Percutaneous treatment of an orbital hydatid cyst: a new therapeutic approach

Percutaneous treatment of liver hydatid cysts: to PAIR or not to PAIR

PURPOSE OF REVIEW

The aim is to review recent literature for percutaneous treatment of liver hydatid cysts (cystic echinococcosis: CE) via different techniques such as PAIR (puncture, aspiration, injection, and reaspiration), standard catheterization, and modified catheterization technique (MoCaT).

RECENT FINDINGS

PAIR is an established technique and considered to be safe and effective for CE1 and CE3a as it is associated with lower morbidity, mortality, recurrence, and shorter hospital stay as compared with surgery. Standard catheterization is also dedicated for the treatment of CE1 and CE3a. PAIR should be preferred for treatment of liver CE1 and CE3a cysts, since PAIR is associated with lower major complication rates and shorter hospital stay. However, standard catheterization technique is indicated when cysto-biliary fistula develops or any technical difficulty arises during the PAIR. In these cases it is needed to switch PAIR to standard catheterization to complete the procedure.

SUMMARY

For CE1 and CE3a cysts, PAIR and standard catheterization are the choice for percutaneous treatments, while MoCaT is a treatment option for CE2 and CE3b cysts.

A case and literature review of intraocular echinococcus causing bilateral visual loss in a HIV-infected patient

Although echinococcosis is a common parasitic disease endemic to Africa, ocular echinococcosis is rare. We present a case of intraocular echinococcosis in a HIV-infected patient. A 38-year-old South African HIV-infected woman presented to a district-level hospital in Kwa-Zulu Natal on 10 March 2020. Her main presenting complaint was that of progressive, painless, bilateral visual loss. A B-ultrasonography scan revealed tractional retinal detachment on the right eye, while the left eye had tractional bands with a ‘double-walled’ cystic cavity causing retinal traction. A systemic work-up revealed a positive Echinococcus ELISA IgG with a value of 1.3, eosinophilia of 5.70% (0.41 × 109), and elevated C-reactive protein and erythrocyte sedimentation rate of 47 mg/L and 93 mm/hr, respectively. Based on the above clinical, biochemical and ultrasonographical evidence, a diagnosis of ocular echinococcosis was made. Our differential diagnosis includes toxic optic neuropathy, Jarisch-Herxheimer-like reaction secondary to immune reconstitution and necrotizing herpetic retinitis. She was initiated on topical and intravitreal steroids which led to decreased intraocular inflammation and dry maculae. Five months after presentation, her visual acuity remained unchanged with no light perception in both eyes. We conclude that ocular echinococcosis, although rare, can lead to severe visual impairment as there are no known definite treatment modalities for intraocular hydatid disease. Reports on co-infections with HIV and Echinococcus are limited with a potential scope for research.

The Echinococcoses: Diagnosis, Clinical Management and Burden of Disease

The echinococcoses are chronic, parasitic diseases that are acquired after ingestion of infective taeniid tapeworm eggs from certain species of the genus Echinococcus. Cystic echinococcosis (CE) occurs worldwide, whereas, alveolar echinococcosis (AE) is restricted to the northern hemisphere, and neotropical echinococcosis (NE) has only been identified in Central and South America. Clinical manifestations and disease courses vary profoundly for the different species of Echinococcus. CE presents as small to large cysts, and has commonly been referred to as 'hydatid disease', or 'hydatidosis'. A structured stage-specific approach to CE management, based on the World Health Organization (WHO) ultrasound classification of liver cysts, is now recommended. Management options include percutaneous sterilization techniques, surgery, drug treatment, a 'watch-and-wait' approach or combinations thereof. In contrast, clinical manifestations associated with AE resemble those of a 'malignant', silently-progressing liver disease, with local tissue infiltration and metastases. Structured care is important for AE management and includes WHO staging, drug therapy and long-term follow-up for at least a decade. NE presents as polycystic or unicystic disease. Clinical characteristics resemble those of AE, and management needs to be structured accordingly. However, to date, only a few hundreds of cases have been reported in the literature. The echinococcoses are often expensive and complicated to treat, and prospective clinical studies are needed to better inform case management decisions.

Large primary intraorbital hydatid cyst in elderly

We report a case of solitary, primary intraorbital hydatid cyst in a elderly female aged 80 years who presented with nontender, nonpulsatile proptosis of left eye with diminution of vision. MRI scan of the head and the orbits, revealed a retro-bulbar cyst. Surgical excision was performed by employing a lateral orbitotomy approach. Histopathology report confirmed hydatid cyst.

Orbital hydatid cyst

Hydatid cysts rarely appear isolated in the orbital cavity without involvement of other organs. Most of these are situated in the superolateral and superomedial angles of the orbit. Inferiorly located cysts are very uncommon. The authors report a case of a primary hydatid cyst of the orbit with inferiolateral localization. The cyst was enucleated surgically via a rhinotomy approach. This case was considered as a primary infection, because there was no previous history of hydatid disease and no findings of liver and lung cysts on radiological examination. Physicians should include orbital hydatid cyst in the differential diagnosis of unilateral proptosis. To avoid complications that might occur during surgery, the cyst can be easily removed using a gentile enucleation technique.

Orbital hydatid cyst

Hydatid cysts rarely appear in the orbital cavity without the involvement of the other organs. Most of them are situated in the superolateral and superomedial angles of the orbit. Inferiorly located cysts are very uncommon. The authors report a case of a primary hydatid cyst of the orbit with inferolateral localization. The cyst was removed surgically via a frontotemporoorbitozygomatic approach combination with puncture-aspiration-injection-reaspiration technique. This case was considered as a primary infection, because there was no previous history of hydatid disease and no findings of liver and lung cysts on radiological examination. Physicians should include orbital hydatid cyst in the differential diagnosis of unilateral proptosis. To avoid complications that might occur during surgery, the cyst can be easily removed using the combination technique detailed in this report.

Two different presentations of orbital echinococcosis: a report of two cases and review of the literature

PURPOSE

To report two patients with different presentations of orbital echinococcosis, namely hydatid and alveolar cysts and to compare their clinical, imaging and histopathologic findings and treatment.

METHODS

This retrospective study includes two young rural children who were referred because of progressive proptosis.

RESULTS

Orbital imaging in both cases revealed cystic intraorbital lesions. With a clinical suspicion of hydatid and alveolar cysts, both patients underwent intact surgical excision. Histopathologic evaluation confirmed the diagnoses.

CONCLUSIONS

Clinical findings and imaging can help in the preoperative diagnosis of patients with orbital echinococcosis. Knowledge of the nature of cystic orbital lesions is important in preventing complications. Alveolar cysts are more invasive than hydatid cysts and their treatment is more complicated.

Long-term follow-up of the percutaneous treatment of hydatid cyst in the adrenal gland: a case report and review of the literature

Although the most involved organs are liver and lung, hydatid cysts occur in adrenal glands, rarely, and constitute only 0.5% of hydatid cysts. Herein, we demonstrate and discuss, for the first time in the literature to the best of our knowledge, the radiological features of adrenal hydatid disease and evaluate the long-term results (57 months of follow-up) of the percutaneous treatment of hydatid cyst in the adrenal gland in a patient.

Sonographic spectrum of hydatid disease

Hydatid disease, caused by Echinococcus granulosus, is a parasitic disease that is endemic in many parts of the world. Hydatid cyst demonstrates a variety of imaging features, varying according to growth stage, associated complications, and affected tissue. The radiologic findings range from purely cystic lesions to a completely solid appearance. Ultrasound is the most important imaging modality for liver hydatid disease and clearly demonstrates the floating membranes, daughter cysts, and hydatid sand characteristically seen in purely cystic lesions. The radiologist's familiarity with the imaging findings of the disease is very important for earlier diagnosis and an appropriate treatment. There are several classification schemes for liver hydatid cysts based on their ultrasound appearances; the initial classification by Gharbi et al and the World Health Organization classification are the most commonly preferred. Computed tomography and magnetic resonance imaging play a key role in recognizing the complications such as rupture and infection of cysts associated with hydatid disease. Today, percutaneous treatment of liver hydatid cysts, a safe, easily applicable, and well-tolerated method, has become the most effective and reliable treatment procedure in most cases if the hydatid cyst is viable. In patients treated with the percutaneous treatment technique, a decrease in the dimensions of the cyst, solidification of the cyst contents, and irregularity in the walls of cysts are signs suggestive of cure. The radiologist should also be familiar with the postoperative follow-up ultrasound findings of hydatid cyst to prevent misinterpretation of the hypoechoic, anechoic, or hyperechoic appearance of posttreatment hydatid disease appearance as recurrence.

[Orbital hydatid cyst]

CASE

A 72-year-old man presented with left exophthalmia, impaired visual acuity and ocular pain. CT revealed a posterolateral homogeneous unilocular cyst in the left orbital cavity. Ultrasound showed a 38 x 17 mm purely cystic retro-ocular thin lined mass. Hydatid serologic tests were positive. The cyst was completely enucleated, after irrigation with hypertonic saline solution. The diagnosis was confirmed histologically.

DISCUSSION

The orbital hydatic cyst is a rare pathology in Western countries but remains relatively frequent in North-African countries. It can be observed in urban centers a high percentage of immigrant population. It is thus necessary to keep this pathology in mind when confronted to an intra-orbital cystic formation and to avoid its rupture.

Diagnosis and percutaneous treatment of soft-tissue hydatid cysts

The purpose of this study is to demonstrate and discuss the radiological features of four patients with muscular hydatid disease and to evaluate the results of percutaneous treatment in these patients. Four patients (three female and one male) with six muscular hydatid cysts underwent percutaneous treatment and were followed up. The mean age of patients was 35 years (range: 12-60 years). Type I (n = 2), type II (n = 1), and type III (n = 3) hydatid cysts were observed in the thigh (n = 3) and gluteal (n = 1) region on radiologic examination. All interventions were performed under sonographic and fluoroscopic guidance. According to the type of the cyst, the procedure was carried out by either a "catheterization technique with hypertonic saline and alcohol" or a "modified catheterization technique." The mean cathaterization time was 13.7 days, ranging from 1 to 54 days. The dimensions of the residual cavity were noted at every sonographic control, and an average of 96.1% volume reduction was obtained in six cysts of four patients. No sign of viability was observed during the follow-up period. Cavity infection and cellulitis were observed as complications, which resolved after medical therapy. Percutaneous treatment is a safe and effective procedure in patients with soft-tissue hydatid cysts and should be considered as a serious alternative to surgery.

Unusual imaging characteristics of complicated hydatid disease

Hydatid disease, a worldwide zoonosis, is caused by the larval stage of the Echinococcus tapeworm. Although the liver and the lungs are the most frequently involved organs in the body, hydatid cysts of other organs are unusual. Radiologically, they usually demonstrate typical imaging findings, but unusual imaging characteristics of complicated cyst of hydatid disease, associated with high morbidity and mortality, are rarely described in the literature. The purpose of this study is to review the general features of hydatidosis and to discuss atypical imaging characteristics of the complicated hydatid disease in the human, with an emphasis on structure and rupture of the cystic lesion as well as ultrasonography (USG), computed tomography (CT), and magnetic resonance imaging (MRI) features of the disease. In our study, the available literature and images of the cases with complicated hydatidosis involving liver, lung, brain, spine and orbit were reviewed retrospectively. In hydatid disease, there are many potential local and systemic complications due to secondary involvement in almost any anatomic location in humans. Radiologically, in addition to the presence of atypical findings such as perifocal edema, non-homogenous contrast enhancement, multiplicity or septations and calcification, various unusual manifestations due to rupture or infection of the cyst have been observed in our cases with complicated hydatid disease. To prevent subsequent acute catastrophic results and the development of recurrences in various organs, it should be kept in mind that complicated hydatid cysts can cause unusual USG, CT, and MRI findings, in addition to typical ones, in endemic areas. Therefore, familiarity with atypical radiological appearances of complicated hydatid disease may be valuable in making a correct diagnosis and treatment.

Orbital Hydatid Cyst in Childhood: A Report of Two Cases

Intraorbital hydatid disease (IHD) is quite rare and represents < 1% of the Echinococcus cases. In our current communication, we report two children with solitary, primary intraorbital hydatid cysts. Both children presented with nontender, nonpulsatile proptosis. Imaging workup, including CT and MRI scans of the head and the orbits, revealed a retro-bulbar cyst in both patients. Surgical resection was performed by employing a fronto-temporo-orbito-zygomatic (FTOZ) approach. Accidental intraoperative rupture occurred in one case with no further consequences. Albendazole was postoperatively employed for 12 weeks. Outcome was excellent in both cases with complete resolution of their symptoms and complete visual recovery. Pertinent literature was reviewed with this opportunity.

[Adenocarcinoma in a pleomorphic adenoma of the lacrimal gland: a case study]

PURPOSE

To report a patient with an adenocarcinoma in a pleomorphic adenoma of the lacrimal gland. Adenocarcinoma constitutes a distinct group of epithelial malignancies of the lacrimal gland.

METHODS

The clinical presentation, workup, surgical approach, and pathological findings were reviewed.

RESULTS

A 56-year-old man presented with a 3-month history of a lacrimal fossa mass. This patient presented a painless mass in the upper outer eyelid with significant displacement of the globe. The tumor was localized to the lacrimal gland. Radiological investigations showed a round, well-defined lesion in the fossa of the lacrimal gland. We performed a lateral orbitotomy; en bloc resection was accomplished. The final specimen showed an adenocarcinoma in a pleomorphic adenoma. No recurrences were detected during follow-up.

CONCLUSION

Although adenocarcinoma has rarely been reported in association with a pleomorphic adenoma of the lacrimal gland, this combination can exist. If the malignant tumor is limited in the pleomorphic adenoma, the prognosis appears to be better than in cases of local extension. Adjuvant therapy, radiation or others, are not useful.

Hydatidosis of the Orbit in Turkey: Results from Review of the Literature 1963–2001

Hydatidosis can involve almost every organ or tissue in the body via the systemic circulation, but hydatid infestation of the orbit comprises far less than 1% of the total incidence. This study investigated the data on all patients of orbital hydatid disease reported in Turkey since 1963. In this meta-analysis, a total of 25 patients were included and slowly progressive unilateral proptosis, with or without pain, was the most frequent clinical manifestation (80%). The other presenting symptoms were visual loss (48%), periorbital pain (24%), chemosis (16%), and headache (12%). The presumptive diagnosis of hydatid cyst was made on the images obtained from ultrasonography (US), computed tomography (CT) and/or magnetic resonance imaging (MRI) examinations. These diagnostic studies demonstrated a well-circumscribed cystic mass in almost all patients. Total surgical removal without rupture remains the best mode of therapy for orbital hydatid disease. The study indicates that in Turkey hydatidosis remains a serious problem, causing blindness. Orbital hydatid cyst should be included in the differential diagnosis of unilateral proptosis and visual handicap in patients from countries where hydatidosis is endemic.

Successful Surgical Management of an Intraorbital Hydatid Cyst through a Transmaxillary Approach: Case Report

A patient with an intraorbital hydatid cyst was treated successfully through a transmaxillary approach. Numerous procedures to remove intraorbital hydatid cysts are discussed.

Vitreoretinal surgery for a subretinal hydatid cyst

PURPOSE

To report the vitreoretinal surgery for management of a subretinal hydatid cyst.

METHODS

Conventional pars plana vitrectomy was performed for the removal of a subretinal hydatid cyst and treatment of retinal detachment in the right eye (RE) of a 34-year-old woman. The cyst content was aspirated by a flute needle after retinotomy and cystotomy. The cyst wall was separated from overlying retina and removed. The retina was attached by liquid perfluorocarbon and silicone oil. Postoperatively, the patient was followed for 15 months.

RESULTS

After vitreoretinal surgery, the retina RE was attached and recurrence of hydatid disease was not seen in vitreous cavity or subretinal space during the follow-up period. Visual acuity increased from counting fingers to 20/63 at the end of the follow-up time.

CONCLUSION

A subretinal hydatid cyst that causes retinal detachment may be treated effectively with vitreoretinal surgery.

Treatment of hydatid disease

Hydatid disease caused by Echinococcus granulosus presents medical, veterinary and economic problems worldwide. Hydatidosis can be treated by medical, surgical and percutaneous modalities. Benzoimidazole carbamates are effective against E. granulosus. Although mebendazole, the first benzoimidazole used, has some beneficial effects on the disease in selected patients, it has also been associated with treatment failure in some cases, perhaps because of its poor absorption. Albendazole, a more recently developed benzoimidazole, is more effective than mebendazole. Praziquantel, an isoquinoline derivative, has recently shown value in the treatment of human echinococcal disease and its use in combination with albendazole is recommended in some patients. Ultrasound guided cyst puncture is another choice of treatment which has been used successfully in selected patients, although anaphylactic and allergic reactions due to spillage of the cyst contents have occurred. Surgical therapy in echinococcal hydatid disease is indicated for large cysts with multiple daughter cysts, superficially located single liver cysts which have a risk of rupture, complicated cysts such as those accompanied by infection, compression or obstruction, and cysts located in vital organs or which are exerting pressure on adjacent vital organs. However, surgical therapy carries high risk of mortality, morbidity or recurrence. Therefore, medical therapy may be an alternative option in uncomplicated cysts and in patients at high risk from surgery. The adjuvant use of drugs with surgery and percutaneous treatment can also be recommended for some patients.

Maxillofacial hydatid cysts

We report 2 cases of hydatid cysts occurring in the submandibular gland and buccal submucosa, respectively. Our first case occurred in the submandibular salivary gland of a 20-year-old woman and the second involved the buccal submucosa of a 6-year-old boy. Both diagnoses were made after the excision of the lesions. Both patients were evaluated after surgery, and both were followed up, but no other organs were involved.

Percutaneous treatment of liver hydatid cysts

Hydatic disease caused by Echinococcus granulosus is an endemic disease and an important public health problem in some countries of the world. The results of surgical treatment are associated with a high rate of mortality, morbidity, postoperative recurrence and a long period of hospital stay and the medical treatment results are still controversial. Although the percutaneous aspiration and treatment of liver hydatid cysts were considered to be contraindicated due to risks of anaphylactic shock and dissemination of clear-crystal fluid into the abdomen, several reports of successful percutaneous treatment of liver hydatid cysts have been published in the literature. Today, percutaneous treatment of liver hydatid cysts is the most effective and reliable treatment procedure in the selected cases. In this review, indications, contraindications, method and techniques, healing criteria, complications, results and importance of the percutaneous treatment of liver hydatid cysts are discussed.