ABSTRACT:
Hydatid cysts are due to parasitic infection caused by the cestode tapeworm Echinoccocus. In humans the hydatid disease commonly involves the liver (75%) & the lungs (15%). The remaining (10-15%) cases involve the other organs of the body-kidney, spleen, heart, brain, bones, pancreas, breast, ovaries, scrotum, thyroid gland, inguinal canal & soft tissues.The disseminated intra-peritoneal hydatid disease is a very rare finding1. We report such a case wherein the abdominal cavity is seen to contain multiple hydatid cysts .Hydatid cysts were also found in the left scrotum, lungs, liver & spleen.

KEY WORDS:
Hydatid cyst, Echinococcus, Peritoneal hydatidoses, Scrotum

CASE REPORT:
A 42 years Hindu male presented with complaints of left scrotal swelling for 6 months, progressive distention of abdomen for 1 year & generalized weakness for 1 ½ years. He had past history of hydatid disease 13 years back, for which cystectomy was done in 1994. He was not taking any drugs. There is no history suggestive of diabetes mellitus, hypertension, tuberculosis, coronary artery disease or history of Filariasis.

On examination, patient was of thin built with blood pressure 110/70 mmHg (both upper limb), pulse rate 84/min (Regular), Respiratory rate of 24/min and temperature of 37oC. He had diminished vesicular breath sounds in both lower lung fields. His abdomen was distended. On inspection, dilated veins were present over the abdomen with flow below upwards. There was a mid line supraumblical scar mark. Flanks were full and contour was irregular. Umblicus was central and everted (Figure 4). On palpation, there was no local rise of temperature, no tenderness, no fluid thrill and shifting dullness. There were multiple ill defined cystic masses all over the abdomen of varying size. There was bilateral scrotal mass which was soft and non-tender with increased scrotal volume. The liver was not enlarged and spleen was not palpable. On auscultation, bowel sound was normal, no bruit heard. Cardiovascular system and central nervous system examinations were within normal limit.

ROUTINE INVESTIGATIONS:
Hb%-10.4gm%, TLC-12,000/mm3, N50E28L22, ESR-48mm(1st hours), FBS-74mg/dl, Blood urea-31mg/dl, Sr creatinine-1.58mg/dl, Sr Na+-143meq/lt, Sr K+-4.9meq/lt, Urine analysis-normal study,ECG-normal.

LIVER FUNCTION TESTS:
Sr Billirubin (total)-0.89mg/dl, Direct-0.22mg/dl, Indirect-0.67mg/dl, SGOT-26.39IU/lt, SGPT-18.40IU/lt, Sr Alkaline phosphatase-149.38IU/lt, HBsAg-negative, Anti HCV Ab-negative.

ULTRASOUND (ABDOMEN & PELVIS):
Multiple hydatid cysts of liver, spleen, left scrotum & through out abdomen, varing from size 1 mm to 6 mm, B/L moderate Hydrocele (Figure 3).

CHEST X-RAY (PA-VIEW):
Circular opacity of size 8x2cm in right basal zone (? hydatid cyst).

C.T.SCAN (ABDOMEN):
Multiple hydatid cyst of liver, spleen, B/L lower lobes of lungs, involving mesentery & retoperitoneal region. Nonvisualization of RT kidney
(? replaced by hydatid cysts) (Figure 1, 2).

C.T.SCAN OF BRAIN: Normal

IMMUNOLOGICAL TEST:
Echinococcus antibody titer - 1:64 (Normal 1:32)

TREATMENT GIVEN:
Surgical resection of the cysts was not possible. Albendazole-400 mg PO BD for life long (with monthly monitoring of Liver function Tests) given. On first two follow ups there was decrease in the abdominal distension & the liver function test was normal.

DISCUSSION:
Hydatid disease is a parasitic infection caused by the Echinococcus granulosus. The dogs are the definite host and the adult worms are found in their small intestine. Human get infected either by contact with the definitive host or by consuming vegetables and water, contaminated with the hydatid ova2. Hydatid disease is endemic in the cattle grazing areas like India, Pakistan, Middle-East, Africa, South America, and New-zealand1. The close association of people with sheep and dogs and the unavailability of clean potable water supplies in India make it a region endemic to disease. Majority of the cases of Hydatid disease seen come from rural areas or people who have settled in urban centers after spending life in villages. Most of the people acquire the disease during their childhood, but do not present with the clinical signs and symptoms until late adult hood. The natural progression of an untreated cyst may include calcification and death of the cyst; however, more frequently the cyst gradually enlarges3.

The liver (75%) and the Lungs (15%) is the commonest site of involvement, although no site in the body may be completely immune from it4. This atypical and rare presentation of the disease may be seen in kidneys (3%), usually the upper and the lower pole of the kidney may be involved. The spleen may be involved in about 4% of the cases and is associated with splenomegaly, fever and abdominal pain4. Cerebral Hydatid cysts occur in only 2% of all the cases reported. The region of the middle cerebral artery distribution specially the parietal lobe is most frequently involved. Cardiac Hydatid cyst is very rare (0.02-2%) and most commonly affects the left ventricular chamber specially the left ventricle in 50%-60% of cases4. The other sites that have been reported to be involved are bones, pancreas, breast, ovaries, scrotum, thyroid glands, inguinal canal and soft tissues.

Hydatid cysts can also be found rarely in the peritoneum1. Most of these cases are the result of traumatic or surgical rupture of a hepatic, splenic or mesenteric cyst. The prevalence of peritoneal hydatid cysts in cases of abdominal Hydatid disease is approximately 13%. In our case the patient had already undergone cystectomy and it is likely that these findings may be associated to previous surgical rupture, although spontaneous rupture of micro cysts into the peritoneum may also occur in about 12% of the cases1. The hydatid cysts may resemble a multiloculated mass filling the entire peritoneal cavity. Such a condition is referred to as peritoneal hydatidoses .

Hydatid cyst may be solitary or multiple. The type of the imaging modality used depends on the site and the size of the hydatid cyst. Ultrasonogarphy (USG) is the first line of screening for abdominal hydatidosis and it is especially useful for detection of cystic membrane, septa, and hydatid sand. CT scan best demonstrates cyst wall calcification and cyst infection. CT scan imaging is also the modality of choice in peritoneal seedling1. The CT scan shows well defined solitary or multiple cysts that may be thin walled or thick walled. A hydatid cyst typically demonstrates a high attenuation value at unenhanced CT even without calcification. Multivesicular cysts can depict a typical honeycomb pattern. The septa represent the walls of the daughter cysts housed within the mother cyst. A “wheel spoke” pattern can be observed when the daughter cysts are separated by hydatid matrix1.

There are different types of serological tests which can be carried out for the diagnosis, screening and follow up of patients with hydatid disease. These include the immunoelectrophoresis, enzyme-linked immunosorbent assay (ELISA), latex agglutination and indirect haemagglutination (IHA) test 4. The diagnosis of HD can thus be established with the help of radiologic and serologic finding4. The diagnosis is also easier when the lesion has multiple locations involving different organs or when daughter cysts, germinal membrane detachment and calcification are present 2.

Surgery is the mainstay of treatment for hydatid cysts of the Liver. Laparotomy is the most common surgical approach6. Liver resection and pericystectomy are procedures that resect the closed cysts with a wide safety margin; however they are considered too radical procedures for hydatid cyst removal. Conservative procedures such as cystectomy and omentoplasty for hydatid disease should be the standard surgical procedure because of their safety, simplicity, and effectiveness in fulfilling the surgical treatment criteria of hydatid disease6. The peritoneal hydatidosis has also been successfully surgically removed with similar conservative procedures5, 7.

CONCLUSION:
Symptomatic or large cysts should be surgically treated. In cases suspected of having peritoneal spillage, antihelminthic drugs should be administered8. In addition, small asymptomatic cysts, some daughter cysts, and peritoneal secondary cysts and splenic cysts may also be effectively treated with Albendazole8.

REFERENCES:

1. Pedrosa I, Saiz A, Arrazola J, Ferreiros J, Pedrosa CS. Hydatid disease: radiologic and pathologic features and complications. Radiographics 2000; 3:795-817.
2. Polat P, Kantarci M, Alper F, Suma S, Koruyucu MB, Okur A.: Hydatid Disease from Head to Toe. Radiographics 2003; 23:475-94.
3. Ammann RW, Eckert J. Cestodes. Echinococcus. Gastroenterol Clin North Am 1996; 3:655-89.
4. Husen YA, Nadeem N, Aslam F, Bhaila I. Primary splenic hydatid cyst: a case report with characteristic imaging appearance. J Pak Med Assoc 2005; 5:219-21
5. Karavias DD, Vagianos CE, Kakkos SK, Panagopoulos CM, Androulakis JA. : Peritoneal echinococcosis. World J Surg 1996; 20:337-40.
6. Buttenschoen K, Carli Buttenschoen D. Echinococcus granulosus infection: the challenge of surgical treatment. Langenbecks Arch Surg 2003; 4:218-30.
7. Hamamci EO, Besim H, Korkmaz A. Unusual locations of hydatid disease and surgical approach. ANZ J Surg 2004; 5:356-60
Balik AA, Celebi F, Basglu M, Oren D, Yildirgan I, Atamanalp SS. Intra-abdominal extrahepatic