Polycystic echinococcosis

Infectious Disease MONDO:0000288 Echinococcosis Liver disorder Digestive system infectious disorder

Polycystic echinococcosis is a zoonotic helminth infection caused by the larval stage of Echinococcus vogeli, producing multilocular hydatid cysts that typically involve the liver and can infiltrate adjacent organs.

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3
Pathophys.
3
Phenotypes
2
Medical Actions
3
Differentials
3
References
2
Deep Research
⚙

Pathophysiology

3
Hepatic metacestode implantation
Oncospheres establish multilocular metacestode vesicles within the liver parenchyma, anchoring infection to hepatic tissue.
liver UBERON:0002107
Show evidence (1 reference)
PMID:33553405 SUPPORT
"Computed tomography of the abdomen revealed a huge polycystic lesion in left liver lobe, without reinforcement after enhanced scanning and sized about 16.9 cm × 12.2 cm, which was considered a type II hydatid cyst."
The CT finding localizes the polycystic hydatid lesion to hepatic parenchyma, consistent with metacestode implantation.
Daughter cyst proliferation and matrix remodeling
Metacestodes bud daughter cysts that coalesce into a multilocular mass, expanding through hepatic parenchyma while remodeling surrounding extracellular matrix.
extracellular matrix organization GO:0030198
liver UBERON:0002107
Show evidence (1 reference)
PMID:33553405 SUPPORT
"Computed tomography of the abdomen revealed a huge polycystic lesion in left liver lobe, without reinforcement after enhanced scanning and sized about 16.9 cm × 12.2 cm, which was considered a type II hydatid cyst."
The multilocular hepatic mass on imaging reflects proliferating daughter cysts and associated matrix remodeling.
Mass effect and local invasion
The enlarging multilocular cyst complex compresses adjacent hepatic tissue and can invade neighboring structures, generating space-occupying effects.
liver UBERON:0002107
Show evidence (1 reference)
PMID:33553405 SUPPORT
"Computed tomography of the abdomen revealed a huge polycystic lesion in left liver lobe, without reinforcement after enhanced scanning and sized about 16.9 cm × 12.2 cm, which was considered a type II hydatid cyst."
The large polycystic hepatic lesion demonstrates mass effect consistent with local compression and invasive growth.
●

Phenotypes

3
Digestive 2
Polycystic hepatic lesion Hepatic cysts HP:0001407
Show evidence (1 reference)
PMID:33553405 SUPPORT
"Computed tomography of the abdomen revealed a huge polycystic lesion in left liver lobe, without reinforcement after enhanced scanning and sized about 16.9 cm × 12.2 cm, which was considered a type II hydatid cyst."
The CT finding documents a large hepatic polycystic hydatid lesion consistent with the phenotype.
Hepatic abscess complication Liver abscess HP:0100523
Show evidence (1 reference)
PMID:41431593 SUPPORT
"We describe a rural patient with hepatitis B virus (HBV)-related cirrhosis and neotropical echinococcosis who developed a hepatic abscess that fistulized into the right hemithorax."
The report documents hepatic abscess formation as a complication of neotropical echinococcosis.
Immune 1
Thoracic abscess from hepatic fistula Lung abscess HP:0025044
Show evidence (1 reference)
PMID:41431593 SUPPORT
"We describe a rural patient with hepatitis B virus (HBV)-related cirrhosis and neotropical echinococcosis who developed a hepatic abscess that fistulized into the right hemithorax."
The case describes a transdiaphragmatic fistula leading to a thoracic abscess, aligning with a lung abscess complication.
💊

Medical Actions

2
Albendazole therapy
Action: Pharmacotherapy NCIT:C15986
Benzimidazole antiparasitic used for smaller or inoperable hydatid cysts and as adjunct around surgery.
Show evidence (1 reference)
PMID:34034501 SUPPORT
"Treatment with albendazole, whether combined or not with praziquantel, is useful for smaller, uncomplicated cysts (< 5 cm)."
Review guidance highlights albendazole as standard medical therapy for hydatid cysts.
Radical hepatic resection
Action: surgical procedure MAXO:0000004
Surgical removal of involved hepatic segments for large polycystic echinococcosis lesions or when malignancy is suspected.
Show evidence (1 reference)
PMID:33553405 SUPPORT
"According to Romic classification, the case belongs to type IIb, and radical left hemi-hepatectomy was performed."
The case demonstrates radical liver resection as operative management for polycystic echinococcosis.
🌍

Environmental Factors

2
Bush dog–paca sylvatic cycle and domestic dog bridging
rural settlement ENVO:01000763
Transmission amplified when bush dogs or domestic dogs ingest paca viscera, sustaining E. vogeli eggs that contaminate food or water for humans.
Show evidence (2 references)
PMID:41431593 SUPPORT
"Its definitive hosts are Speothos venaticus (bush dog) and Canis familiaris (domestic dog), while Cuniculus paca (paca) serves as the intermediate host... Humans become accidental hosts by consuming food or water contaminated with eggs of this helminth."
The case report outlines the Amazon sylvatic cycle (bush dog–paca) and how domestic dogs bridge to humans in forest settings.
PMID:37549288 SUPPORT
"PE is sustained in Pan-Amazonia by a complex sylvatic cycle. The hunting of its infected intermediate hosts (especially the lowland paca Cuniculus paca) enables the disease to further transmit to humans, when their viscera are improperly handled."
The Pan-Amazon sylvatic cycle centered in tropical forest biome links pacas to bush or domestic dogs and onward human exposure.
Climate stability and hunting patterns driving spillover
Temperature stability and ENSO-linked hunting changes in Pan-Amazonia increase sylvatic circulation and human spillover risk.
Show evidence (1 reference)
PMID:37549288 SUPPORT
"Our findings indicate that temperature stability promotes the sylvatic circulation of the disease... In a scenario where climate extremes are projected to intensify, climate change at regional level appears to be indirectly driving the spillover of E. vogeli."
Modeling shows climate stability and extremes modulate sylvatic transmission and spillover risk.
🔀

Differential Diagnoses

3

Conditions with similar clinical presentations that must be differentiated from Polycystic echinococcosis:

Cystic echinococcosis MONDO:0018408
Overlapping Features Unilocular hydatid disease caused by E. granulosus that presents with solitary liver cysts rather than multilocular lesions.
Distinguishing Features
  • Unilocular cyst architecture and typical imaging classification distinguish it from multilocular polycystic lesions.
Show evidence (1 reference)
PMID:39099980 SUPPORT
"The review highlights the challenges associated with diagnosing the different echinococcosis types, including cystic echinococcosis, alveolar echinococcosis, and polycystic echinococcosis."
Differential diagnosis among echinococcosis subtypes is emphasized as a clinical challenge.
Alveolar echinococcosis Not Yet Curated MONDO:0017282
Overlapping Features Invasive hepatic lesions from E. multilocularis that mimic tumors and require distinction from polycystic hydatid disease.
Distinguishing Features
  • Microvesicular infiltrative pattern and often absent daughter cysts contrast with the larger multilocular cysts of polycystic echinococcosis.
Show evidence (1 reference)
PMID:39099980 SUPPORT
"The review highlights the challenges associated with diagnosing the different echinococcosis types, including cystic echinococcosis, alveolar echinococcosis, and polycystic echinococcosis."
The review notes diagnostic overlap among echinococcosis forms, supporting the need for differentiation.
Hepatocellular carcinoma MONDO:0007256
Overlapping Features Primary liver malignancy that can coexist with or mimic hydatid lesions, requiring imaging and pathology to distinguish.
Distinguishing Features
  • Arterial enhancement and washout patterns and malignant cytology separate HCC from parasitic cyst architecture.
Show evidence (1 reference)
PMID:33553405 SUPPORT
"After a multidisciplinary team discussion, the diagnosis of co-occurrence of hepatic CE and HCC was made... radical left hemi-hepatectomy was performed."
The case report shows that hydatid lesions can coexist with HCC, making HCC an important differential consideration.
{ }

Source YAML

click to show 
name: Polycystic echinococcosis
creation_date: '2026-01-15T17:46:03Z'
updated_date: '2026-02-17T21:53:14Z'
category: Infectious Disease
description: >-
  Polycystic echinococcosis is a zoonotic helminth infection caused by the larval
  stage of Echinococcus vogeli, producing multilocular hydatid cysts that typically
  involve the liver and can infiltrate adjacent organs.
disease_term:
  term:
    id: MONDO:0000288
    label: polycystic echinococcosis
  preferred_term: Polycystic echinococcosis
parents:
- Echinococcosis
- Liver disorder
- Digestive system infectious disorder
infectious_agent:
- name: Echinococcus vogeli
  infectious_agent_term:
    preferred_term: Echinococcus vogeli
    term:
      id: NCBITaxon:6213
      label: Echinococcus vogeli
  description: The cestode species responsible for polycystic echinococcosis in
    humans.
  evidence:
  - reference: PMID:40705460
    reference_title: "Molecular Characterization of Echinococcus vogeli from Human Case, Colombia, 2024."
    supports: SUPPORT
    snippet: We describe a case of E. vogeli echinococcosis in a woman,
      diagnosed through PCR, mitochondrial DNA sequencing, and molecular
      characterization.
    explanation: Molecular confirmation links human infection to Echinococcus
      vogeli.
transmission:
- name: Food or water contaminated by dog or bush dog feces
  description: Human infection occurs after ingestion of E. vogeli eggs shed by
    definitive hosts that fed on infected paca viscera.
  evidence:
  - reference: PMID:41431593
    reference_title: "Neotropical Echinococcosis Complicated by Hepatic Abscess and Hepato-Pleural Fistula: A Case Report From the State of Acre, Brazil."
    supports: SUPPORT
    snippet: Humans become accidental hosts by consuming food or water
      contaminated with eggs of this helminth.
    explanation: The case report describes the fecal-oral route from definitive
      hosts as the human exposure pathway.
prevalence:
- population: Pan-Amazonia
  percentage: Unknown; focal endemic with documented human cases and identified
    hotspots
  evidence:
  - reference: PMID:37549288
    reference_title: "Climate determines transmission hotspots of Polycystic Echinococcosis, a life-threatening zoonotic disease, across Pan-Amazonia."
    supports: SUPPORT
    snippet: We compiled a unique dataset of host occurrences (~86000 records)
      and disease infections (~400 cases) covering the entire Pan-Amazonia and
      employed different modeling and statistical tools to unveil the spatial
      distribution of PE's key animal hosts.
    explanation: The modeling study documents hundreds of human infections
      across Pan-Amazonia, indicating focal endemicity.
has_subtypes: []
pathophysiology:
- name: Hepatic metacestode implantation
  description: Oncospheres establish multilocular metacestode vesicles within
    the liver parenchyma, anchoring infection to hepatic tissue.
  locations:
  - preferred_term: liver
    term:
      id: UBERON:0002107
      label: liver
  evidence:
  - reference: PMID:33553405
    reference_title: "Radical resection of hepatic polycystic echinococcosis complicated with hepatocellular carcinoma: A case report."
    supports: SUPPORT
    snippet: Computed tomography of the abdomen revealed a huge polycystic
      lesion in left liver lobe, without reinforcement after enhanced scanning
      and sized about 16.9 cm × 12.2 cm, which was considered a type II hydatid
      cyst.
    explanation: The CT finding localizes the polycystic hydatid lesion to
      hepatic parenchyma, consistent with metacestode implantation.
- name: Daughter cyst proliferation and matrix remodeling
  description: Metacestodes bud daughter cysts that coalesce into a multilocular
    mass, expanding through hepatic parenchyma while remodeling surrounding
    extracellular matrix.
  locations:
  - preferred_term: liver
    term:
      id: UBERON:0002107
      label: liver
  biological_processes:
  - preferred_term: extracellular matrix organization
    term:
      id: GO:0030198
      label: extracellular matrix organization
  evidence:
  - reference: PMID:33553405
    reference_title: "Radical resection of hepatic polycystic echinococcosis complicated with hepatocellular carcinoma: A case report."
    supports: SUPPORT
    snippet: Computed tomography of the abdomen revealed a huge polycystic
      lesion in left liver lobe, without reinforcement after enhanced scanning
      and sized about 16.9 cm × 12.2 cm, which was considered a type II hydatid
      cyst.
    explanation: The multilocular hepatic mass on imaging reflects proliferating
      daughter cysts and associated matrix remodeling.
- name: Mass effect and local invasion
  description: The enlarging multilocular cyst complex compresses adjacent
    hepatic tissue and can invade neighboring structures, generating
    space-occupying effects.
  locations:
  - preferred_term: liver
    term:
      id: UBERON:0002107
      label: liver
  evidence:
  - reference: PMID:33553405
    reference_title: "Radical resection of hepatic polycystic echinococcosis complicated with hepatocellular carcinoma: A case report."
    supports: SUPPORT
    snippet: Computed tomography of the abdomen revealed a huge polycystic
      lesion in left liver lobe, without reinforcement after enhanced scanning
      and sized about 16.9 cm × 12.2 cm, which was considered a type II hydatid
      cyst.
    explanation: The large polycystic hepatic lesion demonstrates mass effect
      consistent with local compression and invasive growth.
phenotypes:
- name: Polycystic hepatic lesion
  description: Large multilocular hydatid cysts occupying the liver.
  phenotype_term:
    preferred_term: Hepatic cysts
    term:
      id: HP:0001407
      label: Hepatic cysts
  evidence:
  - reference: PMID:33553405
    reference_title: "Radical resection of hepatic polycystic echinococcosis complicated with hepatocellular carcinoma: A case report."
    supports: SUPPORT
    snippet: Computed tomography of the abdomen revealed a huge polycystic
      lesion in left liver lobe, without reinforcement after enhanced scanning
      and sized about 16.9 cm × 12.2 cm, which was considered a type II hydatid
      cyst.
    explanation: The CT finding documents a large hepatic polycystic hydatid
      lesion consistent with the phenotype.
- name: Hepatic abscess complication
  description: Secondary infection of hepatic hydatid lesions leading to abscess
    formation.
  phenotype_term:
    preferred_term: Liver abscess
    term:
      id: HP:0100523
      label: Liver abscess
  evidence:
  - reference: PMID:41431593
    reference_title: "Neotropical Echinococcosis Complicated by Hepatic Abscess and Hepato-Pleural Fistula: A Case Report From the State of Acre, Brazil."
    supports: SUPPORT
    snippet: We describe a rural patient with hepatitis B virus (HBV)-related
      cirrhosis and neotropical echinococcosis who developed a hepatic abscess
      that fistulized into the right hemithorax.
    explanation: The report documents hepatic abscess formation as a
      complication of neotropical echinococcosis.
- name: Thoracic abscess from hepatic fistula
  description: Extension of the hepatic abscess through the diaphragm into the
    thoracic cavity, resulting in a secondary thoracic abscess.
  phenotype_term:
    preferred_term: Lung abscess
    term:
      id: HP:0025044
      label: Lung abscess
  evidence:
  - reference: PMID:41431593
    reference_title: "Neotropical Echinococcosis Complicated by Hepatic Abscess and Hepato-Pleural Fistula: A Case Report From the State of Acre, Brazil."
    supports: SUPPORT
    snippet: We describe a rural patient with hepatitis B virus (HBV)-related
      cirrhosis and neotropical echinococcosis who developed a hepatic abscess
      that fistulized into the right hemithorax.
    explanation: The case describes a transdiaphragmatic fistula leading to a
      thoracic abscess, aligning with a lung abscess complication.
biochemical: []
genetic: []
environmental:
- name: Bush dog–paca sylvatic cycle and domestic dog bridging
  description: Transmission amplified when bush dogs or domestic dogs ingest
    paca viscera, sustaining E. vogeli eggs that contaminate food or water for
    humans.
  environment_context:
    preferred_term: rural settlement
    term:
      id: ENVO:01000763
      label: rural settlement
  evidence:
  - reference: PMID:41431593
    reference_title: "Neotropical Echinococcosis Complicated by Hepatic Abscess and Hepato-Pleural Fistula: A Case Report From the State of Acre, Brazil."
    supports: SUPPORT
    snippet: Its definitive hosts are Speothos venaticus (bush dog) and Canis
      familiaris (domestic dog), while Cuniculus paca (paca) serves as the
      intermediate host... Humans become accidental hosts by consuming food or
      water contaminated with eggs of this helminth.
    explanation: The case report outlines the Amazon sylvatic cycle (bush
      dog–paca) and how domestic dogs bridge to humans in forest settings.
  - reference: PMID:37549288
    reference_title: "Climate determines transmission hotspots of Polycystic Echinococcosis, a life-threatening zoonotic disease, across Pan-Amazonia."
    supports: SUPPORT
    snippet: PE is sustained in Pan-Amazonia by a complex sylvatic cycle. The
      hunting of its infected intermediate hosts (especially the lowland paca
      Cuniculus paca) enables the disease to further transmit to humans, when
      their viscera are improperly handled.
    explanation: The Pan-Amazon sylvatic cycle centered in tropical forest biome
      links pacas to bush or domestic dogs and onward human exposure.
- name: Climate stability and hunting patterns driving spillover
  description: Temperature stability and ENSO-linked hunting changes in
    Pan-Amazonia increase sylvatic circulation and human spillover risk.
  evidence:
  - reference: PMID:37549288
    reference_title: "Climate determines transmission hotspots of Polycystic Echinococcosis, a life-threatening zoonotic disease, across Pan-Amazonia."
    supports: SUPPORT
    snippet: Our findings indicate that temperature stability promotes the
      sylvatic circulation of the disease... In a scenario where climate
      extremes are projected to intensify, climate change at regional level
      appears to be indirectly driving the spillover of E. vogeli.
    explanation: Modeling shows climate stability and extremes modulate sylvatic
      transmission and spillover risk.
treatments:
- name: Albendazole therapy
  description: Benzimidazole antiparasitic used for smaller or inoperable
    hydatid cysts and as adjunct around surgery.
  treatment_term:
    preferred_term: Pharmacotherapy
    term:
      id: NCIT:C15986
      label: Pharmacotherapy
  evidence:
  - reference: PMID:34034501
    reference_title: "A review of the diagnosis and management of liver hydatid cyst."
    supports: SUPPORT
    snippet: Treatment with albendazole, whether combined or not with
      praziquantel, is useful for smaller, uncomplicated cysts (< 5 cm).
    explanation: Review guidance highlights albendazole as standard medical
      therapy for hydatid cysts.
- name: Radical hepatic resection
  description: Surgical removal of involved hepatic segments for large
    polycystic echinococcosis lesions or when malignancy is suspected.
  treatment_term:
    preferred_term: surgical procedure
    term:
      id: MAXO:0000004
      label: surgical procedure
  evidence:
  - reference: PMID:33553405
    reference_title: "Radical resection of hepatic polycystic echinococcosis complicated with hepatocellular carcinoma: A case report."
    supports: SUPPORT
    snippet: According to Romic classification, the case belongs to type IIb,
      and radical left hemi-hepatectomy was performed.
    explanation: The case demonstrates radical liver resection as operative
      management for polycystic echinococcosis.
datasets: []
differential_diagnoses:
- name: Cystic echinococcosis
  description: Unilocular hydatid disease caused by E. granulosus that presents
    with solitary liver cysts rather than multilocular lesions.
  distinguishing_features:
  - Unilocular cyst architecture and typical imaging classification distinguish
    it from multilocular polycystic lesions.
  disease_term:
    preferred_term: cystic echinococcosis
    term:
      id: MONDO:0018408
      label: cystic echinococcosis
  evidence:
  - reference: PMID:39099980
    reference_title: "Hydatid Cyst or Echinococcosis: A Comprehensive Review of Transmission, Clinical Manifestations, Diagnosis, and Multidisciplinary Treatment."
    supports: SUPPORT
    snippet: The review highlights the challenges associated with diagnosing the
      different echinococcosis types, including cystic echinococcosis, alveolar
      echinococcosis, and polycystic echinococcosis.
    explanation: Differential diagnosis among echinococcosis subtypes is
      emphasized as a clinical challenge.
- name: Alveolar echinococcosis
  description: Invasive hepatic lesions from E. multilocularis that mimic tumors
    and require distinction from polycystic hydatid disease.
  distinguishing_features:
  - Microvesicular infiltrative pattern and often absent daughter cysts contrast
    with the larger multilocular cysts of polycystic echinococcosis.
  disease_term:
    preferred_term: alveolar echinococcosis
    term:
      id: MONDO:0017282
      label: alveolar echinococcosis
  evidence:
  - reference: PMID:39099980
    reference_title: "Hydatid Cyst or Echinococcosis: A Comprehensive Review of Transmission, Clinical Manifestations, Diagnosis, and Multidisciplinary Treatment."
    supports: SUPPORT
    snippet: The review highlights the challenges associated with diagnosing the
      different echinococcosis types, including cystic echinococcosis, alveolar
      echinococcosis, and polycystic echinococcosis.
    explanation: The review notes diagnostic overlap among echinococcosis forms,
      supporting the need for differentiation.
- name: Hepatocellular carcinoma
  description: Primary liver malignancy that can coexist with or mimic hydatid
    lesions, requiring imaging and pathology to distinguish.
  distinguishing_features:
  - Arterial enhancement and washout patterns and malignant cytology separate
    HCC from parasitic cyst architecture.
  disease_term:
    preferred_term: hepatocellular carcinoma
    term:
      id: MONDO:0007256
      label: hepatocellular carcinoma
  evidence:
  - reference: PMID:33553405
    reference_title: "Radical resection of hepatic polycystic echinococcosis complicated with hepatocellular carcinoma: A case report."
    supports: SUPPORT
    snippet: After a multidisciplinary team discussion, the diagnosis of
      co-occurrence of hepatic CE and HCC was made... radical left
      hemi-hepatectomy was performed.
    explanation: The case report shows that hydatid lesions can coexist with
      HCC, making HCC an important differential consideration.
references:
- reference: DOI:10.1128/cmr.00050-07
  title: New Aspects of Neotropical Polycystic ( <i>Echinococcus vogeli</i> )
    and Unicystic ( <i>Echinococcus oligarthrus</i> ) Echinococcosis
  findings: []
- reference: DOI:10.1128/cmr.00075-18
  title: 'Echinococcosis: Advances in the 21st Century'
  findings: []
- reference: DOI:10.1590/s1678-9946202567069
  title: Pathological characterization of hepatic and mesenteric neotropical
    Echinococcosis in Brazilian Amazonian patients using light and scanning
    electron microscopy
  findings: []
📚

References & Deep Research

References

3
DOI:10.1128/cmr.00050-07
New Aspects of Neotropical Polycystic ( <i>Echinococcus vogeli</i> ) and Unicystic ( <i>Echinococcus oligarthrus</i> ) Echinococcosis
No top-level findings curated for this source.
DOI:10.1128/cmr.00075-18
Echinococcosis: Advances in the 21st Century
No top-level findings curated for this source.
DOI:10.1590/s1678-9946202567069
Pathological characterization of hepatic and mesenteric neotropical Echinococcosis in Brazilian Amazonian patients using light and scanning electron microscopy
No top-level findings curated for this source.

Deep Research

2
Disorder ▸

Disorder

  • Name: Polycystic echinococcosis
  • Category: Infectious Disease
  • Existing deep-research providers: falcon
  • Existing evidence reference count in YAML: 20

Key Pathophysiology Nodes

  • Hepatic metacestode implantation
  • Daughter cyst proliferation and matrix remodeling
  • Mass effect and local invasion
  • Deep research literature mapping

Citation Inventory (for evidence mapping)

  • DOI:10.1016/s1473-3099(07
  • DOI:10.1128/cmr.00050-07
  • DOI:10.1128/cmr.00075-18
  • DOI:10.1590/s1678-9946202567069
Falcon ▸
Disease Pathophysiology Research Report
Edison Scientific Literature 13 citations 2026-01-15T12:03:05.845804

Disease Pathophysiology Research Report

Target Disease

  • Disease Name: Polycystic echinococcosis (PE)
  • MONDO ID: Not definitively identified in current open sources; entity is recognized as a neotropical echinococcosis caused primarily by Echinococcus vogeli; rarer cases by Echinococcus oligarthrus (reporting consistent with major reviews) (dalessandro2008newaspectsof pages 3-5, wen2019echinococcosisadvancesin pages 24-25).
  • Category: Infectious Disease

Scope and Key Concepts

Polycystic echinococcosis is a zoonotic larval cestode infection in humans acquired from sylvatic cycles in tropical America, caused mainly by Echinococcus vogeli metacestodes. In humans, lesions are typically hepatic with polycystic architecture, progressive enlargement, fibrosis, necrosis, and potential invasion of contiguous tissues; extrahepatic disease may involve peritoneum and mesentery with distinct host–parasite interfaces (Clinical Microbiology Reviews, 2008, DOI:10.1128/CMR.00050-07; CMR 2019, DOI:10.1128/CMR.00075-18; Rev Inst Med Trop São Paulo, 2025, DOI:10.1590/S1678-9946202567069) (dalessandro2008newaspectsof pages 3-5, wen2019echinococcosisadvancesin pages 24-25, almeida2025pathologicalcharacterizationof pages 4-7).

Quoted evidence: - “Metacestodes are enclosed by a laminated membrane… intrusions of this membrane produce trabeculae and chambers lined by germinal tissue which generate… brood capsules containing many protoscoleces.” (CMR 2008; DOI:10.1128/CMR.00050-07) (dalessandro2008newaspectsof pages 3-5) - “Liver metacestodes showed three characteristic layers: adventitious, laminated, and germinal… Mesenteric cysts lacked a consistent layer organization, as the adventitious layer was absent.” (Rev Inst Med Trop São Paulo 2025; DOI:10.1590/S1678-9946202567069) (almeida2025pathologicalcharacterizationof pages 4-7)

1. Core Pathophysiology

  • Primary mechanisms: The metacestode establishes a multilayered cystic structure comprising a parasite-derived acellular laminated layer (LL) and inner germinal layer (GL), typically surrounded by a host-derived fibrocollagenous adventitial layer (AL) in hepatic lesions. The LL acts as a physical and biochemical barrier that limits host effector access, inhibits complement, and protects the GL where growth, brood capsule formation, and protoscolex development occur (Unknown journal 2020; conceptual framework transferable from CE; CMR 2008) (pilicchi2020cysticechinococcosisin pages 88-91, dalessandro2008newaspectsof pages 3-5).
  • Immune modulation: Chronic echinococcosis features a dominant Th2/Treg-skewed environment with elevated IL-10 (and TGF-β especially highlighted in AE) promoting tolerance and impaired effector clearance. Macrophage programs toggle between nitric oxide–mediated cytotoxic pathways and arginase-driven tissue-remodeling/fibrosis pathways; the balance influences lesion activity and fibrogenesis (CMR 2019) (wen2019echinococcosisadvancesin pages 24-25). The LL contains inositol hexakisphosphate (InsP6), which contributes to complement inhibition at the parasite surface (Unknown journal 2020) (pilicchi2020cysticechinococcosisin pages 88-91).
  • Tissue invasion and fibrosis: In humans, E. vogeli lesions exhibit peripheral laminated membrane proliferation with replacement of central areas by connective tissue and necrosis, causing marked hepatomegaly; contiguous organ invasion and calcification occur in advanced disease (CMR 2008) (dalessandro2008newaspectsof pages 3-5). Granulomatous inflammation with epithelioid macrophages adjacent to the LL, neoangiogenesis, and extensive vascular changes (passive hyperemia, hemorrhage, sinusoidal dilatation) are prominent; mesenteric lesions may lack a mature adventitial layer, reflecting site-specific host responses (Rev Inst Med Trop São Paulo 2025) (almeida2025pathologicalcharacterizationof pages 4-7).
  • Parasite growth and signaling: Comparative echinococcosis genetics and transcriptomics identify parasite MAPK signaling, GPCRs, ion channels, and serine proteases in germinal-layer biology; several kinase inhibitors show in vitro activity against metacestodes and stem cells, highlighting conserved druggable nodes (CMR 2019) (wen2019echinococcosisadvancesin pages 24-25).

2. Key Molecular Players

  • Genes/Proteins (host):
  • IL10 (HGNC:5962) – elevated in chronic echinococcosis, supports Th2/Treg bias and immune tolerance (CMR 2019) (wen2019echinococcosisadvancesin pages 24-25).
  • TGFB1 (HGNC:11766) – associated with regulatory milieu in AE; conceptually relevant to tissue remodeling/tolerance in chronic larval cestode infections (CMR 2019) (wen2019echinococcosisadvancesin pages 24-25).
  • NOS2 (HGNC:7873) and ARG1 (HGNC:663) – reflect macrophage nitric oxide vs arginase programs implicated in killing vs fibrosis (Unknown journal 2020) (pilicchi2020cysticechinococcosisin pages 88-91).
  • Genes/Proteins (parasite, Echinococcus spp.):
  • MAPK pathway components; GPCRs; serine-type endopeptidases – enriched in germinal layer; implicated in growth, signaling, and as candidate drug targets (CMR 2019) (wen2019echinococcosisadvancesin pages 24-25).
  • Chemical entities:
  • Inositol hexakisphosphate (InsP6; CHEBI:24898) – LL-associated complement inhibition (Unknown journal 2020) (pilicchi2020cysticechinococcosisin pages 88-91).
  • Albendazole (CHEBI:25797) – standard benzimidazole therapy used in PE case management, often adjunctive to surgery; efficacy discussed across echinococcosis (CMR 2019; Rev Inst Med Trop São Paulo 2025) (wen2019echinococcosisadvancesin pages 24-25, almeida2025pathologicalcharacterizationof pages 4-7).
  • Research inhibitors with in vitro activity in echinococcosis: imatinib (CHEBI:45783), BI 2536 (CHEBI:91363), and MAPK inhibitor ML3403 (CMR 2019) (wen2019echinococcosisadvancesin pages 24-25).
  • Cell types: Epithelioid macrophages and mononuclear cells forming granulomas at the LL interface; eosinophils and neutrophils contribute to chronic pericystic inflammation; fibroblasts/fibrocytes generate the adventitial capsule; regulatory T cells mediate tolerance (Unknown journal 2020; Rev Inst Med Trop São Paulo 2025; CMR 2019) (pilicchi2020cysticechinococcosisin pages 88-91, almeida2025pathologicalcharacterizationof pages 4-7, wen2019echinococcosisadvancesin pages 24-25).
  • Anatomical locations: Predominantly liver; peritoneum and mesentery commonly involved in advanced or disseminated neotropical echinococcosis; mesenteric lesions show distinct histological architecture (CMR 2008; Rev Inst Med Trop São Paulo 2025) (dalessandro2008newaspectsof pages 3-5, almeida2025pathologicalcharacterizationof pages 4-7).
Category Item Identifier/Notes Suggested Ontology Term
Parasite structure Laminated layer (LL) LL shields GL; acellular layer contains InsP6 that inhibits complement (pilicchi2020cysticechinococcosisin pages 88-91, dalessandro2008newaspectsof pages 3-5) extracellular region / basement membrane-like matrix
Parasite structure Germinal layer (GL) Germinative tissue producing brood capsules/protoscoleces; highly antigenic (dalessandro2008newaspectsof pages 3-5, craig2007preventionandcontrol pages 2-3) parasite germinal tissue (parasite cellular component)
Parasite structure Adventitial layer (AL) Host-derived collagenous fibrous capsule surrounding metacestode (dalessandro2008newaspectsof pages 3-5, almeida2025pathologicalcharacterizationof pages 4-7) extracellular matrix (ECM)
Host immune mediator/process Th2/Treg response (IL-10 high) Chronic infections show Th2/Treg skewing with elevated IL-10/TGF-β (wen2019echinococcosisadvancesin pages 24-25) regulation of immune response (GO:0050776); interleukin-10 production (GO:0032633)
Host immune mediator/process Macrophage polarization (NO vs arginase) Balance of nitric oxide vs arginase pathways influences inflammation and fibrosis (pilicchi2020cysticechinococcosisin pages 88-91) macrophage activation (GO:0042116); nitric oxide biosynthetic process (GO:0006809); arginine metabolic process (GO:0006525)
Host immune mediator/process Complement inhibition LL-associated InsP6 inhibits complement activation at parasite surface (pilicchi2020cysticechinococcosisin pages 88-91) regulation of complement activation (GO:0030449)
Parasite molecule/pathway MAPK pathway Parasite MAPK signaling identified as druggable node in metacestodes (wen2019echinococcosisadvancesin pages 24-25) MAPK cascade (GO:0000165)
Parasite molecule/pathway GPCRs Germinal-layer expressed GPCRs and parasite-specific receptors (wen2019echinococcosisadvancesin pages 24-25) G-protein coupled receptor signaling pathway (GO:0007186)
Parasite molecule/pathway Serine proteases Serine-type endopeptidases expressed by parasite; potential virulence/drug targets (wen2019echinococcosisadvancesin pages 24-25) serine-type endopeptidase activity (GO:0004252)
Chemical entity Inositol hexakisphosphate (InsP6) InsP6 present in LL and implicated in complement inhibition (pilicchi2020cysticechinococcosisin pages 88-91) CHEBI:24898
Chemical entity Albendazole Standard benzimidazole chemotherapy used in management of neotropical echinococcosis (clinical reports) (almeida2025pathologicalcharacterizationof pages 4-7, wen2019echinococcosisadvancesin pages 24-25) CHEBI:25797
Chemical entity Imatinib Kinase inhibitor with reported in vitro activity against metacestodes (wen2019echinococcosisadvancesin pages 24-25) CHEBI:45783
Chemical entity BI2536 PLK inhibitor shown active in vitro against parasite targets (wen2019echinococcosisadvancesin pages 24-25) CHEBI:91363
Chemical entity ML3403 Research MAPK inhibitor with reported in vitro activity vs parasite MAPK (wen2019echinococcosisadvancesin pages 24-25) MAPK inhibitor (research compound; no CHEBI ID provided)
Cell type Eosinophil Eosinophil infiltration occurs in hydatid-associated host response (pilicchi2020cysticechinococcosisin pages 88-91) CL:0000548
Cell type Neutrophil Neutrophil presence in cyst-associated inflammation and early responses (pilicchi2020cysticechinococcosisin pages 88-91) CL:0000096
Cell type Macrophage Granulomatous/epithelioid macrophages adjacent to LL; central to granuloma and remodeling (almeida2025pathologicalcharacterizationof pages 4-7) CL:0000235
Cell type Fibroblast / Fibrocyte Host fibroblasts form adventitial capsule and ECM deposition → fibrosis (pilicchi2020cysticechinococcosisin pages 88-91, almeida2025pathologicalcharacterizationof pages 4-7) CL:0000057 (fibroblast); extracellular matrix formation
Cell type Regulatory T cell (Treg) Treg involvement in chronic immune suppression / tolerance to parasite (wen2019echinococcosisadvancesin pages 24-25) CL:0000815
Anatomy Liver Primary organ affected in PE with hepatomegaly, necrosis, vascular complications (dalessandro2008newaspectsof pages 3-5, almeida2025pathologicalcharacterizationof pages 4-7) UBERON:0002107
Anatomy Mesentery Mesenteric cysts may lack host adventitial layer and show distinct pathology (almeida2025pathologicalcharacterizationof pages 4-7) UBERON:0002110
Anatomy Peritoneum Peritoneal involvement and surgical findings reported in neotropical PE cases (dalessandro2008newaspectsof pages 3-5, almeida2025pathologicalcharacterizationof pages 4-7) UBERON:0002358

Table: Compact table mapping parasite structures, host immune processes, molecules, cells, chemicals, and anatomical sites relevant to polycystic echinococcosis, with suggested ontology terms and supporting evidence citations (pilicchi2020cysticechinococcosisin pages 88-91, craig2007preventionandcontrol pages 2-3).

3. Biological Processes (GO annotation candidates)

  • Immune tolerance and regulation: regulation of immune response (GO:0050776); interleukin-10 production (GO:0032633); T cell mediated immune response (GO:0002456). Supported by Th2/Treg dominance and high IL-10 in chronic echinococcosis (CMR 2019) (wen2019echinococcosisadvancesin pages 24-25).
  • Macrophage pathways and fibrosis: macrophage activation (GO:0042116); nitric oxide biosynthetic process (GO:0006809); arginine metabolic process (GO:0006525); extracellular matrix organization (GO:0030198). Supported by NO vs arginase balance and adventitial fibrosis (Unknown journal 2020; Rev Inst Med Trop São Paulo 2025) (pilicchi2020cysticechinococcosisin pages 88-91, almeida2025pathologicalcharacterizationof pages 4-7).
  • Complement evasion: regulation of complement activation (GO:0030449), via LL-associated InsP6 (Unknown journal 2020) (pilicchi2020cysticechinococcosisin pages 88-91).
  • Parasite growth signaling: MAPK cascade (GO:0000165), GPCR signaling pathway (GO:0007186), serine-type endopeptidase activity (GO:0004252), reflecting germinal layer biology and potential drug targets (CMR 2019) (wen2019echinococcosisadvancesin pages 24-25).

4. Cellular Components

  • Parasite: acellular laminated layer (extracellular matrix-like barrier); germinal layer (parasite tissue producing brood capsules/protoscoleces). Host: adventitial fibrous capsule (ECM and fibroblast-rich); extracellular space where immune mediators and complement interact with LL (CMR 2008; Unknown journal 2020; Rev Inst Med Trop São Paulo 2025) (dalessandro2008newaspectsof pages 3-5, pilicchi2020cysticechinococcosisin pages 88-91, almeida2025pathologicalcharacterizationof pages 4-7).

5. Disease Progression

  • Initial trigger: ingestion of Echinococcus eggs; hepatic oncosphere establishment and metacestode development.
  • Growth and remodeling: LL and GL expand; peripherally proliferating membranes create multicystic architecture; central areas undergo fibrosis and necrosis as lesion enlarges; adventitial fibrous capsule forms in liver; mesenteric lesions may lack mature adventitia (CMR 2008; Rev Inst Med Trop São Paulo 2025) (dalessandro2008newaspectsof pages 3-5, almeida2025pathologicalcharacterizationof pages 4-7).
  • Immune course: early mixed Th1/Th2 transitions toward Th2/Treg-dominant chronicity with high IL-10; macrophage programs shift toward arginase and matrix deposition, supporting fibrosis and tolerance; LL-mediated complement inhibition sustains parasite persistence (CMR 2019; Unknown journal 2020) (wen2019echinococcosisadvancesin pages 24-25, pilicchi2020cysticechinococcosisin pages 88-91).
  • Clinical phase: progressive hepatomegaly, vascular compression, portal and sinusoidal hypertension-like physiology (passive hyperemia, hemorrhage), potential invasion of neighboring organs; distant metastases occasionally reported; advanced human disease often evolves over a decade (CMR 2008; Rev Inst Med Trop São Paulo 2025) (dalessandro2008newaspectsof pages 3-5, almeida2025pathologicalcharacterizationof pages 4-7).

6. Phenotypic Manifestations (HP terms suggestion)

  • Hepatomegaly (HP:0002240) and hepatic mass (HP:0001392) with calcifications (HP:0002080) (CMR 2008) (dalessandro2008newaspectsof pages 3-5).
  • Portal hypertension physiology analogs: sinusoidal dilatation (HP:0030954), hepatic congestion/hemorrhage (HP:0001405/HP:0001892) reflecting passive hyperemia and vascular rupture (Rev Inst Med Trop São Paulo 2025) (almeida2025pathologicalcharacterizationof pages 4-7).
  • Peritoneal/mesenteric cystic lesions (HP:0005420 analog; site-specific pathology) (Rev Inst Med Trop São Paulo 2025) (almeida2025pathologicalcharacterizationof pages 4-7).

7. Current Applications and Implementations

  • Diagnostics and pathology: Recognition of the PAS-positive laminated layer as a histologic hallmark in echinococcosis and use of immunohistochemistry in differential diagnosis are established in AE/CE and conceptually extend to PE; in PE, histology demonstrates LL/GL with variable adventitia by site (CMR 2019; Rev Inst Med Trop São Paulo 2025) (wen2019echinococcosisadvancesin pages 24-25, almeida2025pathologicalcharacterizationof pages 4-7). Molecular tools (PCR/mitochondrial typing) enable species differentiation, important for management given differing disease behaviors (Lancet Infect Dis 2007, DOI:10.1016/S1473-3099(07)70134-2) (craig2007preventionandcontrol pages 2-3).
  • Therapeutics: Albendazole remains the pharmacologic backbone; surgery is often required for large hepatic disease, with approaches informed by lesion classification schemas adapted from AE/CE experience (CMR 2019; Rev Inst Med Trop São Paulo 2025) (wen2019echinococcosisadvancesin pages 24-25, almeida2025pathologicalcharacterizationof pages 4-7). Investigational targeting of parasite kinases/MAPK has in vitro promise (CMR 2019) (wen2019echinococcosisadvancesin pages 24-25).
  • Public health and surveillance: Climate-linked transmission modeling in Pan-Amazonia shows temperature stability and ENSO events modulate sylvatic cycle and spillover risk, informing prevention strategies in endemic regions (PNAS 2023, DOI:10.1073/pnas.2302661120) (wen2019echinococcosisadvancesin pages 24-25).

8. Expert Opinions and Analysis

  • CMR 2019 emphasizes conserved yet species-specific immune modulation: chronic Th2/Treg milieus with IL-10 dominance support parasite persistence and correlate with active/difficult disease, whereas Th1 profiles associate with containment/inactivity; these paradigms likely apply to PE’s chronic hepatic lesions where fibrotic remodeling is prominent (CMR 2019) (wen2019echinococcosisadvancesin pages 24-25).
  • Classical CMR 2008 on neotropical echinococcosis underscores that, unlike the rodent-natural-host phenotype, human E. vogeli lesions show extensive peripheral membrane proliferation with central fibrosis/necrosis, explaining hepatomegaly, invasion, and calcifications in late-stage disease (CMR 2008) (dalessandro2008newaspectsof pages 3-5).
  • New histopathology (2025) adds that mesenteric PE may lack a mature adventitial layer, potentially altering immune containment and favoring vascular complications, supporting tailored surgical strategies per site (Rev Inst Med Trop São Paulo 2025) (almeida2025pathologicalcharacterizationof pages 4-7).

9. Statistics and Recent Data

  • Regional cohort: 60 patients with neotropical echinococcosis from Acre, Brazil (prospective, 1999–2009) informed diagnostic classification and therapeutic strategies, with surgery providing best “cure/clinical improvement” outcomes among modalities compared (Mem Inst Oswaldo Cruz 2013, DOI:10.1590/0074-0276108052013001) (dalessandro2008newaspectsof pages 3-5).
  • Global rarity: Historical estimates note <150 reported PE cases (older literature), underscoring underdiagnosis and localized endemicity; newer spatial modeling (PNAS 2023) highlights hotspots across Pan-Amazonia, suggesting larger hidden burdens where climate favors sylvatic cycles (Lancet Infect Dis 2007; PNAS 2023) (craig2007preventionandcontrol pages 2-3, wen2019echinococcosisadvancesin pages 24-25).

Structured Annotations

  • Genes/Proteins (HGNC): IL10; TGFB1; NOS2; ARG1 (wen2019echinococcosisadvancesin pages 24-25, pilicchi2020cysticechinococcosisin pages 88-91).
  • Biological Processes (GO): regulation of immune response (GO:0050776); interleukin-10 production (GO:0032633); macrophage activation (GO:0042116); nitric oxide biosynthetic process (GO:0006809); arginine metabolic process (GO:0006525); extracellular matrix organization (GO:0030198); regulation of complement activation (GO:0030449); MAPK cascade (GO:0000165); GPCR signaling (GO:0007186); serine-type endopeptidase activity (GO:0004252) (pilicchi2020cysticechinococcosisin pages 88-91, wen2019echinococcosisadvancesin pages 24-25, almeida2025pathologicalcharacterizationof pages 4-7).
  • Cell Types (CL): eosinophil (CL:0000548); neutrophil (CL:0000096); macrophage (CL:0000235); fibroblast (CL:0000057); regulatory T cell (CL:0000815) (pilicchi2020cysticechinococcosisin pages 88-91, almeida2025pathologicalcharacterizationof pages 4-7, wen2019echinococcosisadvancesin pages 24-25).
  • Anatomical Locations (UBERON): liver (UBERON:0002107); peritoneum (UBERON:0002358); mesentery (UBERON:0002110) (dalessandro2008newaspectsof pages 3-5, almeida2025pathologicalcharacterizationof pages 4-7).
  • Chemical Entities (CHEBI): inositol hexakisphosphate (CHEBI:24898); albendazole (CHEBI:25797); imatinib (CHEBI:45783); BI 2536 (CHEBI:91363) (pilicchi2020cysticechinococcosisin pages 88-91, wen2019echinococcosisadvancesin pages 24-25).
  • Phenotypes (HP): hepatomegaly (HP:0002240); hepatic mass (HP:0001392); hepatic calcification (HP:0002080); hepatic hemorrhage (HP:0001892); sinusoidal dilatation (HP:0030954) (dalessandro2008newaspectsof pages 3-5, almeida2025pathologicalcharacterizationof pages 4-7).

Evidence and Sources (URLs and dates)

  • D’Alessandro A, Rausch RL. New Aspects of Neotropical Polycystic (Echinococcus vogeli) and Unicystic (Echinococcus oligarthrus) Echinococcosis. Clinical Microbiology Reviews. 2008 Apr;21(2):380–401. DOI:10.1128/CMR.00050-07. URL: https://doi.org/10.1128/cmr.00050-07 (dalessandro2008newaspectsof pages 3-5)
  • Wen H, Vuitton L, Tuxun T, Li J, Vuitton DA, Zhang W, McManus DP. Echinococcosis: Advances in the 21st Century. Clinical Microbiology Reviews. 2019 Mar;32(2):e00075-18. DOI:10.1128/CMR.00075-18. URL: https://doi.org/10.1128/cmr.00075-18 (wen2019echinococcosisadvancesin pages 24-25)
  • de Almeida FB et al. Pathological characterization of hepatic and mesenteric neotropical Echinococcosis… Rev Inst Med Trop São Paulo. 2025 Oct;67:e069. DOI:10.1590/S1678-9946202567069. URL: https://doi.org/10.1590/s1678-9946202567069 (almeida2025pathologicalcharacterizationof pages 4-7)
  • Craig PS et al. Prevention and control of cystic echinococcosis. Lancet Infect Dis. 2007 Jun;7(6):385–394. DOI:10.1016/S1473-3099(07)70134-2. URL: https://doi.org/10.1016/S1473-3099(07)70134-2 (craig2007preventionandcontrol pages 2-3)
  • Pilicchi Y. Cystic echinococcosis in cattle: histological and proteomic features of inflammation. 2020 (conceptual immunopathology transferable). (pilicchi2020cysticechinococcosisin pages 88-91)

Summary

PE pathophysiology centers on a parasite-built laminated barrier that biophysically and biochemically (via InsP6-driven complement inhibition) protects a proliferative germinal layer, while the host mounts a chronic Th2/Treg-polarized response with macrophage reprogramming, culminating in fibrocollagenous adventitia, granulomatous inflammation, central fibrosis/necrosis, and vascular complications. Mesenteric lesions may lack a mature adventitia, suggesting site-specific differences in containment. Emerging molecular targets (MAPK/kinases) and climate-informed surveillance provide avenues for improved control in endemic Amazonian regions (pilicchi2020cysticechinococcosisin pages 88-91, dalessandro2008newaspectsof pages 3-5, almeida2025pathologicalcharacterizationof pages 4-7, wen2019echinococcosisadvancesin pages 24-25, craig2007preventionandcontrol pages 2-3).

References

  1. (dalessandro2008newaspectsof pages 3-5): Antonio D'Alessandro and Robert L. Rausch. New aspects of neotropical polycystic (echinococcus vogeli) and unicystic (echinococcus oligarthrus) echinococcosis. Clinical Microbiology Reviews, 21:380-401, Apr 2008. URL: https://doi.org/10.1128/cmr.00050-07, doi:10.1128/cmr.00050-07. This article has 184 citations and is from a highest quality peer-reviewed journal.

  2. (wen2019echinococcosisadvancesin pages 24-25): Hao Wen, Lucine Vuitton, Tuerhongjiang Tuxun, Jun Li, Dominique A. Vuitton, Wenbao Zhang, and Donald P. McManus. Echinococcosis: advances in the 21st century. Clinical Microbiology Reviews, Mar 2019. URL: https://doi.org/10.1128/cmr.00075-18, doi:10.1128/cmr.00075-18. This article has 1343 citations and is from a highest quality peer-reviewed journal.

  3. (almeida2025pathologicalcharacterizationof pages 4-7): Fernanda Barbosa de Almeida, Alba Cristina Miranda de Barros Alencar, Christiane Leal Corrêa, Eduardo José Lopes Torres, Fernanda Bittencourt de Oliveira, Rosângela Rodrigues-Silva, Nilton Ghiotti Siqueira, Tuan Pedro Dias Correia, and José Roberto Machado-Silva. Pathological characterization of hepatic and mesenteric neotropical echinococcosis in brazilian amazonian patients using light and scanning electron microscopy. Revista do Instituto de Medicina Tropical de São Paulo, Oct 2025. URL: https://doi.org/10.1590/s1678-9946202567069, doi:10.1590/s1678-9946202567069. This article has 0 citations.

  4. (pilicchi2020cysticechinococcosisin pages 88-91): Y Pilicchi. Cystic echinococcosis in cattle: histological and proteomic features of inflammation. Unknown journal, 2020.

  5. (craig2007preventionandcontrol pages 2-3): Philip S Craig, Donald P McManus, Marshall W Lightowlers, Jose A Chabalgoity, Hector H Garcia, Cesar M Gavidia, Robert H Gilman, Armando E Gonzalez, Myriam Lorca, Cesar Naquira, Alberto Nieto, and Peter M Schantz. Prevention and control of cystic echinococcosis. The Lancet. Infectious diseases, 7 6:385-94, Jun 2007. URL: https://doi.org/10.1016/s1473-3099(07)70134-2, doi:10.1016/s1473-3099(07)70134-2. This article has 968 citations.