|Year : 2014 | Volume
| Issue : 3 | Page : 377-380
Isolated renal hydatid cyst with ureteric calculus in human immunodeficiency virus (HIV) infected patient
Parag Bhirud1, Priti Bhirud2, Sharad Kankalia1
1 Department of Urology, Dr. D.Y. Patil Medical College, Hospital and Researh Centre, Dr. D.Y. Patil Vidyapeeth, Pune, Maharashtra, India
2 Department of Radiology, Bhirud Hospital, Bhusawal, Maharashtra, India
|Date of Web Publication||18-Mar-2014|
Department of Urology, Dr. D.Y. Patil Medical College, Hospital and Researh Centre, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
Hydatid disease is a cyclozoonotic parasitic infestation caused by the larval stage of the cestode parasites of Echinococcus spp. (Echinococcus granulosus, Echinococcus vogeli, and Echinococcus multilocularis). Isolated renal involvement is extremely rare. A 50-year-old male patient presented with acute left loin pain. Ultrasound revealed left mild hydroureteronephrosis with lower pole mass lesion. Computed tomography (CT) scan abdomen and thorax revealed the isolated renal hydatid disease with upper ureteric calculus. On blood examination, he was found to have HIV infection with immunosuppresion. He underwent left partial nephrectomy with pyelolithotomy. Histopathology confirmed the diagnosis of renal hydatid. Immunosuppression may be the cause of unusual site of hydatid cyst and partial nephrectomy is the treatment of choice in isolated renal hydatid cyst with renal calculus in HIV-infected patients.
Keywords: Calculus, HIV, renal hydatid cyst
|How to cite this article:|
Bhirud P, Bhirud P, Kankalia S. Isolated renal hydatid cyst with ureteric calculus in human immunodeficiency virus (HIV) infected patient. Med J DY Patil Univ 2014;7:377-80
|How to cite this URL:|
Bhirud P, Bhirud P, Kankalia S. Isolated renal hydatid cyst with ureteric calculus in human immunodeficiency virus (HIV) infected patient. Med J DY Patil Univ [serial online] 2014 [cited 2020 Jan 28];7:377-80. Available from: http://www.mjdrdypu.org/text.asp?2014/7/3/377/128991
| Introduction|| |
Hydatid disease is a cyclozoonotic parasitic infestation caused by the larval stage of the cestode parasites of Echinococcus spp. (Echinococcus granulosus, Echinococcus vogeli, and Echinococcus multilocularis).  It is prevalent worldwide and constitutes a real public health problem.  Hydatid cysts are generally formed in the liver (75%) or lung (15%), but 10% of cysts are found in the rest of the body. Urinary tract involvement develops in only 2-4% of cases and isolated renal cysts are extremely rare. ,,
| Case Report|| |
A 50-year-old male patient presented with acute left loin pain. Patient had no significant past medical history, i.e. no history of contact with dog, hydatiduria, hypertension Examination was unremarkable except left loin tenderness. Abdominal ultrasound revealed 6.5 cm lower pole exophytic heterogeneous lesion with no internal vascularity and with mild hydroureteronephrosis [Figure 1]. He underwent contrast-enhanced computed tomography (CECT) abdomen and pelvis which revealed well-defined, exophytic, nonenhancing heterogeneous lesion measuring 6.7 × 6.2 × 4.9 cm, arising from the lower pole of the left kidney [Figure 2]. There were hyperdense areas (120-140 HU) within suggestive of early calcification with interspersed linear areas of fluid attenuation (25-30 HU) suggestive of detached intralesional membranes. Other common sites in body such as liver and lungs were free from hydatid cysts [Figure 3] and [Figure 4].
|Figure 2: CECT showing lower pole hydatid cyst with upper ureteric calculus|
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On blood examination, he was found to have HIV infection which was confirmed ( by enzyme-linked immunosorbent assay (ELISA). His CD4 count was 450/mm 3 . Medical opinion was taken and he was advised to start antiretroviral therapy once the CD4 count went below 400/mm 3 . His serological test for hydatid cyst was not done and diagnosis was made from typical radiological findings.
We decided to use retroperitoneal approach for partial nephrectomy and pyelolithotomy after preoperative albendazole treatment. He was treated with albendazole 10 mg/kg/day for 3 weeks and planned for surgery. Patient was put in right lateral position with kidney bridge underneath. Retroperitoneum was opened by a cutting incision through the 11 th rib. The cyst was isolated and packed all around with betadine soaked gauze pieces (10% povidone iodine). Hydatid cyst was excised with 0.5 cm margin.
Upper ureteric calculus was pushed in pelvis and removed through the same incision taken for hydatid cyst. There was no intraoperative or postoperative complication Histopathologic examination confirmed the diagnosis of hydatid cyst [Figure 5]. Postoperatively, he was treated with albendazole for a total of 3 months, with a gap of 1 week after every 4 weeks. Follow-up ultrasound after 3 months was normal and intravenous urogram after 6 months was normal. Stone analysis was suggestive of calcium oxalate monohydrate calculus.
| Discussion|| |
Cystic hydatidosis is a disease caused by E. granulosus, with humans being the intermediate hosts. 
Surgical options for renal hydatid cyst include total excision(s), partial nephrectomy, partial cystectomy, followed by capitonage. Renal sparing surgery of partial excision is possible in 75% of cases. 
Due to multilocular cyst associated with upper ureteric calculus, we preferred open partial nephrectomy along with pyelolithotomy. Although renal hydatid cyst has been discovered incidentally during percutaneous nephrolithotomy (PCNL), its efficacy has to be established with a larger number of patients and longer follow-up. 
Our case is probably the first case of isolated renal hydatid cyst with calculus disease in HIV-infected patients. The combination of clinical history, imaging studies, and serological and urine investigations yields a reliable pretreatment diagnosis in only 50% of cases and a presumptive diagnosis in 71% of cases. Preoperative diagnosis of renal hydatid disease is difficult even in endemic areas. Imaging studies are suggestive, but usually inconclusive, and the differential diagnosis between a renal tumor and complicated cyst may not be made without surgery.  Symptoms of renal echinococcosis may be absent since echinococcosis is usually an incidental finding. Ameur and colleagues reported 34 cases with renal hydatid cystsClinical features were dominated by pain (63%), mass (26%), hydatiduria (11.4%), hematuria (31.4%), prolonged fever (23%), and hypertension (3%). 
Serological and hemagglutination tests offer low reliability, but their positivity confirms the presence of active disease.  Counterimmunoelectrophoresis against arch-5 has been reported to be highly specific for hydatid disease (79%).  In our case, we have not done any serological tests due to low reliability, and also, as the presence of HIV may alter the immune response to antigen.
Ultrasonography has been used to demonstrate multicystic or multiloculated masses.  Unilocular cysts have been observed in young patients and multilocular cysts in adults.  CT is very useful while intravenous urogram (IVP) and selective angiography have value in determining the nature of the cyst and the extent of renal damage.  Detection of daughter vesicles on ultrasound or CT is characteristic of renal hydatidosis. Surgical options for renal hydatid cyst include total excision, partial nephrectomy, and partial cystectomy. Some researchers suggest using praziquantel before the operation and also after the operation; using daily doses of praziquantel inhibits the development of secondary hydatidosis due to the possible dissemination of protoscolices.
Echinococcosis is now mostly treated with oral albendazole used alone, although data collected recently indicate that combined treatment with albendazole and praziquantel is more effective Postoperative recurrence of intra-abdominal echinococcosis can be seen as a result of intraoperative rupture of cysts and intraperitoneal spillage. Therefore, pre-surgery chemotherapy of echinococcal infections can reduce the size and number of viable protoscolices.  Due to the possibility of intraoperative rupture of cysts, which can exist for up to 5 years following the operation, attention should be given to the early detection of any secondary cystic formations or recurrence. In the literature, there are some reports of patients with cardiac hydatid disease, who had undergone previous operations for cardiac, pericardiac, hepatic, and pulmonary hydatidosis 8-12 years before. 
Immunosuppression could have encouraged the development of hydatid cysts, as a significant role of cellular immunity in controlling the first stages of larva development has been shown.  Hildreth et al. showed that cortisone treatment drastically increased both the number of Echinococcus cysts in mice and the average size of each cyst, when treatment was administered at an early stage. 
| Conclusion|| |
- Immunosuppresion could have been the cause of unusual site of renal hydatid.
- Open retroperitoneal partial nephrectomy is the treatment of choice in isolated renal hydatid cyst with renal calculus in HIV-infected patients.
| Aknowledgement|| |
The authors wish to thank Dr. Surendra Bhirud of Bhirud Hospital Bhusawal and Dr. Amarjit Singh, Dean, Padmashree Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pune for their encouragement and help in preparing this case report for publication.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]