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Indian Journal for the Practising Doctor

Primary Hydatid of Spleen: A Case Report

Author(s): Fazili A, Wani N, Saleem I, Bhat GH, Mir N A

Vol. 5, No. 5 (2008-11 - 2008-12)

ISSN: 0973-516X

Fazili A, Wani N, Saleem I, Bhat GH, Mir N A

Dr Mir Nazir Ahmad, MS, ( Professor), Dr Gh Hassan Bhat, MS, ( Asstt. Professor), Dr Anjum Fazili, MS, ( Lecturer), Dr Nazir Wani, MS, (Lecturer), and Dr Iqbal Saleem, MS, ( Lecturer), Department of Surgery, Government Medical College, Srinagar and the associated SMHS Hospital, Srinagar.

Correspondence: Dr. Iqbal Saleem Mir, Apex Clinic, Gole Market, Karan Nagar, Srinagar, Kashmir, India. 190010
[E-mail iqbalsurg (at) yahoo.com, (Telephone: 009419002750)]

Abstract

Here we present a case with the primary hydatid of spleen – a rare entity. Presentation was a painless, progressive left upper abdominal swelling. Direction of the growth was from superior to inferior pole. There was a fibrous track present between the upper pole of the spleen and the left flexure of the colon. The spleen was huge and almost entirely replaced by the hydatid cyst. Since differentiation from non-parasitic cyst is difficult, the occupational history of the patient was clinching in reaching the diagnosis. Open splenectomy was ideal modality considered in the treatment of this patient with a huge spleen.

Key Words: Hydatid, Spleen, Splenectomy

Introduction

Hydatid disease is a zoonotic disease known since ancient times. The causative organism is usually the larval tapeworm of Echinococcus granulosus. The disease is endemic in South America, parts of north-eastern Africa, the Middle East, Turkey, New Zealand and Australia; these being mostly the sheep breeding regions. No organ is immune to the infection, however, the liver (followed by the lung) is the most common organ involved. Isolated splenic involvement is rare; its occurrence in endemic areas is less than 5 % of the total incidence of echinococcus infestation. Hydatid cyst is the only parasitic cyst of the spleen and is considered to be twice as common as the non-parasitic variety1. The clinical presentation ranges from an asymptomatic state to the life threatening anaphylaxis. Differentiation from the non-parasitic variety is a real diagnostic challenge. Specific serological tests, abdominal ultrasonography, and computed tomography are adjuncts in reaching diagnosis. Treatment may involve percutaneous technique, open or laparoscopic splenectomy.

Case Report

A 45 years old non-diabetic, normotensive female presented as a case of progressively increasing mass of 10 year duration in the left upper abdomen with a mild dragging sensation and mild urinary compressive symptoms but otherwise normal bowel habits and a good appetite. There was no history of any allergic reactions, urticarial rashes or any respiratory obstructive signs and symptoms. There was a positive family history of sheep-rearing. Abdominal examination revealed a huge swelling visible from a distance (Fig 1), almost occupying the whole of the left hypochondrium, firm in consistency and moving with respiration. Investigative profile included a normal CBC; indirect complement fixation test was positive favouring presence of hydatid disease. Abdominal sonogram revealed a single, unilocular, well-defined cystic swelling involving almost whole of the spleen barring a small rim of lower pole measuring 10 × 9.6 cms. Abdominal CT confirmed the sonographic findings (Fig 2) with attenuation value near that of water without wall calcification. The patient was subjected to open splenectomy (Fig 3) and the laminating membrane (Fig 4) was excised in toto along with the spleen, the histopathological examination of which confirmed the diagnosis of primary hydatid of spleen. The patient is doing well and is regularly being followed up.

Discussion

In endemic areas, hydatid disease continues to cause morbidity although the overall incidence is decreasing due to improved hygiene. The disease can involve any organ, however the liver (52 – 77%), the lungs (10– 40%) and spleen (0.5 – 5%) are the common ones. Hydatid spleen may be asymptomatic or may present with an abdominal swelling with or without pain. Very rarely it may present as intraperitoneal rupture or pleural hydatid2.

Biochemical tests employed in diagnosis are complement-fixation test, enzyme-linked immunosorbent assay, indirect hemagglutination test, serum immunoelectrophoresis and western blot test3. Plain x-ray film can show cyst wall calcification, however, there are no definite signs of hydatid cyst on ultrasonogram or computed tomography which could differentiate it from non-parasitic cysts, abscesses, or cystic neoplasms4. Therefore, the diagnosis of primary hydatid cysts requires supplementation of clinical history with positive occupational history, and biochemical as well as radiological investigations.

In the literature, various modalities of treatment are available ranging from medical to the latest minimally invasive surgical procedures. Various surgical options include partial splenectomy, enucleation of cyst, de-roofing of the cyst wall with omentopexy, cystojujenostomy, or external drainage5. Sclerotherapy using mixture of ethanol and polidocanol, and a subsequent injection of albendazole solution has been an effective treatment for cysts smaller than 50 mm6. Laparoscopic splenectomy remains the most advanced option with benefits of minimal access.

References

  1. Fowler RH, Hydatid cysts of spleen. Collective Review of International Abstracts of Surgery. 1953; 96: 105 – 116.
  2. Seymour I, Schwartz, Harold Ellis. Maingot’s Operations. 10th ed, vol II, 1534 – 45.
  3. Kune GA, Morris Di, Schwartz & Ellis. 9th edition Appleton and Lange 1989: 1225 – 40.
  4. Kalouidouris A, Pissilosis C, Pontifix GCT charecterization of multi vesicular hydatid cysts. J Comput Assist Tomograp. 1984: 8; 839 – 45.
  5. Berrada S, Ridai M, Mokhtari M : Hydatid cysts of spleen: Splenectomy or conservative surgery? Ann Chir 1991; 45: 434 – 436.
  6. Zerem E, Nuhanovic A, Caluk J, Modified PAIR technique for treatment of hydatid cysts in the spleen. Bosnian J Basic Med Sci, 2005: 5 ; 3, 74 – 78.

Fig 1: Abdominal swelling in left hypochondrium

Abdominal swelling in left hypochondrium

Fig 2: CT Scan of Hydatid Spleen

CT Scan of Hydatid Spleen

Fig 3: Operative Photograph showing laminating membrane

Operative Photograph showing laminating membrane

Fig 4: Specimen of spleen and Laminating membrane

Specimen of spleen and Laminating membrane

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