Ultrasound has several applications in diagnosing and assessing parasitic diseases: 1) It can identify characteristic ultrasound features of parasites that help in diagnosis of diseases like ascariasis and hydatid cysts. 2) It can detect characteristic pathology caused by parasites, as seen in schistosomiasis and amoebic liver abscess. 3) It guides needle biopsies and aspirates of organs infected by parasites like the liver. 4) It assesses the severity of conditions like schistosomiasis-induced liver fibrosis and monitors changes with treatment. 5) Portable ultrasound enables large-scale epidemiological studies in parasite-endemic areas.

1. Ultrasound
for
Parasitic
Diseases
Prof. Dr. Ibrahim A. Aboul Asaad
MD Lecture
Main Parasitology

2. Imaging Techniques include:
1) Radiography a) X-rays.
b) Computed tomography (CT).
2) Magnetic resonance imaging (MRI).
3) Ultrasound imaging (US).
Imaging techniques especially X rays and Ultrasound, have been
recommended in the Clinical Practice Guidelines, submitted by WHO,
for any curative program.
Overview
Diagnosis of parasitic diseases depends on several laboratory methods,
imaging techniques and endoscopy in addition to clinical diagnosis (history
of exposure to infection and clinical picture).

3. Ultrasound machines are becoming more widely distributed and are fairly
cheap. Portable devices allow field use for population studies and individual
diagnosis of tropical diseases.
Ultrasound is a rapidly developing imaging technology. It is very popular
with operators, patients and communities because it is non-invasive and
painless. A large number of people can be screened in a short period of time
with instant results.
Ultrasonography (US)
Ultrasonic examinations are accessible to all body regions which are not
situated behind bones. Many parasitic diseases have particular
ultrasonography features that help in diagnosis. In addition, US is now
recognized as a valuable tool for the assessment of morbidity due to
parasitic infections.

4. Ultrasound images are available today, with higher resolutions, allowing
physicians to see much clearer definition. During the last 20 years, newer
technologies are set to improve the practical uses of ultrasound as,
o Color Doppler US for imaging blood vessels and blood flow.
o Echocardiogram used to examine the heart.
o Endoscopic US for imaging through intestinal lumen.
o Ultrasound Elastography (FibroScan): measures the stiffness of the
liver to quantify liver fibrosis.

5. Approach to
Diagnosis
Grading of
Morbidity
Assessment
of therapy
Epidemiological
studies
Ultrasound Applications

6. Applications Parasitic Infections
1) Approach to Diagnosis:
a) Characteristic US features
of parasites images
Ascariasis, Hydatid cyst & Lymphatic Filariasis.
b) Characteristic US features
of the pathology
Schistosomiasis & Amoebic liver abscess
c) Guidance for needle
biopsy and aspirate
Liver biopsies for hepato-biliary parasitic infections
Aspirates from liver abscess and cysts.
Amniocentesis for congenital parasitic infections.
3) Grading of Morbidity. By Assessment of pathology & complications, as
Schistosomiasis & Hydatid disease.
3) Assessment of therapy. Regression of the pathological changes before and
after treatment of hepato-biliary parasitic infections,
Lymphatic Filariasis & Hydatid disease.
4) Epidemiological studies. Portable devices allow field use for population
studies, as for schistosomiasis
Applications of Ultrasound in parasitic diseases

7. Site of parasitic infection Parasitic disease
1) Abdominal & Pelvic parasitic
infections
Schistosomiasis
Hydatid disease
Amoebiasis
Congenital Toxoplasmosis
Fascioliasis
Ascariasis
2) Thoracic parasitic Infections Chagas disease
Hydatid disease
3) Soft Tissue parasitic infections Lymphatic Filariasis
Cysticercosis
Hydatid disease
Onchocerciasis
Ultrasonography has valuable applications in the following
parasitic infections:

8. Schistosomiasis
Schistosomiasis mansoni
Us scanning can demonstrate liver lesions typical of
Schistosoma infection as;
• The characteristic induced periportal fibrosis, and
• Hypertrophy of the left hepatic lobe and atrophy
of the right hepatic lobe.
US applications in schistosomiasis mansoni:
By measurement of regression of the pathological
changes before and after treatment.

9. Availability of portable US equipment can aid will
trained examiner to screen a large number of people
in a short period of time with reliable results.
Grading of periportal fibrosis by ultrasonography and
elastography has been shown to correlate with clinical
conditions and risks for complications.
In addition, measurements of portal perfusion by
Doppler US have been correlated with the degree of
oesophageal varices, and probability of gastrointestinal
bleeding.
Schistosomiasis mansoni

10. Grading of the severity of periportal fibrosis by
ultrasonography in schistosomiasis mansoni
According to Niamey Criteria
Hepatic parenchyma patterns according to Niamey classification.
Pattern Sonographic image
A  Normal
B  Starry sky (diffuse echogenic foci)
C  Ring echoes and pipe-stems.
D  Echogenic ruff around portal bifurcation.
E  Highly echogenic patches extending from the portal vessels into
the parenchyma.
F  Highly echogenic bands extending towards the liver periphery
and retracting the subjacent parenchyma.
Source: Niamey Working Group, 2000.

11. Periportal Fibrosis
B – pattern: Starry sky (diffuse echogenic foci of fibrosis)
C – pattern: Ring echoes (transverse view of vessels) and pipe-
stems (longitudinal view of vessels).

12. Periportal Fibrosis
D-pattern: Fibrosis bands around portal vein and its main branches.
E-pattern: Fibrosis patches extending from the portal vessels
into the parenchyma without reaching the hepatic surface.

13. F-pattern, Bird’s claw pattern: Highly echogenic bands of fibrosis extending
towards the liver periphery with retraction of the subjacent parenchyma.
Periportal Fibrosis

14. Doppler sonographic demonstrates
increase in the diameter of portal vein
(1.4 cm) indicating Portal
hypertension.
Oblique cut ultrasonography of the
hepatic hilum to measure the caliber of
the portal vein (1.4 cm indicate portal
hypertension).
Portal hypertension

15. Abdominal US for case of advanced
schistosomiasis mansoni demonstrates
partially portal thrombosis, with
echogenic material inside the portal
vein
Abdominal US for case of
advanced schistosomiasis
mansoni demonstrates ascites.
Portal Thrombosis
Ascites

16. (A) Splenomegaly in schistosomiasis due to portal hypertension. The inferior splenic
margin is blunted, descending below and medial to the left kidney.
(B) Splenic vein dilatations, which result from portal hypertension are present around
the hilum.
Splenomegaly

17. Ultrasound elastography (Fibro-scan): Blue-green-red elastic images were formed. The
more advanced the stage of liver fibrosis, the stiffer the liver parenchyma and the larger
the blue area. The degree of fibrosis correlates with ratio of blue area (% AREA)
Elastography

18. Schistosomiasis haematobium
The value of ultrasound in diagnosing urinary
schistosomiasis is generally accepted.
Detectable alterations include;
o The fibrotic bladder wall and
o Dilatation of the upper urinary tract
However, US is mostly applied for:
US applications:

19. Thickening and heavy calcification
of the bladder wall
Longitudinal transabdominal ultrasound
shows mucosal irregularity with bladder
pseudopolyp granulomas on the base
(arrows)
Urinary Schistosomiasis

20. (A) Hydronephrosis RK and (B) Hydroureter RU, complicating S. haematobium
Calculi in (A) renal pelvis and (B) bladder, complicating S. haematobium.
Urinary Schistosomiasis

21. • Urinary bladder
malignancy ( confirmed by
histopathology), possibly
following schistosomiasis.
Carcinoma

22. Sonographic classification of Hydatid cyst :
o WHO classification (2001).
o Gharbi’s classification (1981).
In both classifications, the cyst can be classified into five different types on
bases of its morphology and stage.
o WHO classification  CE1 to CE5
o Gharbi classified the cysts  Type I to Type V.
There are interactions between both classifications
Hydatid cyst

24. WHO classification (2001)
CE1 (Type I): Unilocular, simple cysts with liquid content
CE2 (Type III): Multivesicular, multiseptated cysts
CE3a (Type II): Cysts with liquid content and specific detached endocyst
CE3b (Type III): Unilocular cysts with daughter cysts inside a mucinous or solid cyst matrix
CE4 (Type IV): Heterogenous solid cysts with degenerative content
CE5 (Type V): Cysts with degenerative content and heavily calcified wall.

25. Comparative description of the WHO and Gharbi
ultrasound classifications of hydatid cysts
WHO Gharbi Description Stage
CE1 Type I Unilocular, simple cysts with liquid content
and double line sign
Active
CE2 Type III Multivesicular, multiseptated cysts
(honeycomb or rosette- like)
Active
CE3a Type II Cysts with liquid content and specific
detached endocyst (Water-lily sign)
Transitional
CE3b Type III Unilocular cysts with mucinous or solid
content and daughter cysts inside
Transitional
CE4 Type IV Heterogenous solid cysts with degenerative
content. No daughter cyst.
Inactive
CE5 Type V Solid cyst with heavily calcified wall. Inactive

26. Hydatid Cyst
Ultrasound scan of the liver show
intact Hydatid cyst with with double
line sign and intramural nodules (CE1-
Type I).
Liver hydatid cysts, CE2 (Type III):
multivesicular, multiseptated, or
multiloculated cysts. May appear
honeycomb like with daughter
cysts completely fill the unilocular
mother cyst.

27. Hydatid Cyst
Liver hydatid cysts, (CE3a -Type II): Detachment of the laminated
membrane (endocyst) from the pericyst (Water lily sign).

28. Large retroperitoneal hydatid with
daughter cyst seen on longitudinal
sonogram in the pelvis, (CE3b -Type
III).
Sonogram shows Renal Hydatid cyst
with daughter cysts, (CE3b -Type III).
Hydatid cyst

29. Ultrasound of the abdomen showing
splenic hydatid cysts with multiple
daughter cysts (CE3b, Type III).
Ruptured splenic hydatid cyst due to
blunt abdominal trauma, which
manifested in the form of
anaphylactic reaction and shock due
to fluid from the ruptured cyst.
Hydatid cyst

30. Ultrasound scan of the liver shows
Heterogenous solid cysts with
degenerative content and partial
calcification, (CE4-Type IV).
Ultrasound of the abdomen showing
Old hydatid cyst in the liver with a
calcified mass
(CE5 ,Type V).
Hydatid cyst

31. (CE1, Type I): Pulmonary hydatid cyst in a child of 11 years detected by Transthoracic
ultrasound. The cyst with double layered wall (the specific sonographic sign for pulmonary
hydatid).
Hydatid cyst
Pulmonary hydatid cyst

32. A: Needle inside the cyst. B: After aspiration. C: After injection of Scolicide hyperosmolar
saline solution. D: After re-aspiration
Liver Hydatid cyst treated by Ultrasound-Guided PAIR

33. Ascariasis
 When there are abdominal symptoms of intestinal obstruction in
association with a vague abdominal mass. The routine
ultrasound scan can provide characteristic US signs leading to
suspension of ascariasis.
 When there are biliary manifestations due to migration of adult
worms to biliary system. In this case, the ultrasound scanning is a
specific diagnostic tool.
In ascariasis, abdominal ultrasound is beneficial in case of:

34. US showing longitudinal three line and
railway track appearance of Ascaris
worms in dilated intestine.
US showing both transverse (target
sign) and longitudinal scans (railway
track ) of Ascaris worms
Ascariasis

35. Abdominal ultrasound revealed a distended and thickened-wall gall bladder
and, inside it, a long linear structure showed spontaneous wave movements.
A hyperechoic double rim layer material was noted in
the extrahepatic bile duct (arrow). It was initially
thought as ascariasis.
Biliary Ascariasis

36. A 35-year-old female with acute pain in the right hypochondrium.
(a) Ascaris seen in the left dilated intrahepatic duct (red arrow) and,
(b) Magnified view of the Ascaris in the dilated left intrahepatic duct, triple
line seen (white arrow)
Biliary Ascariasis

37. Findings were confirmed at the time
of surgery, with drainage of frank
pus containing dead Ascaris worms
from the abscess cavities.
Liver abscess containing coiled tubular
structures
Ascariasis of the liver

38. Parenchymal phase of fascioliasis.
US shows a parenchymal focal lesion with a
halo around (a "wheel spoke" appearance)
in the liver. (arrow).
F. hepatica worms. US demonstrates a
linear echogenic material (arrow) within
the dilated common hepatic duct
representing dead F. hepatica worm.
Fascioliasis

39. Ultrasound scan of the gallbladder shows sludge and vermiform non-shadowing
images of Fasciola hepatica flukes (arrows), which showed active motility.
Differentiate from gall stone ???
Fascioliasis
Gall stone

40. Mild dilatation of the central
intrahepatic bile ducts in the liver of a
cured 60-year-old man.
US scan of the gallbladder of a heavily
infected Chinese man with several
floating echogenic foci (arrows), which
probably indicate worms
Clonorchiasis

41. • Cholangiocarcinoma in
the right hepatic lobe, with
clonorchiasis, in a 63-year-
old man. There is diffuse
dilatation of peripheral
intrahepatic bile ducts
(arrowheads) is attributed to
changes of a C. sinensis
infection, and segmental and
more severe dilatation
around the tumor is caused
by obstruction by the tumor
(arrows)

42. Transverse ultrasound images of the bilateral inguinal regions
show dilated lymphatic channels as multiple cystic spaces.
Lymphatic
Filariasis
Soft Tissues parasitic infections

43. Filarial dance sign: The pathognomonic sign on ultrasound.
Constant movements of the worms in chylus fluid during US of enlarged
inguinal lymph node.
Lymphatic Filariasis

44. Filarial Dance Sign: Pathognomonic sign on ultrasound of active
scrotal filariasis
Lymphatic Filariasis

45. Sonography of Onchocerca nodule: Showing a verminous nodule on the palmaro-
lateral aspect of the right forelimb. The parasite appears as a coiled hyperechoic
line within a hypoechoic nodule.
Onchocerciasis

46. Transverse scan of the patient's left knee. A large cystic onchocercoma can be seen.
Movements of a conglomerate of coiled adult filariae are displayed in the cystic fluid of the
nodule. Static fragments of the worms are visible in the lower left part of the video image
Onchocercoma

47. US of the arm shows Cysticercus cellulosa (arrow) with a scolex (arrowhead) and
surrounding abscess (curved arrow)
Cysticercosis

48. 2-year-old male presented with pain in calf and feeling of a mass in the region.
Ultrasonography shows thick-walled cystic lesion with mural echogenic nodule
(Cysticercosis) in the medial head of gastrocnemius muscle
Cysticercosis

49. • Transverse scan of the liver
showing multiple elliptical calcified
cysticercus cysts.
Hepatic Cysticercosis

50. Endoscopic ultrasonography shows 3-cm- × 2.5-cm-sized heterogeneous
submucosal mass on greater curvature of gastric midbody (arrow)
Biopsy and histopathological examination showed severe inflammatory cell infiltration, and abscess formation
with a submucosal eosinophilic granuloma around the larvae, which are findings consistent with gastric anisakiasis
Anisakiasis
Endoscopic ultrasonography

51. Endoscopic Ultrasonography showing an actively motile tubular structure in
the bile duct. Endoscopic appearance of Fasciola hepatica showing a leaf-like
trematode extracted by using a balloon catheter.
Biliary Fascioliasis
Endoscopic ultrasonography