UNIVERSITATEA DE MEDICINA SI FARMACIE IULIU HATIEGANU CLUJ NAPOCA

STRATEGII N DIAGNOSTICUL SI MONITORIZAREA TERAPEUTICA A CHISTULUI HIDATIC

TEZA DE DOCTORAT
REZUMAT

Petric Teofil Ciobanca Conductor de doctorat:

CUPRINS
LISTA DE PUBLICATII....................................................................................................................2 INTRODUCERE ................................................................................................................................7 PARTEA I STADIUL ACTUAL AL CUNOATERII ...................................................................10 Capitolul 1. GENUL ECHINOCOCCUS .......................................................................................11 1.1. Istoric .....................................................................................................................................11 1.2. Taxonomie i clasificare .......................................................................................................12 1.3. Morfologie ............................................................................................................................12 1.4 Diferene morfologice i genetice ntre specii .......................................................................15 1.5. Epidemiologie ........................................................................................................................17 1.6. Ciclul biologic.......................................................................................................................19 1.6.1. Echinococcus granulosus ...............................................................................................19 1.6.2. Echinococcus multilocularis ...........................................................................................21 1.7. Contaminarea uman ..........................................................................................................22 CAPITOLUL 2: CHISTUL HIDATIC ...........................................................................................23 2.1. Patogenia chistului hidatic .....................................................................................................23 2.2. Evoluia chistului hidatic ......................................................................................................23 2.3. Manifestri clinice ale hidatidozei umane ............................................................................24 2.4. Diagnosticul bolii hidatice .....................................................................................................27 2.4.1. Diagnosticul clinic ..........................................................................................................28 2.4.2. Diagnosticul imagistic ....................................................................................................28 2.4.3. Diagnostic parazitologic .................................................................................................31 2.4.4. Diagnosticul imunologic .................................................................................................32 2.4.5. Diagnosticul diferenial al chistului hidatic ....................................................................34 2.5. Tratamentul chistului hidatic ................................................................................................35 2.6. Profilaxia chistului hidatic .....................................................................................................38 PARTEA II CERCETARI PERSONALE ........................................................................................40 STUDIUL 1: Aplicabilitatea metodelor serologice n diagnosticul, terapia i profilaxia bolii hidatice umane. ...............................................................................................................................................41 1.1. Introducere .............................................................................................................................41 1.2. Scopul i obiectivele studiului ...............................................................................................41 1.3. Material i metod..................................................................................................................42 1.3.1. Material ...........................................................................................................................42 1.3.2. Metoda ............................................................................................................................43 1.4. Rezultate ...............................................................................................................................47 1.4.1. Depistarea persoanelor seropozitive investigate prin teste imunoenzimatice ELISA IgG antiechinococcus n judeele Cluj i Slaj ................................................................................47 1.4.2. Frecvena n funcie de mediul de provenien a persoanelor seropozitive n judeele Cluj i Slaj .......................................................................................................................................48 1.4.3. Frecvena persoanelor seropozitive n judeul Cluj i Slaj n funcie de sex .............50 1.4.4. Aspecte epidemiologice privind persoanele seropozitive n judeul Cluj (inciden, mediul de provenien i repartizarea pe sexe) .........................................................................51 1.4.5. Frecvena persoanelor seropozitive n funcie de sex n judeul Cluj ............................52 1.4.6. Aspecte epidemiologice privind persoanele seropozitive, n judeul Slaj (inciden, mediul de provenien i repartizarea pe sexe) .......................................................53 1.4.7. Frecvena persoanelor seropozitive n funcie de sex n judeul Salaj ...........................54
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1.5. Confirmarea rezultatelor obinute la testrile serologice prin metode imagistice utilizate n diagnosticul echinococozei chistice umane .................................................................................55 1.5.1. Rezultatele examenului imagistic (ecografic, RX toracic, CT) ......................................56 1.6. DISCUII ..............................................................................................................................58 1.7. DESCRIERE CAZURI .........................................................................................................61 CONCLUZII .....................................................................................................................................68 STUDIUL II: Evaluarea i optimizarea metodelor de diagnostic n boala hidatic .........................69 2.1. Introducere .............................................................................................................................69 2.2 Scopul i obiectivele studiului ................................................................................................69 2.3 Material i metod...................................................................................................................70 2.3.1 Material ............................................................................................................................70 2.3.2 Metode paraclinice i clinice utilizate..............................................................................71 2.3.3 Metode statistice de analiz a datelor .............................................................................77 2.4. Rezultate ................................................................................................................................80 2.4.1 Rezultate epidemiologice (luand ca i criteriu sexul, mediul de provenien, varsta) ....80 2.4.2 Rezultate clinice si paraclinice privind diagnosticul bolii hidatice ...............................83 2.4.2.1 Valoarea examenului clinic n diagnosticul chistului hidatic ...................................83 2.4.2.2.Confirmarea chirurgical a diagnosticului prezumtiv de chist hidatic .....................85 2.4.2.3 Evaluarea analizelor de laborator uzuale (hemoleucograma, analize biochimice) folosite pentru depistarea chistului hidatic ..........................................................................86 2.4.2.4. Metode imagistice folosite pentru identificarea chistului hidatic ...........................89 2.4.2.5. Rezultatele obinute prin metode imunoserologice..................................................97 2.4.3. Rezultate comparative ...................................................................................................106 2.5. DISCUII ............................................................................................................................122 2.6. DESCRIERE CAZURI ......................................................................................................131 CONCLUZII: ..................................................................................................................................139 CONCLUZII GENERALE ............................................................................................................140 REFERINE ..................................................................................................................................142

INTRODUCERE Echinococoza/hidatidoza (boala hidatic sau chistul hidatic) este o boal parazitar, cauzat de genul Echinococcus, care poate evolua cu cele mai severe i variate implicaii. In ciuda progreselor din domeniile de supraveghere i control aceast parazitoz continu s reprezinte o problem important de sntate public n cele mai multe pri ale lumii [2]. Conform clasificrii OMS, boala este o zoonoz, care ridic numeroase probleme de sntate, att n ceea ce privete omul ct i animalele, deoarece paraziii cauzali, pentru a ncheia ciclul lor biologic, trec prin mai multe gazde animale vertebrate (de exemplu, cini pentru oameni). Datorit prevalenei ridicate, formelor clinico-evolutive severe, complicaiilor morfofuncionale cu mortalitate primar sau secundar ridicat, boala este frecvent ntlnit atat n mediul rural cat i in mediul urban, la toate grupele de vrst, prevalen alarmant la tineri i la grupe de risc profesional [1] In zona rii noastre patologia hidatic are o frecven destul de ridicat, zona de nord-vest a Transilvaniei fiind descris ca zon endemic, cu o cazuistic important [ 3], medicina clujean avand o important experien n diagnosticul i tratamentul chistului hidatic. n pofida realizrilor nregistrate n ultimul timp n diagnosticul i terapia echinococozei umane, aceasta deine nc un loc important n structura morbiditii i mortalitii n serviciile chirurgicale. Cea ce face util prezentarea unor date succinte asupra aspectelor variate pe care boala hidatic le poate lua n evoluie din punct de vedere clinic, imagistic, serologic i evaluarea importanei acestora n recunoaterea i diagnosticarea precoce a bolii. PARTEA I: STADIUL ACTUAL AL CUNOATERII Capitolul 1. Genul Echinococcus Parazitul responsabil de producerea hidatidozei umane, este un plathelmint, care face parte din clasa cestode (Eucestode), familia Teniidae, Genul Echinococcus. Speciile din genul Echinoccocus considerate ageni etiologici ai echinococozei/hidatidozei, dup experii OMS, sunt urmatoarele: - Echinococcus granulosus (Batsch, 1786) - echinococoza chistic - Echinococcus multilocularis (Leuckart, 1863) echinococoza alveolar - Echinococcus oligarthus (Diesing, 1863) - Echinococcus vogeli (Rausch, Bernstein, 1972) - echinococoza polichistic S-a mai pus problema existenei celei de-a cincea specii, E.cruzi (Rausch i col. 1978; Kumaratilake i Thompson 1982), dar, Rausch i col. (1984), comparnd caracterele acesteia cu E.vogeli i E.oligarthus, au observat c de fapt E. cruzi este sinonim cu E. oligarthus. Distribuia geografic a hidatidozei urmeaz fidel curba dezvoltrii cresctorilor de oi i este determinat de promiscuitatea pastoral, fapt ce l-a determinat pe Deve s afirme c boala hidatic este una din bolile minilor murdare. Larga varietate de specii de animale care pot fi gazde intermediare i deplasarea acestora din Europa n alte pri ale lumii a fcut ca Echinococcus s fie rspndit pe ntreg globul. In anul 2009 ECDC a raportat 790 de cazuri de echinococoz uman, cu 11% mai puine dect n 2008 (n= 891). Printre cazurile declarate, n care se cunoate specia infestant, a predominat infestaia cu E.granulosus (72%) n timp ce infestaia cu E.multilocularis a fost raportat ca avnd o frecven de 3 ori mai mic [4].
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CAPITOLUL 2: CHISTUL HIDATIC Chistul hidatic este o boal adesea invalidizant, cu complicaii posibile i adesea severe (oc anafilactic), cu o terapie chirurgical de multe ori dificil, cu recidive postoperatorii frecvente. Manifestrile clinice datorate complicaiilor instalate prin mecanismele menionate apar, cnd dimensiunile chistului hidatic devin apreciabile. Tabloul clinic al chistului hidatic este puin caracteristic. Foarte adesea el este complet asimptomatic, fiind descoperit ntmpltor. Alteori pacienii acuz jen n hipocondrul drept sau chiar durere intens. Reaciile alergice sunt destul de frecvente, mergnd de la o reacie urticarian pn la alergodermie sau chiar oc anafilactic (n general n caz de fisurare sau chiar ruperea chistului hidatic). Evidenierea morfologic a chisturilor hidatice se poate face prin radiografie toracic, ecografie, tomografie computerizat (CT) i rezonant magnetic (MR). Pentru diagnosticul hidatidozei umane, metodele imagistice se completeaz cu reaciile de imunodiagnostic care au drept scop confirmarea etiologiei parazitare a formaiunilor decelate prin rspunsul imun indus. n ultimii ani exist o tendin de stadializare a dignosticului imunologic ; find folosite mai intai teste primare care urmeaza sa fie confirmate prin alte metode care prezinta o specificitate deosebit de ridicata(teste secundare) [5]. Managementul modern al chistului hidatic solicit participarea tuturor modalitilor terapeutice: medicala, percutana i chirurgicala. Chirurgia nu mai este tratamentul de prim elecie pentru orice chist hidatic hepatic. La pacienii cu chist univezicular mai mic de 4 cm, terapia de elecie este monoterapia cu albendazol. PAIR este indicat cnd durerea este netratabil, sau albendazolul nu d rezultate. Tratamentul percutan combin alcool i polidocanol, dar nu poate fi utilizat n cazurile cu fistul chistobiliar. Chirurgia este utilizat n cazurile n care nu exist experi n terapia percutan si tratamentul percutan nu poate fi efectuat n deplin siguran datorita unei extensii extrahepatice semnificativ cu risc de perforaie a chistului sau/si n cazul rupturii chistului n cavitatea peritoneal [6]. PARTEA II: CERCETARI PERSONALE STUDIUL 1: Aplicabilitatea metodelor serologice n diagnosticul, terapia i profilaxia bolii hidatice umane. Scopul acestui studiu a fost efectuarea i evaluarea unor teste serologice (metoda ELISA) ca metode screening i de diagnostic a echinococozei chistice. Testele au fost efectuate la persoanele simptomatice i asimptomatice din judeele Cluj i Slaj, pentru aprecierea frecvenei afeciunii n aceste judee. Persoanelor crora li s-au detectat anticorpi IgG antiechinococcus, li s-au efectuat examinri imagistice pentru confirmarea diagnosticului clinic i serologic de chist hidatic. Aceste examinri au permis elucidarea aspectelor epidemiologice, diagnostice, terapeutice si prognostice privind echinococoza chistic. Material i metod Studiul a fost efectuat n perioada ianuarie 2007 decembrie 2009 i a inclus 279 de persoane simptomatice i asimptomatice din judeele Cluj i Slaj, cu scopul de a stabili prezena i nivelul anticorpilor antiechinococcus n populaia celor dou zone i implicit a infeciei asimptomatice, folosind metoda imunoenzimatic ELISA.

Pentru confirmarea diagnosticului de chist hidatic depistat prin testri serologice am folosit urmtoarele metode imagistice: ecografie abdomino-pelvian, CT cranian, CT torace, Rx toracic. Rezultate Din cele 279 de persoane investigate n ambele judee (Cluj i Slaj), la 22 pacieni s-a evideniat o serologie pozitiv, frecvena seropozitivitii find de 7,89% (IC= 5% -11,69%) la lotul studiat,cea ce sugereaz infestaia hidatica posibila la persoanele seropozitive. Adevrata frecven a parazitozei este evident mai ridicat, deoarece cazurile simptomatice reprezint doar vrful piramidei infestaiei, n timp ce cazurile asimptomatice formeaz baza nevzut, mult mai mare a acesteia. Screeningul serologic interprins n zona de nord-vest i centru a rii arata prezena infestaiei cu E.granulosus, cu posibilitatea transmiterii sale active. Rezultatele obinute demonstreaz procentul mai crescut al persoanelor seropozitive n judeul Cluj i sugereaz o inciden mai crescut a hidatidozei n aceast zon. Aceast concluzia a fost elaborat ca urmare a desfurrii unui proiect de cercetare cu titlulEvaluarea i optimizarea interdisciplinar a metodelor de screening, diagnostic i tratament n trichineloza i echinococcoza chistic uman i animal n centrul i nord-vestul Romniei desfurat n perioada 2006 - 2008, la care am participat n calitate de membru. Prin examenul imagistic, la 77.14% dintre pacieni, s-a putut confirma diagnosticul de hidatidoz prin metode imagistice. Pacienii prezentau imagini edificatoare pentru chist hidatic cu diverse localizari: hepatic (65.38%), pulmonar (5.88%), renal (5.88%). Rezultatele cercetrilor noastre sugereaz c o anumit proporie din populaia investigat a fost pozitiva IgG anti Echinococcus, fr a prezenta n organism hidatida decelabila prin metode imagistice. Discuii Lipsa cunotinelor, ignorana populaiei i chiar a unor specialiti din domeniul sanitar privind ciclul biologic al speciei E. granulosus, a gazdelor pe care le are, precum i a riscului pe care l implic un contact strns cu gazda definitiv sunt cauze de prim importan pentru rspndirea cu uurin a parazitului. Rezultatele obinute n urma acestui studiu concord cu rezultatele unor studii asemntoare din literatura de specialitate efectuate n zone endemice pentru echinococcoz chistic uman. [3]. Intr-un studiu efectuat pe un lot de persoane asimptomatice, la 12% din cazuri, ecografia nu decela formaiune chistic caracteristic chistului hidatic cu toate c testul serologic era pozitiv [7] . STUDIUL II: Evaluarea i optimizarea metodelor de diagnostic n boala hidatic Studiul are urmtoarele scopuri: 1. Evaluarea examenului clinic n diagnosticul prezumtiv i evaluarea metodelor imagistice de diagnostic n boala hidatic; 2. Evaluarea metodei ELISA, Western Blott i a metodelor de laborator pentru confirmarea diagnosticului clinic i imagistic de chist hidatic; 3. Studiul comparativ al metodelor imagistice (ecografie, Rx, CT, RM) cu metodele serologice (metoda ELISA, metoda Western-blott) i evaluarea utilitii lor n diferenierea echinococozei chistice i alveolare, n efectuarea diagnosticului diferenial i interpretarea reaciilor ncruciate. 2.3 Material i metod Studiul a fost efectuat n perioada 2006 - 2010 i a inclus un eantion reprezentativ de 189 persoane simptomatice, cu simptome sugestive sau cu suspiciune imagistic de boal hidatic. Au

mai fost luate n studiu persoane care au suferit intervenie chirurgical pentru boala hidatic i persoane care prezentau rezultate de laborator nespecifice dar cu suspiciune de boal parazitar. Am folosit ca material de lucru cazuistica medical i chirurgical din Clinicile Medicale i Chirurgicale din Cluj-Napoca i Slaj (Clinica Chirurgie III, Clinica Chirurgie V i ambulatorul unei policlinici private). Tipurile de date colectate folosite n acest studiu au fost: genul, vrsta, mediul de provenien, diagnosticul clinic; complicaiile chistului hidatic; antecedente de chist hidatic; metodele de diagnostic imagistic efectuate (ecografie abdominal, Rx pulmonar, CT, RM, tratamentul chirurgical, examenul piesei operatorii, histopatologic); analize de laborator; localizarea formaiunilor chistice n funcie de segmentaia hepatic i n funcie de organul afectat; metodele de diagnostic serologic efectuate (metoda imunoenzimatica IgG antiechinococcus ELISA, respectiv metoda IgG echinococcus Western- blot). 2.4. Rezultate Din rezultatele obtinute rezult c nu exist o asociere semnificativ ntre eozinofilie i diagnosticul bolii hidatice (p>0.05); Totui, atunci cnd eozinofilia este prezent se constat o coinciden relativ ridicat, de 71% (IC=52% - 85%), cu diagnosticul de chist hidatic. Analiza statistic a corelaiei dintre rezultatele examenului imagistic cu rezultatele obinute pe baza confirmrii chirurgicale i paraclinice a evidentiat o sensibilitate de 96,89% a examenului imagistic, specificitatea fiind 100%; din punct de vedere statistic ele nu difer semnificativ. Valoarea diagnostic a examenului imagistic este dat ns de valoarea predictiv pozitiv (VPP) i respectiv negativ (VPN), ambele fiind peste 84%, cu toate c VPN este semnificativ statistic mai mic dect VPP. Evaluarea rezultatelor examenului IgG antiechinococcus ELISA n raport cu confirmarea chirurgical, histopatologic i paraclinic a diagnosticului de chist hidatic evidentiaza o Specificitate de 96,43% i VPP de 99,19% ; Acestea fiind foarte ridicate se poate considera c metoda ELISA este un bun test de screening. Comparativ cu examenele imagistic, ecografic sau CT, IgG antiechinococcus ELISA are un indice Youden mai mic. Prin urmare, din acest punct de vedere IgG antiechinococcus ELISA pare a fi un test diagnostic mai puin concludent, dect examenele imagistice menionate. Pe de alt parte, comparnd intervalele de ncredere la indicatorii Specificitate, VPP la examenele imagistice (global, ecografic, CT) i IgG antiechinococcus ELISA se constat c nu difer semnificativ statistic. Rezultatele examenului imagistic i cele ale IgG antiechinococcus ELISA se asociaz semnificativ. Este de remarcat c odat cu ceilali coeficieni de asociere (coeficientul de contingen, Kendal tau), coeficientul de concordan dintre rezultatele examenului imagistic i cele ale IgG antiechinococcus ELISA este semnificativ statistic (p<0,001). De menionat c msura de concordan Kappa = 0,522 indic faptul c ntre cele dou examinri exist o concordan moderat. Tehnica imunoblot este un puternic test de confirmare i de diagnostic serologic diferenial ntre cele dou infectii majore relevante: echinococoza chistic i echinococoza alveolar [8]. Evaluarea rezultatelor examenului IgG echinococcus Western Blot n raport cu confirmarea chirurgical, histopatologic i paraclinic a diagnosticului de chist hidatic a relevat o Specificitate de100% i o valoare predictiva pozitiva de100% ;acestea fiind foarte ridicate se poate considera c testul de detectare a IgG echinococcus Western Blot este un bun test de screening. Este de remarcat c odat cu ceilali coeficieni de asociere (coeficientul de contingen, Kendal tau), coeficientul de concordan dintre rezultatele examenului imagistic i cele ale IgG echinococcus Western blot este semnificativ statistic (p<0,001). De menionat c msura de

concordan Kappa = 0,861 indic faptul c ntre cele dou examinri exist o concordan foarte bun. 2.5. Discutii Evaluarea eozinofiliei ca marker diagnostic n echinococoza chistic a permis unor autorii s afirme c eozinofilia nu este un indicator suficient pentru stabilirea diagnosticului de echinococoz chistic, fiind necesar i un diagnostic complementar clinic [9]. Sensibilitatea i specificitatea ecografiei a fost raportat n mai multe studii din literatur ca fiind ntre 88 98% i respectiv 95 100% pentru echinococoza chistic i echinococoza alveolar uman. Autorii o considera golden standard dei recunosc imperfeciunea acestei tehnici. Examenul clinic, examenul de laborator i datele epidemiologice sunt considerate deasemenea importante pentru diagnosticul echinococozei chistice i echinococozei alveolare [10]. Testele serologice contribuie la diagnostic, detecia anticorpilor IgG a avut o sensibilitate de 95% i o specificitate de 94% ntr-un studiu efectuat de Shambesh MA i colaboratorii [11]. Sensibilitatea obinut de Shambesh este semnificativ mai ridicat dect cea determinat n studiul nostru, care raporteaz o sensibilitate de 76,4% cu IC= 69,07% -82,72%. n schimb specificitatea nu difer semnificativ statistic de cea obinut n studiul nostru (96,43%, IC=81,65%-99,91%). Infeciile echinococice sunt considerate unele dintre cele mai periculoase boli helmintice umane. Deosebirea ntre echinococoza chistic i alveolar este important din punct de vedere al prognosticului i tratamentului. In diferite stadii ale echinococozei chistice i echinococozei alveolare testul cel mai relevant s-a apreciat a fi testul Western blot IgG echinococus care a confirmat rezultatele pozitive [12]. Cercetrile efectuate cu scopul de a evidenia prezena IgG echinococcus prin metoda Western blot raportat la metoda de aur considerat (confirmarea chirurgical, histopatologic i diagnostic paraclinic) au demonstrat o sensibilitate de 92,11% (IC = 78,62% - 98,34%), specificitatea fiind de 100% (IC = 83,89% - 100%), date care sunt asemntoare celor ntlnite n literatura de specialitate. n majoritatea rilor echinococoza alveolar a cptat deja un caracter endemic i este n curs de extindere continu cu o rapiditate alarmant, devenind o boal emergent. Parazitul adult E.multilocularis nu a fost depistat n Romnia pn n prezent la nici o gazd definitiv [13]. Studiul efectuat a relevat prin metoda Western blot, pentru prima dat n ara noastr existena probabilitii infeciei cu Echinococcus multilocularis la om. Sunt necesare studii ulterioare pentru depistarea persoanelor cu echinococoz alveolar existente n Romania, n condiiile existenei acesteia n numeroase ri din Europa, inclusiv cele vecine Romniei (Ungaria, Ucraina); Centraliznd cercetrile recente privind situaia epidemiologic, problemele clinice i opiunile terapeutice, autorii au descris primul caz de echinococoz alveolar n Ungaria. Pentru confirmarea acestei infecii rare trebuie s fie luat n considerare diagnosticul diferenial cu alte leziuni hepatice infiltrative [14]. Nu a fost raportat nici un caz la nivelul Romniei, prin alte studii. Recomandm introducerea acestei metode n screeningul i diagnosticul acestei boli grave. n ncercarea de a compara metodele folosite pentru diagnosticarea chistului hidatic i a rezultatelor obinute prin aceste metode, putem afirma c testul Western blot IgG echinococcus este cel mai sensibil pentru a preciza un diagnostic etiologic.

REFERINTE 1. Junie, Monica, Zoe Coroiu, Carmen Costache, 2002, The consequences of Echinococcus granulosus infection n the human population, Rev. Scienia Parasitologica 3:2, 86-91 2. Seres tefania, Monica Junie, V. Cozma, 2009, Prevalence of Echinococcus granulosus in Cluj county, Romania, revealed by PCR, Rev. Scienia Parasitologica, 1o:1-2, 68-71 3. Coroiu, Zoe, Judith Bele, Cornelia Munteanu, Rodica Radu, 2007, Aspecte epidemiologice privind hidatidoza uman n judeul Cluj pe o perioada de 20 de ani (1981-2000), Rev. Scientia Parasitologica, 8:1, 32-38. 4. A. Lahuerta, T. Westrell, J. Takkinen, F. Boelaert, V. Rizzi, B. Helwigh, B. Borck, H. Korsgaard, A. Ammon, P. Mkel: Zoonoses n the European Union: origin, distribution and dynamics the EFSA - ECDC summary report, 2009 5. Craig, P.S., 1997, Immunodiagnosis of Echinococcus granulosus and a comparison of techniques for diagnosis of canine echinococcosis. In: Compendium on cystic echinococcosis n Africa and Middle Eastern countries with special reference to Morocco, Brigham Young University Pris Services, Provo. 6. Schipper H.G. Modern management of echinococcosis. World Gastroenterology News vol. 9, nr. 2, 2004 7. Arda, B., H. Puluku, T. Yamazhan, O.R. Sipahi, S. Tamsel, G. Demirpolat, M. Korkmaz, 2009, Prevalence of Echinococcus granulosus detected using enzyme immunoassay and abdominal ultrasonography n a group of students staying n a state dormitory n Turkey, Turk. J. Med. Sci., 39:1, 1-4. 8. Liance, M., V. Janin, S. Bresson-Hadni, D.A. Vuitton, R. Houin, R. Piarroux, 2000, Immunodiagnosis of Echinococcus infections: confirmatory testing and species differentiation by a new comercial Western blot, J. Clin. Microbiol., 38, 3718-3721. 9. Karadam SY, Ertabaklar H, Sari C, Dayanir Y, Ertu S. Should cystic echinococcosis be investigated n patients having high eosinophil counts?. Turkiye Parazitol Derg. 2009;33(3):203-6. 10. Macpherson CN, Milner R. Performance characteristics and quality control of community based ultrasound surveys for cystic and alveolar echinococcosis. Acta Trop. 2003 Feb;85(2):203-9 11. Shambesh MA, Craig PS, Macpherson CN, Rogan MT, Gusbi AM, Echtuish EF. An extensive ultrasound and serologic study to investigate the prevalence of human cystic echinococcosis n northern Libya. Am J Trop Med Hyg. 1999 Mar; 60(3):462-8. 12. Reiter-Owona I, Grner B, Frosch M, Hoerauf A, Kern P, Tappe D. Serological confirmatory testing of alveolar and cystic echinococcosis in clinical practice: results of a comparative study with commercialized and in-house assays. Clin Lab. 2009;55(1-2):41-8. 13. Sik Barabsi S. i Cozma V. ,2008 , Echinococoza alveolar. O posibil zoonoz emergent n Romnia (Sintez). Rev.Scientia Parasitologica. 9, 1, 48-60; 14. Horvth Andrea, Patonay Attila, Bnhegyi Dnes, Szlvik Jnos, Balzs Gyrgy, Grg Dnes s Werling Klra,. A humn Echinococcus multilocularis infectio els hazai esete. Berkezett: 2007. november 16.; elfogadva: 2008. mrcius 7

CURRICULUM VITAE 1. Nume: Ciobanca 2. Prenume: Petrica Teofil 3. Data i locul naterii: 25.11.1979; Localitatea Zalau, judetul Salaj 4. Cetenie: Romana 5. Stare civil: Casatorit 6. Contact: Tel: 0040-740052584; E-mail :petrica_ciobanca@yahoo.com 7. Studii: Instituia Universitatea Universitatea de Universitate Universitatea de Vest Vasile Medicina si de Medicina de medicina si Goldis Arad FarmacieIuliu Carol Farmacie Hatieganu Cluj Davila Iuliu Napoca Bucuresti Hatieganu Cluj Napoca Perioada: Octombrie Ianuarie2005Ianuarie 2005- Octombrie 2004 februarie2005 Martie 2005 1998Iunie 2005 Septembrie 2004 Grade sau Diploma de Certificat de Certificat de Diploma de diplome Master in Absolvire: curs Absolvire : Licenta obinute Managementul postuniversitar curs Medicina Financiar de ecografie postuniversitar Generala Contabil si generala modul I de ecografie Juridic al generala Firmelor modulul II

Liceul Teoretic Zalau -Sectia MatematicaFizica Septembrie 1994 Iulie 1998 Diploma de Bacalaureat

8. Titlul tiinific: Medic, Asistent Universitar, Doctorand cu frecventa 9. Experiena profesional: Perioada: Functia Responsabilitati 01. 11. 2005 -Asistent Universitar U.M. F Iuliu Hatieganu CLUJ prezent -Medic Rezident Medicina de - Activitate didactica in Microbiologie Laborator (Bacteriologie, Parazitologie, -Doctorand cu frecventa Virusologie, Micologie) cu studentii anului II, III, Medicina Generala, Farmacie, Colegii Medicale, in cadrul UMF Iuliu Hatieganu -Stagii in activitatea de rezidentiat -activitate de cercetare 01.01.2006 -Medic generalist SALVO- SAN prezent -practica medicala in medicina generala 01.06. 2009 SHO RMO RMO INTERNATIONAL 20.11. 2009 -Practica medicala, examinari clinice pre si post operatorii; -managerul echipei de resuscitare in caz de urgenta 15.01.2007 Medic Rezident Medicina de Spitalul Clinic Judetean de Urgenta 14.11.2007 familie Cluj Napoca
10

29.08.2005 10.09.2005 01.01.2005 01.01.2006 14.03.2005 01.04.2005

Medic Stagiar Medic Stagiar Medic Stagiar

- examinari clinice, EKG, diagnostic si tratament, stagii de Obstetrica si Ginecologie, Psihiatrie, Boli Infectioase Spitalul Kantonal Flawil Elvetia -stagii de Medicina Interna, prezentari si explorari diagnostice Spitalul Clinic Municipal Cluj Napoca - stagii de Medicina Interna 6 luni, -stagii de Chirurgie 6 luni Spitalul Clinic de Pediatrie Maria Sklodowska Curie -am asistat la explorarile endoscopice efectuate

Ecografie generala, modulul unu: Ianuarie 2005 februarie 2005 Ecografie generala, modulul doi: Ianuarie 2005 martie 2005 Medicina ocupationala Urgente chirurgicale la copii Curs de resuscitare adulti ALS - London Ambulance Service EPLS - Royal Brompton Hospital London Ultrasonografie de urgenta EKG Ecografie Doppler 10. Locul de munc actual i funcia: Asistent Universitar, Doctorand cu frecventa, U.M.F. Iuliu Hatieganu Cluj Napoca 11 . Vechime la locul de munc actual: 6 ani 12. Lucrri elaborate i / sau publicate

Cursuri post-universitare

Monica Junie, Petrica Ciobanca: (B-783). 2005, Comparison of Antibiotic Resistance of Pseudomonas Aeruginosa Strains Isolated from Different Types of Infections, Abstracts of the XIth International Congress of Bacteriology and Applied Microbiology July 23-28, San Francisco, California, U.S.A ISBN:1-555-81-353-4 Monica Junie, Petrica Ciobanca (M-722). 2005, Evolution of Resistance Phenomenon to Antimycotic Drugs of Candida Species and Dermatophytes, Abstracts of the XIth International Congress of Mycology July 23-28, San Francisco, California, U.S.A ISBN:1-555-81-354-2 Lia Monica Junie, Doina Matinca, Doina Tulescu, AN Ferke, Petrica Ciobanca, 2006, Evolution of Antibiotic Resistance of Pseudomonas aeruginosa strains isolated from Hospital Infectious, International Journal of Infectious Diseases, vol.10, suppl 1, ISSN 1201 9712, pag, S 78 Lisabon, Portugal, ISSN 1201-9712, IJID, indexed in MEDLINE EMCASE /Escerpta Media and Urlichs; Elsevier Publishing, Presented at the International Congress of Infectious Diseases, sesiunea Antibiotic Resistance Gram negatives (poster nr. 13003), iunie 15-18, Lia Monica Junie, Zoe Coroiu i col. AN Ferke, Petrica Ciobanca, 2006, The significance of AntiToxoplasma IgG and IgM Antibodies Detection in Toxoplasmosis Diagnosis, Abstract books the 12 th ISID , pag. 80, Presented at the 12th ISID 15-18 iunie, 2006 Lisbon, Portugal, Sectiunea Parasitic Infectious,

11

 Junie, Monica, Petrica Ciobanca, 2006, Species Distribution and Antifungal Susceptibility Of Candida Isolates Colected From Hospitalised Patients. Abstracts of 16th European Congress Of Clinical Microbiology And Infectious Diseases. Nice France 1- 4 aprilie 2006 Constantea N. i Petrica Ciobanca, 2007, Studiul clinic pentru mbuntirea metodelor de diagnostic de laborator i profilaxia chistului hidatic, Rev.Rom.de Parasitol. 17, 48-49. Junie, Monica, N. Constantea, Petrica Ciobanca, 2007, Surveillance programme in echinococcosis and importance in the prophylaxis and therapy of human infection, Clinical Microbiology and Infection, 13:2., Christofidou M, Spiliopoulou A, Vamvacopoulou S, Stamoulis V, Dimitracopoulos G, Anastassiou E.D, Monica Junie, Costache C, Colosi I, Ciobanca P T., 2008, Species distribution and antifungal susceptibility of Candida isolates collected from hospitalized patients in Romania and Greece, Scientia Parasitologica;1:61-7. ISSN 1582 - 1366, L M Junie, Vasile Cozma, Zoe Coroiu, Petrica Ciobanca, 2009, Epidemiology of human echinococcosis in Europe", pg. 109-127 Junie Monica, S. Rpuntean, N. Fi, Cosmina Cuc, F. Puiu, Gh. Rpuntean, L. Deac Simion, P. T. Ciobanca, 2009, Alternative therapies for combating antimicrobial resistence and reduction of severe nosocomial infections, Abstract Book of IMED (International Meeting on Emerging Diseases and Surveillance), Vienna, Austria, Februarie 13-16, 2009; Abstract 10152, pg.86, V. Cosma, PT Ciobanca, R. Blaga, C. Gherman, Lia Monica Junie, 2009; Hydatidosis Epidemiology at Humans and Animals in the Area of the Center and North-Vest, Romania, Abstract book of IMED International Meeting on Emerging Diseases and Surveillance, Vienna, Austria, Februarie, pg.86 Ciobanca Petrica, Monica Junie, 2011, Serological diagnosis and its applicability to the prophylaxis and therapy of hydatid cyst in human patients, Rev. Scienia Parasitologica, 12:1, 39-46. Ciobanca Petrica Teofil, Junie Lia Monica, 2011, Diagnosis confirmation of human cystic echinococcosis by imagistic methods and immunoserological determinations, Scientia Parasitologica,12(3):151-161

13. Limbi straine cunoscute: Engleza-fluent, Franceza incepator, Germana - incepator 14. Specializri i calificri: Ecografie , Operare PC 15. Experiena acumulat n programe naionale/internaionale: Programul/Proiectul Funcia Perioada:
Constituirea unei reele naionale privind studiul unor zoonoze parazitare i implicaiile lor n sigurana alomentelor,CEEX 178/2005 cu o durat de 24 luni Evaluarea i optimizarea interdisciplinar a metodelor de screening, diagnostic i tratament n trichineloza i echinococoza chistic uman i animal n centrul i nordvestul Romniei - TRICHID, Program CEEX 199/2006. Constituirea unei reele naionale de cercetare a dermatofitozelor la om i animale,Program CEEX 151/2006 realizat in colaborare cu Universitatea de Stiine Agricole i Medicin Veterinar Doctorand, Responsabil economic 2006 2007

realizat ntre Universitatea de Stiine Agricole i Medicin Veterinar 2006 -2008 (conductor al proiectului) i U.M.F. Cluj Napoca (partener ). Doctorand, Responsabil economic realizat ntre USAMV (conductor al proiectului) i U.M.F. Cluj Napoca (partener). Doctorand, Responsabil economic

2006-2008

Declar pe propria rspundere c datele prezentate sunt n conformitate cu realitatea.

12

"IULIU HAIEGANU" UNIVERSITY OF MEDICINE AND PHARMACY OF CLUJ-NAPOCA

STRATEGIES IN HYDATID CYST DIAGNOSIS AND THERAPEUTICAL MONITORING

ABSTRACT OF DOCTOR'S THESIS

TABLE OF CONTENTS
LIST OF PUBLICATIONS ................................................................................................................2 INTRODUCTION ..............................................................................................................................7 PART I CURRENT KNOWLEDGE STATUS ...............................................................................10 Chapter 1. ECHINOCOCCUS GENUS ..........................................................................................11 1.1. Background ............................................................................................................................11 1.2. Taxonomy and classification .................................................................................................12 1.3. Morphology...........................................................................................................................12 1.4 Genetic and morphologic differences between species .........................................................15 1.5. Epidemiology ........................................................................................................................17 1.6. Biological lyfe cycle .............................................................................................................19 1.6.1. Echinococcus granulosus ...............................................................................................19 1.6.2. Echinococcus multilocularis ...........................................................................................21 1.7. Human contamination ..........................................................................................................22 CHAPTER 2: HYDATID CYST ....................................................................................................23 2.1. The pathogeny of the hydatid cyst .........................................................................................23 2.2. The evolution of the hydatid cyst .........................................................................................23 2.3. Clinical occurrence of human hydatidosis ............................................................................24 2.4. Diagnosis of hydatid diseases ...............................................................................................27 2.4.1. Clinical diagnosis ............................................................................................................28 2.4.2. Medical imaging diagnosis ............................................................................................28 2.4.3. Parasitologic diagnosis....................................................................................................31 2.4.4. Immunologic diagnosis ...................................................................................................32 2.4.5. Differential diagnosis in hydatid cyst ............................................................................34 2.5. Treating the hydatid cyst .......................................................................................................35 2.6. The prophylaxis of the hydatid cyst ......................................................................................38 PART II PERSONAL RESEARCHES ............................................................................................40 STUDY 1: The applicability of the serological methods for the diagnosis, therapy and prophylaxis of the human hydatid disease ................................................................................................................41 1.1. Introduction ............................................................................................................................41 1.2. Study aim and objectives ......................................................................................................41 1.3. Material and method ..............................................................................................................42 1.3.1. Material ...........................................................................................................................42 1.3.2. Method ............................................................................................................................43 1.4. Results ...................................................................................................................................47 1.4.1. Detecting the seropositive persons investigated by ELISA IgG Antiechinococcus in Cluj and Slaj Counties.....................................................................................................................47 1.4.2. Frequency depending on the environment the seropositive persons belong to in Cluj and Slaj Counties ...........................................................................................................................48 1.4.3. Seropositve persons frequency in Cluj and Slaj Counties depending on gender ..........50 1.4.4. Epidemiological aspects on seropositive persons in Cluj County (incidence, environment they belong to and distribution on genders) ..............................................................................51 1.4.5. The seropositive persons frequency depending on sex in Cluj County .........................52 1.4.6. Epidemiological aspects on seropositive persons in Slaj County (incidence, environment they belong to and distribution on genders) ..............................................................................53

1.4.7. The frequency of seropositive persons dependending on sex in Salaj Couty ................54 1.5. Confirming the determinations following the serological tests through imagistic methods in human cystic echinococcosis ........................................................................................................55 1.5.1. The results of imagistic determinations (ultrasound scan, thoracic RX, CT) 56 1.6. DEBATES..............................................................................................................................58 1.7. CASE DESCRIPTION ..........................................................................................................61 CONCLUIONS .................................................................................................................................68 STUDY II: Evaluation and optimization of diagnosis methods in hydatid disease ........................69 2.1. Introduction ............................................................................................................................69 2.2 Study aim and objective ..........................................................................................................69 2.3 Material and method ...............................................................................................................70 2.3.1 Material ............................................................................................................................70 2.3.2 Paraclinic and clinical methods involved ........................................................................71 2.3.3 Statistical methods of data analysis ................................................................................77 2.4. Results ...................................................................................................................................80 2.4.1 Epidemiological results (considering the sex, origins, age) ............................................80 2.4.2 Clinical and paraclinical results regarding the hydatid cyst diagnosis ...........................83 2.4.2.1. The clinical examination value in hydatid cyst diagnosis .......................................83 2.4.2.2. Surgical confirmation in hydatid cyst presumtive diagnosis ..................................85 2.4.2.3. Assessing the usual laboratory analysis (haemoleucogram, biochemical analysis used to determine hydatid cyst) ....................................................................................................86 2.4.2.4. Imagistic methods involved to determine the hydatid cyst .....................................89 2.4.2.5. Results obtained through immunoserological methods ..........................................97 2.4.3. Comparative results ......................................................................................................106 2.5. DEBATES............................................................................................................................122 2.6. CASE DESCRIPTION .......................................................................................................131 CONCLUSIONS: ...........................................................................................................................139 GENERAL CONCLUSIONS ........................................................................................................140 REFERENCES ..............................................................................................................................142

INTRODUCTION The Echinococcosis / hydatidosis (the hydatid disease or the hydatid cyst) is a parasitic disease determined by genus Echinococcus, which may evolve with the most severe and different implications. Despite progresses in control and monitoring fields this parasitosis keeps representing an important issue of the public health in the most parts of the world [1]. According to WHO classification the disease is a zoonosis which brings a lot of health issues, both in humans and animals because the causing parasites in order to end their biological cycle pass through more vertebrate animal hosts (as for example, dogs for the humans). Due to its high prevalence, the severe clinical developing forms, the morphofunctional complications with high primary or secondary mortality, the disease if frequently met both in rural and urban environment, at all age groups, alarming prevalence in youngsters and occupational risk groups [2]. In our country area the hydatid pathology has a quite high frequency, the north western part of Transylvania being described an endemic area with important cases [3], the medicine of Cluj having a significant experience in hydatid cyst diagnosis and treatment. Despite the lately achievements in human echinococcosis diagnosis and therapy, it still has an important place in morbidity and mortality structure within surgical services. So in this way presenting some briefly data over the different aspects the hydatid disease may adopt in its development from clinical, imagistic, serological point of view and their importance evaluation in early recognition and diagnosis of the disease. PART I: CURRENT STATUS OF KNOWLEDGE Chapter 1. Genus Echinococcus The parasite responsible for causing human hydatidosis is a Platyhelminthe belonging to Cestoda class (Eucestoda), Taeniidae family, Genus Echinococcus. The species of genus Echinococcus considered as etiologic agents of echinococcosis / hydatidosis according to WHO experts are as follows: - Echinococcus granulosus (Batsch, 1786) - cystic echinococcosis - Echinococcus multilocularis (Leuckart, 1863) alveolar echinococcosis - Echinococcus oligarthus (Diesing, 1863) - Echinococcus vogeli (Rausch, Bernstein, 1972) polycystic echinococcosis The issue of the 5th species existence arose, E.cruzi (Rausch and co. 1978; Kumaratilake and Thompson 1982), but Rausch and co. (1984) comparing its features with E.vogeli and E.oligarthus remarked that in fact E. cruzi is similar to E. oligarthus. The geographical distribution of hydatidosis loyally follows the sheep breeders developing curve and it is determined by pastoral promiscuity fact that determined Deve assert that "the hydatid disease is one of the dirty hands diseases". The wide range of animal species which may be intermediary hosts and their circulation from Europe in other parts of the world made that Echinococcus be spread on the entire globe. In 2009 ECDC reported 790 cases of human echinococcosis, with 11% lower than in 2008 (n= 891). Among the reported cases where the infecting species is known predominated the infection with E.granulosus (72%) while E.multilocularis infection was reported as having a frequency 3 times lower [4].

CHAPTER 2: HYDATID CYST The hydatid cyst is often an invaliding disease with possible and often severe complications (anaphylactic shock), with often difficult surgical therapy and frequent post-surgery recidivations. The clinical behaviours due to the complications settled through the aforementioned mechanisms appear when the hydatid cyst sizes become considerable. The clinical framework of the hydatid cyst is little characteristic. Quite often it is completely asymptomatically and discovered purely by chance. Other times the patients accused discomfort in the right hypochondrium or even intense pain. The allergic reactions are quite frequently from urticaria reaction up to alergodermy or even anaphylactic shock (generally in case of fissure or even the hydatid cyst rupture). The morphological determination of the hydatid cysts may be done through thoracic ultrasound scan, computer tomography (CT) and magnetic resonance (MR). The imagistic methods for human hydatidosis diagnosis are completed with immunodiagnosis reactions aiming the parasitic aetiology confirmation of the determined formations through immune induced response. In the last years exists a tendency of immunologic diagnosis staging; firstly primary tests are used following to be confirmed through other methods having a significantly specificity (secondary tests) [5]. The hydatid cyst modern management require involving all therapeutic methods: medical, percutaneous and surgical. The surgery is not anymore the first election for treating any hepatic hydatid cyst. In patients with univesicular cyst smaller that 4 cm the chosen therapy is the monotherapy with albendazole. PAIR is indicated when the pain in not treatable or the albendazole is ineffective. The percutaneous treatment combines the alcohol and polidocanol but cannot be used in case of cystobilliary fistula. The surgery is used in cases when in percutaneous therapy no experts exist and the percutaneous treatment cannot safely performed due to a significant extra-hepatic extension with perforation risk of the cyst or/and in case of cyst rupture in the peritoneal cavity [6]. PART II: PERSONAL RESEARCHES STUDY 1: The applicability of the serological methods in the diagnosis, therapy and prophylaxis of human hydatid disease The aim of this study was serological tests (ELISA method) conducting and evaluation as screening and diagnosis methods of cystic echinococcosis. The tests were conducted in symptomatic and asymptomatic persons from Cluj and Slaj Counties in order to estimate the disease frequency in these counties. In the persons where anti-echinococcus IgG antibodies were determined imagistic investigations were performed in order to confirm the clinical and serological diagnosis of hydatid cyst. The investigations allowed clarifying the epidemiological, diagnosis, therapeutic and prognostic aspect regarding cystic echinococcosis. Material and method The study was conducted during January 2007 December 2009 and included 279 symptomatic and asymptomatic persons from Cluj and Slaj Counties in order to determine the presence and the level of anti-echinococcus antibodies level in the population of the two regions and implicitly the asymptomatic infection using ELISA immunoenzyme method.

In order to confirm the hydatid cyst diagnosis determined through serological test I used the following imagistic methods: abdominal pelvic ultrasound scan, cranial CT, thorax CT, thorax Rx. Results Out of the 279 persons examined in both counties (Cluj i Slaj), in 22 patients was determined positive serology, the seropositivity frequency was of 7.89% (IC= 5% -11.69%) in the studied sample suggesting the possible hydatid infection in seropositive persons. The real frequency of parasitosis is obviously higher because the symptomatic cases represent only the peak of infestation pyramid while the asymptomatic cases form the unseen higher basis of it. The serological screening performed in the north - western and central region of the country showed the E.granulosus infection presence with the possibility of its active transmission. The obtained results demonstrate the higher percentage of the seropositve persons in Cluj County and suggest a higher incidence of the hydatidosis in this region. This conclusion was elaborated following a research project conducting with the title "Interdisciplinary evaluation and optimization of the screening, diagnosis and treatment methods in triquinelosis, human and animal cystic echinococcosis in the centre and north - west of Romania" conducted during 2006-2008 where I partake as a member. In 77.14% of the patients in imagistic investigation the hydatidosis diagnosis could be confirmed. The patients had clear imagines for hydatid cyst with different locations: hepatic (65.38%), pulmonary (5.88%), renal (5.88%). The results of our researches suggest that a certain proportion of the investigated population was positive in IgG anti-Echinococcus without having in the organism the hydatid determined through imagistic methods. DEBATES The lack of knowledge, population ignorance and even of some specialists in sanitary field regarding the biological cycle of E. granulosus species and the hosts it has as well as the risk involved by a tight contact with the permanent host are causes of main importance in parasite easy spreading. The results obtained following this study are similar with the results of some analogous studies from the specialty literature conducted in endemic areas for human cystic echinococcosis [3]. In a study performed on an asymptomatic sample of persons in 12% of the cases, the ultrasound scan did not determine cystic form characteristic to the hydatid cyst although the serological test was positive [7]. STUDY II: Evaluation and optimization of the diagnosis methods in hydatid disease The study has the following aims: 1. the evaluation of the clinical examination in the presumptive diagnosis and imagistic diagnosis evaluation in the hydatid disease; 2. Evaluation of ELISA method, Western-Blott and the laboratory methods in order to confirm the clinical and imagistic diagnosis of hydatid cyst; 3. The comparative study of the imagistic methods (ultrasound scan, Rx, CT, RM) with the serological methods (ELISA, Western-blott methods) and the evaluation of their utility in differentiating the cystic and alveolar echinococcosis and in performing the differential diagnosis and interpretation of the cross-reactions.

2.3 Material and method The study was performed during 2006 2010 and included a representative sample of 189 symptomatic persons, with suggestive symptoms and imagistic suspicion of hydatid disease. Other studied persons were those for whom surgical intervention was performed in hydatid cyst and persons having non-specific laboratory results but with suspicions of parasitic disease. The working material I used were the medical and surgical cases from the Medical and Surgical Clinics of Cluj-Napoca and Slaj (Clinica Chirurgie III, Clinica Chirurgie V i and the ambulatory of a private policlinic). The types of data collected and used within this study were: gender, age, origin, clinical diagnosis; the hydatid cyst complications; hydatid cyst antecedents; the imagistic diagnosis methods performed (abdominal ultrasound scan, pulmonary Rx, CT, RM, surgical treatment, the examination of the surgical piece, hystopathological); laboratory analysis; finding the location of the cystic formation depending on the hepatic segmentation and depending on the organ in question; the serological diagnosis methods performed (immunoenzyme IgG antiechinococcus ELISA method, IgG echinococcus Western- blot method) 2.4. Results The results obtained determined that there isnt a significant association between IgG echinococcus Western-blot and the hydatid disease diagnosis (p>0.05); notwithstanding when eosinophilia is present results a relatively high coincidence of 71% (IC=52% - 85%) with the hydatid cyst diagnosis. The statistic analysis of imagistic investigation results and surgical and paraclinical confirmation results correlation presented a sensibility of 96.89% for the imagistic investigation, the specificity was of 100%; they don't differ significantly from statistical point of view. The diagnosis value of the imagistic examination is given by the positive predictive value (PPV) and the negative one (NPP) both of them are over 84% although the NPP is statistical significantly lower than PPV. The evaluation of IgG antiechinococcus ELISA results compared with the surgical, hystopathological and paraclinical confirmation of hydatid cyst diagnosis determines a Specificity of 96.43% and a PPV of 99.19%; as these are very high it may be considered that ELISA method is a good screening test. By comparison with imagistic, ultrasound scan or CT investigations, the IgG antiechinococcus ELISA has a lower Youden index. As a consequence from this point of view IgG antiechinococcus ELISA seems to be a less conclusive diagnosis test comparing with the mentioned imagistic investigations. On the other side, comparing the trust intervals of Specificity, PPV and imagistic investigations (globally, ultrasound scan, CT) and IgG antiechinococcus ELISA we observe that they dont differ statistically speaking. The imagistic investigation results and those of IgG antiechinococcus ELISA associate significantly. It is noticeable that at the same time with the other association coefficients (contingency, Kendal tau coefficient) the concordance coefficient between the imagistic investigation results and those of the IgG antiechinococcus ELISA are significantly statistical (p<0,001). It should be mentioned that the concordance measure Kappa = 0,522 indicates the fact that between the two examinations exist a moderate concordance. Imunoblot technique is a strong confirmation and differential serological diagnosis test between the two major relevant infections: the cystic and alveolar echinococcosis [8]. The evaluation of IgG echinococcus Western Blot investigation results by comparison with the surgical, hystopathological and paraclinial confirmation of hydatid cyst diagnosis revealed a

Specificity of 100% an a positive predictive value of 100%; as these are very high you may consider that the IgG echinococcus Western Blot detecting test is a good screening test. It is noticeable that at the same time with the other association coefficients (contingency, Kendal tau coefficient) the concordance coefficient between the imagistic investigation results and those of the IgG echinococcus Western blot are significantly statistical (p<0,001). It should be mentioned that the concordance measure Kappa = 0,816 indicates the fact that between the two examinations exist a very good concordance. 2.5. DEBATES The evaluation of the eosinophilia as diagnosis marker in cystic echinococcosis allowed some authors to assert that eosinophilia is not enough to settle the cystic echinococcosis diagnosis but also a complementary clinical diagnosis [9]. The ultrasound scan sensibility and specificity was reported in more studies in the literature as between 88-98% and 95-100% respectively for human cystic and alveolar echinococcosis. The authors consider it as the golden standard although admit the imperfection of this technique. The clinical investigation, the laboratory examination and the epidemiological data are also considered important for the cystic and alveolar echinococcosis diagnosis [10]. The serological tests contribute to the diagnosis, IgG antibodies detection had a sensibility of 95% and 94% specificity in a study conducted by Shambesh MA and company [11]. The sensibility obtained by Shambesh is significantly higher than that determined in our study, which determines a sensibility of 74% with IC= 69.07%-82.72%. In exchange the specificity doesn't differ significantly from statistical point of view of that obtained in our study (96.43%, IC=81.65%-99.91%). The echinococcosis infections are considered ones of the most dangerous human helminthic diseases. The difference between the cystic and alveolar echinococcosis is important from the prognostic and treatment point of view. In different stages of cystic and alveolar echinococcosis the most relevant test was appreciated the Western blot IgG echinococus test whih confirmed the positive results [12]. The research conducted in order to determined IgG echinococcus presence through Western blot method reported to the considered golden method (surgical, hystopathological and paraclinical diagnosis confirmation) showed a sensibility of 92.11% (IC = 78.62% - 98.34%) the specificity being of 100% (IC = 83.89% - 100%) data like the ones met in the specialty literature. In the most countries the alveolar echinococcosis has an endemic character and is continuously extending with an alarming rapidity becoming an emergent disease. The adult parasite E.multilocularis was not yet found in Romania up now in any permanent 13 host [ ]. The study conducted revealed through the Western blot method for the first time in our country the possibility of infection with Echinococcus multilocularis in human. Next studies are needed to determine the alveolar echinococcosis persons in Romania under the conditions of its existence in a number of countries in Europe including Romania neighbouring countries (Hungary, Ukraine); centralizing the recent researches about the epidemiological situation, the clinical problems and the therapeutic options the authors described in the first case the alveolar echinococcosis in Hungary. In order to confirm these rare infections you must take in consideration the differential diagnosis with other infiltrative hepatic lesions [14]. No case was confirmed in Romania through other studies. We recommend the introduction of this method in the screening and diagnosis of this serious disease.

In the attempt to compare the methods used in hydatid cyst diagnosis and the obtained results through these methods we may assert that Western blot IgG echinococcus test is the most sensible in determining an etiological diagnosis. REFERENCES 1. Junie, Monica, Zoe Coroiu, Carmen Costache, 2002, The consequences of Echinococcus granulosus infection in the human population, Rev. Scienia Parasitologica 3:2, 86-91 2. Seres tefania, Monica Junie, V. Cozma, 2009, Prevalence of Echinococcus granulosus in Cluj county, Romania, revealed by PCR, Rev. Scienia Parasitologica, 1o:1-2, 68-71 3. Coroiu, Zoe, Judith Bele, Cornelia Munteanu, Rodica Radu, 2007, Aspecte epidemiologice privind hidatidoza uman n judeul Cluj pe o perioada de 20 de ani (1981-2000), Rev. Scientia Parasitologica, 8:1, 32-38. 4. A. Lahuerta, T. Westrell, J. Takkinen, F. Boelaert, V. Rizzi, B. Helwigh, B. Borck, H. Korsgaard, A. Ammon, P. Mkel: Zoonoses n the European Union: origin, distribution and dynamics the EFSA - ECDC summary report, 2009 5. Craig, P.S., 1997, Immunodiagnosis of Echinococcus granulosus and a comparison of techniques for diagnosis of canine echinococcosis. In: Compendium on cystic echinococcosis n Africa and Middle Eastern countries with special reference to Morocco, Brigham Young University Pris Services, Provo. 6. Schipper H.G. Modern management of echinococcosis. World Gastroenterology News vol. 9, nr. 2, 2004 7. Arda, B., H. Puluku, T. Yamazhan, O.R. Sipahi, S. Tamsel, G. Demirpolat, M. Korkmaz, 2009, Prevalence of Echinococcus granulosus detected using enzyme immunoassay and abdominal ultrasonography n a group of students staying n a state dormitory n Turkey, Turk. J. Med. Sci., 39:1, 1-4. 8.Liance, M., V. Janin, S. Bresson-Hadni, D.A. Vuitton, R. Houin, R. Piarroux, 2000, Immunodiagnosis of Echinococcus infections: confirmatory testing and species differentiation by a new comercial Western blot, J. Clin. Microbiol., 38, 3718-3721. 9.Karadam SY, Ertabaklar H, Sari C, Dayanir Y, Ertu S. Should cystic echinococcosis be investigated n patients having high eosinophil counts?.Turkiye Parazitol Derg. 2009;33(3):203-6. 10. Macpherson CN, Milner R. Performance characteristics and quality control of community based ultrasound surveys for cystic and alveolar echinococcosis. Acta Trop. 2003 Feb;85(2):203-9 11. Shambesh MA, Craig PS, Macpherson CN, Rogan MT, Gusbi AM, Echtuish EF. An extensive ultrasound and serologic study to investigate the prevalence of human cystic echinococcosis n northern Libya. Am J Trop Med Hyg. 1999 Mar; 60(3):462-8. 12. Reiter-Owona I, Grner B, Frosch M, Hoerauf A, Kern P, Tappe D. Serological confirmatory testing of alveolar and cystic echinococcosis in clinical practice: results of a comparative study with commercialized and in-house assays. Clin Lab. 2009;55(1-2):41-8. 13. Sik Barabsi S. i Cozma V. ,2008 , Echinococoza alveolar. O posibil zoonoz emergent n Romnia (Sintez). Rev.Scientia Parasitologica. 9, 1, 48-60; 14. Horvth Andrea, Patonay Attila, Bnhegyi Dnes, Szlvik Jnos, Balzs Gyrgy, Grg Dnes s Werling Klra,. A humn Echinococcus multilocularis infectio els hazai esete. Berkezett: 2007. november 16.; elfogadva: 2008. mrcius 7

CURRICULUM VITAE 1. Surname: Ciobanca 2. Name: Petrica Teofil 3. Date and place of birth: 25.11.1979; Zalau, Salaj 4. Citizenship: Romanian 5. Marital status: married 6. Contact: Tel: 0040-740052584; E-mail:petrica_ciobanca@yahoo.com 7. Studies:
Iuliu Haieganu Vasile Goldis University of West University Medicine and Arad Pharmacy of ClujNapoca] October 2004 / June 2005 January 2005 / February 2005 Carol Davila University of Medicine of Bucharest] January 2005/ March 2005 Iuliu Haieganu University of Medicine and Pharmacy of Cluj-Napoca] October 1998 / September 2004 University Degree General Medicine Theoretical High School of Zalau; Physics Mathematics specialty] September 1994/ July 1998

Institution

Period:

Skills of diplomas obtained:

Masters Degree Certificate of Certificate of in graduation: graduation: Financial, general general ultrasound Accounting and ultrasound scan scan postLegal post-university university course Management of course module module I the Companies II

High School Diploma

8. Scientific title: Medical doctor, University Assistant, Full-time doctoral student

9. Professional experience: Period: Position 01. 11. 2005 up - University Assistant now - Resident Physician in Laboratory Medicine - Full-time doctoral student Responsibilities U.M. F Iuliu Hatieganu CLUJ - Didactical activity in Microbiology (Bacteriology, Parasitology, Virology, Mycology) with the 2nd, 3rd year students, General Medicine, Pharmacy, Medical Colleges within "Iuliu Hatieganu" University of Medicine and Pharmacy - Stages within residency activity - Research activity SALVO - SAN - medical practice in general medicine RMO INTERNATIONAL -Medical practice, clinical investigations before and after operation; -The manager of resuscitation team in emergency cases Spitalul Clinic Judetean de Urgenta Cluj Napoca - clinical examinations, EKG, diagnosis and treatment, stages in Obstetrics and Gynaecology, Psychiatry, Infectious Diseases Kantonal Flawil Hospital Switzerland -Internal Medicine stages, presentations and diagnosis examinations Spitalul Clinic Municipal Cluj Napoca

01.01.2006 up now 01.06. 2009 20.11. 2009 15.01.2007 14.11.2007 29.08.2005 10.09.2005 01.01.2005

- Physician SHO RMO

Resident physician in Family Medicine Physician in training Physician in training

01.01.2006 14.03.2005 01.04.2005 Physician in training

- Internal Medicine stages for 6 months, - Surgery stages for 6 months Maria Sklodowska Curie Paediatrics Clinical Hospital - I assisted in the performance of endoscopic investigations

Post university courses

General ultrasound scan, first module: January 2005 - February 2005 General ultrasound scan, second module: January 2005 March 2005 Occupational medicine Surgical emergencies in the children Resuscitation course in adults ALS - London Ambulance Service EPLS - Royal Brompton Hospital London Emergency ultrasonography EKG Doppler echography

10. The current place of work and position: University assistant, Full-time doctoral student, Iuliu Hatieganu University of Medicine and Pharmacy of Cluj-Napoca 11. Seniority in the current place of work: 6 years 12. Works elaborated and / or published Monica Junie, Petrica Ciobanca: (B-783). 2005, Comparison of Antibiotic Resistance of Pseudomonas Aeruginosa Strains Isolated from Different Types of Infections, Abstracts of the XIth International Congress of Bacteriology and Applied Microbiology July 23-28, San Francisco, California, U.S.A - ISBN:1-555-81-353-4 Monica Junie, Petrica Ciobanca (M-722). 2005, Evolution of Resistance Phenomenon to Antimycotic Drugs of Candida Species and Dermatophytes, Abstracts of the XIth International Congress of Mycology July 23-28, San Francisco, California, U.S.A ISBN:1-555-81-354-2 Lia Monica Junie, Doina Matinca, Doina Tulescu, AN Ferke, Petrica Ciobanca, 2006, Evolution of Antibiotic Resistance of Pseudomonas aeruginosa strains isolated from Hospital Infectious, International Journal of Infectious Diseases, vol.10, suppl 1, ISSN 1201 9712, pag, S 78 Lisabon, Portugal, ISSN 1201-9712, IJID, indexed in MEDLINE EMCASE /Escerpta Media and Urlichs; Elsevier Publishing, Presented at the International Congress of Infectious Diseases, sesiunea Antibiotic Resistance Gram negatives (poster nr. 13003), iunie 15-18, Lia Monica Junie, Zoe Coroiu i col. AN Ferke, Petrica Ciobanca, 2006, The significance of AntiToxoplasma IgG and IgM Antibodies Detection in Toxoplasmosis Diagnosis, Abstract books the 12th ISID , pag. 80, Presented at the 12th ISID 15-18 iunie, 2006 Lisbon, Portugal, Sectiunea Parasitic Infectious, Junie, Monica, Petrica Ciobanca, 2006, Species Distribution and Antifungal Susceptibility Of Candida Isolates Colected From Hospitalised Patients. Abstracts of 16th European Congress Of Clinical Microbiology And Infectious Diseases. Nice France 1- 4 aprilie 2006 Constantea N. i Petrica Ciobanca, 2007, Studiul clinic pentru mbuntirea metodelor de diagnostic de laborator i profilaxia chistului hidatic, Rev.Rom.de Parasitol. 17, 48-49. Junie, Monica, N. Constantea, Petrica Ciobanca, 2007, Surveillance programme in echinococcosis and importance in the prophylaxis and therapy of human infection, Clinical Microbiology and Infection, 13:2.,

 Christofidou M, Spiliopoulou A, Vamvacopoulou S, Stamoulis V, Dimitracopoulos G, Anastassiou E.D, Monica Junie, Costache C, Colosi I, Ciobanca P T., 2008, Species distribution and antifungal susceptibility of Candida isolates collected from hospitalized patients in Romania and Greece, Scientia Parasitologica;1:61-7. ISSN 1582 - 1366, L M Junie, Vasile Cozma, Zoe Coroiu, Petrica Ciobanca, 2009, Epidemiology of human echinococcosis in Europe", pg. 109-127 Junie Monica, S. Rpuntean, N. Fi, Cosmina Cuc, F. Puiu, Gh. Rpuntean, L. Deac Simion, P. T. Ciobanca, 2009, Alternative therapies for combating antimicrobial resistence and reduction of severe nosocomial infections, Abstract Book of IMED (International Meeting on Emerging Diseases and Surveillance), Vienna, Austria, Februarie 13-16, 2009; Abstract 10152, pg.86, V. Cosma, PT Ciobanca, R. Blaga, C. Gherman, Lia Monica Junie, 2009; Hydatidosis Epidemiology at Humans and Animals in the Area of the Center and North-Vest, Romania, Abstract book of IMED International Meeting on Emerging Diseases and Surveillance, Vienna, Austria, Februarie, pg.86 Ciobanca Petrica, Monica Junie, 2011, Serological diagnosis and its applicability to the prophylaxis and therapy of hydatid cyst in human patients, Rev. Scienia Parasitologica, 12:1, 39-46. Ciobanca Petrica Teofil, Junie Lia Monica, 2011, Diagnosis confirmation of human cystic echinococcosis by imagistic methods and immunoserological determinations, Scientia Parasitologica,12(3): 151-161 13. Foreign languages: English-advanced, French beginner, German beginner 14. Specialties and qualifications: Ultrasound scan, PC operator 15. Experience assimilated within the national / international programs: Program / project Position

Period

Developed in collaboration with the "A national network making regarding Agricultural Sciences and Veterinary the study of some parasitic zoonosis and Medicine University 2006 2007 their implications in food safety"CEEX Doctoral student, Economic 178/2005 lasting 25 months responsible person "Interdisciplinary evaluation and Developed between the Agricultural optimization of the screening, diagnosis Sciences and Veterinary Medicine and treatment methods in triquinelosis, University (project leader) and U.M.F. 2006 -2008 human and animal cystic echinococcosis Cluj-Napoca (partner) in the centre and north - west of Doctoral student, Economic Romania - TRICHID, CEEX program responsible person 199/2006. A national network making for Developed between USAMV (project of researching the dermatophytosis in the leader) and U.M.F. Cluj- Napoca 2006-2008 human and animals" CEEX program (partner). Doctoral student, Economic 151/2006 responsible person I declare on my own liability that the data mentioned are according to reality.