In Asia, Southeast Asia is reported as a non-endemic area of the parasite. However, several indigenous echinococcoses in human and animals were reported in several countries, such as Malaysia, Thailand, the Philippines, Indonesia, Vietnam, Cambodia, and Lao People’s Democratic Republic (PDR). Most human infections are caused by Echinococcus granulosus and only two cases with E. ortleppi. There was no evidence case with E. multilocularis in Southeast Asia. Echinococcus granulosus infection is prevalent in areas that association with dogs and livestocks that close contact with dogs. The incidence is very low. A total of 49 cases of echinococcosis was identified in Southeast Asia from 1885 to 2015. Of which, at least 31 cases were indigenous, 14 cases were imported, and 4 cases were unknown. Thailand is the most prevalent country with echinococcosis in human, followed by very low incidence in Indonesia, Malaysia, Vietnam, the Philippines, Cambodia and Lao PDR. However, it is very difficult to estimate the real number of human echinococcosis case in Southeast Asia due to the long asymptomatic period that is usually >5 years. The disease may be more prevalent in Southeast Asia; however, they were underdiagnosed and not reported.
- Southeast Asia
- Echinococcus granulosus
- Echinococcus ortleppi
Echinococcosis (hydatidosis) is one of the neglected zoonosis caused by adult or larval stage of the cestodes belonging to the genus
Southeast Asia is reported as non-endemic area of the parasite. However, several indigenous echinococcoses in human and animals were reported in several countries, such as Malaysia, Thailand, the Philippines, Indonesia, Vietnam, Cambodia, and Lao People’s Democratic Republic (PDR). Although the surveillance of echinococcosis was not routinely conducted in several countries and the cases were scarcely reported in Southeast Asia. In the recent years, by clinical, radiological, microscopic, and serological aspects, the disease was found in many areas in this region. This situation makes us alert on the possibility of echinococcosis as one of the potential health problems in the Southeast Asia.
Human echinococcosis in Indonesia was first reported in nonindigenous people, in a European with liver hydatidosis in 1885 . Subsequent cases were also confirmed in four European and an Indian in the 1920s . In the late 1930s, a 45-year-old European female was also suspected with
The first indigenous case was diagnosed in a female aged 23 years from the northern part of South Sulawesi in 1988. She was admitted to the hospital with pain in the right under quadrant of the abdomens and in the right part of the hypochondrium, below the right rib. Hepatomegaly or tumor in the right upper quadrant of the abdomen was not found by physical examination. However, a hypoechoic, oval image, with a clear acoustic image on the right, was identified by using ultrasonography. Serological test was not performed, and the diagnosis was confirmed by radiological image examination. The patient has a history of keeping a dog .
Another echinococcosis case was reported in a 90-year-old female from Java in 1988. She was hospitalized in Ujung Pandang (Makassar), South Sulawesi with complaint of severe weakness, fainting, and no appetite. A tumor with no malignant cells was identified in the lower right part of the abdomen. Cysts with hypoechoic image on the walls were detected in the pelvis, right upper liver, and upper left abdomen. Fluid aspiration and serological test were not carried out during patient treatment at the hospital. The hydatidosis was confirmed in the right diaphragm arc/liver, omentum, and adnexa by radio-image. She had not kept dog at home .
In 1997, subsequent indigenous case, a 26-year-old female from Palu, Central Sulawesi, was administered in the Cipto Mangunkusumo Hospital in Jakarta with chronic and progressive headache, space-occupying lesion, blurred vision since the last 6 months, and vomiting. Bilateral edema of the papilla of the eyes was found without other neurological deficits. Cysts were found in many parts of organs. A hypodense, cystic lesion in the left parietal region of the brain divided by several septa with calcifications was discovered by radio-image with tomography (CT) scan. Historically, he lived in an area that kept many dogs, including her house.
In animals, echinococcosis is reported from goat, sheep, pig, water buffalo, and monkey from Sumatra, Madura, Bali, and Sulawesi. A case with liver, lung, and spleen hydatidosis was first identified in a cattle in Buitenzorg (Bogor, West Java) during meat inspection on 1906. Hydatid cysts were subsequently found from the lungs and liver of cattle in North Sumatra in 1907 . At that time, the hydatid cysts were only detected from imported Australian cattles (nonindigenous echinococcosis was also reported among 46 cattles and 3 pigs in Medan, North Sumatra, in 1916) . In 1929, hydatid cysts in indigenous cattle were found for the first time from Bali. This finding was considered that dogs from Bali were probably reservoirs for the adult worm
In Thailand, at least 18 reports of echinococcosis were confirmed in indigenous Thai population, 5 cases were recorded from imported echinococcosis, and other 4 cases were noted with unknown origin during 1936–2007 [17, 18, 19]. Almost all cases were recorded as cystic echinococcosis, and only two cases were identified as alveolar echinococcosis [20, 21, 22, 23, 24, 25]. Indigenous cases are distributed from the northern, central, and southern regions of Thailand [17, 18, 19].
The disease infection was reported for the first time in this country in 1936 from a 52-year-old male with peritoneum infection in Chiang Mai. The patient finally died due to severe infection without surgical removal and antiparasitic drug . Subsequently, human case of echinococcosis was found in a 16-year-old male with
The most frequent echinococcosis case in this country is liver infection. At least 12 cases were reported in the period 1960–2007 [18, 19, 23, 27, 30, 31]. Two cases, 50-year-old male and 50-year-old female, were reported as Thai citizens who had a history of visiting the Middle East in 1994 and 1996, respectively [17, 18], while the other two were identified from non-Thai citizens who previously lived in Middle East countries. Middle East countries are known as an endemic area of echinococcosis.
Liver echinococcosis was also reported in a Thai citizen who had a history of traveling to Switzerland in 2004. One subsequent case was recognized as a Nepali citizen who was visiting Thailand in 1995, while three cases were recorded as unknown origin in 1994 and 2004 . In 2007, two cases were reported with echinococcal cystic mass in the liver that was diagnosed through serological testing using an indirect enzyme-linked immunosorbent assay (ELISA) . Physical examination revealed that hepatomegaly or tumor in the right upper quadrant of the abdomen was detected in almost all of liver echinococcosis cases [19, 23, 27].
The hydatid cysts were also found in the jaw and foot. One case with foot echinococcosis was reported in a Thai 45-year-old female from Nakhon Pathom province in 1989, while jaw echinococcosis was identified in a male, aged 32 years old from Lamphun province .
During these periods (1936–2007), animal infection with echinococcosis was never recorded in Thailand. However, hydatid cysts were reported in slaughtered pigs, cattles, and buffalos in Bangkok and Chiang Mai in the past.
Echinococcosis was found in several countries in the Southeast Asian region; however, before 2013, this disease had never been reported to be infected in both animals and humans in Vietnam. The first case of echinococcosis was recorded in a man, aged 42 years, who resides in Thach Thanh district, Thanh Hoa province. This case is also the first indigenous case because he is a farmer who has never traveled abroad. Positive diagnostics are performed by serological tests using ELISA. Patients recovered after treatment with surgery combined with albendazole 800 mg/day for 30 days .
The second indigenous case was reported in a woman, aged 48 years, who lived in Phu Yen district, Son La province. She is a medical technician who has never traveled abroad. Positive diagnosis is confirmed by the ELISA test. The observations showed a large number of
Previous studies revealed that risk factors for transmission of
Echinococcosis is very rare in Malaysia. So far, only five cases were reported during more than last five decades. The first human case of pulmonary echinococcosis was reported in a Malay child in 1968. However, there is no detailed information reported during that time. In 1989, a first hepatic hydatidosis was reported in a 59-year-old Indian female. She had complained of fever and right hypochondrial pain for 3 days before inpatient. There was no jaundice. The enlarged liver with span of 17 cm, soft were identified. Ultrasonography examination revealed an encapsulated multiloculated anechoic lesions occurring on the most right of the hepatic lobe. Hydatid cysts and a large cystic lesion were also identified. The patient recovered at 1 year after getting surgical treatment combined with mebendazole 40 mg/kg/day for 30 days postoperatively .
The third case was recorded from a 4-year-old girl who was undergoing treatment in a pediatric hospital emergency unit after experiencing repeated cough with high-grade fever, accompanied by severe shortness of breath in 2013. Laboratory investigation was performed with a chest X-ray (CXR) and ultrasound examination. A hypoechoic shadow of a giant cystic lesion and hydatid cyst were detected replacing the whole right lobe of the liver. Surgery was performed, and albendazole was given for 6 months postoperatively. After 1.5 year, the patient demonstrated improved conditions with no recurrence evidence .
In 2015, a case of hydatid cyst of the liver was reported in a 55-year-old Chinese-Australian lady. She has migrated from Malaysia to Australia many years ago and works as a nurse assistant. Australia is considered endemic for the disease. There was no history of contact with cattle or dog. This patient presented a long history of abdominal pain, but with no fever or jaundice. She may have experience acute cholangitis, while the hydatid cyst ruptured in the biliary system. The liver cyst showed a calcified wall with only necrotic debris. Laboratory investigation with a chest X-ray, ultrasound examination, and histological analysis strongly suggests patient had chronic hydatid cyst of the liver .
The latest record of hydatid hepato-pulmonary fistula caused by
Since 1925, only two local cases of human echinococcosis in the lungs have been reported in the Philippines [43, 44]. No detailed information was reported regarding
7. Singapore, Cambodia, Lao People’s Democratic Republic, Myanmar, and Timor-Leste
In Singapore, Singh et al. reported two imported cases of the disease in 1991 . Echinococcosis has also been observed in humans, cattle, sheep, and pigs in Laos and Cambodia. However, the disease is considered to be very rare in these countries. No information about hydatid disease in Myanmar and Timor-Leste [19, 47].
A total of 49 cases of echinococcosis was identified in Southeast Asia from 1885 to 2015. Of which, at least 31 case were indigenous, 14 cases were imported, and 4 cases were unknown. The common clinical manifestations found in patients with echinococcosis are swelling or pressure effects from enlarging cysts and pain due to cyst mass [48, 49, 50, 51]. However, it is very difficult to estimate the real number of human echinococcosis case in Southeast Asia due to the long asymptomatic period that is usually >5 years . Previous studies in China revealed that echinococcosis manifestations usually appear 2–15 years after infection with nonspecific symptoms . With these possible reasons, the disease may be more prevalent in Southeast Asia; however, they were underdiagnosed.
Most human infections are caused by
Hydatid cysts infection is the most common echinococcosis in this region [3, 5, 17, 18, 19, 20, 21, 22, 23, 24, 30, 32, 34, 47, 57, 58, 59, 60], while only two cases of alveolar echinococcosis were reported in Thailand [25, 31]. Of all the recorded cases, liver cyst is a leading cause of echinococcosis in Southeast Asia, followed by cyst infection in the lung, peritoneal, kidney, jaw, and foot. Surgical removal and antiparasitic drug therapy have been shown to be beneficial and effective in the management of echinococcosis.
Besides Thailand, the very low incidence was reported in almost all countries in Southeast Asia. The possible reason for the existence of echinococcosis cases might be different in each country. In Indonesia and Malaysia, where the majority of the population is Muslim, this low case might be caused by Muslims not being encouraged to keep dogs. In addition, under-diagnostic and non-reported cases due to the absence of a routine surveillance system for echinococcosis may also contribute to the low incidence in both countries. In Singapore, the low number of cases is likely due to good urban planning with high-quality health standards, so there is very little potential for food-borne parasitic infections in the country . In several other Southeast Asian countries that are epidemiologically similar to Thailand, namely, Cambodia, Myanmar, and Laos, very few reports of echinococcosis cases may be caused by being underdiagnosed and not reported . The same thing is likely to occur in other Southeast Asian countries, such as the Philippines, Vietnam, and Timor-Leste. Although echinococcosis has not been a serious problem for public health in the region, awareness of the disease is needed. The hydatid cyst diagnosis should be inserted in part of the differential diagnosis of all cystic lesion to find out the magnitude of this disease in Southeast Asia [17, 30]. In addition, serological surveys are necessary in each Southeast Asian country to identify the distribution of the disease. Disease surveillance in domestic dogs and livestock is also needed as a prerequisite to understand epidemiological status of echinococcosis in the region.
According to this review, the incidence of echinococcosis in Southeast Asia is very low. Thailand is the most prevalent country with echinococcosis in human, followed by very low incidence in Indonesia, Malaysia, Vietnam, the Philippines, Cambodia, and Lao PDR, and so far there is no report of the disease in Myanmar and Timor-Leste. The disease may be more prevalent; however, there were underdiagnosed and not reported. Disease surveillance in human, domestic dogs, and livestock are necessary in Southeast Asian countries to identify the distribution of the disease. In addition, awareness and strengthening diagnosis for the disease are also needed in part of
The authors would like to thank all of the data contributor for echinococcosis in all countries in Southeast Asia.
Conflict of interest
The authors declare no conflict of interest.
|ELISA||enzyme-linked immunosorbent assay|
Wen H, Vuitton L, Tuxun T, et al. Echinococcosis: Advances in the 21st century. Clinical Microbiology Reviews. 2019; 32:1-39
Mcmanus DP, Zhang W, Li J, et al. Echinococcosis. Lancet. 2003; 362:1295-1304
DP MM. Echinococcosis with Particular Reference to Southeast Asia. 1st ed. Elsevier Ltd.; 2010
Nakao M, Lavikainen A, Yanagida T, et al. Phylogenetic systematics of the genus Echinococcus (Cestoda: Taeniidae). International Journal for Parasitology. 2013; 43:1017-1020
De Nguyen V, Le Van D. The first report of two cases of cystic echinococcosis in the lung by Echinococcus ortleppi infection, in Vietnam. Research and Reports in Tropical Medicine. 2017; 8:45-51
Balbinotti H, Santos G, Badaraco J, et al. Echinococcus ortleppi (G5) and echinococcus granulosus sensu sticto (G1) loads in cattle from Southern Brazil. Veterinary Parasitology. 2012; 188:255-260
Van Der E. Echinococcus blass ult de lever (Hydatid cyst from the liver). Geneesk. Tijdschr. Ned.-Indie; 24
Boerma V, Kiewiet D, Verspijck M. Echinococcus infectie (Echinococcus infection). Geneesk. Tijdschr. Ned.-Indie. 1921; 61:111-112
Snijders E. Een merkwaardige lever patient (An extraordinary liver patient). Geneesk. Tijdschr. Ned.-Indie. 1939; 79:2485
Amran A, Gella M, Abadi K. Kista hidatid pada hati: laporan kasus (A Hydatid Cyst in the Liver: A Case Report). Jakarta: Kongres Nasional IKARI; 1988
Abadi K, Jobs S, Gella M, et al. Kasus penyakit hidatid unikuler di Ujung Pandang, Sulawesi Selatan (A Unilocular Hydatidosis Case in Ujung Panjang, South Sulawesi). Bogor: National Parasitology Seminar and Fourth P4I Congress; 1988
Vrijburg A. Uit de praktijk in Deli (from a practice in Deli). Ned-Indisch Bl Diergeneesk. 1907; 19:217
Smit H. Echinococcosis in Nederlandsch-Indie (Echinococcosis in Netherlands-Indies). Ned-Indisch Bl Diergeneesk. 1920; 32:25
Muller H, Fooy J. Echinococcose bij het varken in Nederlandsch-Indie (Echinococcosis in pigs in Netherlands-Indies). Ned-Indisch Bl Diergeneesk. 1929; 41:466
Kranefeld F, Douwes J. Aanvullende lijst van voor Nederlandsch-Indie nieuwe parsitaire wormen bij zoogdieren en vogels. Ned-Indisch Bl Diergeneesk. 1940; 52:178-180
Carney W, Cross J, Wheeling C, et al. Natural infection of Echinococcus granulosus in dogs from Sulawesi, Indonesia. Southeast Asian Journal of Tropical Medicine and Public Health. 1974; 5:385-389
Wiwanitki V. A summary of hydatid disease in Thailand. The Internet Journal of Tropical Medicine. 2004; 2:1-5
Waikagul J, Dekumyoy P, Anantaphruti MT. Taeniasis, cycticercosis and echinococcosis in Thailand. Parasitology International. 2006; 55:175-180
Morakote N, Thamprasert K, Lojanapiwat B, et al. Cystic echinococcosis in Thailand with a species note on detection by serology in one family. The Southeast Asian Journal of Tropical Medicine and Public Health. 2007; 38:796-799
Chitrapatima K, Muntarbhorn S. Hydatid cysts in the lung treated by total pneumonectomy. Journal of the Medical Association of Thailand. 1952; 35:1-7
Koanantakool T, Subbannachart P, Tengtrisorn C, et al. The first pulmonary hydatid cyst in Central Cest Hospital. Journal of Communicable Diseases. 1991; 17:178-184
Thanakitcharu S, Saenghirunvattana S, Tovaranonte P, et al. Pulmonary hydatid disease: a case report. Thai Journal of Tuberculosis Chest Diseases. 1992; 13:245-251
Leelakusolwong S. Surgery of hydatid cyst of the liver. Thai Journal of Gastroenterology. 1995; 3:49-53
Leungsuwan P. Hydatid cyst of liver. Siriraj Hospital Gazette. 1960; 12:797-800
Kheedler W. Some rare diseases of Siam Echinococcus cyst. Journal of the Medical Association of Thailand. 1936; 19:773-781
Na-songkla S. Echinococcal cyst of lung: the first indigenous case. In: Scientific meeting of tropical medicine, Faculty of Tropical Medicine. 1980
Rangkasem K, Kattipatanapong W, Thadadoltip W, et al. Human echinococcosis: report of two cases of the hydatid disease at the lungs and liver. Chiang Mai Medical Bulletin. 1995; 35:28-29
Vatanatumrak B, Manothaya C, Udomchanya S. Hydatid cyst of the lung: a case report. The Thai Journal of Surgery. 1980; 1:118-120
Thamprasert K. Renal hydatid cyst (echinococcosis) in Maharaj Nakorn Chiang Mai Hospital: a case report and review of literature. Chiang Mai Medical Bulletin. 1993; 32:31-35
Riengchan P, Suankatay C, Wilde H, et al. Hydatid disease of the liver: the first indigenous case in Thailand and review of the literature. Journal of the Medical Association of Thailand. 2004; 87:725-729
Limawongpranee S, Suankratay C, Wilde H, et al. Alveolar echinococcosis: an unusual liver mass in a Thai patient. Journal of the Medical Association of Thailand. 2004; 56:308-314
Jalleh R, Nuruddin R, Krishnan M. Hydatidosis: diagnostic and therapeutic aspects. Singapore Medical Journal. 1989; 30:210-212
Moshin A, Khorsheed M. Massive hydatid cyst in four years old child patient; Case report. Journal of Advances in Medicine and Medical Research. 2013; 3:31-35
Hayati MPS, Eugene CBT, Jin BJ, et al. Chronic hydatid cyst in Malaysia: a rare occurrence. Malaysian Journal of Medical Sciences. 2015; 22:79-83
Ali TI. Ibrahim OEm, Al-sultan II. Hydatid hepatic-broncho-pleural (hepato-pulmonary) fistula caused by Echinococcosis granulosa: a zoonotic case report. Malaysian Journal of Veterinary Research. 2018; 9:91-97
Boufana B, Stidworthy M, Bell S, Chantrey J, Masters N, Unwin S, et al. Echinococcus and Taenia spp. from captive mammals in the United Kingdom. Veterinary Parasitology. 2012; 190:95-103
Amer S, Helal I, Kamau E, Feng Y, Xiao L. Molecular characterization of Echinococcus granulosus sensu lato from farm animals in Egypt. PLOS One. 2015; 10:e0118509
Pednekar R, Gatne M, Thompson R, Traub R. Molecular and morphological characterization of Echinococcus from food producing animals in India. Veterinary Parasitology. 2009; 165:58-65
Dinkel A, Njoroge E, Zimmermann A, Walz M, Zeyhle E, Elmahdi I, et al. A PCR system for detection of species and genotypes of the Echinococcus granulosus-complex, with reference to the epidemiological situation in Eastern Africa. International Journal for Parasitology. 2004; 34:645-653
Mbaya H, Magambo J, Njenga S, Zeyhle E, Mbae C, Mulinge E, et al. Echinococcus spp. in Central Kenya: a different story. Parasitology Research. 2014; 113:3789-3794
Rojas CA, Romig T, Lighttowlers M. Echinococcus granulosus sensu lato genotypes infecting humans-review of current knowledge. International Journal for Parasitology. 2014; 44:9-18
Deplazes P, Rinaldi L, Rojas C, Torgerson P, Harandi M, Romig T, et al. Global distribution of Alveolar and Cystic Echinococcosis. Advances in Parasitology. 2017; 95:315-493
De Leon W, Leiva L. Echinococcus cyst of the human lung. The Philippine Journal of Science. 1925; 27:361-370
Lavadia P, Canlas B, Durban V. Hydatid cyst of the lung (a case report in a Filipino). Journal of the Philippine Medical Association. 1960; 36:702-708
Tubangui MA. A summary of the parasitic worms reported from the Philippines. The Philippine Journal of Science. 1947; 76:225-322
Singh M, Hian Y, Lay-Hoon C. Current status of food-borne parasitic zoonoses in Singapore. The Southeast Asian Journal of Tropical Medicine and Public Health. 1991; 22:27-35
Matossian R, Rickard M, Smyth J. Hydatidosis: a global problem of increasing importance. Bulletin of the World Health Organization. 1977; 55:499-507
Ammann R, Eckert J. Cestodes: Echinococcus Gastroenterol. Clinics of North America. 1996; 25:655-689
Schaefer J, Khan M. Echinococcosis (hydatid disease): lessons from experience with 59 patients. Reviews of Infectious Diseases. 1991; 13:243-247
Kammerer W, Schantz P. Echinococcal disease. Infectious Disease Clinics of North America. 1993; 7:605-618
Lewis J, Koss N, Kerstein M. A review of echinococcal disease. Annals of Surgery. 1975; 181:390-396
Craig PS. Epidemiology of echinococcosis in western China. In: Torgerson P, Shaikenov B, editors. Echinococcosis in Central Asia: Problems and Solutions. Zürich, Dauir; 2004. pp. 43-58
Carmena D, Cardona G. Canine echinococcosis: Global epidemiology and genotype diversity. Acta Tropica. 2013; 128:441-460
Eckert J, Deplazes P, Craig PS, Gemmell MA, Gottstein B, Health D, et al. Echinococcosis in animals: clinical aspects, diagnosis and treatment. In: Eckert J, Gemmell MA, Meslin FX, Pawlowski ZS, editors. WHO/OIE Manual on Echinococcosis in Humans and Animals: A Public Health Problem of Global Concern. Paris, France: WHO/OIE; 2001
Jenkins DJ. Echinococcus granulosusin Australia, widespread and doing well. International Journal for Parasitology. 2006; 55:203-206
Boufana B, Lahmar S, Rebai W, Safta ZB, Jebali L, Ammar A, et al. Genetic variability and haplotypes of Echinococcus isolates from Tunisia. Transactions of the Royal Society of Tropical Medicine and Hygiene. 2014; 18:706-714
Romig T, Ebi D, Wassermann M. Taxonomy and molecular epidemiology of Echinococcus granulosus sensu lato. Veterinary Parasitology. 2015; 213:76-84
Ortlepp J. Echinococcus in dogs from Pretoria and vicinity. The Onderstepoort Journal of Veterinary Science and Animal Industry. 1934; 3(1):97-108
Thompson R, McManus D. Towards a taxonomic revision of the genus Echinococcus. Trends in Parasitology. 2002; 18:452-457
Shi Y, Wan X, Wang Z, Li J, Jiang Z, Yang Y. First description of Echinococcus ortleppi infection in China. Parasites & Vectors. 2019; 12:398