Echinococcosis Hydatid Cyst
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Cystic echinococcosis (CE) is the larval cystic stage (called echinococcal cysts) of a small taeniid-type tapeworm (Echinococcus granulosus) that may cause illness in intermediate hosts, generally herbivorous animals and people who are infected accidentally. Ultrasonographic appearance of echinococcal cysts is seen in the image below.
Three other species are recognized within the genus Echinococcus, and they may also develop in the human host and cause various forms of echinococcosis (hydatidosis). E granulosus is discussed separately from the other 3 species, notably Echinococcus multilocularis, which causes alveolar echinococcosis, because of marked differences in epidemiology, clinical features, diagnosis, and treatment.
In the normal life cycle of Echinococcus species, adult tapeworms (3-6 mm long) inhabit the small intestine of carnivorous definitive hosts, such as dogs, coyotes, or wolves, and echinococcal cyst stages occur in herbivorous intermediate hosts, such as sheep, cattle, and goats. A number of other suitable intermediate hosts, such as camels, pigs, and horses, are involved in the life cycle in many parts of the world.
In the typical dog-sheep cycle, tapeworm eggs are passed in the feces of an infected dog and may subsequently be ingested by grazing sheep; they hatch into embryos in the intestine, penetrate the intestinal lining, and are then picked up and carried by blood throughout the body to major filtering organs (mainly liver and/or lungs). After the developing embryos localize in a specific organ or site, they transform and develop into larval echinococcal cysts in which numerous tiny tapeworm heads (called protoscolices) are produced via asexual reproduction.
These protoscolices are infective to dogs that may ingest viscera containing echinococcal cysts (with protoscolices inside), mainly because of the habit in endemic countries of feeding dogs viscera of home-slaughtered sheep or other livestock. Protoscolices attach to the dog’s intestinal lining and, in approximately 40-50 days, grow and develop into mature adult tapeworms, once again capable of producing infective eggs to be passed to the outside environment with the dog’s feces.
Because humans play the same role of intermediate hosts in the tapeworm life cycle as sheep, humans also become infected by ingesting tapeworm eggs passed from an infected carnivore. This occurs most frequently when individuals handle or contact infected dogs or other infected carnivores or inadvertently ingest food or drink contaminated with fecal material containing tapeworm eggs.
In primary echinococcosis, metacestodes develop from oncospheres after peroral infection with E granulosus eggs. In secondary echinococcosis, larval tissue proliferates after being spread from the primary site of the metacestode. This can occur by spontaneous trauma such as induced rupture or during medical interventions.
In primary echinococcosis, larval cysts may develop in every organ. Most patients (as many as 80%) have single-organ involvement and harbor a solitary cyst. Approximately two thirds of patients experience liver echinococcosis. The second most common organ involved is the lung.
In each anatomic site, cysts are surrounded by the periparasitic host tissue (pericyst), which encompasses the endocyst of larval origin. Inside the laminated layer, or hyaline membrane, the cyst is covered by a multipotential germinal layer, giving rise to the production of brood capsules and protoscolices. The central cavities of cysts of E granulosus are filled with clear fluid, numerous brood capsules, and protoscolices. In addition, daughter cysts of variable size are often detected. The growth rate of cysts is highly variable and may depend on strain differences. Estimates of the average increase of cyst diameter vary (approximately 1-1.5 cm/y).
The clinical features of cystic echinococcosis are highly variable. The spectrum of symptoms depends on the following:
Involved organs
Size of cysts and their sites within the affected organ or organs
Interaction between the expanding cysts and adjacent organ structures, particularly bile ducts and the vascular system of the liver
Complications caused by rupture of cysts
Bacterial infection of cysts and spread of protoscolices and larval material into bile ducts or blood vessels
Immunologic reactions such as asthma, anaphylaxis, or membranous nephropathy secondary to release of antigenic material
United States
Unfortunately, realistic national or international figures do not exist for total numbers of cases of cystic echinococcosis. The problem is that, until recently, the only basis for diagnosis was surgery, and few countries systematically reported cases. When they did report cases, uneven reporting occurred in different regions of countries. The groups most at risk of cystic echinococcosis are usually underserved by medical services.
However, the increasing use of mass screenings with ultrasonography in endemic countries is generating important epidemiological data. As different cyst stages have been classified according to their sonographic appearance, attempts are being made to match the cyst morphology with the natural history of the cyst. This is evident with the World Health Organization (WHO) standardized classification (see Imaging). At a community level, the relative proportions of cyst types can provide epidemiological information on disease transmission and help design effective control programs. [1]
In the United States, transmission of E granulosus in the dog-sheep cycle is known to occur most frequently in several western states, including California, Arizona, New Mexico, and Utah. In Arizona and New Mexico, cystic echinococcosis is known to occur in American Indians belonging to the Zuni, Navajo, and Santo Domingo tribes, whose members live in close proximity to their animals, kill many of their own animals each year, and generally have limited knowledge concerning the life cycle and transmissibility of the parasite. In the United States, Utah has had the highest number of surgical cases of those states involved, with approximately 45 cases from 1944-1994.
International
E granulosus is a cosmopolitan parasite, and endemic regions exist in each continent. Considerable public health problems occur in many areas, including countries of Central America and South America, Western and Southern/Southeastern Europe, the Middle East and North Africa, some sub-Saharan countries, Russia and adjacent countries, and China. Annual incidence rates of diagnosed human cases per 100,000 inhabitants vary widely, from less than 1 case per 100,000 to high levels. For example, rates in the indicated regions are as follows:
Greece – 13 cases per 100,000 persons
Rural regions of Uruguay – 75 cases per 100,000 persons
Rural regions of Argentina – 143 cases per 100,000 persons in Rio Negro province
Parts of Xinjiang province of China – 197 cases per 100,000 persons
Parts of the Turkana district of Kenya – 220 cases per 100,000 persons
Cystic echinococcosis causes not only illness but also productivity losses in human and agricultural animal population, and it can have large societal impacts on endemic areas. Research is being conducted to evaluate the burden of disease, including nonmonetary costs.
Cystic echinococcosis is rarely fatal. Occasionally, deaths occur because of anaphylactic shock or cardiac tamponade in heart echinococcosis. [2]
Rare locations of the cyst (muscle, bone, brain, orbit) can cause dramatic and disabling symptoms (blindness, paralysis). [3, 4, 5, 6, 7, 8, 9, 10]
No racial predilection exists.
In some endemic countries, females are affected more than males because their lifestyle habits and practices bring them into contact with the parasite.
Individuals of all ages are affected. In some endemic countries, children have higher infection rates because they are most likely to play with dogs.
Prognosis is generally good and depends on the cyst location. For instance, neither surgery nor medical therapy is generally effective for bone, especially spinal, echinococcosis. Surgery to treat cardiac cysts can be risky, and there is very little experience with the use of albendazole in this site.
Sometimes after removal of a cyst, one or more new cysts may develop at a different site. A hypothesis for this is that the growth of some cysts may be inhibited by the presence of the cyst that has been removed.
Larrieu E, Del Carpio M, Mercapide CH, et al. Programme for ultrasound diagnoses and treatment with albendazole of cystic echinococcosis in asymptomatic carriers: 10 years of follow-up of cases. Acta Trop. 2011 Jan. 117(1):1-5. [Medline].
Bouraoui H, Trimeche B, Mahdhaoui A, et al. Echinococcosis of the heart: clinical and echocardiographic features in 12 patients. Acta Cardiol. 2005 Feb. 60(1):39-41. [Medline].
Biyik I, Acar S, Ergene O. Left atrial mobile hydatid cyst mimicking left atrial myxoma and mitral stenosis and causing heart failure and arrhythmia. Int J Cardiovasc Imaging. 2007 Apr. 23(2):193-5. [Medline].
Tsaroucha AK, Polychronidis AC, Laftsidis PA, Pitiakoudis MS, Fotakis SN, Simopoulos CE. Primary adrenal hydatid cyst: a case report. Acta Chir Iugosl. 2007. 54(2):115-7. [Medline].
Tutar N, Cakir B, Geyik E, Tarhan NC, Niron EA. Hydatid cysts in breast: mammography and ultrasound findings. Br J Radiol. 2006 Oct. 79(946):e114-6. [Medline].
Türkmen C, Unal SN, Berberoglu K, Genchellac H, Unal Z, Cantez S. Acute pulmonary embolism due to hydatid cyst. Clin Nucl Med. 2004 Nov. 29(11):760-1. [Medline].
Yuksel BC, Ozel H, Akin T, Avsar FM, Hengirmen S. Primary hydatid cyst of the breast with elevated CA 19-9 level. Am J Trop Med Hyg. 2005 Aug. 73(2):368-70. [Medline].
Pamir MN, Ozduman K, Elmaci I. Spinal hydatid disease. Spinal Cord. 2002 Apr. 40(4):153-60. [Medline].
Bulman W, Coyle CM, Brentjens TE, et al. Severe pulmonary hypertension due to chronic echinococcal pulmonary emboli treated with targeted pulmonary vascular therapy and hepatic resection. Chest. 2007 Oct. 132(4):1356-8. [Medline].
Bron JL, van Kemenade FJ, Verhoof OJ, Wuisman PI. Long term follow-up of a patient with disseminated spinal hydatidosis. Acta Orthop Belg. 2007 Oct. 73(5):678-82. [Medline].
Nagpal V, Kohli K, Chowdhary A, Kumar A, Andley M, Ravi B. Breast lump as a presentation of a hydatid disease. Trop Doct. 2006 Jan. 36(1):57-8. [Medline].
Santivanez S, Garcia HH. Pulmonary cystic echinococcosis. Curr Opin Pulm Med. 2010 May. 16(3):257-61. [Medline].
[Guideline] Brunetti E, Kern P, Vuitton DA,. Expert consensus for the diagnosis and treatment of cystic and alveolar echinococcosis in humans. Acta Trop. 2010 Apr. 114(1):1-16. [Medline].
Neumayr A, Troia G, de Bernardis C, et al. Justified concern or exaggerated fear: the risk of anaphylaxis in percutaneous treatment of cystic echinococcosis-a systematic literature review. PLoS Negl Trop Dis. 2011 Jun. 5(6):e1154. [Medline]. [Full Text].
Macpherson CN, Bartholomot B, Frider B. Application of ultrasound in diagnosis, treatment, epidemiology, public health and control of Echinococcus granulosus and E. multilocularis. Parasitology. 2003. 127 Suppl:S21-35. [Medline].
Gharbi HA, Hassine W, Brauner MW, Dupuch K. Ultrasound examination of the hydatic liver. Radiology. 1981 May. 139(2):459-63. [Medline].
WHO Informal Working Group. International classification of ultrasound images in cystic echinococcosis for application in clinical and field epidemiological settings. Acta Trop. 2003 Feb. 85(2):253-61. [Medline].
Junghanss T, da Silva AM, Horton J, Chiodini PL, Brunetti E. Clinical management of cystic echinococcosis: state of the art, problems, and perspectives. Am J Trop Med Hyg. 2008 Sep. 79(3):301-11. [Medline].
Brunetti E, Junghanss T. Update on cystic hydatid disease. Curr Opin Infect Dis. 2009 Oct. 22(5):497-502. [Medline].
Hosch W, Junghanss T, Stojkovic M, et al. Metabolic viability assessment of cystic echinococcosis using high-field 1H MRS of cyst contents. NMR Biomed. 2008 Aug. 21(7):734-54. [Medline].
Hosch W, Stojkovic M, Janisch T, Kauffmann GW, Junghanss T. The role of calcification for staging cystic echinococcosis (CE). Eur Radiol. 2007 Oct. 17(10):2538-45. [Medline].
Dursun M, Terzibasioglu E, Yilmaz R, et al. Cardiac hydatid disease: CT and MRI findings. AJR Am J Roentgenol. 2008 Jan. 190(1):226-32. [Medline].
Hosch W, Stojkovic M, Janisch T, et al. MR imaging for diagnosing cysto-biliary fistulas in cystic echinococcosis. Eur J Radiol. 2008 May. 66(2):262-7. [Medline].
Stojkovic M, Rosenberger K, Kauczor HU, Junghanss T, Hosch W. Diagnosing and staging of cystic echinococcosis: how do CT and MRI perform in comparison to ultrasound?. PLoS Negl Trop Dis. 2012. 6(10):e1880. [Medline]. [Full Text].
Stojkovic M, Rosenberger KD, Steudle F, Junghanss T. Watch and Wait Management of Inactive Cystic Echinococcosis – Does the Path to Inactivity Matter – Analysis of a Prospective Patient Cohort. PLoS Negl Trop Dis. 2016 Feb 24. [Medline]. [Full Text].
Piccoli L, Tamarozzi F, Cattaneo F, Mariconti M, Filice C, Bruno A, et al. Long-term sonographic and serological follow-up of inactive echinococcal cysts of the liver: hints for a “watch-and-wait” approach. PLoS Negl Trop Dis. 2014 Aug. 8 (8):e3057. [Medline]. [Full Text].
Lissandrin R, Tamarozzi F, Mariconti M, Manciulli T, Brunetti E, Vola A. Watch and Wait Approach for Inactive Echinococcal Cyst of the Liver: An Update. Am J Trop Med Hyg. 2018 Aug. 99 (2):375-379. [Medline].
Saidi F, Habibzadeh F. The Non-operative Management of Asymptomatic Liver Hydatids: Ending Echinococcophobia. J Gastrointest Surg. 2018 Mar. 22 (3):486-495. [Medline].
Larrieu E, Uchiumi L, Salvitti JC, Sobrino M, Panomarenko O, Tissot H, et al. Epidemiology, diagnosis, treatment and follow-up of cystic echinococcosis in asymptomatic carriers. Trans R Soc Trop Med Hyg. 2018 Nov 9. [Medline].
Stojkovic M, Zwahlen M, Teggi A, et al. Treatment response of cystic echinococcosis to benzimidazoles: a systematic review. PLoS Negl Trop Dis. 2009 Sep 29. 3(9):e524. [Medline]. [Full Text].
Liu Y, Wang X, Wu J. Continuous long-term albendazole therapy in intraabdominal cystic echinococcosis. Chin Med J (Engl). 2000 Sep. 113(9):827-32. [Medline].
Bygott JM, Chiodini PL. Praziquantel: neglected drug? Ineffective treatment? Or therapeutic choice in cystic hydatid disease?. Acta Trop. 2009 Aug. 111(2):95-101. [Medline].
Ulger S, Barut H, Tunc M, Aydin E, Aydinkarahaliloglu E, Gokcek A. Radiation therapy for resistant sternal hydatid disease. Strahlenther Onkol. 2013 Jun. 189(6):508-509. [Medline].
Neumayr A. Radiotherapy of osseous echinococcosis: where is the evidence?. Int J Infect Dis. 2015 Jan 10. 33:75-78. [Medline].
El Malki HO, El Mejdoubi Y, Souadka A, et al. Predictive factors of deep abdominal complications after operation for hydatid cyst of the liver: 15 years of experience with 672 patients. J Am Coll Surg. 2008 Apr. 206(4):629-37. [Medline].
Bagheri R, Haghi SZ, Amini M, Fattahi AS, Noorshafiee S. Pulmonary hydatid cyst: analysis of 1024 cases. Gen Thorac Cardiovasc Surg. 2011 Feb. 59(2):105-9. [Medline].
Neumayr A, Tamarozzi F, Goblirsch S, Blum J, Brunetti E. Spinal cystic echinococcosis–a systematic analysis and review of the literature: part 2. Treatment, follow-up and outcome. PLoS Negl Trop Dis. 2013. 7(9):e2458. [Medline].
Li Y, Zheng H, Cao X, Liu Z, Chen L. Demographic and clinical characteristics of patients with anaphylactic shock after surgery for cystic echinococcosis. Am J Trop Med Hyg. 2011 Sep. 85(3):452-5. [Medline]. [Full Text].
Filice C, Pirola F, Brunetti E, Dughetti S, Strosselli M, Foglieni CS. A new therapeutic approach for hydatid liver cysts. Aspiration and alcohol injection under sonographic guidance. Gastroenterology. 1990 May. 98(5 Pt 1):1366-8. [Medline].
Paksoy Y, Odev K, Sahin M, Arslan A, Koç O. Percutaneous treatment of liver hydatid cysts: comparison of direct injection of albendazole and hypertonic saline solution. AJR Am J Roentgenol. 2005 Sep. 185(3):727-34. [Medline].
Paksoy Y, Odev K, Sahin M, Dik B, Ergül R, Arslan A. Percutaneous sonographically guided treatment of hydatid cysts in sheep: direct injection of mebendazole and albendazole. J Ultrasound Med. 2003 Aug. 22(8):797-803. [Medline].
Smego RA Jr, Bhatti S, Khaliq AA, Beg MA. Percutaneous aspiration-injection-reaspiration drainage plus albendazole or mebendazole for hepatic cystic echinococcosis: a meta-analysis. Clin Infect Dis. 2003 Oct 15. 37(8):1073-83. [Medline].
Kabaalioglu A, Ceken K, Alimoglu E, Apaydin A. Percutaneous imaging-guided treatment of hydatid liver cysts: do long-term results make it a first choice?. Eur J Radiol. 2006 Jul. 59(1):65-73. [Medline].
Khuroo MS, Wani NA, Javid G, et al. Percutaneous drainage compared with surgery for hepatic hydatid cysts. N Engl J Med. 1997 Sep 25. 337(13):881-7. [Medline].
Men S, Yucesoy C, Edguer TR, Hekimoglu B. Percutaneous treatment of giant abdominal hydatid cysts: long-term results. Surg Endosc. 2006 Oct. 20(10):1600-6. [Medline].
Schipper HG, Laméris JS, van Delden OM, Rauws EA, Kager PA. Percutaneous evacuation (PEVAC) of multivesicular echinococcal cysts with or without cystobiliary fistulas which contain non-drainable material: first results of a modified PAIR method. Gut. 2002 May. 50(5):718-23. [Medline].
Ustunsoz B, Ugurel MS, Uzar AI, Duru NK. Percutaneous treatment of hepatic hydatid cyst in pregnancy: long-term results. Arch Gynecol Obstet. 2008 Jun. 277(6):547-50. [Medline].
Golemanov B, Grigorov N, Mitova R, et al. Efficacy and safety of PAIR for cystic echinococcosis: experience on a large series of patients from Bulgaria. Am J Trop Med Hyg. 2011 Jan. 84(1):48-51. [Medline]. [Full Text].
Mohan S, Garg SK, Kathuria M, Baijal SS. Mechanical suction through wide bore catheters for nonsurgical management of Gharbi type III hepatic hydatid cysts. Trop Gastroenterol. 2011 Jul-Sep. 32(3):189-95. [Medline].
Yasawy MI, Mohammed AE, Bassam S, Karawi MA, Shariq S. Percutaneous aspiration and drainage with adjuvant medical therapy for treatment of hepatic hydatid cysts. World J Gastroenterol. 2011 Feb 7. 17(5):646-50. [Medline].
Firpo G, Vola A, Lissandrin R, Tamarozzi F, Brunetti E. Preliminary Evaluation of Percutaneous Treatment of Echinococcal Cysts without Injection of Scolicidal Agent. Am J Trop Med Hyg. 2017 Dec. 97 (6):1818-1826. [Medline].
Hosseini SV, Ghanbarzadeh K, Barzin J, Sadjjadi SM, Tanideh N, Mehrabani D. In vitro protoscolicidal effects of hypertonic glucose on protoscolices of hydatid cyst. Korean J Parasitol. 2006 Sep. 44(3):239-42. [Medline].
Brunetti E, Filice C, Meroni V. Comment on percutaneous treatment of liver hydatid cysts. AJR Am J Roentgenol. 2006 Apr. 186(4):1198-9; author reply 1199-200. [Medline].
Brunetti E, Gulizia R, Garlaschelli AL, Filice C. Cystic echinococcosis of the liver associated with repeated international travels to endemic areas. J Travel Med. 2005 Jul-Aug. 12(4):225-8. [Medline].
Budke CM. Global socioeconomic impact of cystic echinococcosis. Emerg Infect Dis. 2006 Feb. 12(2):296-303. [Medline].
Craig PS, McManus DP, Lightowlers MW, Chabalgoity JA, Garcia HH, Gavidia CM. Prevention and control of cystic echinococcosis. Lancet Infect Dis. 2007 Jun. 7(6):385-94. [Medline].
Cunha BA. Antibiotic Essentials. Royal Oak, Mich: Physicians Press; 2005.
Eckert J, Deplazes P. Biological, epidemiological, and clinical aspects of echinococcosis, a zoonosis of increasing concern. Clin Microbiol Rev. 2004 Jan. 17(1):107-35. [Medline].
Franchi C, Di Vico B, Teggi A. Long-term evaluation of patients with hydatidosis treated with benzimidazole carbamates. Clin Infect Dis. 1999 Aug. 29(2):304-9. [Medline].
Kilic M, Yoldas O, Koc M, et al. Can biliary-cyst communication be predicted before surgery for hepatic hydatid disease: does size matter?. Am J Surg. 2008 Nov. 196(5):732-5. [Medline].
Macpherson CN, Milner R. Performance characteristics and quality control of community based ultrasound surveys for cystic and alveolar echinococcosis. Acta Trop. 2003 Feb. 85(2):203-9. [Medline].
Magistrelli P, Masetti R, Coppola R, Messia A, Nuzzo G, Picciocchi A. Surgical treatment of hydatid disease of the liver. A 20-year experience. Arch Surg. 1991 Apr. 126(4):518-22; discussion 523. [Medline].
McManus DP, Zhang W, Li J, Bartley PB. Echinococcosis. Lancet. 2003 Oct 18. 362(9392):1295-304. [Medline].
Nasseri-Moghaddam S, Abrishami A, Taefi A, Malekzadeh R. Percutaneous needle aspiration, injection, and re-aspiration with or without benzimidazole coverage for uncomplicated hepatic hydatid cysts. Cochrane Database Syst Rev. 2011. (1):CD003623. [Medline].
Rogan MT, Hai WY, Richardson R, Zeyhle E, Craig PS. Hydatid cysts: does every picture tell a story?. Trends Parasitol. 2006 Sep. 22(9):431-8. [Medline].
Sayek I, Tirnaksiz MB, Dogan R. Cystic hydatid disease: current trends in diagnosis and management. Surg Today. 2004. 34(12):987-96. [Medline].
Men S, Yücesoy C, Edgüer TR, Hekimoğlu B. Percutaneous treatment of giant abdominal hydatid cysts: long-term results. Surg Endosc. 2006 Oct. 20 (10):1600-6. [Medline].
Enrico Brunetti, MD Associate Professor, Department of Infectious Diseases, Division of Infectious and Tropical Diseases, University of Pavia, Italy; Staff Physician, Department of Infectious Diseases, IRCCS S Matteo Hospital Foundation, Pavia, Italy
Enrico Brunetti, MD is a member of the following medical societies: American Society of Tropical Medicine and Hygiene, European Society of Clinical Microbiology and Infectious Diseases
Disclosure: Nothing to disclose.
Carlo Filice, MD Chief of Ultrasound Unit, Adjunct Professor, Department of Internal Medicine, Division of Infectious and Tropical Diseases, IRCCS S Matteo Hospital, University of Pavia, Italy
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
John W King, MD Professor of Medicine, Chief, Section of Infectious Diseases, Director, Viral Therapeutics Clinics for Hepatitis, Louisiana State University Health Sciences Center; Consultant in Infectious Diseases, Overton Brooks Veterans Affairs Medical Center
John W King, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Federation for Medical Research, Association of Subspecialty Professors, American Society for Microbiology, Infectious Diseases Society of America, Sigma Xi
Disclosure: Nothing to disclose.
Burke A Cunha, MD Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, Infectious Diseases Society of America
Disclosure: Nothing to disclose.
Mark R Wallace, MD, FACP, FIDSA Clinical Professor of Medicine, Florida State University College of Medicine; Clinical Professor of Medicine, University of Central Florida College of Medicine
Mark R Wallace, MD, FACP, FIDSA is a member of the following medical societies: American College of Physicians, American Medical Association, American Society for Microbiology, Infectious Diseases Society of America, International AIDS Society, Florida Infectious Diseases Society
Disclosure: Nothing to disclose.
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