Human Cystic Echinococcosis Research Articles

Could beta-myrcene be an alternative to albendazole for the treatment of experimental cystic echinococcosis?

Echinococcus granulosus causes hydatidosis or cystic echinococcosis in humans and livestock. In humans, this disease can be managed with surgery, percutaneous treatment, chemotherapy and/or observation. The chemotherapeutic agents used and approved for treatment of hydatidosis are benzimidazoles. Because of the difficulties in achieving successful treatment, considerable efforts have been made to find new natural compounds against hydatid disease. Beta-myrcene is a monoterpene presented in the essential oils of different plants. It is the principal component of essential oil of Rosmarinus officinalis (rosemary). The goal of the present study was to evaluate the in vitro effects of beta-myrcene against germinal cells, protoscoleces and murine cyst of E. granulosus, as well also, investigate its chemoprophylactic activity in a murine model of cystic echinococcosis. For the in vitro assays, the parasites were incubated with beta-myrcene at 10, 5 and 1 μg/mL. The treatments were dose and time-dependent, and consistent with the observed morphological alterations. In the chemoprophylactic efficacy study, the effect of beta-myrcene was similar to albendazole, the reference drug for human echinococcosis treatment.

Albendazole and Treatment of Hydatid Cyst: Review of the Literature.

Human hydatid cyst or cystic echinococcosis is a life-threatening zoonotic disease that occurs in most countries worldwide and is recognized as a major public health problem. Following ingestion of Echinococcus granulosus eggs, hydatid cysts which are the larval stage of the worm are formed mostly in liver and lungs, and occasionally in other organs of human. The usual treatment for hydatid cyst is open surgery. One of the problems following surgery is the recurrence. In the last decades, albendazole has been used for the treatment of hydatid cyst. This drug can be used alone or jointly with surgical procedures. However, its efficacy has not been well documented. Thus, in this work, the treatment of hydatid cyst with albendazole in different investigations including case studies, clinical trials in human and experimental works in animals has been reviewed. According to the findings of this review, it can be concluded that treatment of hydatid cyst with albendazole may be associated with the prevention of recurrence and reduction of the size and death of the hydatid cysts.

Distinguishing Echinococcus granulosus sensu stricto genotypes G1 and G3 with confidence: A practical guide

Cystic echinococcosis (CE), a zoonotic disease caused by tapeworms of the species complex Echinococcus granulosus sensu lato, represents a substantial global health and economic burden. Within this complex, E. granulosus sensu stricto (genotypes G1 and G3) is the most frequent causative agent of human CE. Currently, there is no fully reliable method for assigning samples to genotypes G1 and G3, as the commonly used mitochondrial cox1 and nad1 genes are not sufficiently consistent for the identification and differentiation of these genotypes. Thus, a new genetic assay is required for the accurate assignment of G1 and G3. Here we use a large dataset of near-complete mtDNA sequences (n = 303) to reveal the extent of genetic variation of G1 and G3 on a broad geographical scale and to identify reliable informative positions for G1 and G3. Based on extensive sampling and sequencing data, we developed a new method, that is simple and cost-effective, to designate samples to genotypes G1 and G3. We found that the nad5 is the best gene in mtDNA to differentiate between G1 and G3, and developed new primers for the analysis. Our results also highlight problems related to the commonly used cox1 and nad1.To guarantee consistent identification of G1 and G3, we suggest using the sequencing of the nad5 gene region (680 bp). This region contains six informative positions within a relatively short fragment of the mtDNA, allowing the differentiation of G1 and G3 with confidence. Our method offers clear advantages over the previous ones, providing a significantly more consistent means to distinguish G1 and G3 than the commonly used cox1 and nad1.

The benefits of analysing complete mitochondrial genomes: Deep insights into the phylogeny and population structure of Echinococcus granulosus sensu lato genotypes G6 and G7

Cystic echinococcosis (CE) is a zoonotic disease caused by the larval stage of the species complex Echinococcus granulosus sensu lato. Within this complex, genotypes G6 and G7 have been frequently associated with human CE worldwide. Previous studies exploring the genetic variability and phylogeography of genotypes G6 and G7 have been based on relatively short mtDNA sequences, and the resolution of these studies has often been low. Moreover, using short sequences, the distinction between G6 and G7 has in some cases remained challenging. The aim here was to sequence complete mitochondrial genomes (mitogenomes) to obtain deeper insight into the genetic diversity, phylogeny and population structure of genotypes G6 and G7. We sequenced complete mitogenomes of 94 samples collected from 15 different countries worldwide. The results demonstrated that (i) genotypes G6 and G7 can be clearly distinguished when mitogenome sequences are used; (ii) G7 is represented by two major haplogroups, G7a and G7b, the latter being specific to islands of Corsica and Sardinia; (iii) intensive animal trade, but also geographical isolation, have likely had the largest impact on shaping the genetic structure and distribution of genotypes G6 and G7. In addition, we found phylogenetically highly divergent haplotype from Mongolia (Gmon), which had a higher affinity to G6.

Watch and Wait Approach for Inactive Echinococcal Cyst of the Liver: An Update.

Human cystic echinococcosis (CE) is a chronic, complex and neglected infection causing severe disease in humans. Hepatic CE cysts are detected and classified mainly by using ultrasound. Expert opinion and published data suggest that uncomplicated inactive liver cysts do not require treatment and only need to be monitored over time ("Watch and Wait"). Here we update our findings as published in 2014 on the "Watch and Wait" approach applied to inactive, asymptomatic cysts of the liver to keep the medical community informed. Clinical data of patients who accessed the World Health Organization Collaborating Center for CE at the University of Pavia-San Matteo Hospital Foundation from January 1991 to October 2017 were analyzed. Inclusion criteria were presence of one or more inactive uncomplicated cysts in the liver (CE4 or CE5), without any history of previous treatment, and an ultrasound-based follow-up of at least 24 months. Fifty-three patients with 66 inactive cysts fulfilled the inclusion criteria. Of these, 11 patients are newly described here; 37 were part of our previously described cohort and the follow-up for 17 of them was further extended; and five were excluded from the previously published analysis as their follow-up was too short, but could be included now. Without the need for treatment and without development of complications, 98.5% of cysts remained inactive over time. In only one patient (1.9% of patients), a reactivation of one cyst (1.5% of cysts) was observed.

Field evaluation of an immunochromatographic test for diagnosis of cystic and alveolar echinococcosis

BackgroundThe larval stages of the tapeworms Echinocoocus granulosus and Echinococcus multilocularis are the causative agents of human cystic echinococcosis (CE) and human alveolar echinococcosis (AE), respectively. Both CE and AE are chronic diseases characterised by long asymptomatic periods of many years. However, early diagnosis of the disease is important if treatment and management of echinococcosis patients are to be successful.MethodsA previously developed rapid diagnostic test (RDT) for the differential detection of CE and AE was evaluated under field conditions with finger prick blood samples taken from 1502 people living in the Ganzi Tibetan Autonomous Prefecture, China, a region with a high prevalence for both forms of human echinococcosis. The results were compared with simultaneously obtained abdominal ultrasonographic scans of the individuals.ResultsUsing the ultrasonography as the gold standard, sensitivity and specificity, and the diagnostic accuracy of the RDT were determined to be greater than 94% for both CE and AE. For CE cases, high detection rates (95.6–98.8%) were found with patients having active cysts while lower detection rates (40.0–68.8%) were obtained with patients having transient or inactive cysts. In contrast, detection rates in AE patients were independent of the lesion type. The positive likelihood ratio of the RDT for CE and AE was greater than 20 and thus fairly high, indicating that a patient with a positive test result has a high probability of having echinococcosis.ConclusionsThe results suggest that our previously developed RDT is suitable as a screening tool for the early detection of human echinococcosis in endemic areas.

Prevalence of abdominal cystic echinococcosis in rural Bulgaria, Romania, and Turkey: a cross-sectional, ultrasound-based, population study from the HERACLES project

Cystic echinococcosis is a neglected zoonotic infection that is distributed worldwide and prioritised by WHO for control efforts. The burden of human cystic echinococcosis is poorly understood in most endemic regions, including eastern Europe. We aimed to estimate the prevalence of abdominal cystic echinococcosis in rural areas of Bulgaria, Romania, and Turkey. We did a cross-sectional ultrasound-based survey that recruited volunteers from 50 villages in rural areas of Bulgaria, Romania, and Turkey. These villages were in provinces with annual hospital incidence of cystic echinococcosis within the mid-range for the respective countries. All people who attended a session were allowed to participate if they agreed to be screened. Abdominal ultrasound screening sessions were hosted in public community structures such as community halls, primary health-care centres, schools, and mosques. Lesions were classified using an adapted WHO classification. We reported the prevalence of abdominal cystic echinococcosis adjusted by sex and age through direct standardisation, using the country's rural population as a reference. From July 1, 2014, to Aug 3, 2015, 24 693 individuals presented to screening sessions and 24 687 underwent ultrasound screening. We excluded a further six indivduals due to missing data, leaving 24 681 people in our analysis. Abdominal cystic echinococcosis was detected in 31 of 8602 people screened in Bulgaria, 35 of 7461 screened in Romania, and 53 of 8618 screened in Turkey. The age and sex adjusted prevalence of abdominal cystic echinococcosis was 0·41% (95% CI 0·29-0·58) in Bulgaria, 0·41% (0·26-0·65) in Romania, and 0·59% (0·19-1·85) in Turkey. Active cysts were found in people of all ages, including children, and in all investigated provinces. Our results provide population-based estimates of the prevalence of abdominal cystic echinococcosis. These findings should be useful to support the planning of cost-effective interventions, supporting the WHO roadmap for cystic echinococcosis control. European Union Seventh Framework Programme.

Global phylogeography and genetic diversity of the zoonotic tapeworm Echinococcus granulosus sensu stricto genotype G1

Echinococcus granulosus sensu stricto (s.s.) is the major cause of human cystic echinococcosis worldwide and is listed among the most severe parasitic diseases of humans. To date, numerous studies have investigated the genetic diversity and population structure of E. granulosus s.s. in various geographic regions. However, there has been no global study. Recently, using mitochondrial DNA, it was shown that E. granulosus s.s. G1 and G3 are distinct genotypes, but a larger dataset is required to confirm the distinction of these genotypes. The objectives of this study were to: (i) investigate the distinction of genotypes G1 and G3 using a large global dataset; and (ii) analyse the genetic diversity and phylogeography of genotype G1 on a global scale using near-complete mitogenome sequences. For this study, 222 globally distributed E. granulosus s.s. samples were used, of which 212 belonged to genotype G1 and 10 to G3. Using a total sequence length of 11,682 bp, we inferred phylogenetic networks for three datasets: E. granulosus s.s. (n = 222), G1 (n = 212) and human G1 samples (n = 41). In addition, the Bayesian phylogenetic and phylogeographic analyses were performed. The latter yielded several strongly supported diffusion routes of genotype G1 originating from Turkey, Tunisia and Argentina. We conclude that: (i) using a considerably larger dataset than employed previously, E. granulosus s.s. G1 and G3 are indeed distinct mitochondrial genotypes; (ii) the genetic diversity of E. granulosus s.s. G1 is high globally, with lower values in South America; and (iii) the complex phylogeographic patterns emerging from the phylogenetic and geographic analyses suggest that the current distribution of genotype G1 has been shaped by intensive animal trade.

Preliminary Evidence for the Absence of Cystic Echinococcosis in Gabon: A Cross-Sectional Pilot Survey in Humans and Definitive Hosts.

Cystic echinococcosis (CE) is a globally endemic zoonosis caused by the larval stage of the Echinococcus granulosus sensu lato (s.l.) complex. Although the disease is known to be highly prevalent in certain parts of North and East Africa, data on CE, both in humans and definitive hosts, are extremely scarce for Central Africa. The present study assessed the epidemiology of CE in humans and dogs in rural Gabon. An ultrasound and serologic survey was conducted in volunteers from rural villages in Gabon. A two-step approach was used for serological testing with an indirect hemagglutination assay as a screening test and Western Blot as a confirmatory test. Fecal dog samples were analyzed microscopically, and polymerase chain reaction (PCR) amplification of nad1 and cox1 genes was performed when taeniid eggs were visible. Regional hospitals and the national reference center for parasitology in Gabon were contacted for information about previous cases of CE. Randomly selected communities were invited to participate. Three hundred and forty-eight human volunteers from these communities were screened. No suspected cases of CE were detected. Definitive host screening was performed from 128 fecal samples from representative subregions, but no eggs from E. granulosus s.l. were found. No documented cases of echinococcosis were reported from the local health-care institutions and the national diagnostic reference center in Gabon. Cystic echinococcosis seems to be very rare or absent in Gabon. The reason for this lack of evidence for echinococcosis is unknown, but the absence of livestock may play a major role.

Human cystic echinococcosis in Hungary (2000-2014): a retrospective case series analysis from a single-center study.

Cystic echinococcosis (CE) is a parasitic disease caused by the tapeworm Echinococcus granulosus sensu lato. Although in Hungary the disease is listed among reportable infections, inadequacies in the reporting practice of CE by clinicians and pathologists have resulted in underscoring of this disease. The aim of this study was to describe the epidemiological and clinical characteristics of CE in Hungary using a datasource other than the official records that are based mainly on serological data. This retrospective case series study included a total of 45 CE patients confirmed by histopathology in a single Hungarian center between 2000 and 2014. Although CE is the most prevalent reportable endemic helminthosis in Hungary, to date this is the first study on the clinical epidemiology of the disease in this country.

Immunohistochemical observation of local inflammatory cell infiltration in the host-tissue reaction site of human hydatid cysts.

The aim of this study was to evaluate the pattern of local immune cell infiltration in human cystic echinococcosis (CE) by identifying the subtypes of immune cells using immunohistochemistry (IHC). Fifty surgically removed hydatid cyst samples and surrounding tissues were collected from patients referred to Al-Zahra Hospital, Isfahan, Iran. IHC was performed on the surrounding host tissue of hydatid cysts using anti-human CD3, CD19, CD8, CD4, CD68, CD56, Ki-67 and Foxp3 (forkhead box P3) antibodies. The results were then compared to hepatocellular carcinoma and chronic hepatitis. In the host-tissue reaction site of liver hydatid cysts, a distinct pattern of local immune cell response, which outwardly consisted of a pack of the fibrous elements, a layer of palisading macrophages, an eosinophil-containing layer and a layer of accumulated lymphocytes, was observed. However, in some cases there were no positive cells for CD56+ natural killer cells and Foxp3+ regulatory T cells. The CD3+ T cells were the predominant inflammatory cells in all groups, followed by CD19+ B cells. It can be concluded that different immune cells are involved in the local response to human hydatid cysts.

Progress in the pharmacological treatment of human cystic and alveolar echinococcosis: Compounds and therapeutic targets.

Human cystic and alveolar echinococcosis are helmintic zoonotic diseases caused by infections with the larval stages of the cestode parasites Echinococcus granulosus and E. multilocularis, respectively. Both diseases are progressive and chronic, and often fatal if left unattended for E. multilocularis. As a treatment approach, chemotherapy against these orphan and neglected diseases has been available for more than 40 years. However, drug options were limited to the benzimidazoles albendazole and mebendazole, the only chemical compounds currently licensed for treatment in humans. To compensate this therapeutic shortfall, new treatment alternatives are urgently needed, including the identification, development, and assessment of novel compound classes and drug targets. Here is presented a thorough overview of the range of compounds that have been tested against E. granulosus and E. multilocularis in recent years, including in vitro and in vivo data on their mode of action, dosage, administration regimen, therapeutic outcomes, and associated clinical symptoms. Drugs covered included albendazole, mebendazole, and other members of the benzimidazole family and their derivatives, including improved formulations and combined therapies with other biocidal agents. Chemically synthetized molecules previously known to be effective against other infectious and non-infectious conditions such as anti-virals, antibiotics, anti-parasites, anti-mycotics, and anti-neoplastics are addressed. In view of their increasing relevance, natural occurring compounds derived from plant and fungal extracts are also discussed. Special attention has been paid to the recent application of genomic science on drug discovery and clinical medicine, particularly through the identification of small inhibitor molecules tackling key metabolic enzymes or signalling pathways.

A case-control study on risk factors of cystic echinococcosis in humans in Tibetan areas

To understand the risk factors of cystic echinococcosis in Tibetan population, so as to provide the reference for development of prevention and control strategies. Four cystic echinococcosis highly-prevalent townships were selected from Naqu County of Tibet and Shiqu County of Sichuan Province, which had similar environmental and altitude conditions, from August to September, 2017. Applying the 1∶1 case-control study, a household survey was conducted to investigate the risk factors of echinococcosis in humans. A total of 378 residents were investigated, of which the numbers of cases and non-cases were both 189. The univariate analysis showed that the years of keeping dogs (OR = 1.032, P < 0.05), the number of keeping dogs (OR = 1.260, P < 0.05), the way of raising dogs (OR = 1.434, P < 0.05), feeding with raw viscera (OR = 1.531, P < 0.05), and there being stray dogs around (OR = 1.946, P < 0.05) were the risk factors of echinococcosis. As a result of the multivariate logistic regression analysis, only three risk factors, feeding with raw viscera, there being stray dogs around, and drinking water resource, were included in the regression model. Feeding with raw viscera, there being stray dogs around, and drinking water resource are the risk factors of echinococcosis in humans.

In vitro and in vivo effects of chitosan-praziquantel and chitosan-albendazole nanoparticles on Echinococcus granulosus Metacestodes.

Cystic echinococcosis (CE), which is caused by the metacestode of Echinococcus granulosus, is one of the most important zoonoses affecting humans. Benzimidazoles (in particular albendazole) and praziquantel (PZQ) are effective against CE, but poor water solubility of these agents often leads to inadequate results. Here, we evaluate the effects of chitosan-albendazole (ChABZ) and chitosan-praziquantel (ChPZQ) nanoparticles as a new formulation on hydatid cysts both in vitro and in vivo. Developed microcysts in culture were treated with different concentrations of ChABZ and ChPZQ nanoparticles (either alone or in combination), and ABZ + PZQ suspension. The viability rate of microcysts was used to evaluate the drug efficacies. In addition, the prophylactic and therapeutic effects of the drugs were studied on infected DBA/2 mice. Transmission electron microscopy was used to observe the ultra-structural changes. The viability rate of microcysts and differences in cyst weights were compared by ANOVA, and the cyst numbers were compared using the Kruskal-Wallis test. The combination of ChABZ + ChPZQ nanoparticles was more effective than the ABZ + PZQ suspension in vitro (p < 0.05). In prophylaxy, a significant reduction was observed both in size and in number of the cysts in ChABZ + ChPZQ nanoparticle groups compared with the control group (p < 0.05). In the therapeutic stage, however, this treatment only reduced the cyst numbers. Degeneration of the microcysts treated with the drugs was evident in the ultra-structural imaging. Overall, the nanoparticulate drugs were more effective than their suspension counterparts, but further studies are recommended to evaluate the full potential of these nanoparticles in the treatment of human CE.

Degree of calcification and cyst activity in hepatic cystic echinococcosis in humans

To evaluate the relationship between cyst activity and calcification degree in cystic echinococcosis (CE) in humans, 99 hepatic cysts at successive stages of involution, surgically excised from 72 Sardinian patients, have been analyzed. Cysts were classified into 4 groups according to calcification extent: CALC 0 (no calcification); CALC 1 (scattered punctate calcifications); CALC 2 (large coarse segmental/partial calcifications); CALC 3 (complete or nearly complete circumferential ring of calcification up to thick wall of osseous consistency/calcified content of cyst). In addition the possible correlation with antibody response has been explored analyzing IgG1, IgG4 and IgE produced against somatic PSCAg. Results showed that calcification is not restricted to the inactive WHO cyst types CE4 and CE5, but occurs to a varying extent in all morphotypes of metacestode, from active classic unilocular or multivesicular cysts to the more complicated and highly degenerate stages, where cyst wall appears massively calcified. Prevalence of calcification increases with progression of cyst degenerative process, but is not synonymous with parasite inactivity and can be misleading as signs of calcification may coexist with still metabolically active cysts. On the contrary, detection of entirely firmly solidified content seems a reliable indication of cyst inactivity. IgG4 is the dominant isotype associated particularly with the evolutive phase. Positive rates and OD levels, higher in active vs inactive stages, are stable or increase slightly in weakly and moderately calcified cysts (CALC 1/CALC 2), compared to non-calcified ones (CALC 0), strongly decreasing in highly calcified forms (CALC 3). In conclusion, evaluation of calcification extent may be pertinent for staging CE, and immunological tests, particularly for IgG4, and IgE may help to better define cyst activity.

Human cystic echinococcosis in Turkey: a preliminary study on DNA polymorphisms of hydatid cysts removed from confirmed patients.

Cystic echinococcosis caused by the larval stages of Echinococcus granulosus sensu lato s.l is endemic in Turkey with a high public health impact particularly in rural areas. The aim of this study was to investigate the genetic variation and population structure of E. granulosus s.s using metacestode isolates removed from surgically confirmed patients originating from several regions in Turkey and to investigate the occurrence of autochthonous transmission. Using DNA extracted from a total of 46 human-derived CE isolates, we successfully analysed an 827-bp fragment within the cox1 mitochondrial gene and confirmed the causative agent of human cystic echinococcosis in patients included in this study to be Echinococcus granulosus s.s (G1 and G3 genotypes). The haplotype parsimony network consisted of 28 haplotypes arranged within three main clusters and the neutrality indices were both negative and significant indicating negative selection or population expansion. The assessment carried out in this study using GenBank nucleotide sequence data from Turkey for sheep and cattle hosts demonstrated the importance of autochthonous transmission with sheep, cattle and humans harbouring the same haplotypes. Further studies are required to investigate the biological significance, if any, of E. granulosus s.s haplotypes and the genetic variability of CE from human patients using longer nucleotide sequences and a larger sample set.

Genotype characterization of livestock and human cystic echinococcosis in Mazandaran province, Iran.

Echinococcus granulosus is a helminth from the family Taeniidae, which causes cystic echinococcosis (CE) in humans and diverse livestock around the world. The identification of existing genotypes in different regions is a major step towards the prevention and establishment of control programmes for the disease. This study aimed to detect CE genotypes using polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) of the internal transcribed spacer-1 (ITS1) gene and sequencing of the cytochrome c oxidase subunit 1 (Cox1) gene in isolates from the central part of Mazandaran province, northern Iran. Forty isolates were collected from sheep, 17 from cattle and 6 from human formalin-fixed paraffin-embedded tissues (FFPE). The ITS1 and Cox1 genes were successfully amplified by PCR in 41 and 42 samples, respectively. PCR-RFLP and sequencing showed that all isolates had the G1-G3 genotypes in this study. Out of 31 isolates subjected to sequencing for the Cox1 gene, 80.7% had the G1 genotype. G2 (16.1%) and G3 (3.2%) genotypes were observed in five sheep and one cattle samples, respectively. Five human isolates were also sequenced for the ITS1 gene, which showed that all samples belonged to the G1 genotype. Ten haplotypes were determined among the isolates by alignment analysis of the Cox1 gene. In summary, this study demonstrated that G1 was the dominant genotype circulating between humans and livestock in the studied region. Furthermore, high genotypic diversity among the CE isolates was observed.

Genotyping of human cystic echinococcosis in northeastern Iran

Cystic echinococcosis (CE) is a human public health problem in northeast of Iran and there is limited information regarding the genotypes of Echinococcus granulosus senso lato (s.l.) in human in this region. In the present study, we determined the genotypes of E. granulosus s.l. infecting human in northeastern Iran from Khorasan Razavi province using PCR-RFLP of rDNA ITS1 region. From April 2013 to December 2016, 50 hepatic hydatid cysts were recovered from 50 patients who underwent surgical procedure. Protoscoleces were collected from individual cysts, DNA was extracted, and the rDNA ITS1 gene was amplified by PCR and genotypes confirmed by RFLP. All the cyst materials were identified as Echinococcus granulosus senso stricto (s.s.), indicating this species as the main cause of CE in humans in northeast of Iran.

Role of Serology and Histopathology in Diagnostic of Human Cystic Echinococcosis

Role of Serology and Histopathology in Diagnostic of Human Cystic Echinococcosis

Proteome evaluation of human cystic echinococcosis sera using two dimensional gel electrophoresis.

Detection of protein expression changes in human cystic echinococcosis sera by 2D gel electrophoresis. Diagnosis and successful treatment of cystic echinococcosis (CE) is a major challenge, up to now. Identification of related expressed proteins using proteomics tools and bioinformatics analysis of patients' sera have not been investigated, so far. Sera from eight confirmed CE patients and three healthy controls were collected, tested by 2-DE for total protein separation of serum and analyzed using proteomics and bioinformatics methods. The gels were stained by Coomassie blue followed by scan imaging of the gels. The protein spots in each gel were analyzed using progenesis same spots software. Proteins names were obtained from TagIdent server. A total of 263 protein spots with different expression were detected in both normal and diseased samples. Comparison between diseased and normal gels showed the expression of 45 up-regulated protein spots with fold≥2 in diseased gel of which 10 were new proteins with statistical difference by normal gel (p-value<0.05). On the other hand, the expression of 50 down-regulated protein spots were observed of which 11 proteins have been suppressed. Clustering of all detected sera proteins (263) using correlation analysis, divided the proteins into 2 clusters based on up-regulated and down-regulated expression of proteins. Clustering results were approved by principal component analysis (PCA). Significant protein expression changes in human CE sera which is demonstrable by application of proteomics and bioinformatics analysis makes it an impressing tool for diagnosis of CE patients.