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CASE REPORT |
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Year : 2013 | Volume
: 6
| Issue : 2 | Page : 191-193 |
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Intermuscular hydatid cyst in the thigh: An unusual presentation
Sushma Yalavarthi1, Narayana V Satya2, T Ramamurti2, M Supriya1
1 Department of Pathology, Mamata Medical College, Andhra Pradesh, India 2 Department of Pathology, Kamineni Medical College, Andhra Pradesh, India
Date of Web Publication | 10-Apr-2013 |
Correspondence Address: Sushma Yalavarthi Department of Pathology, Mamatha Medical College, Khammam, Andhra Pradesh India
Source of Support: None, Conflict of Interest: None | Check |
DOI: 10.4103/0975-2870.110311
Hydatid cyst is the larval form of Echinococcus granulosus. Hydatid cyst or echinococcosis can be found in any part of the body, but the most commonly affected organs are liver, lungs, and the rest in other organs. Echinococcosis of the musculoskeletal system is very unusual and has a reported incidence of only 0.5-4% of patients in the literature. Primary musculoskeletal Echinococcus infection is very rarely reported in India without involving the thoracic and abdominal organs. Here, we are reporting an unusual case of primary intermuscular hydatid cyst involving left thigh in a 75-year-old male patient, which was diagnosed by fine needle aspiration cytology (FNAC). In the literature, reports of hydatid cyst diagnosed by FNA are very rare. Here, we are presenting both cytological and histopathologic findings of echinococcosis, which will be helpful in the preoperative diagnosis to avoid anaphylactic shock and local recurrence. Keywords: Echinococcosis, fine needle aspiration cytology, primary intermuscular, thigh
How to cite this article: Yalavarthi S, Satya NV, Ramamurti T, Supriya M. Intermuscular hydatid cyst in the thigh: An unusual presentation. Med J DY Patil Univ 2013;6:191-3 |
Introduction | | |
Human Echinococcus infection still remains an important surgical problem in endemic regions. There have been very few reported cases of intramuscular hydatid cyst in India, but there is no reported case of intermuscular hydatid cyst. [1],[2] Here, we are reporting an unusual case of intermuscular hydatid cyst involving thigh, along with cytological and histopathologic details.
Case Report | | |
A 75-year-old male was admitted in general surgery ward with painless swelling in the posterior aspect of the left thigh since 2 years. It started as a small swelling and gradually progressed to the present size. It was not associated with ulceration and discharge. On examination, single huge mass of size 30 × 20 cm was located over the posterior aspect of left thigh. The swelling was located in the middle of thigh in between left buttock and the popliteal fossa [Figure 1]. Skin over the swelling was normal and pinchable. It was soft in consistency with lobulated surface and well-defined borders. Limb distal to swelling was normal. Ultrasonography of the abdomen and liver function tests were advised and were non-contributory. Ultrasonography of thigh was done with a high-frequency ultrasound. An 18 × 15 cm sized, hypoechoic lesion with irregular borders and eccentrically located cystic space was noted in the intramuscular plane. The impression given was soft tissue tumor with cystic change, probably hemangioma/lipoma/soft tissue sarcoma. Clinicians and radiologists opined that it was soft tissue tumor and they advised for aspiration. | Figure 1: Photograph showing huge mass of size 30 × 20 cm located over the posterior aspect of left thigh
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Fine needle aspiration (FNA) was done with a 5-ml syringe and 2 ml of clear fluid was aspirated. In view of lamellated chitinous material against eosinophilic background, hydatid cyst was thought of [Figure 2]. Surgery was planned, and peroperatively hydatid cyst was found in between the muscles and removed in toto [Figure 3]. | Figure 2: Smears made from the clear fluid show lamellated chitinous material against eosinophilic background (H and E, × 100)
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| Figure 3: (a) Photograph of excised mass immediately taken after surgery; (b) photograph showing brood capsules
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Pathological findings
The gross specimen consisted of two soft tissue masses (16 × 8 × 5 cm, 13 × 6 × 4 cm) along with multiple pearly white translucent daughter cysts of varying sizes. On cut section, there was free multiple pearly white translucent brood capsules with clear, colorless gelatinous material [Figure 4]. | Figure 4: Gross features of hydatid cyst showing two soft tissue masses along with multiple pearly white translucent daughter cysts of varying sizes
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Microscopic details
Sections revealed features of hydatid cyst exhibiting the cyst wall consisting of outer fibrous layer with fibrovascular collagenous tissue and mild to moderate chronic mononuclear inflammatory infiltrate, middle thick lamellated cuticle layer, and inner thin germinal layer with small, knob-like excrescences (gemmules) and also brood capsules [Figure 5]. | Figure 5: (a) Cyst wall of hydatid cyst having outer fibrous layer, middle lamellated cutical layer, and inner germinal layer with brood capsules (H and E, × 400); (b) section showing inner germinal layer with small, knob-like excrescences (gemmules) (H and E, × 400)
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Discussion | | |
Hydatid disease is caused by ingestion of eggs of echinococcal species. For Echinococcus granulosus, definite hosts are dogs and the usual intermediate hosts are sheep. For Echinococcus multilocularis, foxes are definite hosts and rodents are intermediate hosts. Human beings are accidental intermediate hosts, infected by ingestion of food contaminated with eggs shed by dogs. Eggs hatch in the duodenum and invade the liver, lungs, or bones.
Although it can involve any part of the body, the most commonly affected organs are liver (75%), lungs (15.4%), and spleen (5.1%). [3] The other rare sites reported are peritoneal cavity, pancreas, thyroid glands, breast, gallbladder, thigh, kidney, brain, supraclavicular region, pericardium, diaphragm, and pleural cavity. [3] Echinococcosis of the musculoskeletal system is very unusual and has a reported incidence of only 0.5-4% of patients in the literature. [4] In a series of 272 cases of hydatid cyst, thigh is reported to be involved in only 0.37% cases. [3] Usually, intramuscular hydatid cysts are secondary, resulting from the spread of cysts from other areas either spontaneously or after operations for hydatidosis in other regions. [5] The case under discussion is a primary intermuscular hydatid cyst without involving other organs.
The disease hydatid cyst or echinococcosis is a worldwide health problem, especially endemic in countries where sheep raising is common, such as Greece, Spain, Turkey, Argentina, Uruguay, Australia, New Zealand, and South Africa. Literature search showed only few case reports involving thigh muscles. The cases reported till now were from Greece, [4],[6] Turkey, [2],[5] Paris, Lebanon, [7] and Italy. [8] Only one case of intermuscular hydatid cyst was reported from Turkey. [2] All other cases were intramuscular in location involving femoral, adductor, gluteus, quadriceps, and psoas muscles. [1],[4],[5],[6],[8] There has been no reported case of intermuscular hydatid cyst in India.
Primary hydatidosis of thigh muscles, being very rare, can cause variety of diagnostic problems. The important differential diagnoses are soft tissue tumor, traumatic and developmental lesions. For this case also, clinical and ultrasound diagnosis made was soft tissue tumor. Present case was diagnosed with the help of fine needle aspiration cytology (FNAC). Although FNAC should be discouraged for the diagnosis of hydatid cyst, it has been reported to be useful to avoid complications like anaphylactic shock and local recurrence. [9]
In conclusion, although the hydatid cyst is not uncommon, the motive behind presenting this case is to suggest that hydatid disease be considered in the differential diagnosis if any clear fluid is aspirated from a huge soft tissue mass detected in the thigh, to avoid any invasive diagnostic measures which may lead to fatal complications.
References | | |
1. | Marwah S, Subramanian P, Marwah N, Rattan KN, Karwasra RK. Infected primary intramuscular echinococcosis of thigh. Indian J Pediatr 2005;72:799-800. |
2. | Cankorkmaz L, Ozturk H, Koyluoglu G, Atalar MH, Arslan MS. Intermuscular hydatid cyst in a 4-year-old child: A case report. J Pediatr Surg 2007;42:1946-8. |
3. | Safioleas M, Misiakos EP, Kakisis J, Manti C, Papachristodoulou A, Lambrou P, et al. Surgical treatment of human echinococcosis. Int Surg 2000;85:358-65. |
4. | Atmatzidis K, Koutelidakis I, Papaziogas B, Alexandrakis A, Chatzimavroudis G, Grigoriou M, et al. Primary hydatid cyst of the thigh. Chirurgia (Bucur) 2006;101:419-21. |
5. | Ates M, Karakaplan M. Hydatid cyst in the biceps and gluteus muscles: Case report. Surg Infect (Larchmt) 2007;8:475-8. |
6. | Kazakos CJ, Galanis VG, Verettas DA, Polychronidis A, Simopoulos C. Primary hydatid disease in femoral muscles. J Int Med Res 2005;33:703-6. |
7. | Abi Saad GS, Musallam KM, Korban ZR, Reslan OM, Mneimne M. Solitary hydatid cyst of the thigh: A challenging diagnosis. Vector Borne Zoonotic Dis 2009;9:743-5. |
8. | Vicidomini S, Cancrini G, Gabrielli S, Naspetti R, Bartoloni A. Muscular cystic hydatidosis: Case report. BMC Infect Dis 2007;7:23. |
9. | Giuffre G, Mondello P, Inferrera A, Furchi A, Gentile HM, Speciale G. Unexpected cytological diagnosis of two cases of echinococcosis. Pathologica 1993;85:747-53. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
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