Lecture 59 - 3rd Asessment - Hydatid & Cysticercosis

Clinical Case •

A 47-year old Syrian sheep farmer who has been living in Kuwait for 20 years presented at outpatient clinic with upper abdominal pain, nausea, anorexia, malaise for 5 wks.

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Physical examination revealed jaundice; he had normal temperature (37°C)

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There was tenderness in the right hypochondrium and epigastrium

Investigations

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Eosinophilia : 1.0 x 109/L Urea and electrolytes: normal Liver enzymes: slightly raised Bilirubin: 58 µmol/l

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CT Abdomen: multilocular cyst in Rt. Lobe of liver

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Guided aspiration of the cyst was done and microscopy of the aspirate showed •

Diagnistic queries  What

is your provisional diagnosis?  What is the differential diagnosis?  What further investigations might help? o o o o o

Is Syria endemic for this infection? Why he presented after such a long time? How would you manage this case? Is Surgery the only option? What special precaution should be taken during surgery?

Hydatid Cyst  Definite

hosts: Dog, Wolves, Foxes, Rarely in cats  Intermediate hosts: Sheep/Horses in Wales, NZ, Austria Pig in E. Europe Camel/donkey in ME Cattle in India.  Infectivity:  Cyst

May differ from different intermediate hosts

fertility: Not related to its size [mostly the cyst is sterile in cattle] The cyst grows 1-5 cm per Year

Hydatid Cyst Daughter

cysts: Derive from ruptured brood-capsules

Protoscolices:

Ingested by carnivores, develop into adult worm

Infection usually takes place in childhood by ingestion of eggs

Sites:

Liver 52-77%, Lungs 9-44%, Kidney 3%, Bones 3%, Brain 2%

Hydatid Disease Life Cycle

Infective Ova

Echinococcus granulosus Organism

Hydatid Cyst

Hydatid Cyst Size:

1 2

2->20cm

Structures: 1. Adventious tissue 2. 3. 4. 5. 6.

Laminated layer Germinal layer Brood Capsules Scolices Cystic fluid

3 4

Hydatid sand: Brood capsules, Scolices, Hooks, Degenerated tissue in cystic fluid

5

Hydatid Cyst

Biopsy

Brood Capsule

Hydatid Cyst Pathogenesis

 In humans, hydatid disease resembles cancer  The hydatid grows and exerts pressure on organs  It can cause metastases with further development of hydatids in new loci.  Material leaks from the cyst and sensitizes the individual.  Anaphylaxis  Cysts may eventually calcify

Hydatid Disease Diagnostic Protocol

I. History 

Previous association with dogs and/or sheep

II. Physical Examination 

Hydatid thrill

III. Laboratory Serology

IV. Ultrasound 

Cystic lesion

Hydatid Disease Diagnosis Laboratory:  Blood

CPC: Eosinophilia

 Serology:  Aspiration

IHA, IFA, IEP (Arc 5 Ag) of the cyst:

Protoscolices

 Histopathology (post-surgery):

Protoscolices, Hooks, Laminated layers

 X-ray, Ultrasound, CT scan, MRI

Hydatid Disease Ultrasound

Bacterial abscess Amebic abscess Hepatic neoplasia Haemangioma Gall bladder disease

Hydatid Disease Management

I. Surgical

II. Medical

I. Surgical removal of the cyst: I. Taking care of spillage II. Use of scolicidal solutions Hypertonic glucose saline, 50% ethanol, 10% formalin III. Cryosurgery

Hydatid Disease Management II. Medical: If surgery is contraindicated: I, Albendazole: 800 mg/d

x 28 days; then rest for 2 wks

Repeat at least 3-4 cycles. Follow up liver enzyme profiles II, Mebandazole III, Albendazole + Praziquantel

Echinococcus multilocularis 

Epidemiology: 

  

Arctic/alpine, Iraq, Adult worm in dogs/foxes, Cyst in rodents Human infection is sporadic (contact with infected furred animal) Definite hosts are Foxes, Reindeers (Restricted to Northern hemisphere)

Echinococcus multilocularis



Mode of Transmission in man: Ingestion of eggs on contaminated fruits/ vegetables



Lesions: Liver, Lungs, Brain [multilocular with little or no fluid]

Kuwait Diving Team Saves Trapped Turtles

Clinical Case •

A 27-year old Kuwaiti lady presented at MAK Hospital with sudden onset of H/O of fits, convulsions in the last 2 weeks.

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She gave no H/O of head injury or drug intake.

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She was in perfect health before presenting with these symptoms

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She travels frequently to different countries on business tours

Clinical Case •

MRI of brain showed 3 ring-enhancing cystic lesions

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Serology for Toxoplasma/CMV infection was negative

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2 months later her younger sister presented with similar complaints

Cysticercosis

Cysticercosis • It is an infection by the larval stage of Taenia solium. •

Prevalence rates up to 10% in some endemic areas

China, India, Mexico, Africa

Cysticerci complete their development within 2-4 months after larval entry and live for months to years

Pathogenesis 10. Initially, the live larva within a thin- walled cyst (vesicular cyst) is minimally antigenic. 2. The host immune response or chemotherapy results in gradual death of the cyst, inflammation with pericyst edema, and (sometimes) vasculitis may result in small cerebral infarcts, increased intracranial pressure and CSF changes may follow

Cysticercosis Pathogenesis

3. Subsequently, the cyst degenerates over 2-7 years, it may disappear or be replaced by a granuloma, calcification, or residual fibrosis. 4. Cysts reach 5-10 mm in soft tissues but may be larger (up to 5 cm) in the central nervous system 5. Attached to the inner wall of the cyst is an invaginated protoscolex with four suckers and a crown of hooks.

Mode of Transmission: I, Ingestion of food/water contaminated with T. solium ova II, Autoinfection

Sites: Central nervous system, subcutaneous tissues and striated muscle, Eye ball, and, rarely, other tissues

Neurocysticercosis

Differential Diagnosis Tuberculoma, Tumor, Hydatid disease, Vasculitis, Chronic fungal disorders, Toxoplasmosis and other parasitic diseases, Neurosyphilis

Cysticercosis Diagnostic Protocol 1. Residence/Travel to endemic area 2. History of epileptic seizures 3. CT, MRI 4. Serology: IHA, ELISA Immunoelectrotransfer blot test

5. Biopsy

Treatment: Praziquantel