title: Pitfalls in diagnosis and treatment of alveolar echinococcosis: a sentinel case series.
abstract: BACKGROUND
  Alveolar echinococcosis (AE) is a neglected zoonosis presenting with focal liver lesions (FLL) with a wide range of imaging patterns resembling benign as well as malignant FLLs. Complementary serology and histopathology may be misleading.
  
  
  OBJECTIVE
  The objective of our study is to highlight pitfalls leading to wrong diagnoses and harmful interventions in patients with AE.
  
  
  METHODS
  This retrospective sentinel case series analyses diagnostic and treatment data of patients with confirmed AE.
  
  
  RESULTS
  80 patients treated between 1999 and 2014 were included in the study. In 26/80 patients treatment decisions were based on a wrong diagnosis. AE was mistaken for cystic echinococcosis (CE) in 12/26 patients followed by cholangiocellular carcinoma (CCA) in 5/26 patients; 61/80 patients had predominantly infiltrative liver lesions and 19/80 patients had a predominantly pseudocystic radiological presentation. Serology correctly differentiated between Echinococcus multilocularis and Echinococcus granulosus in 53/80 patients. Histopathology reports attributed the right Echinococcus species in 25/58 patients but failed to differentiate E. multilocularis from E. granulosus in 25/58 patients. Although contraindicated in AE 8/25 patients treated surgically had instillation of a protoscolicidal agent intraoperatively. One of the eight patients developed toxic cholangitis and liver failure and died 1 year after liver transplantation.
  
  
  CONCLUSIONS
  Misclassification of AE leads to a critical delay in growth inhibiting benzimidazole treatment, surgical overtreatment and bares the risk of liver failure if protoscolicidal agents are instilled in AE pseudocysts.
authors.affiliation: Section Clinical Tropical Medicine , University Hospital Heidelberg , Heidelberg , Germany.
authors.forename: M
authors.initials: M
authors.lastname: Stojkovic
authors.affiliation: Section Clinical Tropical Medicine , University Hospital Heidelberg , Heidelberg , Germany.
authors.forename: C
authors.initials: C
authors.lastname: Mickan
authors.affiliation: Department of Diagnostic and Interventional Radiology , University Hospital Heidelberg , Heidelberg , Germany.
authors.forename: T F
authors.initials: TF
authors.lastname: Weber
authors.affiliation: Section Clinical Tropical Medicine , University Hospital Heidelberg , Heidelberg , Germany.
authors.forename: T
authors.initials: T
authors.lastname: Junghanss
keywords: HEPATOBILIARY PATHOLOGY; HEPATOBILIARY RADIOLOGY; INFECTIOUS DISEASE