Uncommon Clinical Presentation in a Case of Hydatid Cyst of Liver
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CASE REPORT * Asstt. Prof. of Medicine ** Asstt. Prof. of Surgery Dr. S.N. Medical College, Jodhpur. *** Consultant Radiologist Amit X-Ray and Labs., Jodhpur. Uncommon Clinical Presentation in a Case of Hydatid Cyst of Liver Mahendra Singh*, SS Rathore**, Ajit Singh*** Echinococcosis (hydatid cyst disease) is caused by the larval stage of Echinococcus granulosus. The liver and the lungs are the common sites of involvement; most of the cases being discovered incidentally on routine sonographic or X-ray examination. It takes several years (5-20 years) for these cysts to enlarge sufficiently to produce pressure symptoms. Patients with hydatid cyst of liver may present with abdominal pain, and/or palpable mass in upper abdomen. The compression over the bile duct can result in obstructive jaundice and cholangitis. Case history A 17 year old girl presented with high grade intermittent fever with chills and rigor of 7 days duration for which she received anti-malarial drugs and anti-pyretics but without any relief. Three days later she complained of severe pain in the upper abdomen associated with vomitings (2-4/day). One day before hospitalisation she became drowsy. General physical examination at the time of hospital admission revealed high grade temperature (104° F), moderate dehydration with toxic appearance. Vital signs : Pulse 140/minute, BP 80/60 mmHg, respiratory rate 38/minute. Examination of respiratory system revealed scattered crepitations and rhonchi and cardiovascular system examination was normal except tachycardia. The patient was semi- conscious and delirious. There were no signs of meningeal irritation or any focal neurological deficit. Laboratory investigations The laboratory investigations were as follows : TLC 22,300/cubic mm, DLC (neutrophils 80%, lymphocytes 8%, eosinophils 13%), Hb 11.7 gm%, ESR 133 mm/Ist hour; F. blood sugar 60 mg/dl, blood urea 24 mg/dl; liver function abnormalities – total serum bilirubin 5.63 mg/ dl, conjugated bilirubin 4.74 mg/dl, SGOT 268 U/L, serum alkaline phosphatase 600 IU/L, ECG–sinus tachycardia. Four samples of blood (10 ml each) from different vein puncture sites, collected in first 24 hours, were sent for bacteriological culture and sensitivity to various antibiotics. The blood culture report yielded Klebsiella and E. coli organisms sensitive to ceftriaxone, amikacin, and ofloxacin. Urine examination, chest X-ray, and other relevant investigations were normal. Sonography of abdomen revealed enlarged liver showing a well defined cystic mass lesion with small well defined cystic lesion and central solid component of about 69 X 55 X 67 mm size with well defined capsule seen in anteroposterior part of right hepatic lobe. Rest of the parenchymal echotexture was normal (fig. 1). Intra-hepatic biliary radicles were prominent. The gall bladder was distended (fig. 2) with smooth walls and normal thickness and lumen was anechoic. The common bile duct was normal in calibre. CT abdomen revealed hepatomegaly with large rounded well circumscribed multiloculated cyst with peripheral calcification present in right lobe of liver (superior segment). The size of mass lesion being 6.3 X 5.5 cm with multiple enlarged lymph nodes present at porta hepatis region (inflammatory).
Transcript of Uncommon Clinical Presentation in a Case of Hydatid Cyst of Liver
C A S E R E P O R T
* Asstt. Prof. of Medicine** Asstt. Prof. of SurgeryDr. S.N. Medical College, Jodhpur.*** Consultant RadiologistAmit X-Ray and Labs., Jodhpur.
Uncommon Clinical Presentation in a Case ofHydatid Cyst of Liver
Mahendra Singh*, SS Rathore**, Ajit Singh***
Echinococcosis (hydatid cyst disease) is caused bythe larval stage of Echinococcus granulosus. Theliver and the lungs are the common sites ofinvolvement; most of the cases being discoveredincidentally on routine sonographic or X-rayexamination. It takes several years (5-20 years)for these cysts to enlarge sufficiently to producepressure symptoms. Patients with hydatid cyst ofliver may present with abdominal pain, and/orpalpable mass in upper abdomen. Thecompression over the bile duct can result inobstructive jaundice and cholangitis.
Case historyA 17 year old girl presented with high gradeintermittent fever with chills and rigor of 7 daysduration for which she received anti-malarial drugsand anti-pyretics but without any relief. Three dayslater she complained of severe pain in the upperabdomen associated with vomitings (2-4/day).One day before hospitalisation she becamedrowsy.
General physical examination at the time ofhospital admission revealed high gradetemperature (104° F), moderate dehydration withtoxic appearance. Vital signs : Pulse 140/minute,BP 80/60 mmHg, respiratory rate 38/minute.Examination of respiratory system revealedscattered crepitations and rhonchi andcardiovascular system examination was normalexcept tachycardia. The patient was semi-conscious and delirious. There were no signs ofmeningeal irritation or any focal neurologicaldeficit.
Laboratory investigationsThe laboratory investigations were as follows :TLC 22,300/cubic mm, DLC (neutrophils 80%,lymphocytes 8%, eosinophils 13%), Hb 11.7gm%, ESR 133 mm/Ist hour; F. blood sugar 60mg/dl, blood urea 24 mg/dl; liver functionabnormalities – total serum bilirubin 5.63 mg/dl, conjugated bilirubin 4.74 mg/dl, SGOT 268U/L, serum alkaline phosphatase 600 IU/L,ECG–sinus tachycardia.
Four samples of blood (10 ml each) fromdifferent vein puncture sites, collected in first24 hours, were sent for bacteriological cultureand sensitivity to various antibiotics. Theblood culture report yielded Klebsiella andE. coli organisms sensitive to ceftriaxone,amikacin, and ofloxacin. Urine examination,chest X-ray, and other relevant investigationswere normal.
Sonography of abdomen revealed enlargedliver showing a well defined cystic mass lesionwith small well defined cystic lesion and centralsolid component of about 69 X 55 X 67 mmsize with wel l def ined capsule seen inanteroposterior part of right hepatic lobe. Restof the parenchymal echotexture was normal (fig.1). Intra-hepatic biliary radicles were prominent.The gall bladder was distended (fig. 2) withsmooth walls and normal thickness and lumenwas anechoic. The common bile duct wasnormal in calibre.
CT abdomen revealed hepatomegaly with largerounded well circumscribed multiloculated cystwith peripheral calcification present in right lobeof liver (superior segment). The size of masslesion being 6.3 X 5.5 cm with multiple enlargedlymph nodes present at porta hepatis region(inflammatory).
94 Journal, Indian Academy of Clinical Medicine � Vol. 2, No. 1 and 2 � January-June 2001
3. Supportive measures included maintenance offluid and electrolyte balance and oxygentherapy. Patient did not require vasopressors.
Laboratory investigations repeated after one weekof therapy showed following findings. TLC – 8600/cubic mm, DLC – polymorphs 60%, lymphocytes30%, eosinophils 8%, Hb - 8.6 gm%, ESR - 98mm/Ist hour, F. blood sugar 84 mg/dl, blood urea31 mg/dl, S. creatinine 0.9 mg/dl, S. bilirubin -2.4 mg/dl, SGOT - 104 U/L, SGPT - 160 U/L, S.alkaline phosphatase 340 IU/L, S. Na - 134 meq/L, S.K. - 3.8 meq/L, urine exam - mild proteinuria(+), S. albumin - 3.8 mg/dl, S. globulins 3.4 gm/dl, blood pH 7.2.
USG abdomen after one month of treatmentshowed hepatomegaly with capsulated cysticmass of about 5.7 X 5.3 X 5 cm size with smallsonolucent cysts arranged peripherally inposterio-superior part of right lobe of liver and
the gall bladder was seen in normal distention(fig. 3).
The signs and symptoms of septicaemiaameliorated after one week of intensiveantimicrobial treatment. After 3 months hydatidcyst of liver was excised and histopathologicalreport confirmed hydatid cyst containing scolicealhooklets.
Fig. 1 : Sonography abdomen showing cystic mass with smallwell defined cystic lesion and central solid component in rightlobe of liver.
Fig. 2 : Sonography abdomen showing distended gall bladderdue to pressure effect of hydatid cyst of right lobe of liver.
Fig. 3 : Sonogarphy abdomen showing capsulated cystic masswith small sonolucent cyst in right lobe of liver after 1 monthcourse of therapy.
Treatment1. Antimicrobials : Treatment was started on
empirical basis with broad spectrumantibiotics. Ceftriaxone was given in a dose of1 gm IV B.D. for 2 weeks, in combination withthe aminoglycoside amikacin in a dose of 500mg IV B.D. for 10 days and metronidazole ina dose of 400 mg thrice a day for 7 days. Theneed to change the above therapy did not ariseeven after blood culture report was available.
2. Anti-helminthic : Albendazole was given in adose of 400 mg twice a day for 12 weeks.
Journal, Indian Academy of Clinical Medicine � Vol. 2, No. 1 and 2 � January-June 2001 95
CT Scan abdomen (A-D) showing hydatid cystliver with characteristic calcification
CommentsLeakage of cyst may produce fever, eosinophilia
and severe anaphylactic reaction. Intrabiliaryrupture of hydatid cyst of the liver is a severe andrelatively frequent complication1. The rupture ofthe cyst is more frequent in right or left hepaticduct and occasionally in common bile duct (7-9%)2. The rupture of the cyst into biliary tract canlead to spontaneous resolution. Becker et alnoticed the spontaneous rupture of hydatid cystinto the biliary tract leading to resolution of hydatidcyst3. This case is being reported because of itsunusual presentation. The occurrence ofsepticaemia in our case may be due to secondarysuppuration of the cyst alongwith its pressure effecton biliary tree leading to cholangitis.
References1. Ascenti G, Scribano E, Loria G et al. Computerised
tomography in the assessment of obstructive Jaundicecaused by hepatic hydatid cysts. Radiol Med (Torino)1995; 89 (6): 804-8.
2. Alhan E, Calik A, K uc-ukt ul u U et al. The intrabiliaryrupture of hydatid cyst of the liver. Nippon Geka Hokan1994; 63 (8): 3-9.
3. Becker K, Frieling T, Saleh A et al. Resolution of hydatidcyst liver by spontaneous rupture into the biliary tract. JHepatol 1997; 26 (6): 1408-12.
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