Table of Contents  
CASE REPORT
Year : 2014  |  Volume : 7  |  Issue : 1  |  Page : 78-81  

Isolated peritoneal hydatidosis clinically mimicking ovarian tumor: A rare case report


Department of Pathology, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pune, India

Date of Web Publication10-Dec-2013

Correspondence Address:
Pradhan M Pagaro
Department of Pathology, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pune
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.122794

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  Abstract 

Hydatid cyst disease is rare and it is a parasitic infection where humans accidentally get infected by ingesting larval forms of parasite whereas, the definitive hosts are dog. The common sites of hydatid cyst are liver, lungs, spleen. Unusual sites of the hydatid cyst is reported in subcutaneous tissue of anterior abdominal wall, peritoneum. We report an unusual form of the primary hydatid cyst disease involving peritoneum in a 65-year-old female, presenting as swelling in the abdomen since 3 months. Sonography revealed a cystic mass and diagnosis of ovarian tumor was considered. The Cancer Antigen 125 (CA-125), an ovarian malignant marker was normal. Exploratory laprotomy was carried out. Cytological examination, gross, and the histopathological findings suggested the diagnosis of hydatid cyst disease involving only peritoneum. Primary isolated hydatidosis involving peritoneum is very rare and only few cases have been reported. Moreover, it mimics other tumors of the abdomen like in our case we considered it as an ovarian tumor.

Keywords: Hydatidosis, mimicking, ovarian tumor, peritoneal


How to cite this article:
Pagaro PM, Chaudhari PK, Naphade NN, Patil T. Isolated peritoneal hydatidosis clinically mimicking ovarian tumor: A rare case report. Med J DY Patil Univ 2014;7:78-81

How to cite this URL:
Pagaro PM, Chaudhari PK, Naphade NN, Patil T. Isolated peritoneal hydatidosis clinically mimicking ovarian tumor: A rare case report. Med J DY Patil Univ [serial online] 2014 [cited 2019 Nov 19];7:78-81. Available from: http://www.mjdrdypu.org/text.asp?2014/7/1/78/122794


  Introduction Top


Hydatid disease has a wide geographic distribution and is considered as important public-health problem in the world. It is a cyclo-zoonotic parasitic infection usually found in the liver and lung. Echinococcus has been recognized by humans for centuries. It was also recognized by Hippocrates and Galen. Echinococcus has been well-known for the past 2000 years. In 17 th century, Francisco Rodii illustrated that the hydatid cysts of Echinococcus were of animal origin. [1] In 1766, Pierre Simon Pallas predicted that these hydatid cysts found in infected humans were actually larval stages of tapeworms. In 1782, Gueze accurately described cysts and tapeworm heads. In 1786, Batsch accurately described Echinococcus granulosus. [1] In 1850 Carl Von Siebold showed Echinococcus cysts do cause adult tapeworms in dogs. In mid 1990s distinct features of Echinococcus, their life cycles, how they cause disease were more fully described. [1] Hydatid disease in humans is caused in humans by the larval stage of Echinoccocus. Location at unusual site in the body can have atypical presentation and can pose a diagnostic challenge. [2] In such cases, cystic fluid cytology plays an important role for diagnosis. [3],[4] We report a case of isolated peritoneal hydatid cyst because of unusual, rare location creating a diagnostic dilemma with CA Ovary, which was resolved by cytology.


  Case Report Top


A 65-year-old female patient presented with a lump in the abdomen since 3 months. Physical findings revealed a 10 cm × 6 cm, tender cystic swelling. Radiological investigations were suggestive of multiloculated cysts probably arising from ovary. Hematological investigations and CA-125 was normal. Provisional clinical diagnosis was considered as ovarian tumor. Intra-operative cyst fluid showed multiple scolices, hooklets and suckers [Figure 1], [Figure 2], [Figure 3]. Grossly, the lesion showed cystic mass measuring 10 cm × 6 cm × 4 cm in dimensions, external surface was smooth and white [Figure 4]. The cut surface showed multiple daughter cysts, which were smooth, white, and gelatinous [Figure 5]. Histologically the cyst wall was acellular and laminated [Figure 6].
Figure 1: Externally cystic mass measuring 10 cm × 6 cm × 4 cm, well circumscribed, smooth, whitish

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Figure 2: Cut surface of cyst showed multiple daughter cysts which are smooth, whitish, gelatenous

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Figure 3: Cytocentrifuged deposit of fluid showing multiple scolices (×40)

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Figure 4: Scolex of hydatid cyst showing sucker (arrowhead) within a vesicle (×40)

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Figure 5: Scolex of hydatid cyst showing hooklets (arrowhead) within a vesicle (×400)

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Figure 6: Laminated acellular cyst wall. Left (×40) and right (×400) (H and E)

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  Discussion Top


Hydatid cyst is a parasitic, zoonotic infection caused by E. granulosus and Echinococcus multilocularis and it is caused by larval forms of Echinococcus. Dogs are definitive hosts, and humans are intermediate hosts and mode of transmission of infection is fecal -oral route through infected vegetables and water contaminated with hydatid ova. Hydatid disease is caused by two dog tapeworms namely E. granulosus and E. multilocularis. Ova of E. granulosus discharged by dogs and foxes are ingested by an intermediate host such as sheep, goats, cattle pigs or man. After hatching the embryos penetrate the venules of the intestinal wall and become established in the liver. If they can get beyond the hepatic circulation, they lodge in the lungs. A small proportion may reach other tissues including, muscle and brain. Hydatid cysts are unilocular show a featureless eosinophilic capsule and an inner germinal epithelium consisting of daughter cysts. Rarely, metastatic cysts may develop elsewhere in the body as a result of dissemination through bloodstream. In sheep rearing countries where hydatidosis is most frequent in man, skeletal muscle is involved in over 5% of cases in humans. In brain, it may cause cerebral cysticercosis or meningeal reaction with the local cerebral damage. Elsewhere, it behaves like an invasive tumor. [5] E. granulosus is present world-wide. Areas of occurrence of hydatid disease coincide with the rural grazing areas where dogs are able to ingest organs from infected animals E. multilocularis is extremely uncommon; however, has an ability to spread and usually causes alveolar ecchinosis. Echinococcus vogeli and Echinococcus oligarthus are extremely rare. [6] Eggs of Echinococcus are called as oncosphere or hexacanth because these embryos have six hooklets. Eggs are passed through feces of definite host and ingestion of eggs lead to infection in an intermediate host. Egg releases embryo, which develops into hydatid cyst, which grows to 5-10 cm within the 1 st year and is able to survive for years in organs of the body. [6],[7] Cysts continue to grow over years to decades and may contain several liters of fluid. Once cyst reaches 1 cm it differentiates into thick outer non-cellular membrane, which covers the thin germinal epithelium. From this epithelium cells begin to grow within the cyst, becomes vacuolated known as brood capsules from which protoscolices bud. Adult worms develop from protoscolices consisting of scolex, neck and three proglottids, one mature, one immature and the third is gravid containing eggs. The scolex contains four suckers and 25-50 hooklets. Disease causing species of Echinococcus are transmitted to intermediate host via ingestion of eggs and are transmitted to definite host mainly dogs by means of eating infected cyst containing organs, and humans are accidental intermediate hosts by handling soil, dirt or animal hair containing eggs. Incubation period can be months, years, or decades and depends on location of cyst and how fast it grows. [6] Life cycle of worm requires a definite host mainly dog and the intermediate host namely goats, sheep, and swine. Humans functions as accidental hosts because they are usually dead end for the parasitic infection cycle. The life cycle consists of adult worm in the small intestine of dog. Gravid proglottids release eggs that are passed in feces of definite host. These eggs ingested by sheep, goat, cattle, and humans hatches in the small intestine and release an oncosphere that penetrates the intestinal wall and goes into the circulation and mainly involves the liver and lung. The oncosphere develops into cyst, which slowly enlarges creating protoscolices and daughter cysts. [6] The diagnosis of hydatid disease involves Imaging techniques such as ultrasonography, magnetic resonance imaging, or computed tomography scans, Histopathology and serology tests like casoni reaction test. The disease presents as a slow growing mass and symptoms depends on size and location of the hydatid cyst. The patient can be asyptomatic. If the hydatid cyst involves lungs then the patient may complain of cough, breathlessness and chest pain. If the disease involves liver the patients complains of (C/O) abdominal pain, there is abdodminal tenderness, hepatomegaly, with an abdominal mass, jaundice, fever and even anaphylactic reaction if cyst ruptures while in the body. [6] Treatment consists of the surgical removal of cysts combined with chemotherapy using albendazole or mebendazole before and after surgery for 3-6 months. If the cysts are in multiple locations or in risky locations then surgery is impractical. In such cases, chemotherapy is the main treatment or puncture, aspiration, injection of scolicidal solution for 20-30 min. [8],[9] Recently, relative new treatment involving percutaneous thermal ablation of germinal layer in the cyst by means of radiofrequency ablation device is currently under research and study. [10] Prevention consists of health education programs, improved water sanitation and hygiene, Deworming and vaccination of dogs. Liver 75% and Lungs 15% are the common organs involved. Peritoneal involvement is usually related to secondary involvement from other organs, probably due to traumatic rupture of hepatic or splenic hydatid cyst. Primary peritoneal involvement is seen only in 2% of all abdominal hydatid disease. The involvement may be via lymphatic or systemic circulation. [11],[12] Primary peritoneal hydatid cyst disease was reported by Karavias. [11] Mayak Baid described a primary peritoneal hydatid cyst in a 76-year-old farmer. [12] A solitary primary subcutaneous hydatid cyst in the abdominal wall of 70-year-old was reported by Ousadden. [13] And an unusual presentation of hydatid cyst in anterior abdominal wall was reported by Srivastava et al. [14] Sandhara Babu reported an intra-abdominal hydatid cyst by cytology. [15] Astarcioglu reported an isolated mesosigmoid hydatid cyst as an unusual cause of colonic obstruction. [16] Buttenschoen describes the challenges of surgical treatment of E. granulosus infection. [17] Peritoneal hydatid disease does not produce any symptoms and diagnosis is mainly done by ultrasonography, CAT scan, and serological tests. Laprotomy is usually done in such cases. Anthelminthic drugs are given before and after the operation for a prescribed period. There are many similarities between hydatid cyst and the pelvic malignant disease on the basis of imaging findings. Cytologic and exploratory laprotomy and the histopathological examination contribute to the definite diagnosis of hydatid cyst.


  Conclusion Top


This case illustrates that echinococcal disease should be considered in the differential diagnosis of every cystic mass in any anatomic location irrespective of endemic areas.

 
  References Top

1.Balik AA, Celebi F, Baºglu M, Oren D, Yildirgan I, Atamanalp SS. Intra-abdominal extrahepatic echinococcosis. Surg Today 2001;31:881-4.  Back to cited text no. 1
    
2.Wani RA, Wani I, Malik AA. Hydatid disease at unusual sites. Int J Case Rep Images 2012;3:1-6.  Back to cited text no. 2
    
3.Hira PR, Shweiki H, Lindberg LG, Shaheen Y, Francis I, Leven H, et al. Diagnosis of cystic hydatid disease: Role of aspiration cytology. Lancet 1988;2:655-7.  Back to cited text no. 3
    
4.Vercelli-Retta J, Mañana G, Reissenweber NJ. The cytologic diagnosis of hydatid disease. Acta Cytol 1982;26:159-68.  Back to cited text no. 4
    
5.Symmers WC. Systemic Pathology. 3 rd ed., Vol. 4. New York: Longman Group UK Ltd., Churchill Livingstone; 1990. p. 187.  Back to cited text no. 5
    
6.Wikipedia, the free encyclopedia. Available from: http://en.wikipedia.org/wiki/Echinococcosis [Last accessed 2013 Nov 15].  Back to cited text no. 6
    
7.Mandell GL. Mandell, Douglas and Benet's Principles of Infectious Diseases. 7 th ed., Ch. 290. Philadelphia, PA: Elsevier Inc.; 2010.  Back to cited text no. 7
    
8.Kemp C, Roberts A. Infectious disease: Echinococcus (hydatid disease). J Am Acad Nurse Pract 2001;13:346-7.  Back to cited text no. 8
    
9.Park KH, Jung SI, Jang HC, Shin JH. First successful puncture, aspiration, injection, and re-aspiration of hydatid cyst in the liver presenting with anaphylactic shock in Korea. Yonsei Med J 2009;50:717-20.  Back to cited text no. 9
    
10.Sharma D, Babu R, Borgharia S, Baruah D, Thomas S, Kumar A. Laparoscopy for liver hydatid disease: Where do we stand today? Surg Laparosc Endosc Percutan Tech 2009;19:419-23.  Back to cited text no. 10
    
11.Karavias DD, Vagianos CE, Kakkos SK, Panagopoulos CM, Androulakis JA. Peritoneal echinococcosis. World J Surg 1996;20:337-40.  Back to cited text no. 11
    
12.Baid M, Kar M, Chejara S, Mukhopadhya M. Primary peritoneal hydatidosis in a 76 year old farmer. Niger J Surg 2012;18:100-1.  Back to cited text no. 12
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13.Ousadden A, Elbouhaddouti H, Ibnmajdoub KH, Mazaz K, Aittaleb K. A solitary primary subcutaneous hydatid cyst in the abdominal wall of a 70-year-old woman: A case report. J Med Case Rep 2011;5:270.  Back to cited text no. 13
    
14.Srivastava P, Gangopadhyay AN, Upadhyaya VD, Sharma SP, Jaiman R. An unusual presentation of hydatid cyst in anterior abdominal wall. Kathmandu Univ Med J (KUMJ) 2008;6:511-3.  Back to cited text no. 14
    
15.Babu KS, Goel D, Prayaga A, Rao IS, Kumar A. Intraabdominal hydatid cyst: A case report. Acta Cytol 2008;52:464-6.  Back to cited text no. 15
    
16.Astarcioglu H, Koçdor MA, Topalak O, Terzi C, Sökmen S, Ozer E. Isolated mesosigmoidal hydatid cyst as an unusual cause of colonic obstruction: Report of a case. Surg Today 2001;31:920-2.  Back to cited text no. 16
    
17.Buttenschoen K, Carli Buttenschoen D. Echinococcus granulosus infection: The challenge of surgical treatment. Langenbecks Arch Surg 2003;388:218-30.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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