Diagnostic and Interventional Imaging (2013) 94, 1157—1160

RADIOLOGIC PATHOLOGIC CORRELATION / Gastrointestinal imaging

Peritoneal hydatidosis and hepatic hydatid cyst perforation H. Benhamiche a,∗, D. Sottier a, M. Funes De La Vega b, B. Cuisenier c, N. Mejean a, D. Krausé a a

Department of radiology and of diagnostical and therapeutic medical imaging, CHU de Dijon, 14, rue Gaffarel, 21079 Dijon, France b Department of pathological anatomy and cytology, CHU de Dijon, 14, rue Gaffarel, 21079 Dijon, France c Department of parasitology and mycology, CHU de Dijon, 14, rue Gaffarel, 21079 Dijon, France

KEYWORDS Hydatidosis; Peritoneal rupture; Cyst; Child

∗

Case report This is a rare case of secondary late asymptomatic peritoneal hydatidosis revealed by the imaging carried out for post-traumatic rupture of a hepatic hydatid cyst. A 10-year-old boy, born in Rumania, consulted for generalised hives treated by intravenous corticotherapy (Solumedrol® ) and antihistamines (Polaramine® ). The next day, he was hospitalised for intense abdominal pain and then reported a recent abdominal trauma (several days before). The abdominal sonography and then the CT-scan detected a cyst enclosing an echogenic membrane of the right liver 8 cm in diameter (Fig. 1), echogenic peritoneal effusion of average abundance and a multivesicular cyst of the right iliac fossa of 7.5 cm (Fig. 2). The diagnosis of hydatidosis was raised. The lab tests detected anaemia (Hb: 10.9 g/dl) and hyperleukocytosis with CRP at 92 mg/l. The surgeons operated in emergency and then saw a ruptured hydatid cyst on hepatic segment VII with haemoperitoneum and a non-ruptured cyst in the greater omentum extending by a thin opening towards the anterior side of the liver. They performed a resection of the protruding dome of the cysts and a peritoneal cleansing with isotonic solution with drainage. The macroscopic (Fig. 3) and parasitological (Fig. 4) examination confirmed the diagnosis by detecting multiple intracystic daughter vesicles and the presence of scolex and hooks of Ecchinococcus granulosus in the peritoneal fluid. Treatment with Albendazole® was prescribed for 3 months.

Corresponding author. E-mail address: [email protected] (H. Benhamiche).

2211-5684/$ — see front matter © 2013 Éditions françaises de radiologie. Published by Elsevier Masson SAS. All rights reserved. http://dx.doi.org/10.1016/j.diii.2013.04.009

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Figure 1. Ruptured hepatic cyst. a: CT examination with star-shaped appearance characteristic of the floating nature of the detached membrane; b: corresponding sonographic appearance with undulating and floating echogenic membrane in the cyst contents.

Figure 2. Cyst of the greater omentum. a: CT examination revealing a type 3 peritoneal cyst according to Gharbi’s classification with daughter vesicles without enhancement of their wall; b: ‘‘honeycomb’’ or ‘‘wheel spoke’’ appearance representing the multiple daughter vesicles.

Discussion Hydatidosis is a severe zoonosis, endemic in the Mediterranean region, Latin America and Oceania. In France, the

Figure 3. Macroscopy after surgery. Discus proligerus of the ruptured hepatic cyst in the peritoneal cavity (black arrow). Peritoneal cyst intact with incision of its membrane during the anatomopathology revealing multiple endocystic daughter vesicles (white arrow).

cases detected are specific to the arrival of immigrants (Maghreb, Eastern Europe. . .). Human contamination occurs through the ingestion of foods contaminated by dog faeces containing E. granulosus eggs. Peritoneal hydatidosis is one of the serious complications of the disease with a frequency ranging from 4.5 to 6.9% according to the series [1]. Often associated with another visceral location, it affects all ages and all segments of the peritoneal cavity. The rare, primitive form occurs by haematogenic contamination [2]. The secondary form (85% of the cases) includes the acute intraperitoneal cystic ruptures and the late forms after preoperative contamination (insufficient protection of the operating fields, ineffective scolicidal solution) or cyst perforation after a low intensity or spontaneous abdominal trauma (favoured by the superficial seat of the cyst, its large size, a thin wall and high intracystic pressure [3]). The sonography, in first intention, helps confirm the diagnosis and assess the number, location and anatomic relationship of the cysts. The sensitivity is high (between 90 and 100%) allowing for better visualisation of the endocavity vesicles or the partial detachment of the membrane [1]. However, its topographic reliability is lower than that of CT examination that also allows for an optimum analysis of the calcifications and the relationship with the urinary

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Figure 4. Parasitological examination; a: scolex hooks revealed in the peritoneal fluid punctured during the surgery confirming the diagnosis of hydatidosis; b: microscopic appearance of a scolex of Ecchinococcus granulosus.

or vascular tract avoiding examinations with more exposure to radiation (angiography. . .). The MRI indications are dominated by the study of the biliary and vascular complications [4]. Different authors have proposed classifications initially based on sonography for hepatic cysts that can be used for the analysis of all cysts both in sonography and in CT and MRI [4]. The classification by Gharbi et al., most often used, comprises five evolving stages, taking into account the echostructure of the cyst contents, the presence of a floating membrane, daughter vesicles or parietal calcifications: • type 1: simple univesicular cyst, under pressure, in the form of a round lesion, with a thin wall, purely anechogenic in sonography with posterior enhancement and with hypodense content in the CT-scan, without enhancement after iodine injection; • type 2: differs from type 1 by the presence of seemingly floating hyperechogenic membrane detachment with a ‘‘star-shaped’ image (pathognomonic of the hydratic cyst); • type 3: multivesicular cyst (daughter vesicles), with isoor hypoechogenic content of the vesicles with respect to that of the mother cyst; • type 4: heterogeneous with very polymorphous sonographic appearance and more or less regular contours. In the CT-scan, the daughter vesicles become rare and are

arranged at the periphery of the cyst, calcifications are more frequent with a denser mother cyst content. The pericyst is thicker and may be spontaneous dense due to the calcifications; • type 5: entirely calcified with sonography study restricted due to a posterior cone of shadow artefacting the analysis of the wall. The CT-scan reveals peripheral calcifications, in a ring or massive that may provide a heterogeneous «curled up» appearance if there is impairment of the matrix. Lewall’s classification proposes a classification specific for the cyst and its ruptures while the classification by the World Health Organization Informal Working Group Echinococcus (WHO-IWGE) [5] is based on the viability of the cyst, introducing the idea of fertile or infertile lesion (Table 1). The presence of a peritoneal hydatid cyst requires careful surgery (resection of the protruding dome), often associated with a pre- and post-surgical anti-parasitic treatment (Albendazole® ) to reduce the risk of recurrence [2]. With acute rupture, surgery is performed on an emergency basis with the evacuation of the peritoneal effusion and careful cleaning associated with the cure of the perforated cyst [3]. The prognosis of peritoneal hydatidosis depends on the general state and the compliance of the patient and the visceral locations. The morbidity is due to the risk of deep

Table 1 Lewall and World Health Organization Informal Working Group Echinococcus (WHO-IWGE) classifications in sonography. Lewall’s classification

Sonography

WHO-IWGE classification

Sonography

Type 1 Type 2 Type 3 Rupture

Unilocular Multilocular Calcified Contained Communicating Direct

CL CE1 CE2 CE3 CE4 CE5

Unilocular cyst, without its own wall Unilocular cyst with wall Multivesicular cyst Cyst with membrane detachment Heterogeneous, pseudotumoral cyst Calcified cyst

CL: cystic lesion; CE: cystic echinococcosis.

1160 infected collections (Douglas, sub-phrenic. . .) and recurrence (10 to 18%) by sub-serous grafts [1]. In the acute ruptures, the morbidity is related to the gravity of the peritonitis but does not exceed 5% in the recent series [3].

Conclusion Hydatidosis is a parasitosis that is rare in France and its peritoneal location only accounts for a few dozen cases per year. The diagnosis may easily be suspected by sonography and specified by the CT-scan (location, calcifications. . .) and is confirmed by the parasitological examination.

Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.

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