Abstract

Background:

Cystic echinococcosis is a zoonotic parasitic disease with heterogeneous presentation and stage-conscious management. Data describing the clinical profile, imaging pathways, management patterns, and outcomes of pediatric cases in Jordan remain limited.

Methods:

We retrospectively reviewed 41 patients (0–13 years) with radiologically confirmed hydatid cysts treated between March 2022 and May 2025. Diagnosis was established using abdominal ultrasound and/or computed tomography (CT), and cysts were staged according to the Gharbi and WHO criteria. Forty patients underwent open cyst deroofing combined with albendazole (15–20 mg/kg/day; one preoperative course and six months post-operatively), whereas one received medical therapy alone. Collected variables included demographics, exposure history, cyst location and stage, operative metrics (duration and blood loss), length of stay, postoperative complications, and recurrence during follow-up (median 12 months).

Results:

The mean age was 9.3 ± 3.1 years; 56% were female, and 76% reported domestic animal contact. Liver involvement was most common (56%), followed by lung (39%); 90% had single-organ disease. Type III cysts predominated (37%). The mean operative time was 105 ± 24 min, and the mean hospital stay was 6 ± 3 days. Postoperative complications occurred in 34% (pneumonia 15% and intra-abdominal collections 10%). Recurrence during follow-up (median 12 months) was 4.9%.No demographic or exposure factors significantly predicted complications or recurrence (p > 0.05).

Conclusions:

Open deroofing plus albendazole in Northern Jordanian children was associated with low recurrence and acceptable morbidity. Expanded ultrasound screening, community zoonosis education, and WHO-aligned protocols are needed.

Introduction

Cystic echinococcosis (CE), or hydatid cyst disease, is a parasitic disease caused by the tapeworm Echinococcus granulosus. Cystic echinococcosis results from cysts formed by the larval stage of the parasite. These cysts develop brood capsules, each containing 30–40 protoscoleces. Each protoscolex is capable of developing into a single adult tapeworm within the host. Cystic echinococcosis is mainly a hepatic and pulmonary disease, producing fluid-filled hydatid cysts in the liver and lungs. Infrequent sites include muscle (5%), bone (3%), kidney (2%), and the spleen, central nervous system, pancreas, and heart (each ∼1%) (1). The disease is endemic in rural livestock communities where sheep and dogs are commonly raised, owing to close contact among humans, sheep, and dogs. It is particularly prevalent in Mediterranean countries, including the Middle East and Turkey, as well as Africa, South America, New Zealand, Australia, Central Asia, and the Russian Federation (2).

Cystic echinococcosis can affect individuals of all age groups; however, pediatric susceptibility may be higher due to environmental exposure, as children are more likely to contact contaminated soil and domestic animals during play, and because an immature immune system may increase vulnerability to infection. The clinical presentation of a hydatid cyst depends on its location and size, and on whether the cyst is intact or ruptures (3). In most cases, asymptomatic or intact hydatid cysts are detected incidentally on imaging; however, larger cysts may cause symptoms due to compression of adjacent organs (3). As mentioned earlier, hydatid cysts primarily affect the liver or lungs. When the liver is involved, presentation is often asymptomatic in the early stages; however, symptoms may include upper right quadrant abdominal pain, abdominal distention, nausea, and vomiting as the cyst enlarges. When the lungs are involved, children may present with chronic cough, hemoptysis, chest pain, and dyspnea; in some cases, pulmonary disease may remain asymptomatic (4–7). Some children may also present with atypical symptoms depending on cyst location: cardiac involvement can lead to palpitations and arrhythmias, bone involvement can result in localized pain and swelling, and central nervous system involvement may present with headache and vomiting. Early diagnosis and management are important to prevent complications, such as rupture and secondary bacterial infection (4–7).

Current WHO and WHO-IWGE guidance emphasizes imaging-based, stage-specific management, with ultrasonography as the preferred first-line modality in organs accessible to ultrasound and CT/MRI used as complementary tools in selected cases. However, real-world practice may differ according to the organ involved, referral patterns, and available expertise (8–11). As previously stated, the disease is endemic in rural and livestock areas where sheep and dog husbandry are common, making it a significant public health issue in Jordan and the Middle East. However, data on pediatric hydatid cyst cases in Jordan remain limited. Therefore, we conducted this study to analyze the clinical characteristics, diagnostic tools, management strategies, and outcomes of pediatric hydatid disease in Northern Jordan.

MethodsParticipants and settings

This retrospective, single-center study was conducted at Princess Rahma Teaching Hospital, affiliated with Yarmouk University. We reviewed the medical records of children aged 0–13 years with a diagnosis of hydatid cyst disease between March 2022 and May 2025. A total of 41 patients with radiologically confirmed hydatid cysts were included; cases with incomplete documentation or insufficient follow-up were excluded. These represented all eligible pediatric cases managed at our center during the study period, reflecting the experience of a major pediatric referral hospital in Northern Jordan.

Study design and procedure

Diagnosis was confirmed using computed tomography (CT) and/or ultrasound (US). Data collection encompassed demographic characteristics (age, gender, residency, exposure to animals), clinical symptoms, laboratory results, imaging findings, cyst characteristics, management strategies (medical or surgical), operative details, postoperative complications, hospital stay duration, and recurrence rates. Cyst morphology was described using available imaging records. In abdominal/hepatic lesions where ultrasound-based staging was applicable, cysts were categorized according to the Gharbi and WHO Informal Working Group on Echinococcosis (WHO-IWGE) frameworks. Because this was a retrospective cohort reflecting routine clinical practice, imaging pathways were not standardized, and computed tomography was frequently used for diagnostic clarification, pulmonary disease assessment, multiorgan evaluation, and preoperative planning (8–11) (Tables 1, 2).

Gharbi's 1981WHO classificationType ICE1ActiveType IICE3aType IIICE2TransitionCE3bType IVCE4InactiveType VCE5

Classification for hydatid cyst type.

Gharbi'sWHONumber (%)Type ICE18 (19.5%)Type IICE3a4 (9.8%)Type IIICE26 (14.6%)15 (36.6%)CE3b9 (22.0%)Type IVCE48 (19.5%)Type VCE56 (14.6%)

Hydatid cyst types according to Gharbi's classification and WHO staging.

Surgical management primarily involved open deroofing, with all patients receiving standard perioperative care, including albendazole therapy. Patients were administered albendazole at a dosage of 15–20 mg/kg/day (maximum 800 mg/day),with one course given preoperatively and continuation for six months postoperatively. Treatment decisions were made by the treating surgical team on a case-by-case basis according to clinical presentation, organ involved, symptom burden, imaging findings, complication profile, and operative feasibility. Because the study cohort was derived from a pediatric surgical service, it was enriched for patients referred for operative management. Inactive stage alone should not be interpreted as a routine indication for surgery in all settings (8, 10).

Postoperative follow-up was conducted using CT, US, or both to monitor for recurrence. When US suggested a potential cyst recurrence or was equivocal, confirmation was obtained through CT imaging to ensure accurate diagnosis and further management. Serological testing for echinococcosis was not uniformly available in this retrospective cohort and was therefore used as an adjunct to imaging and clinical assessment rather than as a standalone diagnostic criterion (12).

Surgical technique

Patients eligible for surgery underwent a thorough preoperative assessment, including imaging studies to characterize the cysts. An open approach was employed to access and identify the cyst. To minimize the risk of dissemination in case of spillage, gauze soaked with 0.5% cetrimide was packed around the cyst. The cyst was then aspirated to collapse, followed by the injection of 0.5% cetrimide, which was left in place for 10 min before complete aspiration. This maneuver was repeated twice. This scolicidal protocol (0.5% cetrimide; 10-minute dwell time; repeated twice) reflects the institution's standard operative practice to reduce spillage-related dissemination. The puncture in the cyst was subsequently widened to facilitate careful extraction of the germinal membrane and daughter cysts. The cyst wall was excised, and the inner epithelial lining was cauterized using monopolar diathermy. The excised specimen was sent for histopathological examination. Hemostasis was ensured, and appropriate suction was performed before placing a 10–14 Fr Redivac drain near the cyst site.

For pulmonary hydatid cysts, lung-preserving open surgery was performed with evacuation of cyst contents and management of the residual cavity according to intraoperative findings, including capitonnage when appropriate, followed by chest tube drainage as indicated (13, 14).For pulmonary hydatid cysts, a chest tube was inserted postoperatively to facilitate fluid drainage and manage potential complications such as postoperative pneumothorax. In cases involving hepatic and renal hydatid cysts, a Redivac drain was placed near the cyst to manage fluid collection and prevent complications.

Outcomes measured

Short-term postoperative complications included biliary leaks, wound infections, intra-abdominal collections, pneumothorax, pleural effusions, and pneumonia. Long-term outcomes were assessed based on recurrence, which was evaluated using CT and US during follow-up visits.

Statistical analysis

Continuous variables were summarized as mean ± standard deviation or median (interquartile range), as appropriate. Categorical variables were summarized as frequencies and percentages. Group comparisons were exploratory and performed using the chi-square test or Fisher's exact test for categorical variables, depending on expected cell counts, and the independent-samples t test or Mann–Whitney U-test for continuous variables, according to distributional assumptions. A two-sided p value < 0.05 was considered statistically significant. Analyses were performed using SPSS version 25 (IBM Corp., Armonk, NY, USA).

Ethical considerations

This study was approved by the Institutional Review Board (IRB/2024/184) of Yarmouk University, and all procedures adhered to ethical guidelines concerning patient confidentiality and informed consent.

Results

A total of 41 pediatric patients diagnosed with hydatid cyst disease were included in this study. The majority were female (56.1%, n = 23), with the predominant age group being 7–13 years (73.2%, n = 30).The vast majority of patients were local residents (78.0%, n = 32), and a considerable proportion (75.6%, n = 31) reported exposure to domestic animals, primarily dogs (Table 3).

Patient characteristics(n = 41)Age0–6 years [n (%)]11 (26.8%)7–13 years [n (%)]30 (73.2%)GenderMale [n (%)] F18 (43.9%)Female [n (%)]23 (56.1%)ResidencyLocal [n (%)]32 (78%)Immigrant [n (%)]9 (22%)Contact with dogs or domestic animalYes [n (%)]31 (75.6%)No [n (%)]10 (24.4%)Clinical symptomsAsymptomatic [n (%)]7 (17.1%)Skin rash [n (%)]2 (4.9%)Cough [n (%)]13 (31.7%)Shortness of breath [n (%)]6 (14.6%)Fever [n (%)]6 (14.6%)Abdominal pain [n (%)]15 (36.6%)Anaphylactic shock and rupture [n (%)]2 (4.9%)Jaundice [n (%)]2 (4.9%)Laboratory ResultsUnremarkable [n (%)]11 (26.8%)Leukocytosis [n (%)]13 (31.7%)Hyper eosinophilia > (0–0.8) x103 [n (%)]13 (31.7%)Serology (echinococcosis titer)Positive [n (%)]10 (24.4%)Negative [n (%)]11 (26.8%)Not performed [n (%)]20 (48.8%)PresentationSingle organ involvement [n (%)]37 (90.2%)Two organs involvement [n (%)]2 (4.9%)Multi-organ [n (%)]2 (4.9%)ImagingCT [n (%)]26 (63.4%)US [n (%)]0 (0.0%)Both [n (%)]15 (36.6%)Locations (single organ)Lung [n (%)]16 (39%)Spleen [n (%)]7 (17.1%)Liver [n (%)]23 (56.1%)Kidney [n (%)]1 (2.4%)Multiple Organ InvolvementYes [n (%)]4 (9.8%)No [n (%)]37 (90.2%)Number of cysts1 [n (%)]24 (58.5%)2 [n (%)]13 (31.7%)3 [n (%)]2 (4.9%)4 [n (%)]2 (4.9%)Management StrategyInvasive approach [n (%)]40 (97.6%)Medical [n (%)]1 (2.40%)Type of SurgeryOpen approach [n (%)]40 (97.6%)Deroofing40 (97.6%)OperationOperative time [Minutes ± SD]104.63 ± 23.832EBL [ml ± SD]53.66 ± 23.426LOS [Days ± SD]6.02 ± 2.697Timing of Drain removal after surgery [Days ± SD]4.32 ± 2.196Post-op complicationYes [n (%)]14 (34.1%)Type of Post-op complicationBiliary Leak [n (%)]2 (4.9%)Wound infection [n (%)]2 (4.9%)Intra-abdominal collection [n (%)]4 (9.8%)Pneumothorax or pleural effusion [n (%)]4 (9.8%)Air leak [n (%)]4 (9.8%)Pneumonia [n (%)]6 (14.6%)Readmission [n (%)]4 (9.8%)Follow-up imagingCT [n (%)]35 (85.4%)US [n (%)]2 (4.9%)Both [n (%)]4 (9.8%)RecurrenceYes [n (%)]2 (4.9%)Follow-up duration (months)12 [n (%)]36 (87.8%)6 [n (%)]5 (12.2%)

Baseline patient characteristics, clinical presentation, imaging findings, management, and outcomes (n = 41).

CT, computed tomography; US, ultrasound; n, number.

Laboratory findings are not mutually exclusive (patients may have >1 abnormality).

The most frequently reported clinical presentations included abdominal pain (36.6%, n = 15), cough (31.7%, n = 13), and fever (14.6%, n = 6). Additional symptoms observed were shortness of breath (14.6%, n = 6), asymptomatic cases (17.1%, n = 7), skin rash (4.9%, n = 2), anaphylactic shock with rupture (4.9%, n = 2), and jaundice (4.9%, n = 2) (Table 3). Laboratory findings revealed that leukocytosis (31.7%, n = 13) and hypereosinophilia (31.7%, n = 13) were frequently encountered. Serological testing for echinococcosis was positive in 24.4% (n = 10) and negative in 26.8% (n = 11), while it was not performed in 48.8% (n = 20). In this cohort, serology was used as an adjunct to imaging and clinical assessment rather than as a uniform diagnostic requirement (Table 3).

Imaging modalities used in diagnosis varied, with CT being the sole imaging tool in 63.4% (n = 26) of cases, while 36.6% (n = 15) underwent a combination of US and CT. The liver was the most commonly affected organ (56.1%, n = 23), followed by the lungs (39.0%, n = 16), spleen (17.1%, n = 7), and kidney (2.4%, n = 1). Single-organ involvement was predominant (90.2%, n = 37), while 4.9% (n = 2) of cases exhibited two-organ involvement, and another 4.9% (n = 2) presented with multi-organ disease (Table 3). The number of cysts varied among patients, with 58.5% (n = 24) having a single cyst, 31.7% (n = 13) presenting with two cysts, and a minority presenting with three (4.9%, n = 2) or four (4.9%, n = 2) cysts (Table 3).

According to Gharbi's classification and WHO staging, type III cysts were the most prevalent (36.6%, n = 15), followed by type I (19.5%, n = 8) and type IV (19.5%, n = 8) (Tables 1, 2). The treatment strategy was predominantly surgical, with open deroofing performed in 97.6% (n = 40) of cases, while only one patient (2.4%) underwent medical management. The mean operative time was 104.63 ± 23.83 min, with an estimated blood loss (EBL) of 53.66 ± 23.43 mL. The mean hospital stay was 6.02 ± 2.70 days, and the mean drain removal time was 4.32 ± 2.20 days postoperatively (Table 3).

Postoperative complications were documented in 34.1% (n = 14) of cases. Among the most common complications, pneumonia was observed in 14.6% (n = 6), while intra-abdominal collections (9.8%, n = 4), pneumothorax or pleural effusion (9.8%, n = 4), air leaks (9.8%, n = 4), and readmission (9.8%, n = 4) were also noted. Biliary leak (4.9%, n = 2) and wound infection (4.9%, n = 2) were the least frequently reported complications (Table 3). The recurrence rate over a median follow-up period of 12 months was 4.9% (n = 2) (Table 3).

Statistical analyses indicated no significant associations between age, gender, residency status, or animal exposure and clinical outcomes, including recurrence (p = 1.0), postoperative complications (p = 0.196–0.719), operative time (p = 0.108–0.956), estimated blood loss (p = 0.121–0.602), and length of hospital stay (p = 0.324–0.869) (Tables 4–11).

Age vs. categorical variables (univariable analysis)0–6 years (n = 11)7–13 years (n = 30)P-valueAsymptomatic [n (%)]1 (9.09)6 (20).651Multiple Organ Involvement [n (%)]0 (0.0)4 (13.3).559Post-op complication [n (%)]3 (27.3)11 (36.6).719Recurrence [n (%)]0 (0.0(2 (6.7)1.0

Age group and categorical outcomes: univariable analysis.

Age vs. continuous variables (univariable analysis)0–6 years (n = 11)7–13 years (n = 30)P-valueOperative time [minutes ± SD]98.2 ± 14107 ± 26.3.3EBL [mL ± SD]50 ± 055 ± 27.4.552LOS [days ± SD]5.8 ± 1.56.1 ± 3.1.771

Age group and continuous outcomes: univariable analysis.

EBL, estimated blood loss; LOS, length of stay.

Gender vs. categorical variables (univariable analysis)Male (n = 18)Female (n = 23)P-valueAsymptomatic [n (%)]2 (11.1)5 (21.7).438Multiple Organ Involvement [n (%)]3 (16.7)1 (4.35).303Post-op complication [n (%)]4 (22.2)10 (43.5).196Recurrence [n (%)]0 (0.0(2 (8.7).495

Sex and categorical outcomes: univariable analysis.

Gender vs. continuous variables (univariable analysis)Male (n = 18)Female (n = 23)P-valueOperative time [minutes ± SD]100 ± 29.1108.2 ± 18.6.276EBL [mL ± SD]47.2 ± 11.858.7 ± 28.8.121LOS [days ± SD]6.5 ± 3.75.6 ± 1.5.324

Sex and continuous outcomes: univariable analysis.

EBL, estimated blood loss; LOS, length of stay.

Immigrant vs. categorical variables (univariable analysis)Local (n = 32)Immigrant (n = 9)P-valueAsymptomatic [n (%)]7 (21.9)0 (0.0).315Multiple Organ Involvement [n (%)]3 (9.4)1 (11.1)1.0Post-op complication [n (%)]11 (34.4)3 (33.3).196Recurrence [n (%)]2 (6.25)0 (0.0).495

Residency status and categorical outcomes: univariable analysis.

Immigrant vs. continuous variables (univariable analysis)Local (n = 32)Immigrant (n = 9)P-valueOperative time [minutes ± SD]107.8 ± 24.893.3 ± 16.4.108EBL [mL ± SD]54.7 ± 26.550 ± 0.602LOS [days ± SD]6.2 ± 35.44 ± 1.01.472

Residency status and continuous outcomes: univariable analysis.

EBL, estimated blood loss; LOS, length of stay.

Contact with dogs or domestic animal vs. Categorical variables (univariable analysis)Yes (n = 31)No (n = 10)P-valueAsymptomatic [n (%)]7 (22.6)0 (0.0).164Multiple Organ Involvement [n (%)]3 (9.7)1 (10)1.0Post-op complication [n (%)]10 (34.4)4 (40).712Recurrence [n (%)]2 (6.5)0 (0.0)1.0

Animal exposure and categorical outcomes: univariable analysis.

Contact with dogs or domestic animal vs. Continuous variables (univariable analysis)Yes (n = 31)No (n = 10)P-valueOperative time [minutes ± SD]104.5 ± 26.1105 ± 15.8.956EBL [mL ± SD]54.8 ± 26.950 ± 0.577LOS [days ± SD]6.06 ± 2.95.9 ± 1.73.869

Animal exposure and continuous outcomes: univariable analysis.

EBL, estimated blood loss; LOS, length of stay.