98

ULTRASOUND middot May 2004 middot Volume 12 middot Number 2

Correspondence R Conlon Leeds Teaching Hospital Trust Leeds UK

copy British Medical Ultrasound Society 2004 DOI 101179174227104225019608

Short Course on AbdominalUltrasound in Tropical MedicinePavia University Pavia Northern

Italy 16ndash20 February 2004Rosie Conlon

Leeds UniversityOPT IN Overseas Project Leeds Teaching Hospitals Trust Leeds UK

Having had considerable practical experience of ultrasoundin Tropical Medicine during my work in Africa establishingultrasound training programmes it was as a result of verykind sponsorship from Philips Medical Systems and BMUSthat I had the opportunity to reinforce this with some theo-retical education and training through attendance at thisexcellent short course held at the Division of Infectious andTropical Disease at Pavia University Pavia is an old provin-cial capital of Roman origin in Northern Italy and home to oneof the more ancient universities in Europe it is situatedapproximately 40 km south of Milan and in 1999 came firstin the most lsquoliveable cityrsquo competition It is a peaceful cleantown with a number of fine medieval churches and palaces inits cobbled streets

Dr Enrico Brunetti organizer of this annual course withconsiderable experience and interest in ultrasound is head ofthe ultrasound unit within the Infectious and Tropical Diseasesunit which is part of the St Matteo hospital that has approxi-mately 1200 beds 60 of which are within this specialized unitThe course consisted of 20 h lsquohands-onrsquo practical teachingand 20 h of lectures Emerging and re-emerging infectiousdiseases that used to be virtually unknown to physicians inindustrialized countries are now increasingly encounteredbecause of immigration from endemic countries Topicsincluded in the syllabus were

middot Ultrasound in prevalence studies of parasitic diseasemiddot Ultrasound in the diagnosis and treatment of abdominal

abscess cystic echinococcosis and schistosomiasismiddot Ultrasound in AIDS fascioliasis and abdominal TBmiddot Ultrasound and hepatocarcinoma along with the role of

ultrasound in filiariasis and the tropical spleen

So it was time for a little acute revision in my reliable companionfor the past few years the Oxford Handbook of Tropical Medi-cine Other participants in the course were clinicians from allover Europe and Russia with a variable amount of ultrasoundexperience each with different medical expertise but all shar-ing a common interest in Tropical Medicine some intending towork Overseas in the near future (see Fig 1)

The mornings consisted of practical scanning sessions inthe lsquoEchographicarsquo Department where many interesting ultra-sound examinations and diagnoses were observed along withinterventional procedures

Detailed lectures included the increasing use of ultrasoundin the diagnosis of cystic echinococcosis hepatocellular carci-noma and sonography in AIDS as well as ultrasound as anessential tool in the study of schistosomiasis details of some ofthe content is discussed below

Cystic Hydatid Disease

Echinococcus granulosis is a small 3ndash6-mm tapeworm thatlives in the small intestine of dogs and occasionally othercarnivores such as foxes and wolves Eggs passed in caninefaeces are infective to humans following ingestion theydevelop into larvae that penetrate intestinal mucosa and passto target organs such as the liver (50) lungs and peritonealcavity1 There the larvae mature and form an expanding fluid-filled vesicle or hydatid cyst mdash these may be multiple andreach massive proportions

Cystic echinococcosis (CE) is due to infection with themetacestode stage of echinococcus granulosis it has a globaldistribution but is most prevalent amongst low socio-economicgroups where safe piped water is generally unavailablehygiene is poor and where hospital veterinary and educa-tional facilities are of a low standard2 Screening is justified anddesirable in endemic areas as diagnosis at a early stage ofinfection can lead to a better prognosis following treatmentStandardized ultrasound classifications have recently beendeveloped for CE3 The sensitivity and specificity of ultrasoundhas been reported to be between 88ndash98 respectively forCE The cysts have pathognomic signs on ultrasound and thetechnique is considered to be the gold standard although it isstill an imperfect test and clinical laboratory and epidemio-logical data also play an important role in the diagnosis2 Ultra-sound results should where possible be evaluated in relationto these findings The use of the WHO standardized ultrasoundclassifications for CE should be used so that the properties ofthe test are standardized (see Fig 2)

The following ultrasound images of hepatic lesions areconsidered to be pathognomic diagnostic signs of CE due toechinococcus granulosis

middot CE1 unilocular anechoic lesions which are round oroval with a clear well defined wall (laminated membrane)double line sign (laminated membrane and pericyst) Suchcysts may or may not contain small dense mobile echoes(hydatid sand)

middot CE2 multivesicular or multiseptated cysts with a wheel likeappearance or unilocular cysts with daughter cysts whichmay present with a wheel like appearance (see Fig 3)

middot CE3 cysts with floating laminated membranes which mayalso contain daughter cysts

CE cyst types CE4 and CE5 which although highly suggestiveof CE are not pathognomic

middot CE4 heterogeneous hypo-echoic contents May show alsquoball of woolrsquo sign which is indicative of degeneratingmembranes

99

ULTRASOUND middot May 2004 middot Volume 12 middot Number 2

hepatic cysts consistent with echinococcus granulosis andserology was positive and treatment given During the coursethe patient returned for a follow-up scan of the now lsquoinactiversquocysts (see Fig 4) The disease is prevalent in areas of sheepfarming this gentleman was a forestry worker in such an area

Puncture aspiration injectionre-aspiration (PAIR)

This is an option for the treatment of cystic echinococcosiscommonly known as hydatid disease it is a minimally invasive

Figure 1 Dr Brunetti (centre) with some of the guest lecturers and students

Figure 2 Ultrasound classification of CE images showing cyst types that have pathognomic signs Types CE4 and 5 are highly suggestive of CE

middot CE5 cysts characterized by thick calcified wall which isarch-shaped producing a cone-shaped shadow Degreeof calcification varies from partial to complete

Given the current growth of the application of ultrasound inthis field the scientific community working in this area isencouraged to use the proposed standard classificationsystem3

Case History

A 52-year-old Sicilian male was admitted to hospital withsymptoms of renal colic Further investigation identified two

Figure 3 CE3 with pathognomic ultrasound appearance

100

ULTRASOUND middot May 2004 middot Volume 12 middot Number 2

therapeutic alternative to surgery and chemotherapy4 Per-formed under ultrasound guidance it is percutaneous drainageof echinococcal cysts located in the abdomen Dr Brunettithe course organizer was instrumental in the development ofthe WHO Guidelines on PAIR produced by the department ofCommunicable Disease Surveillance and Response in 2003

Hepatocellular Carcinoma (HCC)

The department provides care for a large number of patientswith HCC and has noticed an increasing prevalence of HCC asa result of the increasing number of patients with Hepatitis CVirus (HCV) The patients at increased risk of developing HCCinclude those infected with Hepatitis B Virus (HBV) HCV HIValcoholics patients with haemochromatosis Wilsonrsquos diseaseand primary biliary cirrhosis

For patients who do not have HIV the progression of thedisease is slow with chronic hepatitis it may take more than15 years to develop HCC whereas with HIV there is a fastprogression to liver related death

The mean age of patients with HCC is 63 years whereas inthe presence of HCV and HIV the mean age is only 43 years5

Interestingly in Europe there is a decrease in the incidenceof HCC from infection with HBV because of vaccination yet anincrease in the incidence of HCV whereas in the developingworld Hepatitis B is still on the increase

Also it is unusual to develop extra-hepatic metastases withHCC but when HIV is present the likelihood of extra-hepaticmetastases is more likely6

The consultants within the unit offer treatment for HCC inthe form of surgery or radio frequency ablation They frequentlyuse ultrasound contrast agents to aid visualization HCC is fedby an arterial supply and therefore demonstrated immediatelyduring the arterial phase

Sonography in AIDS

Liver lesionsNinety-eight per cent of deceased HIV seropositive patientspresent with liver lesions neoplastic lesions tend to be focalwhereas inflammatory or diffuse lesions tend to be diffuseLymphomas and Kaposirsquos sarcoma are the most commontumours in AIDS patients7

Focal lesions include either neoplastic lesions such asAIDS-related lymphoma (ARL) Burkittrsquos lymphoma Kaposirsquossarcoma or liver metastases and opportunistic lesionsor abscesses which may be bacillary mycobacteria ormyceties7

AIDS and the biliary treeHIV patients are at increased risk of cholangiopathy it isthe most common cause of abdominal pain in adult AIDSpatients It makes up 71 of surgical cases and 17ndash20 ofnon-surgical cases of hospital admission for AIDS7 Relatedsclerosing cholangitis is the most common finding and almostall patients present with abnormal blood tests indicatingcholestatis often caused by pathogens resulting in stenosis ofthe terminal portion of the CBD Gallbladder wall thickeningmay also be witnessed in the absence of stones and this againmay be due to cryptogenic pathogens More rarely a malignantneoplasm occurs as a result of Kaposirsquos sarcoma7

Renal involvementHIV associated nephropathy is a unique form of renal diseasespecific to HIV infection generally note increased echogenicityof the entire kidney Biopsy reveals sclerotic glomeruli anddilated tubules It is now estimated that 10 of patients withHIV go on to develop renal disease severe enough to requireintervention7

LymphadenopathyWell-known feature of HIV with the upper abdominal nodesinvolved more often than those in the lumbariliac region (seeFig 5) Lymphomas occur in 4ndash10 HIV patients7

AIDS and tuberculosis (TB)High incidence of TB with AIDS patients and TB has nowbeen adopted by the Centres for Disease control as one of thecriteria for the diagnosis of AIDS Negative chest X-ray findingsin 50 of cases and ultrasound is useful for more criticalevaluation

SpleenIn addition to lymphomatous involvement of the spleen multiplehypo-echoic lesions have been reported in the spleen of HIVpatients consistent with disseminated tuberculosis8

PancreasUltrasound of the pancreas in AIDS is sensitive but notspecific

Figure 4 (top) 52-year-old Sicilian male with 2 x echinococus cysts (bottom)Right lobe of liver ndash CE4

ULTRASOUND middot May 2004 middot Volume 12 middot Number 2

101 101

Ultrasound in the Evaluation ofUrinary Schistosomiasis

Schistosomiasis (bilharzia) is the second most commoncause of parasitic death after malaria affecting 200ndash300 millionpeople in 76 countries and is mainly a disease of rural popula-tions Schistosoma haematobium causes urinary schistoso-miasis and is found in Africa and South East Asia Transmissionoccurs when humans are exposed to water infested with theintermediate snail host whilst swimming washing or collectingwater1

Urinary schistosomiasis begins 3 months after infectionoften accompanied by painless haematuria which may persistfor months and may be accompanied by pain and mild feverFibrosis and calcification of the bladder tend to reduce itsvolume producing frequency and dribbling In severe casesthere may be urinary retention statis stone formation and renalfailure

Studies indicate that urinary tract abnormalities arecommon (18 overall prevalence)10 Research with the useof ultrasound examinations have shown that praziquanteland metrifonate therapy are rapidly effective in reversingurinary tract abnormalities with the exception of malignantbladder tumours that may develop The reproducibleultrasound examination is an effective tool in the study ofurinary schistosomiasis9

Hepatosplenic schistosomiasisHepatosplenic schistosomiasis is characterized by the peri-portal fibrosis (Symmerrsquos fibrosis) portal hypertension andsplenomegaly Demonstration of pathological lesions due toSchistosoma mansoni can be achieved by utilizing differenttechniques but because of its sensitivity specificity andsimplicity ultrasound has replaced biopsy of the liver as thegold standard for detecting schistosomal periportal fibrosis10

Dr Brunetti is to be congratulated on the content and thepopularity of this annual course and it leaves one with the tastethat there is so much more to learn but I can highly recommendits value for anyone interested in the role of ultrasound inTropical Medicine or Infectious Diseases Italian hospitalitywas abundant and I am extremely grateful to BMUS PhilipsMedical Systems and Leeds University for affording me thisopportunity

References

1 Oxford Handbook of Tropical Medicine Oxford MedicalPublications Oxford 1999

2 Macpherson C Milner R Performance characteristics andquality control of community based ultrasound surveys for cysticand alveolar echinococcosis Acta Tropica 200385203ndash209

3 WHO Informal working group on echinococcosis Internationalclassification of ultrasound images in cystic echinococcosis forapplication in clinical and epidemiological settings ActaTropica 2003

4 Filice C Brunetti E Andrea F Minimal Invasive treatment forhydatid abdominal cysts PAIR (Puncture Aspiration InjectionRespiration) mdash state of the art WHOCTDSIP973

5 Filice C Hepatocellular carcinoma lecture notes PaviaUniversity Pavia 2004

6 Filice C Tumori ed Infezione da HIV- GIGAT Nov 2002

7 Brunetti E Sonography in AIDS lecture notes Pavia UniversityPavia 2004

8 Reichel C Theisen A Rockstroh JK Splenic abscesses andabdominal tuberculosis in patients with AIDS Z Gastroenterol199634494ndash496

9 King CH Ultrasound monitoring of structural urinary tractdisease in Schistosoma haematobium infection Mem InstOswaldo Cruz 200297 Suppl 1149ndash152

10 Ravera M Reggiori A Cocozza E Clinical and endoscopicaspects of hepatosplenic Schistosomiasis in Uganda Eur JGastroenterol Hepatol 19968693ndash697

Figure 5 Lymphomatous mass in an AIDS patient

100

ULTRASOUND middot May 2004 middot Volume 12 middot Number 2

therapeutic alternative to surgery and chemotherapy4 Per-formed under ultrasound guidance it is percutaneous drainageof echinococcal cysts located in the abdomen Dr Brunettithe course organizer was instrumental in the development ofthe WHO Guidelines on PAIR produced by the department ofCommunicable Disease Surveillance and Response in 2003

Hepatocellular Carcinoma (HCC)

The department provides care for a large number of patientswith HCC and has noticed an increasing prevalence of HCC asa result of the increasing number of patients with Hepatitis CVirus (HCV) The patients at increased risk of developing HCCinclude those infected with Hepatitis B Virus (HBV) HCV HIValcoholics patients with haemochromatosis Wilsonrsquos diseaseand primary biliary cirrhosis

For patients who do not have HIV the progression of thedisease is slow with chronic hepatitis it may take more than15 years to develop HCC whereas with HIV there is a fastprogression to liver related death

The mean age of patients with HCC is 63 years whereas inthe presence of HCV and HIV the mean age is only 43 years5

Interestingly in Europe there is a decrease in the incidenceof HCC from infection with HBV because of vaccination yet anincrease in the incidence of HCV whereas in the developingworld Hepatitis B is still on the increase

Also it is unusual to develop extra-hepatic metastases withHCC but when HIV is present the likelihood of extra-hepaticmetastases is more likely6

The consultants within the unit offer treatment for HCC inthe form of surgery or radio frequency ablation They frequentlyuse ultrasound contrast agents to aid visualization HCC is fedby an arterial supply and therefore demonstrated immediatelyduring the arterial phase

Sonography in AIDS

Liver lesionsNinety-eight per cent of deceased HIV seropositive patientspresent with liver lesions neoplastic lesions tend to be focalwhereas inflammatory or diffuse lesions tend to be diffuseLymphomas and Kaposirsquos sarcoma are the most commontumours in AIDS patients7

Focal lesions include either neoplastic lesions such asAIDS-related lymphoma (ARL) Burkittrsquos lymphoma Kaposirsquossarcoma or liver metastases and opportunistic lesionsor abscesses which may be bacillary mycobacteria ormyceties7

AIDS and the biliary treeHIV patients are at increased risk of cholangiopathy it isthe most common cause of abdominal pain in adult AIDSpatients It makes up 71 of surgical cases and 17ndash20 ofnon-surgical cases of hospital admission for AIDS7 Relatedsclerosing cholangitis is the most common finding and almostall patients present with abnormal blood tests indicatingcholestatis often caused by pathogens resulting in stenosis ofthe terminal portion of the CBD Gallbladder wall thickeningmay also be witnessed in the absence of stones and this againmay be due to cryptogenic pathogens More rarely a malignantneoplasm occurs as a result of Kaposirsquos sarcoma7

Renal involvementHIV associated nephropathy is a unique form of renal diseasespecific to HIV infection generally note increased echogenicityof the entire kidney Biopsy reveals sclerotic glomeruli anddilated tubules It is now estimated that 10 of patients withHIV go on to develop renal disease severe enough to requireintervention7

LymphadenopathyWell-known feature of HIV with the upper abdominal nodesinvolved more often than those in the lumbariliac region (seeFig 5) Lymphomas occur in 4ndash10 HIV patients7

AIDS and tuberculosis (TB)High incidence of TB with AIDS patients and TB has nowbeen adopted by the Centres for Disease control as one of thecriteria for the diagnosis of AIDS Negative chest X-ray findingsin 50 of cases and ultrasound is useful for more criticalevaluation

SpleenIn addition to lymphomatous involvement of the spleen multiplehypo-echoic lesions have been reported in the spleen of HIVpatients consistent with disseminated tuberculosis8

PancreasUltrasound of the pancreas in AIDS is sensitive but notspecific

Figure 4 (top) 52-year-old Sicilian male with 2 x echinococus cysts (bottom)Right lobe of liver ndash CE4

ULTRASOUND middot May 2004 middot Volume 12 middot Number 2

101 101

Ultrasound in the Evaluation ofUrinary Schistosomiasis

Schistosomiasis (bilharzia) is the second most commoncause of parasitic death after malaria affecting 200ndash300 millionpeople in 76 countries and is mainly a disease of rural popula-tions Schistosoma haematobium causes urinary schistoso-miasis and is found in Africa and South East Asia Transmissionoccurs when humans are exposed to water infested with theintermediate snail host whilst swimming washing or collectingwater1

Urinary schistosomiasis begins 3 months after infectionoften accompanied by painless haematuria which may persistfor months and may be accompanied by pain and mild feverFibrosis and calcification of the bladder tend to reduce itsvolume producing frequency and dribbling In severe casesthere may be urinary retention statis stone formation and renalfailure

Studies indicate that urinary tract abnormalities arecommon (18 overall prevalence)10 Research with the useof ultrasound examinations have shown that praziquanteland metrifonate therapy are rapidly effective in reversingurinary tract abnormalities with the exception of malignantbladder tumours that may develop The reproducibleultrasound examination is an effective tool in the study ofurinary schistosomiasis9

Hepatosplenic schistosomiasisHepatosplenic schistosomiasis is characterized by the peri-portal fibrosis (Symmerrsquos fibrosis) portal hypertension andsplenomegaly Demonstration of pathological lesions due toSchistosoma mansoni can be achieved by utilizing differenttechniques but because of its sensitivity specificity andsimplicity ultrasound has replaced biopsy of the liver as thegold standard for detecting schistosomal periportal fibrosis10

Dr Brunetti is to be congratulated on the content and thepopularity of this annual course and it leaves one with the tastethat there is so much more to learn but I can highly recommendits value for anyone interested in the role of ultrasound inTropical Medicine or Infectious Diseases Italian hospitalitywas abundant and I am extremely grateful to BMUS PhilipsMedical Systems and Leeds University for affording me thisopportunity

References

1 Oxford Handbook of Tropical Medicine Oxford MedicalPublications Oxford 1999

2 Macpherson C Milner R Performance characteristics andquality control of community based ultrasound surveys for cysticand alveolar echinococcosis Acta Tropica 200385203ndash209

3 WHO Informal working group on echinococcosis Internationalclassification of ultrasound images in cystic echinococcosis forapplication in clinical and epidemiological settings ActaTropica 2003

4 Filice C Brunetti E Andrea F Minimal Invasive treatment forhydatid abdominal cysts PAIR (Puncture Aspiration InjectionRespiration) mdash state of the art WHOCTDSIP973

5 Filice C Hepatocellular carcinoma lecture notes PaviaUniversity Pavia 2004

6 Filice C Tumori ed Infezione da HIV- GIGAT Nov 2002

7 Brunetti E Sonography in AIDS lecture notes Pavia UniversityPavia 2004

8 Reichel C Theisen A Rockstroh JK Splenic abscesses andabdominal tuberculosis in patients with AIDS Z Gastroenterol199634494ndash496

9 King CH Ultrasound monitoring of structural urinary tractdisease in Schistosoma haematobium infection Mem InstOswaldo Cruz 200297 Suppl 1149ndash152

10 Ravera M Reggiori A Cocozza E Clinical and endoscopicaspects of hepatosplenic Schistosomiasis in Uganda Eur JGastroenterol Hepatol 19968693ndash697

Figure 5 Lymphomatous mass in an AIDS patient

ULTRASOUND middot May 2004 middot Volume 12 middot Number 2

101 101

Ultrasound in the Evaluation ofUrinary Schistosomiasis

Schistosomiasis (bilharzia) is the second most commoncause of parasitic death after malaria affecting 200ndash300 millionpeople in 76 countries and is mainly a disease of rural popula-tions Schistosoma haematobium causes urinary schistoso-miasis and is found in Africa and South East Asia Transmissionoccurs when humans are exposed to water infested with theintermediate snail host whilst swimming washing or collectingwater1

Urinary schistosomiasis begins 3 months after infectionoften accompanied by painless haematuria which may persistfor months and may be accompanied by pain and mild feverFibrosis and calcification of the bladder tend to reduce itsvolume producing frequency and dribbling In severe casesthere may be urinary retention statis stone formation and renalfailure

Studies indicate that urinary tract abnormalities arecommon (18 overall prevalence)10 Research with the useof ultrasound examinations have shown that praziquanteland metrifonate therapy are rapidly effective in reversingurinary tract abnormalities with the exception of malignantbladder tumours that may develop The reproducibleultrasound examination is an effective tool in the study ofurinary schistosomiasis9

Hepatosplenic schistosomiasisHepatosplenic schistosomiasis is characterized by the peri-portal fibrosis (Symmerrsquos fibrosis) portal hypertension andsplenomegaly Demonstration of pathological lesions due toSchistosoma mansoni can be achieved by utilizing differenttechniques but because of its sensitivity specificity andsimplicity ultrasound has replaced biopsy of the liver as thegold standard for detecting schistosomal periportal fibrosis10

Dr Brunetti is to be congratulated on the content and thepopularity of this annual course and it leaves one with the tastethat there is so much more to learn but I can highly recommendits value for anyone interested in the role of ultrasound inTropical Medicine or Infectious Diseases Italian hospitalitywas abundant and I am extremely grateful to BMUS PhilipsMedical Systems and Leeds University for affording me thisopportunity

References

1 Oxford Handbook of Tropical Medicine Oxford MedicalPublications Oxford 1999

2 Macpherson C Milner R Performance characteristics andquality control of community based ultrasound surveys for cysticand alveolar echinococcosis Acta Tropica 200385203ndash209

3 WHO Informal working group on echinococcosis Internationalclassification of ultrasound images in cystic echinococcosis forapplication in clinical and epidemiological settings ActaTropica 2003

4 Filice C Brunetti E Andrea F Minimal Invasive treatment forhydatid abdominal cysts PAIR (Puncture Aspiration InjectionRespiration) mdash state of the art WHOCTDSIP973

5 Filice C Hepatocellular carcinoma lecture notes PaviaUniversity Pavia 2004

6 Filice C Tumori ed Infezione da HIV- GIGAT Nov 2002

7 Brunetti E Sonography in AIDS lecture notes Pavia UniversityPavia 2004

8 Reichel C Theisen A Rockstroh JK Splenic abscesses andabdominal tuberculosis in patients with AIDS Z Gastroenterol199634494ndash496

9 King CH Ultrasound monitoring of structural urinary tractdisease in Schistosoma haematobium infection Mem InstOswaldo Cruz 200297 Suppl 1149ndash152

10 Ravera M Reggiori A Cocozza E Clinical and endoscopicaspects of hepatosplenic Schistosomiasis in Uganda Eur JGastroenterol Hepatol 19968693ndash697

Figure 5 Lymphomatous mass in an AIDS patient