Spectrum of imaging findings in pediatric hydatid disease

Pulmonary echinococcosis mimicking tuberculosis in a child from a dual-endemic region: a case report

Background

Pulmonary echinococcosis represents a significant health challenge, particularly in endemic regions, and is associated with substantial morbidity and mortality. Its nonspecific clinical presentation and radiological diversity often lead to misdiagnosis. Here, we report a case of pulmonary echinococcosis initially misdiagnosed as pulmonary tuberculosis.

Case presentation

We report a case of a 13-year-old girl from a region endemic for both echinococcosis and tuberculosis. She initially presented with recurrent cough, hemoptysis, night sweats, and a pulmonary cystic lesion and was diagnosed with pulmonary tuberculosis. However, her condition progressively deteriorated despite antituberculosis therapy. Ultimately, surgical intervention and histopathological examination confirmed pulmonary echinococcosis, and the patient achieved complete recovery after therapy.

Conclusion

For patients from regions endemic for both tuberculosis and echinococcosis who present with cough, hemoptysis, or pulmonary cystic or cavitary lesions, it is crucial to differentiate pulmonary echinococcosis from pulmonary tuberculosis. The final diagnosis should be supported by other microbiological-serological and/or histopathological tests.

Tension Hydropneumothorax Caused by a Ruptured Hydatic Cyst in the Pleural Cavity: Case Report

Hydatid disease is a zoonosis caused by a larva of the tapeworm Echinococcus. All organs can be involved, but it is frequently located in liver for adults and lung for children. The clinical features are nonspecific. Imaging findings has an important place in the diagnosis and the follow-up. Rupture is the most common complication of a hydatic cyst and has a variety of imaging findings depending on the ruptured layer, the amount of air within the cyst and the type rupture. We report the case of a 10-year-old boy presenting shortness of breath and fever among other symptoms revealing by chest X-ray and thoracic CT scan, a lung ruptured hydatic cyst to the pleural cavity causing a tension hydro-pneumothorax and a superadded infection.

Proteomics investigation of human sera for determination of postoperative indicators of pulmonary cystic echinococcosis

BACKGROUND

Cystic echinococcosis (CE)/hydatidosis is an important zoonotic parasitic disease caused by the larval stage of Echinococcus granulosus. The disease is a major health problem all over the world. Finding specific and sensitive biomarkers for follow-up of CE in patients after surgery is essential. Using proteomics methods, the present study aimed to evaluate post-surgical treatment by finding probable biomarker/s in the serum of human lungs CE.

METHODS

A total of 24 human sera were tested. These sera included eight confirmed lung/s CE patients sera before surgery (BS), eight sera 12 months post-surgery (12MPS) as well as eight control sera from healthy people. Proteomics methods including 2DE and LC-MS/MS were performed on the specimens followed by bioinformatics analysis. Differentially expressed proteins (DEP) were detected and, separately integrated with protein-protein interaction (PPI) data to construct the PPI network.

RESULTS

A total of 171 protein spots were detected in three groups including BS, 12MPS, and control groups; of which a total of 106 DEP have been expressed based on fold changes > = 2 and p-value < 0.05. More analysis was performed and a total of 10 protein spots were selected for identification by mass spectrometry showing the following proteins: APOA1, BGN, SPP2, EAF1, ACOXL, MRPL55, MCTP2, SEPTIN1, B4GALNT1, and ZNF843. Based on centrality parameters of the PPI network (degree and betweenness) five Hub-bottlenecks proteins with significant centrality values were found including APOA1, BGN, SPP2, EAF1, and ACOXL.

CONCLUSION

This study showed five proteins as hub-bottleneck proteins; of which APOA1 was more prominent. It can be concluded that a change in expression of this protein in patients' sera could be used as an indicator tool for the achievement of lungs CE surgical therapy.

Paediatric pulmonary echinococcosis: A neglected disease

Echinococcosis is a worldwide public health problem causing considerable paediatric morbidity and mortality in endemic areas. The presentation of cystic echinococcosis (CE) varies by age. Unlike adults, where hepatic involvement is common, pulmonary CE is the dominant site in the paediatric population. Pulmonary cysts are typically first seen on chest X-ray, either as an incidental finding or following respiratory symptoms after cyst rupture or secondary infection of the cyst. In children, pulmonary cysts have a broad differential diagnosis, and a definitive diagnosis relies on the combination of imaging, serology, and histology. In countries with high infectious burdens from diseases such as acquired immunodeficiency syndrome (AIDS) and tuberculosis (TB), the diagnosis is additionally challenging, as atypical infections are more common than in developed countries. Pulmonary CE is treated with a combination of surgery and chemotherapy.

Hydatid cyst in the third ventricle of the brain: case report of an exceptionally rare condition

Hydatid disease is an endemic zoonotic disease caused by the cestode Echinococcus multilocularis and Echinococcus granulosus. Intra-ventricular hydatid cysts are extremely rare. Even more rarely, and to the best of our knowledge, only three cases of third ventricle involvement have been reported. Herein, we present the fourth case of an intraventricular hydatid cyst in a pediatric patient located in the third ventricle. It is about a 7-year-old girl, of a rural origin, admitted for intracranial hypertension, deterioration of the general status, and weakness on the right side of her body. A cerebral magnetic resonance imaging (MRI) showed the presence of a rounded cystic formation in the third ventricle. The patient was operated through a transfrontal transventricular approach, and the cyst was removed. Postoperative course was uneventful. Hydatid disease should be considered part of the differential diagnosis for cystic lesions of the central nervous system, especially in endemic regions. Total removal of the cysts without rupture is a challenge, but best treatment remains an active nationwide prevention.

Bilateral Pulmonary Hydatid Cyst in a Young Child: A Rare Case Report from North India

Echinococcosis or hydatid disease is caused by the larval stage of the dog tapeworm, that is, Echinococcus granulosus , E. multilocularis , E. vogeli , or E. oligarthrus . Echinococcus granulosus causes cystic echinococcosis, which has a worldwide distribution. Liver is the most common site, affecting approximately two-third of the patients, whereas lung involvement is seen in approximately 25% of cases. This case is a very rare scenario of bilateral pulmonary hydatid cysts in a young child having exposure to a pet dog with negative hydatid serology and normal eosinophil count.

Magnetic resonance imaging as an adjunct to computed tomography in the diagnosis of pulmonary Hydatid cysts

Introduction:

Although pulmonary hydatid cysts can be diagnosed on computed tomography (CT), sometimes findings can be atypical. Other hypodense infective or neoplastic lesions may mimic hydatid cysts. We proposed that magnetic resonance imaging (MRI) may act as a problem-solving tool, aiding the definite diagnosis of hydatid cysts and differentiating it from its mimics. The aim of this study is to assess the findings of pulmonary hydatid cysts on CT and MRI and the additional contribution of MRI in doubtful cases.

Materials and Methods:

This is a retrospective study of 90 patients with suspected hydatid cysts. CT and MRI findings were noted and role of MRI in diagnosing hydatid cysts and its mimics was studied. Descriptive statistics for CT findings and sensitivity and specificity of MRI were calculated using surgery or histopathology as gold standard.

Results:

Of the 90 patients with suspected pulmonary hydatid cysts, there were 52 true-positive and 7 false-positive cases on CT. Commonest CT finding was unilocular thick-walled cyst. In the 26 patients who had additional MRI, based on T2-weighted hypointense rim or folded membranes, accurate preoperative differentiation of 14 patients with hydatid cysts from 10 patients with alternate diagnosis was possible. There was one false-positive and one false-negative case on MRI.

Conclusion:

Although hydatid cyst can be diagnosed on CT on most occasions, sometimes there are challenges with certain mimics and atypical appearances. T2-weighted MRI can act as a problem solving tool to conclusively diagnose hydatid cyst or suggest an alternate diagnosis.

The spectrum of imaging findings in pulmonary hydatid disease and the additive value of T2-weighted magnetic resonance imaging in its diagnosis

Purpose

To describe the spectrum of imaging findings in pulmonary echinococcosis and to study the additive value of T2-weighted magnetic resonance imaging (MRI) in the characterisation of pulmonary hydatid disease.

Material and methods

This was a descriptive, prospective study conducted for a period of 3 years from December 2016 to November 2019. Patients suspected of having pulmonary echinococcosis (n = 110) on preliminary chest radiography were examined with chest computed tomography (CT). Among them 41 cases were additionally examined with T2-weighted MRI of thorax. Final diagnosis was based on surgery or histopathology.

Results

Of the 110 patients enrolled for the study 15 were lost to attrition, and among the final cohort of 95 patients CT correctly diagnosed 68/84 (80.9%) as hydatid cyst, whereas 16/84 (19.1%) received an erroneous alternate diagnosis on CT. Based on the classical findings of hyperintense pulmonary cystic lesion with T2-weighted hypointense rim or detached internal T2-weighted hypointense membrane, a correct diagnosis of hydatid cyst was possible in 30 patients whereas a correct alternate diagnosis was made in 8 cases. T2-weighted MRI was found to have sensitivity of 96.7%, specificity of 80%, positive predictive value (PPV) of 93.7% and negative predictive value (NPV) of 88.9% with an overall diagnostic accuracy of 92.6%. Using the McNemar test, MRI was found to be diagnostically superior to CT (p = 0.019).

Conclusions

Most of the pulmonary hydatid cysts can be diagnosed on CT; however, sometimes the findings may be indeterminate or atypical, leading to a diagnostic dilemma. MRI, owing to its ability to demonstrate hypointense endocyst, can act as a useful adjunct to correctly diagnose hydatid cyst or suggest an alternative diagnosis.

Radiological manifestations of thoracic hydatid cysts: pulmonary and extrapulmonary findings

Hydatid cyst caused by the larval form of Echinococcus is a worldwide zoonosis. The lungs and liver are the most common sites involved. While the lung parenchyma is the most common site within the thorax, it may develop in any extrapulmonary region including the pleural cavity, fissures, mediastinum, heart, vascular structures, chest wall, and diaphragm. Imaging plays a pivotal role not only in the diagnosis of hydatid cyst, but also in the visualization of the extent of involvement and complications. The aim of this pictorial review was to comprehensively describe the imaging findings of thoracic hydatid cyst including pulmonary and very unusual extrapulmonary involvements. An outline is also given for the findings of complications and differential diagnosis of thoracic hydatid cyst.

Echinococcus Granulosus in Childhood: A Retrospective Study of 187 Cases and Newer Data

Echinococcus granulosus, first reported by Goeze in 1782, is the causative parasite of cystic echinococcosis (hydatidosis) especially for countries that are endemic areas. Since the 1970s, the incidence of echinococcosis in Greece has been very high. Nevertheless, with the implementation of special prevention measures in the 1980s, a large reduction in the incidence of hydatidosis meant that it reached European levels. Therefore, we analyzed the demographics, multiple organ localizations of the parasite, diagnosis, and conservative and optimal surgical treatment over a total period of 39 years, especially for pulmonary and hepatic echinococcosis in children. The higher incidence of pulmonary echinococcosis compared with other localizations, male predominance, wide range of age, and various cystic sizes were some of the main demographics. Because cystic echinococcosis remains a main public health problem, we advocate a meticulous clinical investigation and treatment methodology to bridge the gap between knowledge and awareness of this important disease.

Prospective Comparison of MRI and Contrast-Enhanced MDCT for Evaluation of Pediatric Pulmonary Hydatid Disease: Added Diagnostic Value of MRI

OBJECTIVE. The objective of our study was to prospectively investigate the diagnostic accuracy and added value of fast MRI for evaluating pulmonary hydatid disease in children by comparing fast MRI findings with MDCT findings. SUBJECTS AND METHODS. Twenty-eight consecutive children (24 boys and four girls; mean age ± SD, 8.93 ± 3.1 years; range, 5-17 years) with clinically suspected pulmonary hydatid disease were enrolled in this prospective research study for the period from October 2012 to July 2018. Fast MRI without contrast material and contrast-enhanced MDCT of the chest were performed within 48 hours of each other in all children. Two pediatric radiologists independently evaluated the lungs for the presence of consolidation, nodule, and mass (solid vs cyst). Cysts were further evaluated for the presence of fluid, air, and an internal membrane. The accuracies of fast MRI and MDCT for detecting pulmonary hydatid disease were obtained and compared. Interobserver agreement was measured with the kappa coefficient. RESULTS. The accuracy of fast MRI and MDCT for detecting pulmonary hydatid cyst was 92.86%. There was no difference between fast MRI and MDCT for accurately detecting pulmonary hydatid cyst (p < 0.001). Internal membranes were detected in 11 of 28 patients (39.28%) with fast MRI and three of 28 patients (10.71%) with MDCT. Almost perfect interobserver agreement was present between the two independent reviewers (κ = 1). CONCLUSION. Fast MRI without contrast material is comparable to contrast-enhanced MDCT for accurately detecting lung cysts in pediatric patients with pulmonary hydatid disease. However, fast MRI provides added diagnostic value by showing internal membranes of cysts, which is specific to pulmonary hydatid disease.

The study of biochemical profile of cyst fluid and diffusion-weighted magnetic resonance imaging in differentiating hepatic hydatid cysts from liver simple cysts

PURPOSE

The aim of this study was to investigate the value of biochemical profile of cyst fluid and diffusion-weighted imaging (DWI) in differentiating hepatic hydatid cysts (HCs) from liver simple cysts.

MATERIALS AND METHODS

Forty-six patients underwent MR imaging. Twenty-nine patients had 29 hydatid cysts and 17 patients had liver simple cysts. Thirteen patients with hydatid cysts and seven patients with liver simple cysts were evaluated with cyst fluid biochemical analysis. The concentration of glucose, protein, calcium ion (Ca2+ ) electrolyte, macroscopic appearance, and parasitological sediment were evaluated in this study.

RESULTS

In the respect of biochemical analysis cyst fluid, the concentration of glucose and calcium ion of HCs was significantly higher than that of the liver simple cysts. In the respect of DWI, in the b 1000 s/mm2 value in respect of mean application data center (ADC) values, there was a statistically significant difference between HCs group (the mean value was (2.50±0.79)×10-3  mm/s2 ) and liver simple cysts group (the mean value was (2.92±0.66)×10-3  mm/s2 ). However, no statistically significant results were obtained in the ADC measurements of b 500 s/mm2 between two groups.

CONCLUSION

The analysis of cyst fluid combined with the measurement of ADC values in the b 1000 s/mm2 value could be considered a promising parameter as an alternative to the differential diagnosis of hepatic hydatid cysts from liver simple cysts.

Computed Tomography (CT) Findings of Pulmonary Hydatid Cysts in Children and the Factors Related to Cyst Rupture

Background

The lungs are the most common site of hydatid cysts in children. Rupture is the main complication of cysts causing morbidity and mortality. In this study we aimed to comprehensively describe the CT signs for cysts and analyze the relationship of cyst ruptures to the diameter and location of cyst.

Material/Methods

A total of 145 cysts from 102 patients, aged 17 years or younger, who underwent a multi-detector computed tomography (MDCT) evaluation and had surgically proven pulmonary hydatid disease were included retrospectively. The CT images were analyzed for radiologic findings and signs of cyst rupture.

Results

The cysts had a mean diameter of 5.45±3.03 cm. Most of the patients had a solitary cyst (70.6%). The most common lobes involved were the lower lobes (58.6%). Peripherally located cysts were more common than central cysts. The overall number of ruptured cysts was 69 (47.5%). The most common sign was the waterlily sign with a prevalence of 24.6%. After exclusion of cysts of 1 cm, the mean cyst diameter was 6.23±2.83 cm in the unruptured group and 5.02±2.80 cm in the complete ruptured group (p=0.020). The mean cyst diameter was 6.38±3.11 cm for centrally located cysts, and 4.31±2.37 cm for peripherally located cysts (p<0.0001).

Conclusions

Pulmonary hydatid cysts commonly presents as solitary cysts with a predilection for lower lobes and the peripheral regions of the lung. Peripherally located cysts are more common but smaller than centrally located cysts. Radiologists should also be aware of atypical imaging findings of cyst rupture, and radiologic signs should be explored during radiologic evaluation.

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.

Imaging in pulmonary hydatid cysts

Hydatid disease is a zoonosis that can involve almost any organ in the human body. After the liver, the lungs are the most common site for hydatid disease in adults. Imaging plays a pivotal role in the diagnosis of the disease, as clinical features are often nonspecific. Classical radiological signs of pulmonary hydatid cysts have been described in the literature, aiding in the diagnosis of the disease. However, complicated hydatid cysts can prove to be a diagnostic challenge at times due to their atypical imaging features. Radiography is the initial imaging modality. Computed tomography can provide a specific diagnosis in complicated cases. Ultrasound is particularly useful in peripheral lung lesions. The role of magnetic resonance imaging largely remains unexplored.

Cystic pulmonary hydatidosis

Cystic echinococcosis (CE) is a zoonotic parasitic disease caused by the larval stages of the cestode Echinococcus granulosus. Worldwide, pulmonary hydatid cyst is a significant problem medically, socially, and economically. Surgery is the definitive therapy of pulmonary hydatidosis. Benzimidazoles may be considered in patients with a surgical contraindication. This review will focus on pathogenesis, lifecycle, clinical features, and management of pulmonary hydatid disease.

Cerebral intraventricular echinococcosis in an adult

Background:

Echinococcosis in humans occurs as a result of infection by the larval stages of taeniid cestodes of the genus echinococcus. Intracranial hydatid cysts usually develop at an intraparenchymal site. Hydatid cyst within the cerebral ventricle is quite unusual.

Methods:

We reviewed the literature on adult intraventricular hydatid cyst and found case reports mainly in children with an only handful of cases in adults. We reported a rare case of cerebral intraventricular (left lateral ventricle) hydatid cyst in a 21-year-old adult female.

Results:

Although cerebral hydatid cysts are most commonly seen in children and young adults cerebral intraventricular hydatid cyst are comparatively rarer in adults.

Conclusion:

The possibility of infection with Echinococcus granulosus should be included in the differential diagnosis of raised intracranial hypertension in patients from endemic areas.

Hydatid disease located in the cerebellomedullary cistern

Hydatid disease is an endemic zoonotic disease in many areas of the world. Liver, followed by lung, is the most commonly affected organ and involvement of other organs is rare. When brain is involved, lesions are typically supratentorial, and infratentorial localisation is even rarer. We present a 45-year-old woman with hydatid disease located in premedullary location compressing the brain stem, an exceedingly rare location for cerebral echinococcosis. Relevant literature regarding typical properties of cerebral disease was reviewed.

Cystic and cavitary lung lesions in children: radiologic findings with pathologic correlation

A number of diseases produce focal or multiple thin-walled or thick-walled air- or fluid-containing cysts or cavitary lung lesions in both infants and children. In infants and children, there is a spectrum of focal or multifocal cystic and cavitary lung lesions including congenital lobar emphysema, congenital cystic adenomatoid malformation, pleuropulmonary blastoma, bronchogenic cyst, pulmonary sequestration, Langerhans cell histiocytosis, airway diseases, infectious diseases (bacterial infection, fungal infection, etc.), hydatid cysts, destroid lung, and traumatic pseudocyst. For the evaluation of cystic or cavitary lung lesion in infants and children, imaging plays an important role in accurate early diagnosis and optimal patient management. Therefore, a practical imaging approach based on the most sensitive and least invasive imaging modality in an efficient and cost-effective manner is paramount. We reviewed the conventional radiographs and computed tomography findings of the most common cystic and cavitary lung lesions in infants and children.

Imaging of parasitic infections of the central nervous system

Parasitic infections of the central nervous system (CNS) have increased over the last couple of decades, partly due to a drop in the living conditions of large populations in the world and the AIDS epidemic. Parasitic infections of the CNS are indolent and often life threatening, hence, an early diagnosis is imperative. While brain biopsy and laboratory analysis remain the gold standard for diagnosis, neuroimaging contributes significantly to diagnosis and follow-up. Imaging can demonstrate the extent of infection and complications and possibly, the type of parasitic infection when characteristic features are evident. The disappearance of the parasite or inflammation, gliosis, and/or calcification suggest a therapeutic response. The initial experience of the CT scan has been greatly enhanced by MRI which is currently the imaging modality of choice. This has been due to the greater tissue contrast resolution of MRI and its ability to detect subtle changes in the tissue parenchyma. Advanced techniques such as diffusion-weighted imaging (DWI), perfusion imaging (PI), MR angiography (MRA), and MR spectroscopy (MRS) have been used to improve the sensitivity for characterizing the type, viability, and burden of the parasites and the host tissue response. Additionally, it is possible to demonstrate the complications of the primary infection and those secondary to treatment, in some cases.

Varied types of intracranial hydatid cysts: radiological features and management techniques

BACKGROUND

Even when radiological images are considered pathognomic for intracranial hydatid cysts, subtle image characteristics are evident depending upon the status/types of hydatid cysts. These imaging features, if finely scrutinized, may help to modify conventional surgical techniques of cyst excision.

METHODS

From January 2006 to December 2011, nine patients (male:female 7:2, age range 4-44 years, median 7 years) harbouring intracranial hydatid cysts were managed at our centre. In addition to CT scans, all patients underwent plain and contrast-enhanced MRI scans. Based on these radiological findings, the types of hydatid cysts were characterized into simple or complicated (infected) cysts. Complicated cysts were further differentiated into ruptured or intact subtypes based on imaging features. Surgical procedures including the Dowling water dissection technique, in addition to head rotation, were performed for removing these cysts intact.

RESULTS

Children (n = 4) aged 6 years or less presented with increasing head size as the only complaint, while the rest of the patients (n = 5) had symptoms of raised intracranial pressure. MRI features of hypo-intensity on T1-weighted images, hyper-intensity on T2-weighted images, and non-contrast-enhancing cysts were noted for all simple cysts (n = 7), while iso- to mixed intensity on T1-weighted images and hyper-intensity on T2-weighted images with contrast-enhancing pericyst correctly diagnosed all complicated (infected) hydatid cysts (n = 2). One of these complicated cysts had spilled the infected contents outside the cyst wall, but within the confines of the cerebral parenchyma (pericyst). Such a case of contained spontaneously ruptured complicated hydatid cyst is described for the first time. At a median follow-up of 18 months, all patients remain free from cyst recurrence.

CONCLUSION

Subtle changes in radiological features of CNS hydatid cysts should be appreciated so as to diagnose the type of cyst correctly. The surgical strategy should be tailored according to the type of cyst for favourable outcome.

Primary spinal hydatid cyst in a patient with acquired immunodeficiency syndrome

Spinal hydatid cyst is a serious and unusual infectious disease. There is little information on infections caused by cestodes in patients with human immunodeficiency virus (HIV) infection. Although infrequent, infections by cestodes constitute a cause of disease in HIV-infected patients, especially in endemic areas. This report presents, for the first time in the literature, primary spinal cyst hydatid in a patient with acquired immunodeficiency syndrome.

Parenchyma-Preserving Surgery in the Management of Pulmonary Hydatid Cysts

Pulmonary hydatid cysts remain a significant health problem in endemic regions like Turkey. Here, we present our surgical experience in patients with pulmonary hydatid cysts. Between January 1985 and January 2001, 1118 operations were performed in 1032 patients (528 males, 504 females; mean age 32.7 years; range 1-87 years) with pulmonary hydatid cysts in our department. Posterolateral thoracotomy was performed in 1015 (98.3%), two-stage thoracotomy in 34 (3.3%), and median sternotomy in 17 (1.7%) patients. We preferred conservative surgical procedures. As a surgical procedure, cystotomy and capitonnage was performed in 626 (56%), cystotomy alone in 368 (33%), wedge resection in 81 (7%), enucleation in 29 (3%), and decortication in 11 (1%) patients. None of our patients were treated with anatomic resection. During surgery, 949 patients (92%) had unruptured and 83 patients (8%) had ruptured hydatid cyst. The morbidity ratio was 6.7%. Major complications were wound infection (2.3%), prolonged air leak (1.9%), atelectasis (1.2%), pleural effusion (0.8%), postoperative hemothorax (0.6%), and empyema (0.3%). Two patients (0.2%) died within the first month postoperatively. Mean follow-up was 31.2 months. Recurrence was detected in only 35 patients (3.3%). Treatment of pulmonary hydatid cyst is primarily surgical. Medical treatment is indicated for recurrent and multiple hydatid cysts postoperatively. Cystotomy alone, or cystotomy and capitonnage, as parenchyma-preserving surgery, is preferred. Radical surgery including pneumonectomy, lobectomy, and segmentectomy should be avoided.

Experience with video-assisted thoracoscopic removal of pulmonary hydatid cysts in children

Pulmonary hydatid disease is prevalent in many parts of world including India. In our small series of 5 pediatric patients, all patients were diagnosed with clinical and radiological findings on plain X-ray chest and CT (Computed Tomography) chest. All of them received oral albendazole 10 mg/kg/day soon after diagnosis except in one patient in which preoperative differential diagnosis was bronchogenic cyst and lung abscess (case 4). All underwent video assisted thoracoscopy. Simple endotracheal intubation was utilized in all cases along with CO(2) insufflation. Complete thoracoscopic removal was successful in 3 cases, while conversion to open thoracotomy was required in 2 cases. All of them showed rapid recovery except for one patient in whom prolonged intercostal drainage was present for 2 weeks. The average duration of procedure was 150 minutes and average length of hospital stay was 4.5 days except case 2, which was discharged on day 15 due to prolonged air leak. Histopathology in all cases was suggestive of hydatid cyst. At mean follow up of 6 months, all patients are asymptomatic and doing well.

Spontaneous expulsion of intact germinative membrane of liver hydatid cyst in a child

A 10-year-old girl presented with an acute abdomen because of spontaneous rupture of a liver hydatid cyst (HC) and associated pelvic cystic mass. The pelvic cyst was found to be an intact germinative membrane of the ruptured HC of the liver at operation. This is the first pediatric case presenting with expulsion of an intact germinative membrane of a spontaneously ruptured HC. Intact germinative membrane should be included in the differential diagnosis of intraabdominal and pelvic cystic masses in children. The liver should be evaluated for ruptured cyst, and the lungs should also be evaluated to detect accompanying pulmonary hydatid disease (HD) especially in children living in countries in which the HD is endemic.

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.

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.

Neurohydatidosis

Early and non-invasive evaluation of hydatid infestation of brain and spine is of paramount importance, especially in endemic areas. We present a spectrum of imaging findings in neurohydatidosis with a brief review of literature.

Percutaneous Treatment of Hydatid Liver Cysts in Children as a Primary Treatment: Long-term Results

PURPOSE

To evaluate the effectiveness and long-term results of percutaneous treatment for hydatid liver cysts in pediatric patients.

MATERIALS AND METHODS

Thirty-four pediatric patients (15 male, 19 female; ages 4-17 years; mean age, 9.4 years) with 51 hydatid liver cysts underwent ultrasound (US)-guided percutaneous treatment with albendazole prophylaxis. There were 15 type II lesions with membrane detachment and 36 type I lesions resembling simple hepatic cysts with pure anechogenic content or small echogenic reflections and a regular well-delineated wall. The method of US-guided puncture, aspiration, injection of hypertonic saline solution, and reaspiration was preferred for 21 lesions. For the remaining 30 larger cysts, the intervention was performed with the same percutaneous technique but followed by catheterization, drainage, control cystography, and sclerotherapy with ethanol. During follow-up, US examinations were performed at 1, 3, 6, and 12 months for the first year and yearly thereafter.

RESULTS

Percutaneous treatment of hepatic hydatid disease was successful in 33 patients (97.1%). During follow-up, US findings in the lesions changed significantly; at year 1, the inner content of the lesions became heterogeneous with a semisolid appearance, and the mean reduction in volume was 81.4%. At 2-year follow-up, most hydatid cysts had become solid in nature and the reduction in volume reached 65%-99% (mean, 85.1%). There were no recurrences or additional lesions after the follow-up of 1-6 years (mean, 3.1 years). Average hospital stay for the whole group in this study was 3.5 days.

CONCLUSIONS

The long-term results of percutaneous liver hydatid cyst treatment in children are in accordance with the results in adults. Percutaneous treatment of uncomplicated type I and type II liver hydatid cysts in pediatric patients is an efficient and safe treatment with short hospitalization.

Salmonella typhi-infected lung hydatid cyst

A 12-year-old girl presented with hemoptysis, fever and weight loss. She was initially diagnosed and treated for presumed tuberculosis and a lung abscess. Salmonella typhi was isolated from the abscess. Hydatid cyst was diagnosed at surgery. This is the first reported case of a pulmonary hydatid cyst infected with S. typhi.

Pseudo food allergy

Hydatid disease is a common zoonosis caused by the larval cysts of Echinococcus granulosus (parasitic tapeworm). In children, lung hydatid cysts are more common than liver cysts, whereas in adults the reverse is true. Pulmonary hydatids can be accompanied by concurrent liver cysts. Leakage or rupture of a hydatid cyst can cause allergic reactions including anaphylaxis. Albendazole is effective therapy either alone or as an adjunct to surgery.

Alveolar echinococcosis: MR findings in the liver

PURPOSE

To clarify the magnetic resonance (MR) imaging findings of alveolar echinococcosis in the liver.

MATERIALS AND METHODS

Thirty-five patients with 50 lesions histologically proven to be alveolar echinococcosis were evaluated with MR imaging. Lesions were assessed with regard to the distribution pattern of solid and cystic components and pattern of contrast material enhancement.

RESULTS

Cystic components exhibited two patterns at T2-weighted MR imaging: small round cysts and large and/or irregular cysts. Forty-eight lesions (96%) contained small round cysts. Twenty-six lesions (52%) had large and/or irregular cysts. Forty-five lesions (90%) were associated with a solid component. MR imaging characteristics were categorized into five types: multiple small round cysts without a solid component (two lesions [4%], type 1), multiple small round cysts with a solid component (20 lesions [40%], type 2), a solid component surrounding large and/or irregular cysts with multiple small rounds cysts (23 lesions [46%], type 3), a solid component without cysts (two lesions [4%], type 4), and a large cyst without a solid component (three lesions [6%], type 5). In most cases (97%), contrast enhancement was weak.

CONCLUSION

The MR findings of alveolar echinococcosis in the liver are multiple small round cysts with a weakly enhanced solid component. The cystic component can be a large and/or irregular lesion, and such lesions are depicted clearly at T2-weighted MR imaging.

Radiological characteristics of pulmonary hydatid disease in children: less common radiological appearances

OBJECTIVE

To evaluate the chest roentgenogram and CT characteristics of pulmonary hydatid disease (PHD).

MATERIAL AND METHODS

Forty-seven (27 male and 20 female, aged between 3 and 11 years) consecutive pediatric patients with surgically proven pulmonary hydatid cysts were enrolled for the study. Posteroanterior and lateral chest roentgenograms, CT of the chest, and laboratory findings (latex agglutination, Casoni skin test, and eosinophil count) were obtained from all of the patients. The radiological features (localization, internal architecture, number, diameter) were determined.

RESULTS

On CT examination, a total of 79 cysts were determined. On chest roentgenogram, 57 of 79 cysts were detected in all patients. Single cysts were seen in 33 patients, while multiple cysts were seen in 14. Median CT density of the cysts was 21 Hounsfield units (HU) (0-80). There were six giant cysts (>10 cm of cyst diameter). The crescent sign, water lily sign, and air-fluid level were seen in two, five and eight of the cysts, respectively. Apart from the classically described features of pulmonary hydatid cysts of the lung, a crescent-shaped rim of air at the lower end of the cyst (inverse crescent sign) was detected in three cysts. All of the liquid content of the cyst was expelled to the bronchial system (dry cyst sign) was observed in seven cysts. There were two infected cysts. Heavily calcified curvilinear cyst wall was present in one cyst. Pericystic reaction in the lung tissue was observed in five patients. Other features included pleural effusion (n=2), mediastinal shift (n=6) and atelectasis (n=7).

CONCLUSIONS

Chest roentgenogram is helpful for diagnosis of intact cysts but, it is impossible to define entire morphology of the complicated cysts. CT imaging recognize certain details of the lesions and discover others that are not visible by conventional radiography. In conclusion, CT examination should be done to elucidate cystic nature of the lung mass and for accurate localization in the preoperative period. In addition, inverse crescent sign should be recognized as feature of pulmonary hydatid cysts on CT.

Surgical treatment of pulmonary hydatid cysts in pediatric patients

Hydatid cyst is a zoonotic infection that is caused by Echinococcus granulosus and alveolaris, and that can result in endemics in rural regions. Infections caused by Echinococcus granulosus are more commonly seen in our country. In this retrospective study, we aimed at discussing the experience we have accumulated on pediatric pulmonary hydatid cyst cases over the last 6 years. Between 1995-2001, in the Department of Thoracic and Cardiovascular Surgery in Gaziantep University, 38 cases underwent 39 operations due to pulmonary and hepatic hydatid cysts. Of these, 24 were males and 14 were females, with an age range of 2-16 years. Operations were frequently performed via thoracotomy. Nineteen cysts were intact, and 26 were perforated. One case had sternotomy, another had sequential thoracotomy, and the rest of the cases underwent thoracotomy, which resulted in cystotomy-capitonnage. In the postoperative period, 2 patients had sustained air leakage, and 2 other cases developed skin infections. Average hospital stay was 5 days. After the operation, the patients received chemotherapy (albendazole 10 mg/kg/day) for 1.5 months. Early or late deaths or recurrences were not observed. We conclude that cystotomy-capitonnage is a successful treatment for pediatric pulmonary hydatid cysts, as it preserves the parenchyma. Chemotherapy in the postoperative period is beneficial in preventing the recurrences.

Past to present: echinococcosis in Turkey

Echinococcosis is a zoonotic infection caused by Echinococcus spp. and is one of the most important helminthic diseases worldwide. Two forms of echinococcosis occur in Turkey, i.e. Echinococcus granulosus and E. multilocularis. The life cycle of E. granulosus is predominantly in dogs and sheep, and most sheep farmers in Turkey keep a dog or two. Stray dogs are numerous and prevention or treatment of infection in these dogs is very difficult. Cystic echinococcosis (CE) occurs throughout Turkey whereas alveolar echinococcosis (AE) predominantly occurs in the eastern Anatolian region of the country. Both CE and AE are known to be endemic but few surveys have been performed. Most data on human CE and AE have been collected from hospital records. The first reference of echinococcosis, "Kyste hydatique multiloculaire", in Turkey dates as far back to 1872 by an Ottoman Physician, C.R. Katibian. The results of the first Turkish study on E. granulosus were published in 1928. According to Ministry of Health records, 21303 patients had operations to treat or confirm CE in the period 1987-1994 which corresponds to approximately 2663 patients per year. The estimated surgical case rate of CE is 0.87-6.6 per 100000 in Turkey. The prevalence of E. granulosus infection in dogs in Turkey is between 0.32 and 40% and varies widely with geographical location. The reported prevalence of CE in domestic animals in Turkey has ranged from 11.2 to 50.7% and has varied widely with geographical location. Although no detailed information has been published on AE in domestic and wild animals in Turkey, the main definitive and intermediate hosts of E. multilocularis are assumed to be rodents and red foxes, respectively. However, there has been only a single published report of E. multilocularis in a wild animal (fox) in the northwest in 1965 by Merdivenci. The first human case of AE in Turkey was reported by Mutlu in 1939, and total cumulative reported case number is 202 between 1980 and 1998.

One-stage operation for hydatid disease of lung and liver: principles of treatment

OBJECTIVE

Hydatid disease is endemic in many countries throughout the world. Although we do not have exact figures, the disease is prevalent in Turkey. A considerable number of patients have additional liver cysts as well. In this study we reviewed our experience with hydatid disease of the lung and liver and discussed the principles of treatment.

METHODS

From 1971 to 1999, 2509 patients with pulmonary hydatidosis were referred to us, and 485 of them had concomitant liver cysts. Of these, 405 patients had cysts located on the dome of the liver, and they were operated on with phrenotomy through a right thoracotomy. Eighty patients who were found to have concomitant liver cysts in the lower part of the liver were referred to general surgery for a laparotomy.

RESULTS

Hydatid cysts located in the lungs were managed by means of cystotomy and capitonnage. For liver cysts, cystotomy and inversion of the cavity with sutures was the surgical method of choice, and a drain was left in place. In case of multiple cysts in the liver, needle aspiration was preferred. Twelve major complications, including excessive biliary drainage and bronchobiliary fistula, occurred in these patients.

CONCLUSIONS

We believe that management of pulmonary and hepatic cysts simultaneously through the thoracic route is convenient and should be encouraged in patients because this prevents a second operation. Needle aspiration can be applied only for liver cysts. It is absolutely contraindicated in lung hydatid cysts.

Cerebral hydatid disease CT and MR findings

In this study, we reviewed the computed tomography (CT, n=9) and magnetic resonance (MR, n=5) imaging findings of 11 patients with pathologically confirmed cerebral hydatid disease. Among our patients, there were 10 cases of Echinococcus granulosus and 1 case of Echinococcus multilocularis. Common CT and MR imaging findings of E. granulosus lesions were well-defined, smooth thin-walled, spherical, homogeneous cystic lesions with no contrast enhancement, no calcification, and no surrounding edema. E. multilocularis lesions showed calcified round, solid pattern with definite margins, contrast enhancement, and surrounding edema.

Pictorial essay. Various locations of cystic and alveolar hydatid disease: CT appearances

Hydatid disease (echinococcosis) is a parasitic infection caused by the larval stage of the tapeworm Echinococcus. In humans, the two main forms are cystic hydatid disease, caused by E. granulosus, and less frequently alveolar hydatid disease, caused by E. multilocularis. They can be found in various sites in the body. The purpose of this essay is to illustrate the CT appearances of cystic and alveolar hydatid disease in various locations.

Surgical treatment of pulmonary hydatid cysts in children

OBJECTIVE

Hydatid disease is a parasitosis and endemic in many sheepraising areas; it is still an important health problem in Turkey. We report our experience with childhood hydatid cyst and discuss the concepts of treatment.

METHODS

The clinical courses of 128 children with thoracic and liver hydatid cyst operated on from 1994 to 2000 were reviewed. The group consisted of 71 boys and 57 girls aged from 8 months to 16 years. Intact cysts were found in 144 patients and ruptured cysts in 68.

RESULTS

In the postoperative course we have encountered 20 perioperative complications in 16 patients. The most common complication was residual pleural space and delayed air leakage, which occurred in 9 patients. There was no early death.

CONCLUSION

Surgery is the treatment of choice for most patients with pulmonary hydatid disease. The aim of surgery is evacuation of the cyst, removal of the endocyst, and management of the residual cavity. Conservative surgical methods that preserve lung parenchyma should be preferred.