Clinical Brief
Hepatic Hydatid Cyst Rupture and Anaphylaxis After a Fall Muzaffer Elmali1, Meltem Ceyhan1, Mehtap Ilgar1, Cinar Koprulu1, Meral Ozfindik2 and Recep Sancak2 Departments of 1Radiology, 2Pediatry, Ondokuz, Mayis University Faculty of Medicine, Samsun, Turkey
ABSTRACT A 15-year-old boy presented to the emergency unit complaining of dyspnea, urticaria and vomiting developed after he fell down when he was playing football. Abdominal ultrasound showed a ruptured hydatid cyst in the right lobe of the liver which was of communicating type. Echinococcus granulosus serologic tests were positive. Medical treatment was started immediately. One week later, follow up US showed no changes in the findings. Intrabdominal fluid leakage was not detected. Patient’s general condition showed improvement and he was discharged 12 days later. [Indian J Pediatr 2009; 76 (3) : 329-330] E-mail:
[email protected] Key words: Liver; Trauma; Hydatid cyst; Ultrasound; Anaphylaxis
Hydatid disease which is caused by echinococcus granulosus, is a common parasitic infestation especially in endemic regions like the Middle East, Mediterranean, and South American Countries. Although it mostly involves the liver, it has been reported in almost all parts of the body.1-3 We present herein the clinical, laboratory and radiological findings of a patient developed anaphylactic reaction after falling down, which resulted in rupture of his hepatic hydatid cyst. CASE REPORT A 15-year-old boy presented to the emergency unit complaining of dyspnea and vomiting developed after he fell down when he was playing football. He was admitted just 30 minutes following the accident. Symptoms like dyspnea, periorbital and perioral edema were already present at the time of admission. On physical examination blood pressure was 100/60 mmHg, heart rate: 80/min, and temperature: 37.5 ºC. There were a diffuse maculopapular rash on the whole body mainly on the face and trunk. The patient
Correspondence and Reprint requests : Muzaffer Elmali, Ondokuz Mayis University Faculty of Medicine, Department of Radiology, 55139 Kurupelit, Samsun, Turkey. [DOI–10.1007/s12098–009–0011–7] [Received September 30, 2007; Accepted April 28, 2008]
Indian Journal of Pediatrics, Volume 76—March, 2009
Fig. 1. Ultrasonographic image shows a communicating type ruptured hydatid cyst, inside of which floating membranes are present. Discontinuity in the cyst wall and extra-capsular fluid collection were also seen (arrow).
received oxygen and intravenous fluid as supportive treatment. Chest and abdomen radiographs were normal. Transabdominal ultrasound (US) (Toshiba Aplio 80, Toshiba Medical System Corporation, 2004, Japan) performed for evaluation of intra-abdominal organs showed a thick walled cystic lesion in the right lobe of the liver measuring about 27x40 mm in diameters and containing floating membranes. The wall of the cyst showed discontinuity at a point, from which fluid leaked to the outside of the wall (Fig. 1). The capsule of the liver was intact. Other abdominal organs were normal and there was no free fluid inside peritoneal 329
Muzaffer Elmali et al cavity. Diagnosis of a communicating type ruptured hepatic hydatid cyst was made by clinical and US findings. Treatment with diphenylhydramine, methylprednisolone and albendazole(10mg/Kg/day) was started immediately. One day later, there was a significant improvement in symptoms like rash, periorbital and perioral edema. Echinococcus granulosus Ig and indirect hemagglutination (titres of 1/256) tests were positive. One week later, follow up US showed no changes in the findings of US performed at the time of admission. Liver capsul was intact. Intrabdominal fluid leakage was not detected. Patient’s general condition showed improvement and he was discharged 12 days later. Follow up was recommended. One month later US showed the cyst measuring 25x33mm in diameter. There was an increase in the internal echogenity of the cyst and membranes were not distinguished. DISCUSSION Hydatid disease is a parasitic infection caused by echinococcus granulosus characterised by cyst formation in any organ, although the liver is the most commonly involved.1-11 Most cysts are clinically silent. However, when it becomes large enough, it can produce pressure –related symptoms. When ruptures, it can result in serious clinical condition and life threatening anaphylaxis. Rupture could be spontaneous or may result from a trauma. 1, 3-5, 10-12 The present patient presented with dyspnea and vomiting after abdominal trauma, a diagnosis of ruptured hydatid cyst was suggested by US findings and confirmed by serological tests. Lewall et al9 classified ruptured hydatid cysts into three categories; contained, communicating and direct . In contained rupture only the endocyst is torn and cyst contents are confined within the surrounding layer of host reactive tissue, the pericyst. Communicating rupture consists of a tear of the endocyst with escape of cyst contents via bronchioles or biliary radicles that have been incorporated in the pericyst. A tear of both the pericyst and endocyst allowing cyst contents to spill into the peritoneal or pleural spaces is direct rupture. Radiologists can play a primary role in reaching diagnosis by their imaging techniques. US, computed tomography, and magnetic resonance imaging appearances have been described in detail. US is the first choice in establishing the diagnosis, as it is very effective, easy, cheap and a non invasive method.6, 9, 12
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High frequency transducers of 5-10mHz can demonstrate in detail both cyst wall and its contents in lesions located close to the anterior surface of the liver and also in thin patient and children. The presence of a cyst in the liver of a patient who developed anaphylactic reaction, with detection of membrane like structures inside the cyst and discontinuity of the wall are considered diagnostic for ruptured hydatid cyst. The most useful serologic tests are ELISA IgG and indirect hemagglutination in diagnosis of hydatid cyst. Serological tests are used both in diagnosis and following after treatment. Treatment methods include surgical removal of the cyst, percutaneous drainage, and the use of albendazole. Early diagnosis and appropriate treatment of the disease will help in reducing mortality. REFERENCES 1. Bitton M, Kleiner-Baumgarten A, Peisser J, Barki Y, Sukenik S. Anaphylactic shock after traumatic rupture of a splenic echinococcal cyst. Harefuah 1992; 122:226-228. 2. Erkilic S, Ozsarac C, Kocer NE, Bayazit YA. Hydatic Cyst of the thyroid gland in a child. Int J Pediatr Otorhinolaryngol 2004;68:369-371. 3. Gulalp B, Koseoglu Z, Toprak N et al. Ruptured hydatic cyst following minimal trauma and few signs on presentation. Neth J Med 2007;65: 117-118. 4. Kurt N, Oncel M, Gulmez S, Ozkan Z, Uzun H. Spontaneous and traumatic intraperitoneal perforations of hepatic hydatid cysts: a case series. J Gastrointest Surg 2003;7:635-641. 5. Navsaria PH, Forlee MV, Nicol AJ. Traumatic rupture of a hepatic hydatid cyst. S Afr J Surg 2002;40:103-105. 6. Sezgin O, Altintas E, Saritas U, Sahin B. Hepatic alveolar echinococcosis: Clinical and radiologic features and endoscopic management. J Clin Gastroenterol 2005;39:160167. 7. Erdogmus B, Yazici B, Akcan Y, Ozdere BA, Korkmaz U, Alcelik A. Latent fatality due to hydatid cyst rupture after a severe cough episode. Tohoku J Exp Med 2005;205:293296. 8. Kantarci M, Onbas O, Alper F, Celebi Y,Yigiter M, Okur A. Anaphylaxis due to a rupture of hydatid cyst: Imaging findings of a 10-year- old boy. Emerg Radiol 2003;10:49-50 9. Lewall DB, McCorkell SJ. Rupture of echinococcal cysts:diagnosis, clasification, and clinical implications. AJR Am J Roentgenol 1986;146:391-394. 10. Eyal I, Zveibil F, Stamler B. Anaphylactic shock due to rupture of a hepatic hydatid cyst into a pericystic blood vessel following blunt abdominal trauma. J Pediatr Surg 1991; 26: 217-218. 11. Kok AN, Yurtman T, Aydin NE. Sudden death due to ruptured hydatid cysts of the liver. J Forensic Sci 1993; 38: 978-980. 12. Gunay K, Taviloglu K, Berber E, Ertekin C. Traumatic rupture of hydatid cysts: a 12- year experience from an endemic region. J Trauma 1999; 46: 164-167.
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