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| CASE REPORT |
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| Year : 2021 | Volume
: 26
| Issue : 1 | Page : 71-76 |
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Uncommon locations of hydatid disease: A series of seven cases
Musaib Ahmad Dar, Obaid Ashraf, Suhail Rafiq, Inayat Elahi, Showkat Ahmad Banday
Department of Radiodiagnosis, Government Medical College, Srinagar, Jammu and Kashmir, India
| Date of Submission | 22-Apr-2020 |
| Date of Acceptance | 21-Apr-2021 |
| Date of Web Publication | 29-Jun-2021 |
Correspondence Address:
Dr. Suhail Rafiq
Resident Hostel, Government Medical College, Srinagar - 190 010, Jammu and Kashmir
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jmgims.jmgims_43_20
Echinococcosis is an infection caused in humans by larval stage of Echinococcus, especially Echinococcus granulosus and is endemic in the Middle East and Central Asia. Humans who act as intermediate host get infected incidentally by ingestion of eggs from the fecal matter. The eggs hatch inside the intestine, penetrate the walls enter portal circulation and lymphatic system eventually reaching the liver and lungs commonly. They can lodge in almost any part of body including brain, heart, and bones. There are two types of Echinococcus infections, Echinococcus granulosis and Echinococcus multilocularis. In this article, we are going to report atypical locations of hydatid disease with reference to review of literature. Keywords: Echinococcosis, hydatid disease, metastasis
How to cite this article:
Dar MA, Ashraf O, Rafiq S, Elahi I, Banday SA. Uncommon locations of hydatid disease: A series of seven cases. J Mahatma Gandhi Inst Med Sci 2021;26:71-6 |
How to cite this URL:
Dar MA, Ashraf O, Rafiq S, Elahi I, Banday SA. Uncommon locations of hydatid disease: A series of seven cases. J Mahatma Gandhi Inst Med Sci [serial online] 2021 [cited 2022 May 16];26:71-6. Available from: https://www.jmgims.co.in/text.asp?2021/26/1/71/319848 |
| Introduction | |  |
Echinococcosis is an infection caused in humans by larval stage of Echinococcus, especially Echinococcus granulosus, and is endemic in the Middle East and Central Asia. Hydatid disease (HD) continues to be a significant health problem in underdeveloped areas where animal husbandry is common, but no veterinary control exists (e g, parts of South America, the Mediterranean region, the Middle East, Africa, and Australia). In Europe, HD is uncommon and is seen only in immigrants or persons with a history of travel to endemic areas.[1],[2],[3],[4],[5],[6],[7],[8] Humans who act as intermediate host get infected incidentally by ingestion of eggs from the fecal matter. The eggs hatch inside the intestine and penetrate the walls, enter portal circulation and lymphatic system, eventually reaching the liver and lungs commonly. They can lodge in almost any part of body including brain, heart, and bones. There are two types of Echinococcus infections: Echinococcus granulosis is the more common type, whereas Echinococcus multilocularis is less common but more invasive, mimicking a malignancy.[9] Radiologically HD can have different morphologies. Conventionally, hydatid cyst is classified into four types on the basis of their appearance.[1]
- Type I: Simple cyst with no internal architecture
- Type II: Cyst with daughter cyst (s) and matrix daughter cysts are seen inside the mother cyst
- Type III: Calcified cyst Type III lesions are dead cysts with total calcification
- Type IV: Complicated hydatid cyst complications include rupture and superinfection and may be seen in both Type I and Type II HCs.
The liver and lungs are the two most frequently affected organs in humans because the swallowed eggs hatch in the intestines and are transported by the portal system to the liver.[10] In this article, we report seven cases of uncommon location of HD with a spectrum of different imaging appearances.
| Cases | | |
Case 1
A 19-year old girl was admitted in the hospital with chief complaints of abnormal body movements (one episode) and vomiting. Neurological examination was unremarkable. Routine laboratory examination was unremarkable.
Computed tomography (CT) of the brain revealed a round fluid attenuation area in the right frontotemporal region with no evidence of calcification or hemorrhage seen in the lesion. Magnetic resonance (MR) of the brain was advised for further evaluation.
MR of the brain study revealed intra-axial lesion T1 hypointense, T2 weighted image (T2WI) hyperintense area with suppression on fluid-attenuated inversion recovery in the right frontoparietal region with surrounding sulcal effacement and midline shift. There was no evidence of the surrounding edema. There was no evidence of hemorrhage [Figure 1] and [Figure 2]. The hypointense rim on T2WI is characteristic of hydatid cyst of the brain. Absence of edema and hemorrhage differentiates hydatid brain from cystic tumours of the brain. Calcification is rare in cerebral hydatid cyst. | Figure 1: Axial T2 weighted magnetic resonance brain image revealing intra-axial lesion hyperintense area in the right frontoparietal region with surrounding sulcal effacement and midline shift with no evidence of surrounding edema or hemorrhage. T2 hypointense rim is also seen (characteristic)
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 | Figure 2: Axial fluid-attenuated inversion recovery magnetic resonance brain image showing suppression of internal T2 hyperintense contents in [Figure 1]
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Case 2
A 40-year-old male was admitted in the hospital with chief complaints of recurrent headaches with one episode of vomiting. Neurological examination was unremarkable. Routine laboratory examination was unremarkable.
CT of the brain revealed multiple fluid attenuation areas in the left parietotemporal region with no evidence of calcification or hemorrhage seen in the lesion. MR of the brain was advised for further evaluation which revealed multiple cystic lesions which had cerebrospinal fluid attenuation with mild surrounding edema. This one represented unusual imaging characteristics such as surrounding edema and multicystic nature. Multicystic variant is rare in cerebral HD [Figure 3] and [Figure 4]. | Figure 3: Axial T2-weighted magnetic resonance of the brain image showing multiple cystic lesions which have cerebrospinal fluid attenuation with mild surrounding edema
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 | Figure 4: Coronal T1-weighted brain images showing multicystic cerebrospinal fluid attenuation lesion with surrounding edema
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Case 3
A 50-year-old female presented with chief complaints of palpitation, breathlessness, and chest pain. On examination, respiratory rate was 26brpm and heart rate was 80 bpm. Electrocardiogram was normal. On auscultation lungs were normal, no cardiac murmur, JVP was not raised. There was no gallop rhythm. Laboratory investigations were normal.
X-ray of the chest was done which revealed increased density in the cardiac shadow. Right and left paravertebral lines were obscured [Figure 5]. | Figure 5: X-ray of the posteroanterior showing increased density in the cardiac shadow with obscuration of right and left paravertebral lines
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Pulmonary angiogram was advised to rule out pulmonary embolism, which revealed fluid-attenuated cystic lesion in relation to left atrium with multiple septa within- consistent with cardiac hydatid [Figure 6] and [Figure 7]. | Figure 6: Contrast-enhanced axial computed tomography image showing fluid-attenuated cystic lesion in relation to left atrium with multiple septa within--consistent with cardiac hydatid
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 | Figure 7: Contrast-enhanced coronal computed tomography image showing fluid-attenuated cystic lesion in relation to left atrium with multiple septa within--consistent with cardiac hydatid
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An ultrasound was done retrospectively for academic purposes which revealed a complex fluid cyst with septation (laminated membrane) noted in atrium [Figure 8]. | Figure 8: Ultrasound image showing complex fluid cyst with septations (laminated membrane) noted in related to the left atrium
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Case 4
A 30-year old male presented with pain in the epigastrium and left flank. Examination was unremarkable. For the above symptoms, an ultrasound was performed which revealed a complex cyst noted in the left kidney.
A contrast-enhanced CT of the abdomen was performed which showed a fluid attenuation well-defined multiseptated cystic lesion in the left kidney with fluid attenuation showing calcification in the wall and within the cyst. There was no evidence of hemorrhage. There was no evidence of any enhancement on postcontrast study consistent with hydatid cyst of the kidney [Figure 9] and [Figure 10]. | Figure 9: Axial noncontrast computed tomography image showing well-defined fluid attenuation multiseptated cystic lesion in the left kidney with calcification in the wall and within the cyst
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 | Figure 10: Axial postcontrast computed tomography image showing no definite enhancement of the lesion in [Figure 9] consistent with hydatid cyst of kidney
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Case 5
A 45-year-old male presented with pain in the right flank. Examination was unremarkable. Ultrasound was performed which revealed calcified mass along the upper pole of the right kidney. Contrast CT was advised which revealed ill-defined non-enhancing peripherally calcified lesion along upper pole of right kidney consistent with renal HD [Figure 11] and [Figure 12]. | Figure 11: Coronal noncontrast computed tomography image showing calcified lesion along the upper pole of the right kidney
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 | Figure 12: Coronal postcontrast computed tomography image showing no definite enhancement of the lesion in [Figure 11] consistent with hydatid cyst of kidney
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Case 6
A 50-year-old male patient with long-standing pain in the left hypochondrium came for routine ultrasonography which revealed a large cystic lesion in the spleen and liver with multiple septations within. Contrast CT was done which reveal large fluid attenuation nonenhancing lesion with subtle enhancement of internal septations. The findings were consistent with liver and splenic HD [Figure 13] and [Figure 14]. | Figure 13: Postcontrast coronal computed tomography revealing large fluid attenuation non enhancing lesion with a subtle enhancement of internal septation
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 | Figure 14: Postcontrast coronal computed tomography revealing large fluid attenuation nonenhancing lesion with subtle enhancement of internal septations. Liver hydatid can be seen as well
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Case 7
A 56-year-old patient with known liver HD presented in the emergency department with features of breathlessness. Emergent CT pulmonary angiogram was ordered which revealed multiple nonenhancing septate lesions in the right pulmonary artery with imaging characteristics same as that of liver HD. The diagnosis of pulmonary artery HD was made [Figure 15] and [Figure 16]. | Figure 15: Axial contrast-enhanced chest computed tomography revealing multiple nonenhancing septate lesion in right pulmonary artery with imaging characteristics same as that of liver hydatid disease
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 | Figure 16: Contrast computed tomography section just above the section in [Figure 15] showing extension of lesion into the branches of the pulmonary artery as well
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| Discussion | | |
HD primarily affects the liver and typically demonstrates characteristic imaging findings. Furthermore, secondary involvement due to hematogenous dissemination may be seen in almost any anatomic location (e.g. lung, kidney, spleen, bone, brain). Ultrasonography (US) is particularly useful for the detection of cystic membranes, septa, and hydatid sand. CT best demonstrates cyst wall calcification and cyst infection. Chest radiography, US, CT, and MR imaging are all useful in depicting transdiaphragmatic migration of HD.
There is much variability in imaging characteristics of HD as per organ involvement, like calcification and multicystic nature is common in hepatic hydatid. However, in case of cerebral involvement, both calcifications and multivesicularity are uncommon. Arachnoid cysts, porencephalic cysts, and epidermoid tumors should be taken into consideration in the differential diagnosis of cerebral hydatid. However, porencephalic and arachnoid cyst are not completely surrounded by brain parenchyma.[9] Epidermoid cyst shows restricted diffusion which differentiates it from cerebral hydatid cyst.
Cardiac involvement in HD is very rare (0.02%–2% of cases) and may be due to hematogenous spread or rupture of a lung HC.[11],[12] The most commonly affected cardiac chamber is left ventricle.[13] CT and MR imaging can show the cystic nature of the mass and its relationship to the cardiac chambers. The cyst may be unilocular or multivesicular in appearance [Figure 5],[Figure 6],[Figure 7].
Renal involvement of the kidney is rare (3% of cases).[9] Any type of HC can be seen in renal HD. Eighteen percent of renal HCs can rupture into the collecting system, leading to acute colic and hydatiduria. Peripheral calcification can be seen in the wall of the HC [Figure 9] and [Figure 10]. A unilocular HC can mimic necrotic renal cell carcinoma, and HCs can be misdiagnosed as a renal abscess. The differential diagnosis can be made only with percutaneous puncture in most cases.[9]
The reported prevalence of splenic involvement in HD varies from 0.9% to8%.[14],[15] The most frequent clinical signs and symptoms are abdominal pain, splenomegaly, and fever. Splenic hydatid cysts are usually solitary, and their imaging characteristics are similar to those of hepatic hydatid cysts. CT may linear wall without calcification as well as daughter vesicles within the cyst [Figure 13] and [Figure 14].
The pulmonary arteries are an exceptionally rare location for hydatid cysts involvement. Hydatid cysts located in the pulmonary arteries are frequently the consequence of embolisms from primary cardiac locations.[16] There are only few case reports depicting intrapulmonary artery hydatid cyst. In our case, the patient was known liver HD with sudden-onset breathlessness and with nonenhancing multiseptate lesion within the right pulmonary artery [Figure 15] and [Figure 16].
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16]
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