peer reviewed ; Until now, Belgium has been considered as a low-risk country for alveolar echinococcosis. However it was recently demonstrated by necropsy series that, in some parts of southern Belgium (Wallonia), up to 51% of the red foxes (Vulpes vulpes) may be infected by E. multilocaris. The authors, working in a university hospital in southern Belgium, described in 2002 the first autoctuthonous Belgian case of hepatic alveolar echinococcosis. More importantly, in 2004, they diagnosed three other patients with alveolar echinococcosis. One underwent surgical resection, but two others had bilateral pulmonary involvement at time of definite diagnosis. Palliative albendazole therapy was initiated. These patients had been diagnosed with hepatic mass from unknown origin for several months. The previous experience with the first case allowed the authors to consider and to confirm alveolar echinococcosis diagnosis, made by pathology and/or serological tests and imaging. These four patients with alveolar echinococcosis were living either in the Liege or the Luxembourg province. Considering the high prevalence of E. multilocaris infection of red foxes and the recent increase of the fox population due to rabies vaccination in southern Belgium, and also the presence of E. multilocaris infection of red foxes in northern Belgium, it is likely that not only Wallonia, but also maybe the whole Belgium, may face endemic alveolar echinococcosis in the next years.