PM R 7 (2015) 218-219
www.pmrjournal.org
Images
Primary Subcutaneous Hydatid Cyst Presenting With Low Back Pain Ayhan Duman, MD, Alparslan Yetis‚gin, MD, Ali Tosun, MD, Timur Ekiz, MD A 48-year-old woman presented with insidious onset of right lumbosacral pain. She reported dull pain that worsened progressively over several months time provoked by lying in a semisupine position with compression over the painful area. There were no specific physical examination findings. Diagnostic ultrasound (US) over the painful area revealed a multilobulated cystic structure (Figure 1). Magnetic resonance imaging (MRI) (Figure 2) confirmed the presence of a hydatid cyst (HC). She underwent surgery for excision and received antithelmintic treatment. HC is the parasitic infestation caused by tapeworms of Echinococcus granulosus. The majority of the cases involve the liver and lungs. Less than 5% of cases affect the musculoskeletal system. Although this cyst was localized to the subcutaneous fat, the patient did present with low back pain. Although most of the cysts in the musculoskeletal system remain asymptomatic for a period of time, they can present with a painful mass and compression of adjacent tissues. The cyst also can result in complications, including rupture, secondary infection, allergic reaction, neurovascular pressure, and sudden fractures [1]. Ultrasound can very likely indicate the diagnosis of HC with typical features as the first imaging tool [2]. However, MRI is required for differentiating HC from other soft-tissue masses and cysts, particularly for the primary musculoskeletal involvement without infection of any other organ. Lewall has classified HC into 3 categorizes: type I HC is the early lesion and US images feature a round/oval-shaped, anechoic, nonspecific cystic lesion with well-defined borders [2]. The cyst is hypointense on T1-weighted and hyperintense on T2-weighted MRI [3,4]. Type II HC comprises the parent cyst, many daughter cysts, and matrix within the parent cyst with/without cyst wall calcification. US images of type II HC feature a multiseptated appearance
with laminated borders without calcification [2]. MRI shows the daughter cysts as relatively hypointense on T1-weighted and hyperintense on T2-weighted relative to the matrix. Floating membranes within the cyst can be seen as a low signal intensity structure as well. Type III HC is the calcified, degenerated, and nonviable form. The cyst has irregular shape in this phase. Although US shows the calcification as the hyperechoic areas with shadowing, MRI illustrates the hypointense areas. This case represented a type II HC. HC should be considered in the differential diagnosis of cysts, especially in endemic regions such as the Mediterranean, South America, North Africa, Asia, and Australia. US and MRI are complementary imaging modalities, with US useful and convenient for follow-up examination.
Figure 1. Ultrasound image (by using Hitachi EUP L53 linear probe, Japan) shows the anechoic, well-shaped, and multiseptated cyst (type II hydatic cyst) with laminated borders. The cyst comprises the anechoic mother cyst (arrows), daughter cysts (asterisks), and matrix (m) within the mother cyst without wall calcification.
1934-1482/$ - see front matter ª 2015 by the American Academy of Physical Medicine and Rehabilitation http://dx.doi.org/10.1016/j.pmrj.2014.09.016
A. Duman et al. / PM R 7 (2015) 218-219
219
Figure 2. Magnetic resonance images illustrate type II hydatic cyst (49 28 mm). The cyst is well-shaped, multiseptated with laminated borders, hypointense to matrix on T1-weighted image (A) and hyperintense on T2-weighted image (B). Arrows: mother cyst, asterisks: daughter cysts, m: matrix.
References 1. Mandal S, Mandal MD. Human cystic echinococcosis: Epidemiologic, zoonotic, clinical, diagnostic and therapeutic aspects. Asian Pac J Trop Med 2012;5:253-260. 2. Lewall DB. Hydatid disease: Biology, pathology, imaging and classification. Clin Radiol 1998;53:863-874.
3. Polat P, Kantarci M, Alper F, et al. Hydatid disease from head to toe. Radiographics 2003;23:475-494. quiz 536-537. 4. Yuksel M, Demirpolat G, Sever A, et al. Hydatid disease involving some rare locations in the body: A pictorial essay. Korean J Radiol 2007;8:531-540.
Disclosure A.D. Department of Radiology, S‚anlıurfa Training and Research Hospital, S‚anlıurfa, Turkey Disclosure: nothing to disclose A.Y. Department of Physical Medicine and Rehabilitation, S‚anlıurfa Training and Research Hospital, S‚anlıurfa, Turkey Disclosure: nothing to disclose A.T. Department of Radiology, S‚anlıurfa Training and Research Hospital, S‚anlıurfa, Turkey Disclosure: nothing to disclose
T.E. Department of Physical Medicine and Rehabilitation, Ankara Physical Medicine and Rehabilitation Training and Research Hospital, Ankara, Turkey. Address correspondence to: T.E., Ankara Fizik Tedavi ve Rehabilitasyon Egitim ve Aras‚tırma Hastanesi, Tu ¨rkocagı St. No:3 Sıhhiye, 06230, Ankara, Turkey; e-mail: [email protected] Disclosure: nothing to disclose
Submitted for publication June 5, 2014; accepted September 23, 2014.
www.pmrjournal.org
Images
Primary Subcutaneous Hydatid Cyst Presenting With Low Back Pain Ayhan Duman, MD, Alparslan Yetis‚gin, MD, Ali Tosun, MD, Timur Ekiz, MD A 48-year-old woman presented with insidious onset of right lumbosacral pain. She reported dull pain that worsened progressively over several months time provoked by lying in a semisupine position with compression over the painful area. There were no specific physical examination findings. Diagnostic ultrasound (US) over the painful area revealed a multilobulated cystic structure (Figure 1). Magnetic resonance imaging (MRI) (Figure 2) confirmed the presence of a hydatid cyst (HC). She underwent surgery for excision and received antithelmintic treatment. HC is the parasitic infestation caused by tapeworms of Echinococcus granulosus. The majority of the cases involve the liver and lungs. Less than 5% of cases affect the musculoskeletal system. Although this cyst was localized to the subcutaneous fat, the patient did present with low back pain. Although most of the cysts in the musculoskeletal system remain asymptomatic for a period of time, they can present with a painful mass and compression of adjacent tissues. The cyst also can result in complications, including rupture, secondary infection, allergic reaction, neurovascular pressure, and sudden fractures [1]. Ultrasound can very likely indicate the diagnosis of HC with typical features as the first imaging tool [2]. However, MRI is required for differentiating HC from other soft-tissue masses and cysts, particularly for the primary musculoskeletal involvement without infection of any other organ. Lewall has classified HC into 3 categorizes: type I HC is the early lesion and US images feature a round/oval-shaped, anechoic, nonspecific cystic lesion with well-defined borders [2]. The cyst is hypointense on T1-weighted and hyperintense on T2-weighted MRI [3,4]. Type II HC comprises the parent cyst, many daughter cysts, and matrix within the parent cyst with/without cyst wall calcification. US images of type II HC feature a multiseptated appearance
with laminated borders without calcification [2]. MRI shows the daughter cysts as relatively hypointense on T1-weighted and hyperintense on T2-weighted relative to the matrix. Floating membranes within the cyst can be seen as a low signal intensity structure as well. Type III HC is the calcified, degenerated, and nonviable form. The cyst has irregular shape in this phase. Although US shows the calcification as the hyperechoic areas with shadowing, MRI illustrates the hypointense areas. This case represented a type II HC. HC should be considered in the differential diagnosis of cysts, especially in endemic regions such as the Mediterranean, South America, North Africa, Asia, and Australia. US and MRI are complementary imaging modalities, with US useful and convenient for follow-up examination.
Figure 1. Ultrasound image (by using Hitachi EUP L53 linear probe, Japan) shows the anechoic, well-shaped, and multiseptated cyst (type II hydatic cyst) with laminated borders. The cyst comprises the anechoic mother cyst (arrows), daughter cysts (asterisks), and matrix (m) within the mother cyst without wall calcification.
1934-1482/$ - see front matter ª 2015 by the American Academy of Physical Medicine and Rehabilitation http://dx.doi.org/10.1016/j.pmrj.2014.09.016
A. Duman et al. / PM R 7 (2015) 218-219
219
Figure 2. Magnetic resonance images illustrate type II hydatic cyst (49 28 mm). The cyst is well-shaped, multiseptated with laminated borders, hypointense to matrix on T1-weighted image (A) and hyperintense on T2-weighted image (B). Arrows: mother cyst, asterisks: daughter cysts, m: matrix.
References 1. Mandal S, Mandal MD. Human cystic echinococcosis: Epidemiologic, zoonotic, clinical, diagnostic and therapeutic aspects. Asian Pac J Trop Med 2012;5:253-260. 2. Lewall DB. Hydatid disease: Biology, pathology, imaging and classification. Clin Radiol 1998;53:863-874.
3. Polat P, Kantarci M, Alper F, et al. Hydatid disease from head to toe. Radiographics 2003;23:475-494. quiz 536-537. 4. Yuksel M, Demirpolat G, Sever A, et al. Hydatid disease involving some rare locations in the body: A pictorial essay. Korean J Radiol 2007;8:531-540.
Disclosure A.D. Department of Radiology, S‚anlıurfa Training and Research Hospital, S‚anlıurfa, Turkey Disclosure: nothing to disclose A.Y. Department of Physical Medicine and Rehabilitation, S‚anlıurfa Training and Research Hospital, S‚anlıurfa, Turkey Disclosure: nothing to disclose A.T. Department of Radiology, S‚anlıurfa Training and Research Hospital, S‚anlıurfa, Turkey Disclosure: nothing to disclose
T.E. Department of Physical Medicine and Rehabilitation, Ankara Physical Medicine and Rehabilitation Training and Research Hospital, Ankara, Turkey. Address correspondence to: T.E., Ankara Fizik Tedavi ve Rehabilitasyon Egitim ve Aras‚tırma Hastanesi, Tu ¨rkocagı St. No:3 Sıhhiye, 06230, Ankara, Turkey; e-mail: [email protected] Disclosure: nothing to disclose
Submitted for publication June 5, 2014; accepted September 23, 2014.
