment is available.

Precautions and Contraindications :

    Cyst characteristics: Because of relatively long time required for effect of antiparasitic drugs and its unpredictability, large cysts that have a risk of rupture (especially those superficially located or infected) should be excluded from medical therapy. (1)

    Pregnancy: Benzimidazoles show teratogenic potential in animals and therefore there use in pregnancy especially during the third trimester is contraindicated. (1,4,6-8) It should be noted however that several pregnant women have been accidentally exposed to albendazole in early pregnancy and no fetal abnormalities reported to date. (4)

    Bone marrow suppression: Benzimidazoles are contraindicated in this situation. (1,4)

    Liver disease: Benzimidazoles should be given with extreme caution if at all to these patients and if benefits of chemotherapy outweigh associated risks. Dosage should be reduced specially in those with cholestasis or portal hypertension. (3) These patients also require frequent monitoring of serum drug levels and liver function tests.

    Diabetes mellitus: Mebendazole may reduce insulin requirement, therefore the serum glucose levels of diabetics should be carefully monitored during treatment.(1)

    Lactation: Exposure with mebendazole or albendazole during breast feeling does not appear to put the infant at risk of side effects. (1) However, they should be avoided if possible. (8)

Monitoring of patients (1) :

Clinical examination and liver function tests are necessary initially every 2 weeks and then monthly. Leukocyte counts should be checked at 2 weeks intervals during the first 3 months. Although usually not possible, measurement of serum drug concentrations (albendazole-sulfoxide or mebendazole) is recommended after 2 weeks and 4 weeks of chemotherapy, respectively, in order to identify levels that are too high (possibly toxic) or too low (ineffective).
Funding
None
Conflict of Interest
None
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Last Updated : Sunday, April 01, 2012 Vol 9 Issue 4 Art #20
DOI: 10.7199/ped.oncall.2012.20
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Khazaei S, Motlagh I M, Khazaei S. NONSURGICAL TREATMENT OF CYSTIC ECHINOCOCCOSIS. Pediatric Oncall [serial online] 2012[cited 2012 January 1];9. Art #20. Available From : http://www.pediatriconcall.com/Journal/Article/FullText.aspx?artid=483&type=J&tid=&imgid=&reportid=364&tbltype=
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