Cystic echinococcosis (CE) is a zoonotic parasitic disease. According to the World Health Organization (WHO), worldwide economic losses due to CE exceed three billion US dollars annually (WHO, 2020). Globally, most human CE cases are caused by
In Pakistan, CE is considered an endemic disease (Ahmed
Pakistan is located in South Asia and is the fifth most populated country in the world . In 2019, the population of Pakistan was approximately 211.2 million, with 61.4 % of the population 15 – 64 years of age, 22.1 % of the population 5 – 14 years of age, 12.1 % of the population 4 years of age and younger, and 4.4. % of the population 65 years of age and older (GOP, 2020). Males make up 51 % of the population (GOP, 2020). Most of Pakistan’s population lives in rural and peri-rural areas (GOP, 2020). Due to a lack of medical facilities, in rural areas, most of the population must visit larger cities for medical treatment. Pakistan is a largely agricultural country with a semi-arid landscape and a subtropical climate (Ahmed
Punjab province is located in the southern part of the country, with fertile agricultural land and deserts (Khan
In current study, data was collected retrospectively for CE patients treated surgically at SKMCH & RC from 2007 to 2018 were included in this study. Pre-surgical diagnosis was performed via ultrasound (US), magnetic resonance imaging (MRI), or computed tomography (CT) scan. All cases were confirmed by histopathology performed on surgically removed cysts. In addition to surgical management, all patients received antiparasitic treatment with albendazole (400 mg twice a day for 28 to 90 days). Patient medical charts were reviewed to collect demographic information, including age, sex, ethnicity, and place of residence. Cyst localization and number of cysts per organ were documented.
Frequencies of the assessed variables were recorded as percentages, with patient age presented using 10-year age categories.
This study was approved by the SKMCH & RC Institutional Ethics Committee under EXMPT-22-06-18-01. Informed consent for the use of medical records for future research was obtained from all patients at the time of treatment.
In total, 536 surgically confirmed CE cases were treated at SKMCH & RC from 2007 to 2018. Out of the 536 patients, 226 (42.2 %) were male and 310 (57.8 %) were female. Patient age ranged from 1 to 82 years of age (Table 1). Males made up 50.3 % of cases 20 year of age or younger, 36.7 % of cases aged 21 – 50 years, and 49.3 % of cases 51 years of age and older. Patients were from throughout Pakistan, with 336 cases (62.7 %) from the province of Khyber Pakhtunkhwa, 147 cases (27.4 %) from Punjab, 18 cases (3.3 %) from Baluchistan, 3 cases (0.6 %) from Sindh, 2 cases (0.4 %) from Islamabad, 1 case (0.2 %) from Gilgit, and 1 case (0.2 %) from Azad Jammu and Kashmir. An additional 28 cases (5.2 %) were from the neighboring country of Afghanistan (Fig. 1; Table 2). A further breakdown by city of origin is presented as supplementary material (Table S1). Most patients were members of the Pashtun (n=197; 36.7 %), Hindku (n=142; 26.5 %), and Punjabi (n=118; 22.0 %) ethnic groups (Table 3).
Province level distribution of 536 CE cases treated surgically at Shoukat Khanum Memorial Cancer Hospital and Research Centre in Lahore, Pakistan from 2007 – 2018.
Age and sex of 536 CE cases treated surgically at Shoukat Khanum Memorial Cancer Hospital and Research Centre in Lahore, Pakistan from 2007 – 2018.
Age (years) | Male (%) | Female (%) | Total Cases (%) |
---|---|---|---|
1 – 10 | 32 (14.1) | 20 (6.4) | 52 (9.7) |
11 – 20 | 41 (18.1) | 52 (16.7) | 93 (17.3) |
21 – 30 | 52 (23) | 83 (26.7) | 135 (25.2) |
31 – 40 | 37 (16.3) | 68 (21.9) | 105 (19.6) |
41 – 50 | 27 (11.9) | 49 (15.8) | 76 (14.2) |
51 – 60 | 17 (7.5) | 25 (8.1) | 42 (7.8) |
61 ≥ | 20 (8.8) | 13 (4.2) | 33 (6.2) |
226 (42.2) | 310 (57.8) | 536 (100) |
Province or region of origin for 536 CE cases treated surgically at Shoukat Khanum Memorial Cancer Hospital and Research Centre in Lahore, Pakistan from 2007 – 2018.
Province or Region | 2007 – 2010 | 2011 – 2014 | 2015 – 2018 | Total Cases (%) |
---|---|---|---|---|
Khyber Pakhtunkhwa | 65 | 158 | 113 | 336 (62.7) |
Punjab | 45 | 53 | 49 | 147 (27.4) |
Afghanistan | 5 | 16 | 7 | 28 (5.2) |
Baluchistan | 2 | 8 | 8 | 18 (3.3) |
Sindh | 2 | - | 1 | 3 (0.6) |
Islamabad | - | 1 | 1 | 2 (0.4) |
Gilgit Baltistan | - | - | 1 | 1 (0.2) |
Azad Jammu and Kashmir | - | 1 | - | 1 |
119 (22.20%) | 237 (44.22%) | 180 (33.58%) | (0.2) 536 (100) |
Ethnicity for 536 CE cases treated surgically at Shoukat Khanum Memorial Cancer Hospital and Research Centre in Lahore, Pakistan from 2007 – 2018.
Ethnicity | Total cases (%) |
---|---|
Pashtun | 197 (36.7) |
Hindku | 142 (26.5) |
Punjabi | 118 (22.0) |
Afghani | 28 (5.2) |
Saraiki | 26 (4.9) |
Balochi | 18 (3.4) |
Other* | 7 (1.3) |
Total | 536 (100) |
*Gilgit, Kashmiri, Muhajir, Sindhi
The highest number of CE cases was reported in 2013 (n=90), with the lowest number of cases in 2007 (n=24) (Table 4). The largest number of cysts was obtained from the liver (137/536; 25.6 %), followed by the lungs (86/536; 16.0 %), brain (43/536, 8.0 %), abdomen (41/536; 7.6 %), uterus and ovaries (26/536; 4.9 %), chest (25/536; 4.7 %), spleen (24/536; 4.5 %), and kidneys (14/536; 2.6 %), with anatomical location not available for 52 (9.7 %) cysts (Table 4). Twenty-six (4.8 %) patients presented with multiple cysts. Data on World Health Organization Informal Working Group on Echinococcosis (WHO-IWGE) ultrasound-based cyst staging were not available. A detailed breakdown of cases by age, sex, ethnicity, and cyst location is provided as supplementary material (Table S2).
Treatment year, anatomic cyst location, and imaging technique used for 536 CE cases treated surgically at Shoukat Khanum Memorial Cancer Hospital and Research Centre in Lahore, Pakistan from 2007 – 2018.
Parameter | Number of Cases | Percentage (%) |
---|---|---|
Year | ||
2007 | 24 | 4.5 |
2008 | 28 | 5.2 |
2009 | 41 | 7.6 |
2010 | 30 | 5.6 |
2011 | 52 | 9.7 |
2012 | 51 | 9.5 |
2013 | 90 | 16.8 |
2014 | 51 | 9.5 |
2015 | 48 | 9.0 |
2016 | 48 | 9.0 |
2017 | 38 | 7.1 |
2018 | 35 | 6.5 |
Cyst location | ||
Liver | 137 | 25.6 |
Lungs | 86 | 16.0 |
Brain | 43 | 8.0 |
Abdomen | 41 | 7.6 |
Uterus and ovary | 26 | 4.9 |
Chest | 25 | 4.7 |
Spleen | 24 | 4.5 |
Kidney | 14 | 2.6 |
*Other | 88 | 16.4 |
Site not mentioned | 52 | 9.7 |
Imaging technique | ||
Computed tomography scan | 405 | 75.6 |
Ultrasound | 223 | 41.6 |
Magnetic resonance imaging | 107 | 20.0 |
Radiography | 87 | 16.2 |
Data not available | 52 | 9.7 |
*Heart, gallbladder, pancreas, face, neck, thigh, intestines, back, femur, shoulder, thyroid, pituitary, eye, pelvic region, liver + spleen, liver + gallbladder, spleen + lung, pancreas + spleen
City and province of origin for 536 CE cases treated at Shoukat Khanum Memorial Cancer Hospital and Research Centre Lahore, Pakistan from 2007 - 2018.
City | Province | 2007 | 2008 | 2009 | 2010 | 2011 | 2012 | 2013 | 2014 | 2015 | 2016 | 2017 | 2018 | Total |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Afghanistan | Afghanistan | 1 | 3 | 1 | 14 | 2 | 1 | 2 | 1 | 3 | 28 | |||
Islamabad | Islamabad | 1 | 1 | 2 | ||||||||||
Bagh | AJK | 1 | 1 | |||||||||||
Abbottabad | KPK | 1 | 1 | 2 | ||||||||||
Bajaur | KPK | 1 | 1 | 1 | 3 | |||||||||
Bannu | KPK | 2 | 2 | 1 | 1 | 6 | ||||||||
Bara | KPK | 1 | 2 | 1 | 2 | 1 | 7 | |||||||
Charsada | KPK | 2 | 1 | 2 | 1 | 1 | 1 | 8 | ||||||
Dassu | KPK | 1 | 1 | |||||||||||
Dera Ismail Khan | KPK | 1 | 1 | 1 | 2 | 5 | ||||||||
Daggar | KPK | 1 | 1 | |||||||||||
Hangu | KPK | 1 | 1 | 1 | 3 | |||||||||
Jamrud | KPK | 1 | 1 | 2 | ||||||||||
Kohat | KPK | 1 | 1 | 2 | 1 | 5 | ||||||||
Kurram | KPK | 1 | 1 | |||||||||||
Karak | KPK | 1 | 1 | 1 | 2 | 1 | 2 | 8 | ||||||
Khar Bajaur | KPK | 1 | 2 | 1 | 4 | |||||||||
Khyber | KPK | 1 | 1 | |||||||||||
Kabal | KPK | 3 | 22 | 2 | 1 | 28 | ||||||||
Landi Kotal | KPK | 1 | 1 | |||||||||||
Lakki Marwat | KPK | 1 | 1 | 3 | 5 | |||||||||
Lower Dir | KPK | 1 | 1 | 1 | 1 | 4 | ||||||||
Malakand | KPK | 1 | 1 | 1 | 1 | 2 | 1 | 7 | ||||||
Mansehra | KPK | 1 | 1 | |||||||||||
Mardan | KPK | 1 | 1 | 1 | 3 | 2 | 1 | 1 | 2 | 12 | ||||
Miran Shah | KPK | 1 | 1 | 1 | 3 | |||||||||
Mohmand | KPK | 1 | 1 | |||||||||||
N.Waziristan | KPK | 1 | 2 | 3 | ||||||||||
Nowshera | KPK | 2 | 2 | 1 | 1 | 3 | 9 | |||||||
Peshawar | KPK | 3 | 11 | 15 | 14 | 15 | 19 | 25 | 4 | 9 | 10 | 6 | 9 | 140 |
Parachanar | KPK | 1 | 1 | |||||||||||
Razmak | KPK | 1 | 1 | 2 | ||||||||||
Sawabi | KPK | 1 | 1 | |||||||||||
Swat | KPK | 1 | 1 | 5 | 3 | 20 | 14 | 9 | 3 | 2 | 58 | |||
Upper Dir | KPK | 1 | 1 | 2 | ||||||||||
Waziristan | KPK | 1 | 1 | |||||||||||
Arifwala | Punjab | 1 | 1 | |||||||||||
Attock | Punjab | 1 | 1 | 1 | 3 | |||||||||
Bahawalnagar | Punjab | 2 | 2 | |||||||||||
Bhakkar | Punjab | 1 | 1 | |||||||||||
Bahawalnagar | Punjab | 1 | 1 | |||||||||||
Bahawalpur | Punjab | 1 | 1 | 1 | 1 | 4 | ||||||||
Bakkar | Punjab | 1 | 1 | |||||||||||
D.G Khan | Punjab | 2 | 2 | 1 | 5 | |||||||||
Faisalabad | Punjab | 2 | 1 | 1 | 1 | 1 | 2 | 8 | ||||||
Gujranwala | Punjab | 2 | 1 | 1 | 1 | 1 | 2 | 2 | 2 | 12 | ||||
Gujrat | Punjab | 1 | 1 | 2 | ||||||||||
Jhang | Punjab | 1 | 1 | 2 | 5 | |||||||||
Jehlum | Punjab | 1 | 1 | |||||||||||
Kasur | Punjab | 1 | 1 | |||||||||||
Khanpur | Punjab | 1 | 1 | 2 | ||||||||||
Lodhran | Punjab | 1 | 1 | |||||||||||
Lahore | Punjab | 9 | 5 | 6 | 4 | 3 | 4 | 11 | 5 | 1 | 5 | 8 | 4 | 65 |
Mianwali | Punjab | 1 | 1 | |||||||||||
Multan | Punjab | 1 | 2 | 1 | 1 | 5 | ||||||||
Muzaffargarh | Punjab | 1 | 1 | 2 | ||||||||||
Okara | Punjab | 1 | 1 | 2 | ||||||||||
Rahim Yar Khan | Punjab | 1 | 1 | 1 | 1 | 1 | 5 | |||||||
Rawalpindi | Punjab | 1 | 1 | 1 | 1 | 1 | 5 | |||||||
Sadiq abad | Punjab | 1 | 1 | |||||||||||
Sialkot | Punjab | 1 | 1 | 1 | 3 | |||||||||
Sahiwal | Punjab | 1 | 1 | |||||||||||
Sargodha | Punjab | 1 | 1 | 1 | 1 | 2 | 6 | |||||||
Taunsa | Punjab | 1 | 1 | |||||||||||
Chaman | Balochistan | 1 | 1 | 2 | ||||||||||
Quetta | Balochistan | 1 | 1 | 1 | 3 | 1 | 2 | 3 | 2 | 2 | 16 | |||
Karachi | Sindh | 1 | 1 | 2 | ||||||||||
Sukkur Taluka | Sindh | 1 | 1 | |||||||||||
Skardu | Gilgit Baltistan | 1 | 1 | |||||||||||
Total | 24 | 28 | 38 | 29 | 52 | 50 | 84 | 51 | 45 | 52 | 38 | 45 | 536 |
*KPK- Khyber Pakhtunkhwa
Sex, ethnicity, and cyst location by age group for CE patients (n=546) treated at Shoukat Khanum Memorial Cancer Hospital and Research Centre Lahore, Pakistan from 2007 - 2018.
Age (in years) | |||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Parameters | <7 | 7-12 | 13-18 | 19-24 | 25-30 | 31-36 | 37-42 | 43-48 | 49-54 | 55-60 | 61+ | Total | |
Sex | |||||||||||||
Female | 4 | 26 | 27 | 34 | 64 | 36 | 40 | 29 | 18 | 20 | 13 | 311 | |
Male | 11 | 28 | 28 | 20 | 38 | 27 | 12 | 15 | 11 | 16 | 19 | 225 | |
Ethnicity | |||||||||||||
Pashtun | 8 | 20 | 19 | 22 | 33 | 27 | 18 | 12 | 16 | 15 | 7 | 197 | |
Hindko | 5 | 18 | 13 | 16 | 32 | 14 | 15 | 8 | 7 | 9 | 5 | 142 | |
Punjabi | 8 | 14 | 8 | 22 | 14 | 13 | 17 | 3 | 7 | 12 | 118 | ||
Afghani | 1 | 3 | 6 | 2 | 2 | 4 | 2 | 3 | 2 | 1 | 2 | 28 | |
Saraiki | 3 | 2 | 4 | 4 | 2 | 4 | 2 | 5 | 26 | ||||
Balochi | 1 | 2 | 1 | 1 | 8 | 2 | 2 | 1 | 18 | ||||
Other | 1 | 1 | 2 | 1 | 1 | 1 | 7 | ||||||
Cyst location | |||||||||||||
Liver | 4 | 9 | 14 | 16 | 22 | 17 | 11 | 11 | 9 | 15 | 9 | 137 | |
Lung | 3 | 17 | 10 | 9 | 18 | 13 | 7 | 3 | 1 | 2 | 3 | 86 | |
Brain | 3 | 4 | 8 | 6 | 9 | 6 | 3 | 4 | 43 | ||||
Abdomen | 2 | 3 | 4 | 7 | 6 | 4 | 3 | 3 | 4 | 5 | 41 | ||
Uterus and ovary | 1 | 1 | 2 | 7 | 7 | 4 | 2 | 1 | 1 | 26 | |||
Chest | 1 | 4 | 1 | 9 | 3 | 2 | 3 | 1 | 1 | 25 | |||
Spleen | 2 | 1 | 6 | 2 | 4 | 5 | 1 | 1 | 2 | 24 | |||
Kidney | 2 | 2 | 3 | 2 | 1 | 1 | 3 | 14 | |||||
Eye | 1 | 5 | 2 | 2 | 2 | 12 | |||||||
Pelvic region | 2 | 1 | 3 | 2 | 1 | 1 | 10 | ||||||
Face | 1 | 1 | 1 | 1 | 1 | 5 | |||||||
Gallbladder | 1 | 2 | 2 | 1 | 6 | ||||||||
Neck | 1 | 1 | 1 | 1 | 1 | 5 | |||||||
Thigh | 1 | 1 | 1 | 1 | 1 | 5 | |||||||
Intestines | 1 | 2 | 1 | 1 | 1 | 6 | |||||||
Back | 1 | 1 | 1 | 3 | |||||||||
Calf | 1 | 1 | 2 | ||||||||||
Femur | 1 | 1 | 2 | ||||||||||
Heart | 1 | 1 | 2 | ||||||||||
Shoulder | 1 | 1 | 2 | ||||||||||
Thyroid | 2 | 2 | |||||||||||
Pancreas | 1 | 1 | |||||||||||
Pituitary | 1 | 1 | |||||||||||
Skin | 1 | 1 | 2 | ||||||||||
Liver and spleen | 1 | 3 | 1 | 1 | 1 | 1 | 1 | 9 | |||||
Pancreas and spleen | 1 | 1 | 1 | 3 | |||||||||
Spleen and lung | 1 | 1 | |||||||||||
Liver and gallbladder | 1 | 1 | 1 | 1 | 2 | 3 | 9 | ||||||
Not provided | 1 | 5 | 5 | 2 | 16 | 3 | 6 | 6 | 2 | 2 | 4 | 52 |
CE is considered a neglected tropical disease (NTD) of global concern (Khan
In the current study, the highest numbers of cases were in young and middle age adults. However, of note, is the large number of patients under 11 years of age (n=52; 9.7 %), indicating recent parasite transmission. This finding concurs with another study conducted in Pakistan where 10.5 % of reported cases were in children less than 11 years of age (Khan
The largest numbers of cysts were obtained from the liver and lungs, which is in line with studies from other geographic locations in Pakistan (Khan
The majority of cases presenting to SKMCH & RC during 2007 – 2018 were from Khyber Pakhtunkhwa Province, which is a neighboring province to Punjab. A recent retrospective study conducted on hospital records from five major metropolitan cities located in Pakistan showed that the majority of treated patients were from Sindh Province (67.5 %), with 32.4 % of the patients from Punjab (Muqaddas
Demographically, in Pakistan, the largest ethnic group is Punjabi (44.7 %), followed by Pushtun (15.4 %), Sindhi (14.1 %), Saraiki (8.4 %), Muhajir (7.6 %), Hindku (6.2 %), and Balochi (3.6 %) (Misachi, 2019). The current findings showed that most CE cases treated in the hospital in Lahore were Pashtun (36.7 %), followed by Hindku (26.5 %), and Punjabi (22.0 %). In comparison, a study by Khan
This study described the epidemiological characteristics of CE cases managed surgically at a single reference hospital in the city of Lahore. While these cases don’t portray the full spectrum of cases seen in the country, most CE patients in Pakistan continue to be treated surgically despite WHO-IWGE guidelines indicating that certain cases are best managed medically or using a watch-and-wait approach (Brunetti
This study showed that CE continues to be a problem throughout the country of Pakistan. There is an urgent need for community-based US screening following WHO-IWGE international guidelines to ensure the timely diagnosis and appropriate cyst stage-based management of the disease (WHO-IWGE, 2003; Brunetti