Hydatid Cyst and When Surgical Management is Needed

Author(s): Jessica Chapelet, Angie Cardona, Bharti Sharma, Cristina Coyle, Zahra Shafaee, Ruoqing Huang, Nora Morgenstern, Jennifer Whittington

Background: Hydatid cyst is a parasitic infection caused by the cestode Echinococcus granulosus [1]. Humans are incidental hosts, and cystic lesions usually develop primarily in the liver and the lungs. When symptomatic, the disease is managed with albendazole, other adjunct treatments, such as praziquantel, may or may not be added. Surgery is usually reserved for large or complicated cysts (>10 cm) [2,3].

Case presentation: A 61-year-old Tibetan male patient presented to the emergency department with right upper quadrant pain for 3 days, poor oral intake, chills, and night sweats. He had a past medical history of hydatid cysts in 2017, for which he underwent puncture, aspiration, injection, and re-aspiration (PAIR) and received treatment with albendazole. The physical examination showed mild right upper quadrant tenderness with no rebound or guarding. The laboratory tests had notable Liver function tests (LFTs) for transaminitis, elevated alkaline phosphatase, very mild eosinophilia, and elevated C reactive protein (CRP) and erythro sedimentation rate (ESR). Computed tomography of the abdomen and pelvis with contrast revealed a peripherally calcified cystic lesion in the right lobe of the liver measuring up to 4.1 cm in diameter. There was trace perihepatic fluid overlying the lesion. Ultrasound of the abdomen revealed a heterogenous hepatic lesion with peripheral discontinuous linear echogenicity compatible with the peripherally calcified hypodense hepatic lesion seen by computed tomography scan. After multiple attempts of incomplete/ non-compliance with albendazole and a multidisciplinary discussion of the infectious disease, the decision was made to proceed with surgical resection. The patient underwent a total cystopericystectomy with right posterior liver resection. Adhesions and a walled-off collection were noted between the liver, anterior abdominal wall, and diaphragm. The patient was discharged home with albendazole and close Infectious Disease follow-up.

Conclusion: This case illustrates the failed medical management of hydatid cysts and when to go to surgical management.