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CASE REPORT Table of Contents   
Year : 2009  |  Volume : 52  |  Issue : 2  |  Page : 213-214
Multiple disseminated abdominal hydatidosis presenting with gross hydatiduria: A rare case report


Department of Pathology, Lady Hardinge Medical College and Smt. Sucheta Kriplani Hospital, New Delhi, India

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   Abstract 

Cystic hydatid disease may develop in almost any part of the body. Approximately 70% of the hydatid cysts are located in the liver followed by the lung (25%). The kidneys, spleen, mesentry, peritoneum, soft tissues and brain are uncommon locations for hydatid cysts. Renal involvement in echinococcosis is extremely rare. Hydatiduria accompanies only 10-20% of all cases of renal hydatidosis and is usually microscopic. Gross hydatiduria is an exceptional presentation of hydatidosis. We report an exceptionally rare case of multiple hydatidosis with cysts in the liver, spleen, kidney and peritoneal cavity, presenting with gross hydatiduria.

Keywords: Hydatid disease, hydatiduria, multiple hydatidosis

How to cite this article:
Shukla S, Singh SK, Pujani M. Multiple disseminated abdominal hydatidosis presenting with gross hydatiduria: A rare case report. Indian J Pathol Microbiol 2009;52:213-4

How to cite this URL:
Shukla S, Singh SK, Pujani M. Multiple disseminated abdominal hydatidosis presenting with gross hydatiduria: A rare case report. Indian J Pathol Microbiol [serial online] 2009 [cited 2020 Apr 8];52:213-4. Available from: http://www.ijpmonline.org/text.asp?2009/52/2/213/48921



   Introduction Top


Renal hydatidosis is rare and represents only 2-3% of all patients with hydatid disease. [1] It may be asymptomatic; however, in a majority of the cases, the patient presents with a flank mass, renal colic, persistent fever, hematuria, dysuria, pyuria, renal stones or hypertension. Cystic rupture into the collecting system causes hydaturia, which is pathognomonic, although seen in only 10-20% of renal hydatidosis and is usually microscopic. [2] Gross passage of cysts in the urine is rather uncommon but has a tremendous diagnostic utility. [2],[3],[4]

We report an exceptionally rare case of multiple hydatid cysts of the liver, spleen, kidney and peritoneal cavity presenting with gross hydatiduria.


   Case Report Top


A 20-year-old female presented with constipation, abdominal pain, fever off and on for 3 months and intermittent passage of small, white, balloon-like, grape-sized structures in the urine. On systemic examination, the abdomen was soft with ill-defined round masses in the epigastrium and the hypogastrium. Normal bowel sounds were present. A mass was felt on per rectal examination measuring approximately 4cm ´ 3cm. Hematological examination revealed anemia (hemoglobin 8.5 gm%). Biochemical examination for kidney function test and liver function test were within normal limits except for mildly elevated alkaline phosphatase (234 IU/mL).

Ultrasonography revealed many multiseptate lesions in the liver, spleen, peritoneal cavity, retroperitoneum and cul de sac suggestive of multiple hydatid cysts. The right kidney was compressed by cysts with splitting of the pelvicalyceal system, suggestive of hydronephrosis. The left kidney was normal in size and echotexture. The uterus was normal in size and echotexture, with an ill-defined uterine wall and cysts in the cul de sac. An impression of disseminated hydatid cyst was made.

Crush/squash smears were prepared from the small, white, grape-like structures passed in the urine. These revealed multiple small dagger-shaped refractile hooklets [Figure 1] and body wall of Echinococcus granulosus . The patient underwent exploratory laprotomy with evacuation of multiple hydatid cysts from the peritoneal cavity. Some cysts were laid open after injection of scolicide 10% povidone iodine and aspiration of the cyst contents was carried out when evacuation was not feasible. The patient was advised albendazole 400 mg BD for 4 weeks.

Pathological findings

The gross specimen comprised of multiple white cystic structures varying in size from 0.5cm to 7cm in diameter. The wall thickness varied from 1mm to 2mm [Figure 2].

Microscopic examination showed the typical outer cuticular laminated layer (ectocyst) and inner germinal layer (endocyst) of hydatid cyst [Figure 3].


   Discussion Top


Hydatid disease, also known as echinococcosis or hydatidosis, is caused by infection with the larva of the tapeworm of the genus Echinococcus. E. granulosus cysts following primary infection may inhabit any anatomic site. The two most common organs involved are the liver (65%) and the lungs (25%). Other less common sites affected by cysts include the muscles (5%), bones (3%), kidneys (2%), spleen (1%), heart (1%), pancreas (1%) and central nervous system (1%). [5] Primary peritoneal hydatidosis is extremely rare. Secondary hydatid disease of the peritoneum is usually the result of traumatic or surgical rupture of a hepatic, splenic or mesenteric cyst with abdominal and pelvic dissemination. [6] Renal hydatid cysts usually remain asymptomatic for years. However, the patient may present with renal colic, hematuria, pyuria and fever off and on. Rupture of the cyst into the collecting system causing hydatiduria is pathognomonic, but it is seen in only 10-20% of the renal hydatidosis and is usually microscopic. [2] Macroscopic hydatiduria is very rare [2],[3],[4] and, if present, has a tremendous diagnostic utility.

Routine hematological and biochemical tests do not help in the diagnosis of hydatid disease. Serology and imaging modalities establish the diagnosis in most of the cases. Enzyme-linked immunosorbent assay (ELISA) is the most widely used assay. The arc 5 immunoelectrophoresis test is confirmatory as it detects antibodies against immunodominant and specific antigen (antigen 5) of the cestode. A polymerase chain reaction (PCR) using recombinant DNA antigen is valuable in defining the particular species of Echinococcus. [5] Abdominal ultrasonography and computerized tomography (CT) scan are the most useful in establishing the diagnosis of hydatid disease. CT is more sensitive and accurate as compared with ultrasound. [7]

However, no serological tests like ELISA or PCR were performed in the index case due to the cost factor and the diagnosis was confirmed on the cheaper squash preparation. The patient was lost to follow-up.

The gross hydatiduria is a very rare presentation of hydatidosis as seen in the present case. Moreover, the present case highlights the belief that sometimes simple tests like cytologic examination of the cysts passed in the urine are enough to confirm the diagnosis without having to resort to more sophisticated techniques like ELISA, PCR, etc. Ultrasonography and CT are very useful in detecting disseminated peritoneal hydatidosis.

 
   References Top

1.Kiresi DA, Karabacakoglu A, Odev K, Karakose S. Pictorial review: uncommon locations of hydatid cysts. Acta Radiologica 2003;44:622-36.  Back to cited text no. 1    
2.Unsal A, Cimentepe E, Dilmen G, Yenidunya S, Saglam R. An unusual cause of renal colic: Hydatiduria. Int J Urol 2001;8:319-21.  Back to cited text no. 2    
3.Mongha R, Narayan S, Kundu AK. Primary hydatid cyst of kidney and ureter with gross hydatiduria: A case report and evaluation of radiological features. Indian J Urol 2008;24:116-7.  Back to cited text no. 3    Medknow Journal
4.Ozturk A, Onur K, Ozturk E, Sirmatel O. An unusual complication of renal hydatid disease: macroscopic hydatiduria. Eur J Radiol 2003;54:35-7.  Back to cited text no. 4    
5.Khuroo MS. Hydatid disease: Current status and recent advances. Ann Saudi Med 2002;22:56-64.   Back to cited text no. 5  [PUBMED]  
6. Lewall DB, McCorkell SJ. Rupture of echinococcal cysts: Diagnosis, classification, and clinical implications. AJR Am J Roentgenol 1986;146:391-4.  Back to cited text no. 6    
7.Çol C, Çol M, Lafηi H. Unusual localizations of hydatid disease. Acta Medica Austriaca 2003;30:61-4.  Back to cited text no. 7    

Top
Correspondence Address:
Mukta Pujani
Department of Pathology, Lady Hardinge Medical College and Smt. Sucheta Kriplani Hospital, New Delhi - 110 001
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.48921

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    Figures

  [Figure 1], [Figure 2], [Figure 3]

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