Cystic echinococcosis: progress and limits in epidemiology and immunodiagnosis

This study discusses the epidemiology and immunodiagnosis of cystic echinococcosis (caused by Echinococcus granulosus). Despite the development of molecular methods to prepare antigens, nowadays there is no standard, highly sensitive, and specific test available for antibody detection in cystic echinococcosis. Furthermore, because serological tests can give only a limited support to clinical findings there is a clear need for new advances in immunodiagnosis of E. granulosus infection.     

Application of antigens from Taenia hydatigena cyst fluid for the immunodiagnosis of human hydatidosis

Fluid was collected from cysts of Taenia hydatigena in 60 adult sheep and fluid from each animal pooled separately. By double diffusion antigen 5 was demonstrated in all pools but one. The criteria are described for selection and standardization of these preparations for use as antigens for the immunodiagnosis of human hydatid disease. Sera from 50 persons harbouring hydatid cysts and from 50 patients with other disease conditions were examined by the arc-5 double-diffusion test, using two antigens prepared from Echinococcus granulosus and T. hydatigena cyst fluids, respectively. The results showed that a higher diagnostic sensitivity was obtained with the hydatid antigen. The significance of the findings is discussed in terms of their application to human immunodiagnosis in areas where hydatidosis, but not cysticercosis, is rare in livestock.     

Shared and non-shared antigens from three different extracts of the metacestode of Echinococcus granulosus

Hydatid cyst fluid (HCF), somatic antigens (S-Ag) and excretory-secretory products (ES-Ag) of Echinococcus granulosus protoscoleces are used as the main antigenic sources for immunodiagnosis of human and dog echinococcosis. In order to determine their non-shared as well as their shared antigenic components, these extracts were studied by ELISA-inhibition and immunoblot-inhibition. Assays were carried out using homologous rabbit polyclonal antisera, human sera from individuals with surgically confirmed hydatidosis, and sera from dogs naturally infected with E. granulosus. High levels of cross-reactivity were observed for all antigenic extracts, but especially for ES-Ag and S-Ag. Canine antibodies evidenced lesser avidity for their specific antigens than antibodies from human origin. The major antigenic components shared by HCF, S-Ag, and ES-Ag have apparent molecular masses of 4-6, 20-24, 52, 80, and 100-104 kDa, including doublets of 41/45, 54/57, and 65/68 kDa. Non-shared polypeptides of each antigenic extract of E. granulosus were identified, having apparent masses of 108 and 78 kDa for HCF, of 124, 94, 83, and 75 kDa for S-Ag, and of 89, 66, 42, 39, 37, and 35 kDa for ES-Ag.     

Isolation of fraction no. 10 from Taenia saginata and evaluation of its specificity for the diagnosis of bovine cysticercosis

In an attempt to prove the specificity of the crude Taenia saginata antigen for the immunodiagnosis of bovine cysticercosis, a major and highly immunogenic fraction (F10), responsible for the formation of the typical "long band" reaction in immunoelectrophoresis, has been isolated from T. saginata proglottides by immunoaffinity chromatography. The immunoabsorbent was prepared by coupling a specifically raised hyperimmune serum (HIS) anti-F10 to Sepharose 4B. The purity of the isolated F10 was demonstrated by immunoprecipitation reactions. The HIS anti-F10, however, cross-reacted with several larval and adult Taenia spp. Consequently, F10 showed cross-reactions with the sera of animals infected with hydatid cysts or larval T. hydatigena. F10 also reacted with HIS anti-F5 (Echinococcus granulosus) but was shown to be non-identical with the well known F5 of E. granulosus. These data prove that F10 of T. saginata was not species-specific but showed a group specificity for the taeniid family - a situation analogous to F5 of E. granulosus.     

Immunodiagnosis of ocular toxocariasis using Western-blot for the detection of specific anti-Toxocara IgG and CAP for the measurement of specific anti-Toxocara IgE

A prospective multicentric study was carried out to assess both the performance of Western-blot (WB) detecting specific anti-Toxocara IgG and that of CAP measuring specific IgE titre for the immunodiagnosis of ocular toxocariasis. For 14 outpatients presenting ophthalmic symptoms (choroiditis, chorioretinitis, papillar oedema, hyalitis, retinal detachment and/or uveitis), samples of serum and aqueous fluid (AF) were sent to the Department of Parasitology, University Hospitals, Toulouse, France. All patients but two tested positive with WB on the serum; 13 WB tests were performed on the AF, 12 of which were positive. The two patients who had a negative WB serum result tested positive for the AF. Specific IgE detection was considered as a complementary test of WB. Two patients showed a greater specific IgE titre in the AF than in the serum, and one had a positive result in the AF, but not in the serum. These six patients were considered as clear cases of ocular toxocariasis. Western-blot coupled with specific anti-Toxocara IgE detection appeared therefore to be an accurate procedure for the immunodiagnosis of ocular toxocariasis, provided the testing was simultaneously performed on the serum and AF.     

A recombinant antigen with potential for serodiagnosis of Echinococcus granulosus infection in dogs

Antibodies specific for Echinococcus granulosus were affinity purified from dog serum on transfer blots containing putative serodiagnostic antigens. These antibodies and serum pools derived from dogs with E. granulosus infections were used to screen a lambda gt11 cDNA library constructed using E. granulosus protoscolex mRNA. Nine definitive antigenic clones were isolated and characterized, of which one (c10P1) gave strong specific reactions in plaque immunoassay with sera from E. granulosus infected dogs. These clones were all subcloned into the plasmid vector pGEX-1. Antigenicity of clones was confirmed in colony immunoassay and/or immunoblot. Glutathione S-transferase (GST) fusion proteins of individual subclones were produced in Escherichia coli, purified by affinity chromatography and evaluated in ELISA using sera from dogs with infections of E. granulosus, Taenia spp. or nematodes, and helminth-free dog sera. The GST fusion protein 10P1 showed a specificity of 100% in ELISA for diagnosis of E. granulosus infection in dogs despite its relatively low sensitivity. Further investigations aim to identify additional recombinant antigens and test 10P1 expressed in alternative expression systems to increase diagnostic sensitivity of the ELISA.     

Serological differentiation between Echinococcus granulosus and E. multilocularis infections in man

An enzyme-linked immunosorbent assay (ELISA) was adapted for the serological differential diagnosis of cystic or alveolar echinococcosis in man caused by Echinococcus granulosus or E. multilocularis respectively. By affinity chromatography using rabbit anti hydatid fluid IgG coupled covalently to CNBr-Sepharose 4B a protein fraction (Em 1) containing shared antigens of both parasites could be isolated from an extract of E. multilocularis metacestode tissue. From the same source another antigen fraction (Em 2) with a high degree of specificity for E. multilocularis was prepared by immunosorption. Antigen Em 1 was equally sensitive for the detection of antibodies against E. granulosus and E. multilocularis, whereas antigen fraction Em 2 appeared to be more specific for E. multilocularis. A correct serological differential diagnosis was achieved in 95% of 57 confirmed cases of human cystic or alveolar echinococcosis by the simultaneous use of both antigen fractions in the ELISA and by comparison of their reactivities.     

Development of a new PCR protocol for the detection of species and genotypes (strains) of Echinococcus in formalin-fixed, paraffin-embedded tissues

The aim of our study was to establish a new PCR protocol for the detection and discrimination of Echinococcus granulosus complex on one hand and Echinococcus multilocularis in formalin-fixed, paraffin-embedded tissues (FFPTs) on the other. The target sequences for all PCRs are located on a 471bp segment of the mitochondrial ND1 gene, the fragment sizes of the amplification products are 295bp (for the sheep strain of E. granulosus), 204bp (for the pig strain of E. granulosus) and 252bp (for E. multilocularis), respectively. In total, 80 FFPTs from patients with histologically confirmed echinococcosis (76 with E. granulosus and four with E. multilocularis) operated on in Austrian hospitals between 1978 and 2005 were examined. In 68 (85%) samples, we were able to detect specific DNA fragments with our newly established PCR protocols. Thirty-eight (47.5%) of 80 clinical samples were identified as the G1 strain, 26 (32.5%) as the G5, 6 or 7 strains and four (5%) as E. multilocularis. The specificity of all three PCRs was 100%; for the discrimination between G6 and G7 strains, sequencing of an additional 234bp PCR fragment was necessary and showed that three out of 26 G5, 6 or 7 PCR-positive patients were infected with E. granulosus genotype G6 (the camel strain).     

Analysis on the reactivity of five subunits of antigen B family in serodiagnosis of echinococcosis

In this study, the reactivity and differences of five subunits of echinococcus antigen B (AgB) family, recognizing specific antibodies in echinococcosis patient serum, were analyzed. Eight recombinant subunit antigens from Echinococcus granulosus (EgAgB1-EgAgB4) and Echinococcus multilocularis (EmAgB1-EmAgB3 and EmAgB5) were tested by ELISA using a panel of 243 serum samples collected from cystic echinococcosis (CE), alveolar echinococcosis (AE), cysticercosis (CC) patients and clinically normal individuals (NH). The results showed that the diagnostic sensitivity of the subunits for CE sera were 83.06%, 62.90%, 29.03%, 75.81% and 41.13%, and the specificities were 73.95%, 72.27%, 76.47%, 73.11% and 85.71%, respectively. The reactivity of three paralogous subunits, EgAgB1, EgAgB2 and EgAgB3 from E. granulosus and EmAgB1, EmAgB2 and EmAgB3 from E. multilocularis were compared by serological assay. All of the orthologous subunits showed no statistical difference (P>0.05) in detecting CE and AE sera; it revealed that the reactive epitopes may be similar between the orthologous subunits. In a total of 124 CE sera, the positive recognition rate by EgAgB1 was the highest (103/124), yet cocktail subunit antigens may detect even more positives from 100/124 to 112/124 using different subunit combinations. IgG4 subclass was the predominant antibody in reacting with subunit antigens. To conclude, the epitopes of orthologous AgB subunits from E. granulosus and E. multilocularis that recognize specific antibodies may be similar. The paralogous subunits EgAgB1, EgAgB2 and EgAgB4 were the main reactive subunit in sera detection and may have utility as echinococcosis diagnostics, with EgAgB1 possessing the greatest potential. Cocktail subunits may improve the positive detection rate.     

Partial characterisation of carbohydrate-rich Echinococcus granulosus coproantigens

Coproantigen ELISA based tests for diagnosis of canine echinococcosis provide high specificity and sensitivity. However, the antigenic molecules present in faeces from infected dogs have not yet been characterised. While initial attempts to determine the molecular weights of Echinococcus granulosus coproantigens by SDS-PAGE and Western blotting with coproantigen reactive capture antibodies were equivocal, they suggested presence of a significant carbohydrate component. Periodate treatment of coproantigen positive faecal supernatants resulted in a significant reduction (53%) in ELISA activity, suggesting that carbohydrates are involved in the antigenic structure of E. granulosus coproantigens. Protease treatment of antigenic molecules resulted in an 11% reduction in absorbance in ELISA, indicating that protein components were also present which affected by enzyme activity. Lectin-binding ELISA assays indicated strong affinity of E. granulosus coproantigens to concanavalin agglutinin and Lens culinaris agglutinin, and moderate binding to wheat-germ agglutinin and peanut agglutinin. No binding was detectable to Ulex europaensis agglutinin-I, Bandeiraea simplicifolia or Dolichos biflorus agglutinin. These data indicate that E. granulosus coproantigens from infected dog faeces possibly contained alpha-D-mannose and/or alpha-D-glucose, beta-galactose and N-acetyl-beta-glucosamine residues. To verify the role of carbohydrate moieties in coproantigens, faecal samples were treated with exoglycosidase and tested in the coproantigen ELISA. Treatment with beta-galactosidase or N-acetyl-beta-glucosamine reduced ELISA activity by 44 and 30%, respectively. Incubation with a panel of other specific exoglycosidases including alpha-galactosidase as well as alpha-L-fucosidase, alpha-mannosidase, beta-mannosidase, alpha-glucosidase, beta-glucosidase, beta- fructosidase, or neuraminidase, did not alter coproantigen detection in ELISA. The results indicate that coproantigens present in faeces from E. granulosus naturally infected dogs were highly glycosylated and contain beta- galactose and N-acetyl-beta-glucosamine. The putative relationship of antigenic molecules with the tapeworm glycocalyx is discussed.     

The diagnosis of Echinococcus granulosus in dogs

The problem of diagnosing Echinococcus granulosus in dogs has still only been partially resolved, even after the advent of biotechnology. The eggs of taeniid Cestoda are extremely similar, and thus identification by microscopic examination of the faeces is risky and non-specific. For this reason, Echinococcus granulosus was traditionally diagnosed in dogs ante mortem after an arecoline hydrobromate purge. The faeces were examined macro and microscopically to establish if the adult tapeworm or its proglottids were present. Although this method is 100% specific, it is bio-hazardous and time-consuming, requires trained personnel, and its sensitivity varies. In the 1990s copro-antigens were discovered and characterised. These are released by the adult worm in the faeces. This made it possible to use enzyme-linked immune-adsorbent assay (ELISA) for in vitam diagnosis of Echinococcus granulosus. In recent years several PCR protocols have been published on the identification of Echinococcus granulosus DNA from eggs or from adult parasites and new ways of diagnosing this cestode have been developed.     

Echinococcus granulosus genotypes circulating in alpacas (Lama pacos) and pigs (Sus scrofa) from an endemic region in Peru

The identification of the genotypes of Echinococcus granulosus present in livestock and wild animals within regions endemic for cystic echinococcosis (CE) is epidemiologically important. Individual strains display different biological characteristics that contribute to outbreaks of CE and that must be taken into account in the design of intervention programs. In this study, samples of hydatid cysts due to E. granulosus were collected from alpacas (4) in Puno and pigs (8) in Ayacucho in Peru, an endemic region for CE. Polymerase chain reaction amplification and DNA sequencing of specific regions of the mitochondrial cytochrome C oxidase subunit 1 and NADH dehydrogenase subunit 1 genes confirmed the presence of a strain common to sheep, the G1 genotype, in alpacas. Two different strains of E. granulosus were identified in pigs: the G1 and the G7 genotypes. This is the first report of the G1 genotype of E. granulosus in alpacas in endemic regions of CE in Peru.     

The determination of antigen-specific immune complexes by an immunoenzyme method]

The methodological approach permitting the detection of immune complexes containing specific antibodies to a definite antigen in the enzyme-linked immunosorbent assay (ELISA) is described. The basic conditions of the assay were optimized. Immune complexes were precipitated from blood serum with 3.5% polyethylene glycol 6000 for 4 hours. The precipitate thus obtained was dissolved and incubated in polystyrene plates with immobilized antigen at 37 degrees C for a long time (at least 6 hours) in a humid chamber. The amount of bound antibodies, determined by ELISA techniques, was conjectured from the level of antigen-specific immune complexes. The proposed approach can be used in the immunodiagnosis of infectious diseases.     

Treatment of hepatic hydatid disease with mebedazole: preliminary results in four cases.

Mebendazole was given to four patients with hepatic hydatid disease. In three patients hydatidosis had remained after surgery, and in the fourth it could not be treated surgically. Mebendazole was given orally in maximum doses of 400-600 mg three times a day during courses lasting 21 to 30 days. Ultrasonic echotomography showed a complete regression of the intrahepatic cysts after four to 13 months in all four cases. In three patients the course of treatment had to be repeated. Mebendazole also induced clinical improvement and a progressive lowering of the concentration of specific IgE of Echinococcus granulosus. During treatment circulating blood levels of specific immune complexes of antigen 5 were increased. These observations indicate that mebendazole has a lethal effect on E granulosus cysts in primary hydatid disease in man and that the efficacy of chemotherapy can be assessed with ultrasonography and by measuring changes in the concentration of specific IgE of E granulosus and circulating immune complexes.     

Protein A immunocapture assay detecting antibodies to fluke cysteine proteinases for immunodiagnosis of human paragonimiasis and fascioliasis

Enzyme-linked immunosorbent assays (ELISAs) which detect specific antibodies to fluke cysteine proteinases have provided good sensitivity and specificity for the immunodiagnosis of trematode diseases. To detect specific antibodies without the need for purified proteinase antigens, an immunocapture assay using Protein A was applied for the immunodiagnosis of paragonimiasis and fascioliasis. ELISA plate wells were coated with Protein A, incubated with diluted patient sera, then incubated with a preparation containing fluke cysteine proteinases, excretory-secretory (ES) products of adult Paragonimus westermani or Fasciola sp. The activity of fluke cysteine proteinases bound on the wells was measured by adding fluorogenic peptidyl substrate, Z-Phe-Arg-MCA or Boc-Val-Leu-Lys-MCA. This assay detected specific immunoglobulin G to cysteine proteinases of P. westermani and Fasciola sp. by measuring proteinase activity on the plate wells. Patient sera showed significant high values of proteinase activity when the wells were treated with the respective homologous ES products, whereas the sera had low values after treatment with the heterologous ES products. The sera of patients with other parasitoses and uninfected healthy individuals also showed low values after treatment with the above fluke ES products. Thus, Protein A immunocapture assay, which detected IgG specific for fluke cysteine proteinases, provided a high sensitivity and specificity for immunodiagnosis of paragonimiasis and fascioliasis.     

A PCR system for detection of species and genotypes of the Echinococcus granulosus-complex, with reference to the epidemiological situation in eastern Africa

We describe the development of a specific and sensitive PCR/semi-nested PCR system for the rapid diagnosis of Echinococcus granulosus genotype G1, E. granulosus genotype G6/7, and Echinococcus ortleppi (G5). Diagnosis of G1 and the group G5/6/7 is performed by a simple PCR, while discrimination between E. ortleppi (G5) and G6/7 involves a subsequent semi-nested PCR step. The target sequence for amplification is part of the mitochondrial 12S rRNA gene. Specificity of the PCRs was 100% when evaluated with isolates of 16 species of cestodes, including Echinococcus multilocularis, Echinococcus equinus, E. ortleppi and three strains of E. granulosus (G1, G6 and G7). Sensitivity threshold was 0.25pg of DNA. This new approach was compared with published protocols of restriction fragment length polymorphism-PCR and sequencing of mitochondrial cytochrome c oxidase subunit 1 and NADH dehydrogenase 1 genes using Echinococcus isolates of human, sheep, goat, camel, cattle and pig origin from Kenya and Sudan. Additionally, two internal DNA probes were developed, one hybridising only with G1, the other with G5, G6 and G7 amplification products. Preliminary epidemiological results obtained with this PCR approach include the detection of a camel strain (G6) infection for the first time in a human patient from eastern Africa, and the first reports of E. ortleppi (G5) in livestock from Kenya and the Sudan.     

Comment on the status of Echinococcus granulosus in the UK

Echinococcus granulosus is composed of a complex of strains, the status of which has caused controversy and doubt. All have different characteristics which have arisen from animal husbandry practices, resulting in isolation and restriction of gene flow, and/or from the reproductive characteristics of the organisms. Whatever the mechanism for strain variation, Don McManus, Alan Lymbery and Andrew Thompson have no doubts that distinct variants occur in spite of a recent publication that suggests there is only one form of E. granulosus in the UK.     

Canine echinococcosis in Kyrgyzstan: using prevalence data adjusted for measurement error to develop transmission dynamics models

Echinococcosis is a major emerging zoonosis in central Asia. A cross-sectional study of dogs in four villages in rural Kyrgyzstan was undertaken to investigate the epidemiology and transmission of Echinococcus spp. A total of 466 dogs were examined by arecoline purgation for the presence of Echinococcus granulosus and E. multilocularis. In addition, a faecal sample from each dog was examined for taeniid eggs. Any taeniid eggs found were investigated using PCR techniques (multiplex and single target PCR) to improve the diagnostic sensitivity by confirming the presence of Echinococcus spp. and to identify E. granulosus strains. A total of 83 (18%) dogs had either E. granulosus adults in purge material and/or E. granulosus eggs in their faeces as confirmed by PCR. Three genotypes of E. granulosus: G1, G4 and the G6/7 complex were shown to be present in these dogs through subsequent sequence analysis. Purge analysis combined with PCR identified 50 dogs that were infected with adult E. multilocularis and/or had E. multilocularis eggs in their faeces (11%). Bayesian techniques were employed to estimate the true prevalence, the diagnostic sensitivity and specificity of the procedures used and the transmission parameters. The sensitivity of arecoline purgation for the detection of echinococcosis in dogs was rather low, with a value of 38% (credible intervals (CIs) 27-50%) for E. granulosus and 21% (CIs 11-34%) for E. multilocularis. The specificity of arecoline purgation was assumed to be 100%. The sensitivity of coproscopy followed by PCR of the isolated eggs was calculated as 78% (CIs 57-87%) for E. granulosus and 50% (CIs 29-72%) for E. multilocularis with specificity of 93% (CIs 88-96%) and 100% (CIs 97-100%), respectively. The 93% specificity of the coprological-PCR for E. granulosus could suggest coprophagia rather than true infections. After adjusting for the sensitivity of the diagnostic procedures, the estimated true prevalence of infection of E. granulosus was 19% (CIs 15-25%) and the infection pressure in the dog population was estimated to be 0.29 infections per year (CIs 0.014-0.75). Logistic regression analysis failed to identify any significant risk factors for infections for E. granulosus. After adjusting for the sensitivity of the test procedures, the estimated true prevalence for E. multilocularis was 18% (CIs 12-30%). Dogs that were restrained had a significantly lower prevalence of E. multilocularis of 11% (CIs 6-29%) compared with 26% in free-roaming dogs (CIs 17-44%) and independently within these groups hunting dogs were more likely to be infected than non-hunting dogs.     

Hydatid control in Australia: where it began, what we have achieved and where to from here

Echinococcus granulosus was imported into Australia with domestic livestock about 200 years ago. It spread rapidly through domestic animals and quickly became a public health problem in the new colony. Control was hampered by ignorance of the transmission pattern. The association between metacestodes and tapeworms was not elucidated until 63 years after the arrival of the First Fleet. Australian wildlife were highly susceptible to infection with E. granulosus and wildlife/domestic animal interaction facilated rapid infiltration of wildlife by E. granulosus. The wildlife reservoir has hampered hydatid control campaigns on mainland Australia but successful eradication has been achieved in the island state of Tasmania where there was no wildlife reservoir. The application of a new recombinant vaccine for sheep in control campaigns and the use of praziquantel baits for controlling infection in dingoes around bush campsites and picnic areas is discussed.     

Further observations on the specificity of antigen 5 of Echinococcus granulosus.

The presence of IgE antibodies to antigen 5 of Echinococcus granulosus was detected by means of radioimmunoelectrophoresis in the sera of two of six patients infected with E. multilocularis. Sera from three of these patients gave a precipitin band in gel diffusion tests identical to that produced by a monospecific rabbit anti-E. granulosus antigen 5 serum, when tested against whole hydatid fluid. Sera from 19 individuals infected with Fasciola hepatica, 20 with Schistosoma mansoni, and 5 with with Taenia saginata showed no detectable antibodies against antigen 5 of E. granulosus, The monospecific rabbit anti-E. granulosus antigen 5 serum did not react in immunodiffusion with homologous antigen when absorbed with either 4 mg/ml of whole hydatid fluid or with 200 mg/ml of a soluble E. multilocularis extract. Absorption of the monospecific antiserum with crude antigens of either F. hepatica, Onchocerca volvulus, S. mansoni, or T. saginata did not abolish the reaction with antigen 5. It appears, therefore, that antigen 5 can no longer be considered specific for E. granulosus, but is also present in E. multilocularis. In the light of this observation, some reevaluation of immunodiagnostic tests in hydatid disease will be necessary.