Paraspinal hydatid cyst with unusual presentation: a case report

Sarang Gotecha; Deepak Ranade; Umesh Phalke; Balaji Dhaigude; Megha Kotecha; Prashant Punia

doi:10.4103/1687-7942.163417

CASE REPORT

Year : 2015 | Volume : 8 | Issue : 1 | Page : 78-80

Paraspinal hydatid cyst with unusual presentation: a case report

Sarang Gotecha, Deepak Ranade, Umesh Phalke, Balaji Dhaigude, Megha Kotecha, Prashant Punia
Department of Neurosurgery, Padmashree Dr. D. Y. Patil Medical College, Pimpri, Pune, India

Date of Submission	09-Feb-2015
Date of Acceptance	30-Apr-2015
Date of Web Publication	24-Aug-2015

Correspondence Address:
Sarang Gotecha
Resident MCh, Neurosurgery, Padmashree Dr. D. Y. Patil Hospital, Pimpri, Pune
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/1687-7942.163417

Abstract

Hydatid disease is a zoonotic infection most commonly caused by Echinococcus granulosis. Primary hydatid cysts of the skeletal muscles are extremely rare. In this paper, we present a case in which a patient had a hydatid cyst in the paraspinal muscle. A 19 years old female patient presented with a painless swelling over the left side on the back for the last two months. On local examination, a solitary, firm, non tender well defined, non movable, oval swelling was present over the left paraspinal region from T12 -L3. Provisional diagnosis of hydatid cyst was made on ultrasonography. Magnetic Resonance imaging revealed a well defined ovoid lesion measuring 4.3 × 4.54 × 2.3cm within the left erector spinae muscle. Operative intervention was planned and preoperative albendazole therapy (15 mg/kg/day) was given for two weeks. Hydatid disease is caused by the larval form of Echinococcus granulosus, It is most frequently located in the liver (75%) and lungs (15%). Musculo-skeletal involvement is secondary and uncommon. Spinal and paraspinal involvement is rare, with an incidence of less than 1%. Investigations for diagnosis include Ultrasonography, Computed tomography, Magnetic Resonance Imaging and Serologic tests. Surgical removal is the most effective treatment of hydatid cyst. Therapy with nontoxic scolocidal agents or combination chemotherapy with mebendazole is of therapeutic value. Albendazole is suggested to be given post operatively. Primary paraspinal echinococcosis must be considered in the preoperative differential diagnosis of the atypical presentation of paraspinal lesions in countries where Echinococcus infestation is endemic. Early diagnosis and radical surgery combined with antihelminthic therapy of sufficient duration are mandatory for the treatment of this disease.

Keywords: Echinococcus granulosus , hydatid cyst, paraspinal lesion

How to cite this article:
Gotecha S, Ranade D, Phalke U, Dhaigude B, Kotecha M, Punia P. Paraspinal hydatid cyst with unusual presentation: a case report. Parasitol United J 2015;8:78-80

How to cite this URL:
Gotecha S, Ranade D, Phalke U, Dhaigude B, Kotecha M, Punia P. Paraspinal hydatid cyst with unusual presentation: a case report. Parasitol United J [serial online] 2015 [cited 2023 Mar 21];8:78-80. Available from: http://www.new.puj.eg.net/text.asp?2015/8/1/78/163417

Introduction

Hydatid disease is a zoonotic infection most commonly caused by Echinococcus granulosus. It is common in countries of the temperate zones, including the Middle East, South America, New Zealand, Australia, Southeast Asia and parts of China ^[1],[2] . Unavailability of clean potable water supplies and close association of people with sheep and dogs makes the disease endemic in India ^[3] . The liver is the most frequently involved organ (75%), followed by the lung (10%) ^[4] . Primary hydatid cysts of the skeletal muscles are extremely rare even in areas where echinococcal infestation is frequent. Isolated case reports, of such presentation have been reported ^[1] . In this paper, we present a case of hydatid cyst in the paraspinal muscle.

Case summary

A 19-year-old female patient from Andhra Pradesh in India presented to the hospital with a painless swelling over the left side on the back for the last 2 months. There was no history of trauma, fever, or weight loss. General, physical, and systemic examinations were normal. On local examination, a solitary, nontender, well-defined, immovable, oval swelling, which was firm in consistency, was present over the left paraspinal region from T12 to L3. Neurological examination of the lower limbs revealed no motor or sensory deficit. Ultrasonography of the abdomen was carried out and it was normal. Ultrasonography of the swelling showed a well-defined, anechoeic lesion with a thick echogenic wall within the erector spinae muscle with a wall thickness of 7 mm and a provisional diagnosis of hydatid cyst was made.

MRI revealed a well-defined ovoid lesion measuring 4.3 × 4.54 × 2.3 cm within the left erector spinae muscle on the left side of the spinal region. Operative intervention was planned and preoperative albendazole therapy (15 mg/kg/day) was administered for 2 weeks ([Figure 1] and [Figure 2]).

Figure 1 Hydatid cyst wall.

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Figure 2 Preoperative T2 weighted axial MR image at the level of D12 spinal level showing a well-defined ovoid lesion measuring 4.3 × 4.54 × 2.3 cm noted in the erector spinae muscle on the left side spinal region. Image of the cyst wall.

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With the patient in the prone position, a ventral paraspinal incision was performed. Layer by layer dissection was carried out until the thick (1.5 cm) wall of the lump was identified. An attempt was made to excise the lump in toto along with the thick wall, which was difficult due to the close proximity with vertebrae. The macroscopic structure of the hydatid cyst was identified along with the white wall. Complete removal of the cyst was achieved. During surgical intervention, all precautions such as antiscolicidal solutions along with meticulous surgical technique were taken to prevent leakage of the contents of the hydatid cyst. The cavity was sterilized with alcohol-soaked iodine dressings for several minutes. Histopathological examination confirmed that it was a hydatid cyst. Postoperatively, albendazole (15 mg/kg/day) was continued for 6 weeks. Follow-up MRI was performed 1 year later, which showed no signs of recurrence.

Discussion

Hydatid disease is caused by the larval form of E. granulosus, commomly called as dog tapeworm, which causes the common unilocular form, and E. multilocularis the graver alveolar form ^[5] . The dog is the definitive host, and, as a pet, it is the most common source of infection transmitted to the intermediate hosts - humans, sheep, and cattle. Close contact with the infected dogs causes infection, the ovum thus gaining entry into the human gastrointestinal tract. The hydatid cyst is most frequently located in the liver (75%) and lungs (15%). The involvement of all other organs, including the brain, heart, kidney, bone, skeletal muscle, breast, and thyroid gland, is 10%, which are sites of unusual localization ^[4] . Theoretically, it can occur at any site except teeth, hair, and nails. Primary hydatid cyst disease of the skeletal muscle without other organ involvement is uncommon. Moreover, paraspinal muscles are much more rarely affected ^[2] . The liver and lungs act as filters for oncospheres following penetration of intestinal mucosa, thus making it quite difficult for them to reach muscular tissue ^[6] . High lactic acid level in muscular tissue is regarded to be unsuitable for the survival of cysts, and muscular contractions prevent fixation of larva to the muscular tissue. Spinal and paraspinal involvement is rare, with an incidence of less than 1% ^[7] .

Paraspinal and spinal hydatid cysts were first described by Chaussier in 1807 ^[8] . The pathogenesis of muscular localization remains poorly understood. Most authors believe that the embryo can reach the muscles from the systemic circulation after leaving the intestine and passing through two filters: the liver and the lungs ^[1] .

Muscle function, however, may be an impediment, for implantation of the embryo ^[9] . Clinically, growth of the cyst may manifest itself with local symptoms related to compression of adjacent structures. In our case, no symptoms were present, except for a mass that was growing on the paravertebral side. Spinal involvement was reported in 50% of these cases, with a mortality of 50% on an average of 5 years after the onset of symptoms ^[10] .

The ultrasonographic examination can show the membranes, septations, and daughter cysts within the cystic cavity. Computed tomography (CT) and MRI have recently become the most sensitive among diagnostic modalities. The CT examination shows characteristic findings of detachment of the laminated membrane as linear areas of increased attenuation within the cyst, known as 'water lilly sign'. CT scanning also provides a precise assessment of the relation between the cysts and osseous structures, the extension into the soft tissues, and the calcifications of the peripheral rim of the cyst. The MRI detects the anatomic location of the cyst and involvement of the neural structures more precisely compared with the other methods, but seems to be less helpful compared with CT for showing osteolytic changes ^[2] .

Serologic tests such as enzyme-linked immunosorbent assay, Casoni skin tests, latex agglutination, immunoelectrophoresis, and direct hemagglutination are serological methods used for the diagnosis of hydatid disease. Sensitivity of serology is high (80-100%) for liver cysts, but low for lung (50-56%) and other organs (25-56%). Importance of these tests lies mainly in the follow-up of treated patients. An increase in titer indicates the recurrence of disease and a decrease in titer indicates resolution ^[3] .

There are various treatment options for the uncomplicated hydatid cyst and include needle aspiration under ultrasound guidance, laparoscopic approach, direct surgical intervention, or medical treatment with the use of albendazole. En-bloc resection without inducing rupture and spreading of the daughter cyst is a recommended treatment strategy and accepted to be curative for intramuscular hydatid cyst ^[6] .

Preliminary aspiration and instillation of hypertonic saline (20%), silver nitrate (0.5%), formalin, and other chemicals should be used to prevent seeding of the cyst contents and to inactivate the protoscolices if presurgical diagnosis is hydatid cyst ^[11] .

Therapy with nontoxic scolocidal agents or combination chemotherapy with mebendazole is of therapeutic value in the treatment of patients with recurrence or a high risk of contamination ^[12] .

Albendazole is suggested to be given postoperatively for 1-3 months ^[13] .

Conclusion

Primary hydatid disease must be considered as a differential diagnosis of paraspinal cystic lesions, especially in countries where Echinococcus spp. infection is endemic. Early diagnosis and radical surgery with care taken to avoid spillage of cystic contents combined with antihelminthic therapy of sufficient duration are mandatory for the treatment of this disease.

Acknowledgements

Conflicts of interest

There are no conflicts of interest.

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