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Division of Infectious and Tropical Diseases University of Pavia
IRCCS S. Matteo Pavia, Italy
Institute of Infectious Diseases University of Pavia IRCCS S. Matteo
Pavia, Italy
We read with great interest the article by Paksoy et al. [1], "Percutaneous Treatment of Liver Hydatid Cysts: Comparison of Direct Injection of Albendazole and Hypertonic Saline Solution." Following studies in animals [2, 3], the authors take intracystic injection of albendazole to the next step and show that this procedure is effective in humans as well.
However, albendazole is known to be poorly absorbed and its therapeutic effects in cystic echinococcosis are credited to its active metabolite, albendazole sulphoxide [4].
In their otherwise articulate and detailed paper, Paksoy et al. [1] do not mention the use of sulfoxide. Did they use it and, if not, then how pharmacologically active was the drug they injected?
In a previous paper, they had studied the effect of albendazole intracystic injection in sheep. Differently from a similar study by a different group [2], they again do not mention the use of sulfoxide, so the reader assumes they injected albendazole. Nonetheless, the drug had a definite effect, as also shown by the comparison with the effect of a pharmacologically inert saline injection [3]. While in their human study the results are difficult to interpret because of the simultaneous administration of oral albendazole for two months [1], which may well have contributed to the therapeutic effect, this is not the case in their animal study, in which the therapeutic effects can be credited entirely to intracystic injection of albendazole.
A recent review [4] poses the question: How are helminths actually affected by albendazole? Given that the drug is very insoluble, do helminths ingest it? If absorption of albendazole and metabolism to the sulfoxide have been shown to occur in nematodes [4], it is tempting to speculate that the same could happen with cestodes. We are not aware of any such report concerning Echinococcus granulosus. Further experimental study is needed to elucidate this issue.
Along this line of reasoning, the efficacy of intracystic injection of albendazole also could be explained by the fact that the drug was left in situ. Because of its mechanism of action (inhibition of the assembly of tubulin into microtubules, which impairs the uptake of glucose and interferes with the homeostasis of the parasite), albendazole takes time to exert its effects.
Should the drug turn out to be pharmacologically inactive, then its effects could simply be physicochemical: This would not detract from its therapeutic value and safety.
We are very much looking forward to Dr. Paksoy's reply; in any event, should their results be confirmed by further studies, they will have made percutaneous treatments for unilocular echinococcal cysts safer and simpler. For this they deserve the gratitude of both the clinicians dealing with this disease and their patients.
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