Multiple Daughter Cysts Research Articles

A Boulder in the Brain

A 43–year–old man presented to the casualty department with history of spontaneous fall while working in the fields. He had headache and few episodes of vomiting. He reported history of repeated such falls in the past 3 years but had never consulted a physician. The patient was irritable but coherent and scored 14 on Glasgow coma scale (eye opening-spontaneous- 4, verbal response- oriented-5, motor response-localises pain-5). The neurologist referred the patient for computed tomography of the head. Non-contrast axial computed tomography of the head [Table/Fig-1] revealed haemorrhagic contusions in both frontal lobes (a) and a well-defined, densely calcified, round lesion in the right parieto-occipital region. Calcification was peripheral as well as central curvilinear. The lesion shows undulating membranes (b) which is almost diagnostic for hydatid cyst. Calcified membranes were attached to the choroid plexus (c). Coronal CT revealed the peripheral calcification and floating membranes. Intraoperatively, the cyst was attached to the choroid plexus. It was excised in toto without rupture and sent for histopathology which confirmed the diagnosis of hydatid. Hydatid cyst of the brain accounts for 1-2 % of all Echinococcal infections [1]. Usually these are seen in the paediatric population [2] and in the supratentorial compartment [1]. It is extremely rare for hydatid cysts to occur at intraventricular site [3]. Hydatid disease produced by the larval stage of the Echinococcus tapeworm is a worldwide zoonosis. Among the many carnivorous definite hosts of echinococcus, the most common is the dog. The intermittent hosts are all mammals (often sheep and cattle). Humans get infected secondarily through the faeco-oral route by ingestion of contaminated food or milk. The contamination occurs by dog faeces containing ova of the parasite or by direct contact with dogs. The eggs are digested in the stomach, releasing the embryos. The embryos pass through the wall of the intestinal mucosa into the portal system and are carried to the liver where most larvae get lodged in the hepatic capillaries. Some may reach the lungs and occasionally, some may get entry into the systemic circulation, at times reaching the brain. The wall of Echinococcal cyst is composed of 3 layers: the outermost pericyst, the middle laminated layer and the inner germinal layer. Calcification of hydatid cysts usually manifests with a curvilinear or ring-like pattern representing calcification of the pericyst [4]. During the natural evolution towards healing, dense calcification of all components of the cyst occurs. The undulating membrane sign seen at computed tomography in our case is due to contained rupture of the endocyst. The hydatid fluid escapes into the potential space between the pericyst and endocyst; and the endocyst collapses. On CT and MR imaging, hydatid cysts are well-defined cystic lesion with signal intensity similar to that of cerebrospinal fluid. There is no associated oedema, the lesion does not enhance after intravenous administration of contrast material, and calcification is extremely rare [5]. A recent classification based on MRI findings classifies the cysts on the basis of their fertility activity and imaging morphology. Type 1 cystic echinococcosis (CE1) are fertile active cysts and appear as unilocular cysts with or without any visible wall. Type 2 cysts (CE2) are active and seen as a unilocular cyst containing multiple vesicles arranged peripherally . Type 3 (CE3) is a transitional form containing scolices and are seen as cysts filled by multiple daughter cysts. CE4 cysts show detached membranes and CE5 are calcified lesions. CE4 and CE5 are inactive forms of hydatid cysts that have lost their fertility [6]. [Table/Fig-1]: Non-contrast axial computed tomography of the head showing haemorrhagic contusions in both frontal lobes (a) and a well-defined, densely calcified, round lesion in the right parieto-occipital region. The lesion shows undulating membranes (b) which are ... Differential diagnosis may include arachnoid cysts, porencephalic cysts and epidermoid tumors. Arachnoid cysts and porencephalic cysts are neither spheric nor are they entirely surrounded by brain tissue. The absence of significant rim enhancement, perifocal edema and mural nodules differentiates hydatid cysts from brain abscess and cystic astrocytoma [7]. The differential leukocyte count shows eosinophilia in many cases. Exploratory cyst puncture is dangerous as accidental rupture may cause anaphylaxis or secondary seeding. Stool, sputum or vomit samples can be studied for scolex if the cyst has ruptured into intestine, bronchus or bile duct. In routine laboratory diagnosis, the Enzyme-Linked Immunosorbent Assay (ELISA), the indirect immunofluorescence antibody test, immunoelectrophoresis (IEP) and immunoblotting (IB) are used [8].

Abdominal Wall Hydatid Cyst: Case Report and Review of Literature

A 60-year-old woman presented with a swelling in right paraumbilical region of one-year duration. Examination revealed a painless cystic swelling 15 × 10 cm with cough impulse. Ultrasound and CECT abdomen showed a subcutaneous cystic swelling with intramuscular extension. No other intraabdominal cystic lesions were found. Surgical exploration showed a cystic lesion adherent to peritoneum without any intraperitoneal extension. Cyst was carefully excised without any spillage. Gross specimen on opening showed multiple daughter cysts consistent with hydatid cyst, confirming the diagnosis of solitary abdominal wall hydatid cyst.

Synchronus paraspinal and hepatic hydatid disease ; a rare presentation

Hydatid cystic disease is a common zoonotic infection in the Indian subcontinent. However in the following case we report a rare presentation found in a young patient synchronously in the paraspinal and intrahepatic location without intercommunication. A high index of clinical suspicion is necessary for diagnosis. Hydatid disease is to Echinococcus species commonly granulosus, sometimes multilocularis. The common locations of hydatid cysts are the liver (65% to 75%) and lungs (25%-30%). Hydatid disease rarely develops in locations such as spleen, kidney, bones, heart, brain, peritoneum, myocardium and muscles (1-4%). A 25 year old male presented with complaining of backache on the right and fullness in the right paraspinal region. On clinical examination he had a non ballotable lump in right paraspinal region within intra muscular plane extending from posterior subcostal margin to iliac region. CT abdomen (P+C) revealed a well defined hypodence non-enhancing cystic lesion in the right lobe of the liver with peripheral calcification with lesion of similar morphology in right paraspinal muscles. Exploration of the right paraspinal region was done. Cyst was beneath the oblique & lattisimus dorsi, superficial to psoas muscle without invasion in it. Cyst opened multiple daughter cysts along with pus evacuated. Cyst excised in totto without spillage. Hydatid cyst is frequently asymptomatic, most prevalent in sheep and cattle-breeding areas. The cysts can not easily grow in muscles due to their contractility and lactic acid content. The latent period of cyst development varies between 5-20 years. Surgery is the optimal treatment for hydatid cysts. Open cyst evacuation is indicated for gharbi types 4&5, posterior cysts, central cysts, more than 3 cysts, infected cysts, biliary communication, pulmonary communication & peritoneal rupture. Alternative therapy with non-toxic scolocidal agents or combination chemotherapy has been advocated in the management of recurrence and high risk of contamination.

Computed tomography findings in cerebral hydatid disease

To describe imaging findings of cerebral hydatid cysts on computed tomography of brain. We retrospectively reviewed CT scans of brain in 5 patients with pathologically confirmed hydatid cysts in cerebral hemispheres. The patients were scanned either on a spiral (single slice) CT or on multidetector-row CT before and after intravenous injection of iodinated contrast material. All the patients were children aged 8 to 13 years with 3 boys and 2 girls. Features of raised intracranial tension were present in all the cases at presentation. CT findings of a large intracerebral cystic lesion with significant mass effect and without any calcification or enhancement were common in all 5 cases. Perilesional edema was present in 1 case. Cerebral hydatid was seen as either a homogenous fluid attenuation unilocular cyst (3 cases) or a unilocular cyst with few peripheral daughter cysts (1 case) or cyst filled by multiple daughter cysts inside (1 case). All the cases were operated and cyst was removed completely after craniotomy. Accurate preoperative diagnosis of cerebral hydatid by CT followed by surgery with care to avoid cyst rupture can result in favorable outcome.

Splenic hydatic cyst as a cause of sinistral portal hypertension and isolated gastric variceal bleeding

A 60-year-old male, living in a rural area, presented with recurrent upper gastrointestinal bleeding. Isolated fundal varices were seen on endoscopy. A lesion similar to cyst hydatid was seen in the spleen on abdominal ultrasonography and computerized tomography scanning. Also, sinistral (left-sided) portal hypertension and collaterals were seen due to the compression of the splenic vein by the cyst. Indirect hemagglutination antibody test for Echinococcus granulosus was positive. By screening, no other cyst was found in any other site of the body. The patient underwent open abdominal surgery, and the anterior wall of the cyst was resected partially; within it were multiple daughter cysts and hydatid fluid. After decontamination of the daughter cysts and hydatid fluid, germinative membrane omentoplasty was performed with a part of the omentum. However, the patient suffered from recurrent gastrointestinal bleeding postoperatively and he was re-evaluated. Later, splenectomy was performed in order to relieve left-sided portal hypertension. The patient did not experience further bleeding and gastric varices disappeared following splenectomy.

Whole-body MR and cysticercosis: reply to Wiwanitkit

We thank Dr. Wiwanitkit for interest expressed in our article [1]. Whole-body MR (WB-MR) is a recent development that refers to simultaneous whole-body coverage by acquiring multiple overlapping stations with the use of parallel acquisition technique (PAT) [2]. It is not the same as separate and non-contiguous conventional scanning of different body regions, which Dr. Wiwanitkit seems to have inferred. This distinction has been adequately emphasized in the article [1] and in the literature [2]. To the best of our knowledge, use of whole-body MR in the diagnosis of a disseminated parasitic disease has not been previously reported and hence, in our opinion, it is unique in the given scenario. Hydatid cysts have been described in multiple locations besides liver. The unusual locations include lung, kidney, bone, brain, heart, spleen, pancreas, muscle, adrenal, ovary and peritoneum [3, 4]. The imaging appearances of hydatid are distinctly different from cysticercosis, with the hydatid disease primarily consisting of large cysts (size usually of few centimeters to more than 15 cm) that do not show any enhancement except for a thin rim of enhancement in few cases. Even when there is disseminated hydatid disease, the cysts are usually of large size and contain multiple small daughter cysts [5]. The muscle hydatids are extremely rare and have been reported as single or few conglomerate cysts, typically in one location [3–5]. In contrast, cysticercus cysts are typically very small, usually only a few millimeters. The cysticerci primarily occur in the brain or muscles. They are extremely unusual in liver and other solid abdominal organs, which are the usual sites of hydatid involvement. Such extensive involvement of the muscles of the whole body with involvement of practically every muscle fibre as seen in our case has been described in literature in disseminated cysticerci (but not by whole-body MRI) and has not been described in hydatid disease. In our patient, the differential of hydatid disease of disseminated cysticercosis is therefore inconceivable.

Letter to the Editor

September 2007 Dear Editor, PRIMARY ILEAL MESENTERIC HYDATIDOSIS: A RARE CAUSE OF COLICKY ABOMINAL PAIN IN CHILDHOOD A 3-year old boy from a rural village in western India presented with intermittent pain in his abdomen for a duration of 15 days, associated with weight loss of around 6 kg over 3 months, which his mother put down to loss of appetite. His family ran a cattle farm and had intimate contact with goat and sheep. There was no history of hydatid disease in other members of the family who all lived under one roof. On examination, he had mild tenderness in the right hypochondrium and a vague, irregular, mobile, palpable mass, but no abdominal distension or visible peristalsis. Full blood count, alanine transaminase, alkaline phosphate, aspartate transaminase, gamma glutamyl transpeptidase, bilirubin and blood glucose were normal. An abdominal ultrasound showed multiple cystic areas in the central abdomen, with cysts measuring 2 mm to 8 cm with multiple loculi. The liver, spleen and kidneys were normal (Fig. 1). The provisional diagnosis was mesenteric hydatid disease and the patient underwent laparotomy and resection of the affected small bowel segment. The involved ileum and mesenteric mass including all hydatid cysts were excised. The liver and other organs were free of the disease. The gross specimen, a 25 × 25 × 15 cm mesenteric cystic mass, consisted of the terminal portion of jejunum and proximal portion of ileum (Fig. 2). Histopathology showed multiple daughter cysts within larger cysts that varied in diameter from 0.4 to 8 cm. He was discharged, taking long-term cyclic treatment with albendazole (10 mg/kg daily for 8 months as per World Health Organisation recommendations). Consecutive ultrasounds over 5 years showed no recurrence. Ultrasound showing multi-cystic areas in abdomen. Intra-operative picture showing small bowel mesentery mass with multiple multi-cystic masses and daughter cysts of varying sizes. Hydatid disease in humans is caused by Echinococcus granulosus (dog tapeworm). The dog is the definitive host. Ova shed in dog faeces infect the intermediate host (e.g. cattle, sheep), making it endemic in lamb/sheep rearing countries. Human infection occurs after the ingestion of ova, which penetrate the intestinal wall, passing via the portal vein into the liver, lungs and other tissues. A hydatid cyst can develop anywhere in the body, most commonly in the liver, although <25% occur in the lungs.1,2 Immigration, travel and migration make this disease globally important. Infections affecting bone are rare but they have been reported in pathology text and articles. The patient can present with pain in the abdomen, hepatomegaly, loss of weight, failure to thrive and complications due to the rupture of a cyst into the peritoneal cavity, anaphylactic shock, eosinophilia, urticaria, implantation into other organs and viscera, jaundice and cholangitis.3 This boy's clinical presentation at such a young age was atypical. We present this case to illustrate the importance of ultrasound scan in diagnosis.

MRI features of hydatid disease of the spine

Objective To analyze the typical MRI findings and to evaluate the value of MRI in the diagnosis of hydatid disease of the spine. Methods This retrospective study consisted of 16 patients with hydatidosis of the spine evaluated with MRI. All patients had surgery with histological diagnosis. MR myelography (MRM) was done in 4 cases, contrast-enhanced scan in 2 cases and perfusion weighted imaging (PWI) in 1 case. X-ray was performed in 8 cases and CT in 5 cases. Results All 16 cases were diagnosed as hydatid disease with multicysts. Hydatid disease involved thoracic spine in 5 cases, lumbar spine in 4 cases, sacrum in 3 cases, lumbnsacral spine in 2 cases and a combination of thoracic, lumbar spine and sacrum in 2 cases. MR imaging showed bone destruction with wedge shaped compression of single or multiple vertebra. The lesions were round in contour with different sizes and involved the bony spinal canal, appendix of vertebra and neighboring soft tissues. Cystic lesions with multiple daughter cysts demonstrated long T1 and long T2 abnormal signal intensity on MR imaging. On T2-weighted images, a hypointense rim was seen. Cystic lesions were better seen on T2 SPIR and MRM. Mild contrast enhancement of these lesions were seen. A single case showed iso-perfusion on PWI. Conclusions MRI can demonstrate hydatid cysts in vertebra, spinal canal, paravertebral and neighboring soft tissue. MRI is a valuable tool in the diagnosis and treatment planning of hydatid disease of the spine. Key words: Hydatid disease; Spine; Magnetic resonance imaging

Magnetic resonance appearance of cerebral cystic echinococcosis: World health organization (WHO) classification

Cystic echinococcosis (CE) of the brain is an uncommon parasitic infestation. The World Health Organization (WHO) recently published a classification of hepatic CE based upon ultrasonographic findings. To evaluate whether the new WHO classification of hepatic CE can be used in the classification of cerebral CE. The magnetic resonance (MR) imaging findings of 17 patients (14 male, three female), aged 10-24 years (mean age 16 years), with pathologically proved cerebral CE, and who underwent pre- and postcontrast MR imaging, were retrospectively evaluated. The cysts were classified according to the new WHO classification and their clinical stages. The MR imaging findings were correlated to the histopathologic findings. The fertile active cysts (n=12) that showed protoscoleces appeared as unilocular cysts with no visible wall (cystic lesions; CL), unilocular spherical cysts with a clear visible wall (CE1), or as a unilocular mother cyst with multiple vesicles arranged peripherally along the cyst wall (CE2). The transitional form (CE3) (n=2) containing scoleces showed multiple daughter cysts entirely filling the maternal cyst. The inactive cysts (n=3) that had lost their fertility appeared as a "ball of wool" with collapsed membrane or had detached membrane with water-lily sign (CE4) and calcified lesions (CE5). The WHO classification of hepatic CE can be used in the classification of cerebral CE when evaluated by MRI, as it can differentiate fertile active cysts from the transitional and inactive forms of cerebral cystic echinococcosis. This information is essential for treatment planning.

A young woman with multiple cardiac mass lesions

A 22-year-old woman presented with breathlessness, weight loss and anorexia of 6 months’ duration. Clinical examination was suggestive of mild to moderate cardiomegaly with systolic murmur. Routine laboratory investigations revealed normal cardiac enzymes. An electrocardiogram revealed T-wave inversion in lead II, III, aVF and I, aVL and V4–6. A chest radiograph showed widened mediastinal shadow with minimally multilobulated rightand left-sided margins of cardiac and mediastinal silhouette. No obvious calcifications or altered density difference was seen in this region. Twodimensional echo cardiography (not shown) revealed

Symptoms of bovine endocardial hydatidosis

In December 2007, a 5-year-old dairy cattle with jugular pulsation, harsh murmur, tooth grinding, weakness and loss of milk yield was referred to the department of clinical sciences, and due to clinical signs, endocarditis was diagnosed tentatively. In the slaughterhouse, a large non gravid hydatid cyst with 4-cm diameter was observed in the right ventricle that contains multiple daughter cysts. Histopathological examination showed some degrees of myocyte atrophy, severe myocardial fibrosis, and presence of numerous giant cells adjacent to the cyst wall. The present case report decides to explain the clinical signs of an unusual hydatid cyst occurrence.

Intrabiliary rupture of hydatid cyst demonstrated by magnetic resonance cholangiopancreatography

A 13-year-old girl presented with right hypochondriac pain associated with fever, rigors and chills. Physical examination was remarkable for mild icterus, pyrexia (high grade) and tender hepatomegaly. Laboratory investigations revealed...

Mediastinal Hydatid Cyst Rupturing into the Pleural Cavity Associated with Pneumothorax: Case Report and Review of the Literature

Hydatid disease remains a serious health problem in Mediterranean countries. Living in a rural area is an important risk factor for the disease. Hydatid cysts are usually located in the liver, lungs and brain. Mediastinal hydatid disease is very rare and has been noted only anecdotally in the literature. The present article reports a case of a mediastinal hydatid cyst rupturing into the pleural cavity, which was associated with pneumothorax of the same side. The patient's previous chest x-rays (posteroanterior and left lateral views) showed a well-defined mediastinal mass on the left side, and contrast-enhanced computed tomography of the thorax (taken a few days after the chest x-ray) showed multiple round-to-oval soft tissue opacities with partial collapse of the left lung. An indirect hemagglutination test for echinococcus was positive. Even after two weeks of intercostal tube drainage, the patient's condition did not improve. During thoracotomy, multiple daughter cysts were found in the pleural cavity, and the diagnosis of a hydatid cyst was confirmed after histopathological examination.

An asymptomatic ruptured hepatic hydatid cyst case presenting with subdiaphragmatic gas in a traumatic patient

Hydatid disease presents as hydatid cysts primarily in the liver and lungs. Although hepatic hydatid cysts (HHCs) may be asymptomatic for many years, they may be symptomatic due to expansion, rupture, and pyogenic infection. Rupture of the HHC into the biliary tract is one of the most serious complications and is frequently related to overenlargement of the cyst or major trauma. Patients with this disease usually have jaundice or fever. We report an asymptomatic HHC ruptured after minor trauma. While the ruptured cyst was presented as the subdiaphragmatic gas on the chest radiography, it was detected as a large cyst with multiple daughter cysts on ultrasound, computed tomography scan, and magnetic resonance imaging.

Ruptured primary uterine serosal hydatid cyst: a rare case report

A 17-year-old girl presented in the surgical emergency department with clinical features of acute peritonitis. At operation, it was found that she had ruptured a multi-cystic mass arising from the anterior serosal surface of the uterus. The cyst contained multiple daughter cysts and laminated membrane. Hydatid cystic disease was confirmed on histological examination. Pelvic hydatid cystic disease should always be considered in differential diagnosis of pelvic cystic masses in endemic areas and ruled out by appropriate investigations in order to prevent morbidity from the disease, as recurrence is common if precautionary measures are not taken.

Hidatidosis en la infancia: Albendazol en su tratamiento médico y quirúrgico

The aim of this study was to observe the response of hydatid disease in children to albendazole, either combined with or without surgery. The study was performed at Dr. L. Calvo Mackenna Hospital, between 1997 and 2000, in 15 patients. Thirteen patients received post surgery treatment because of daughter cyst finding and 2 received chemotherapy only. Albendazole was given orally (dose: 5 mg/kg bid for a mean time of 25 days) in 1 to 5 courses. Treatment evaluation was based on changes in cyst morphology, sonography and computed tomography, hematological and serological analysis. Seven patients had full response; the other had clinical and serological improvement. According with previously published experience, albendazole was efficient as a paliative pharmacological treatment instead of surgical procedure, in case of non-practicable hydatid cyst surgery. Moreover, albendazole is useful in case of multiple daughter cysts, well tolerated and reduced side effects in the follow-up.

Treatment of Hydatid Disease

Hydatid disease caused by Echinococcus granulosus presents medical, veterinary and economic problems worldwide. Hydatidosis can be treated by medical, surgical and percutaneous modalities. Benzoimidazole carbamates are effective against E. granulosus. Although mebendazole, the first benzoimidazole used, has some beneficial effects on the disease in selected patients, it has also been associated with treatment failure in some cases, perhaps because of its poor absorption. Albendazole, a more recently developed benzoimidazole, is more effective than mebendazole. Praziquantel, an isoquinoline derivative, has recently shown value in the treatment of human echinococcal disease and its use in combination with albendazole is recommended in some patients. Ultrasound guided cyst puncture is another choice of treatment which has been used successfully in selected patients, although anaphylactic and allergic reactions due to spillage of the cyst contents have occurred. Surgical therapy in echinococcal hydatid disease is indicated for large cysts with multiple daughter cysts, superficially located single liver cysts which have a risk of rupture, complicated cysts such as those accompanied by infection, compression or obstruction, and cysts located in vital organs or which are exerting pressure on adjacent vital organs. However, surgical therapy carries high risk of mortality, morbidity or recurrence. Therefore, medical therapy may be an alternative option in uncomplicated cysts and in patients at high risk from surgery. The adjuvant use of drugs with surgery and percutaneous treatment can also be recommended for some patients.

Magnetic resonance appearance of multiple intracranial epidermoid cysts: intrathecal seeding of the cysts?

A 44-year-old man presented to the hospital with multiple intracranial epidermoid cysts. The clinical manifestations of his disease included chronic headaches and one seizurelike episode. Findings determined by magnetic resonance (MR) imaging, surgery, and histological analysis indicated intrathecal and intraventricular seeding of the cysts. Spontaneous (nontraumatic) seeding of multiple daughter cysts from intracranial epidermoid cysts is still very rare and their multiple appearances on MR imaging should be distinguished from the simple scattering of oily contents due to cyst rupture.

Chronic pancreatitis resulting from primary hydatid disease of the pancreas: a case report and review of the literature

A 24-year-old Jordanian man presented with epigastric pain radiating to the back associated with vomiting; identical episodes had been occurring since age 12 years. He had no weight loss, jaundice or diarrhea, and there was no history of alcohol abuse, abdominal trauma, hyperlipidemia, or family history of pancreatitis. Physical examination revealed an acutely ill man with a temperature of 100° F. The abdominal examination demonstrated hypoactive bowel sounds, epigastric tenderness, and no rebound or guarding. Laboratory data revealed a white blood cell count of 13,700/mm3, a hematocrit of 40%, and 395,000/ mm3 platelets. There was no eosinophilia. His amylase was 571 units/L (normal 25-125), lipase 757 units/L (normal 8-70), and liver function tests were normal. US of the abdomen showed no stones in the gallbladder or biliary ductal dilation but did reveal a dilated pancreatic duct (PD) with calcifications. CT disclosed enlargement of the head of the pancreas with atrophy and calcifications in the body and tail. There was marked dilation of the main PD, and a 2.5 × 3.5 cm cystic lesion was seen projecting from the tail (Fig. 1). A diagnosis of idiopathic chronic pancreatitis and pseudocyst of the pancreas was made and endoscopic therapy was considered. ERCP revealed a dilated main PD with multiple filling defects consistent with stones (Fig. 2). A stricture was seen in the PD in the head, with upstream dilation of the remaining duct. An abrupt “cutoff ” of the duct was observed in the region of the presumed pseudocyst. A PD sphincterotomy to facilitate stone extraction was performed, followed by placement of a 7F × 9 cm PD stent. The cholangiogram was normal. The patient was readmitted for recurrent pain 1 month later, and ERCP was repeated. The PD stent was removed and found to be occluded. Several filling defects thought to be pancreatic stones were again observed, and on sweeping the pancreatic duct with an 11.5 mm balloon-tipped catheter, copious amounts of milky white gelatinous secretions poured out of the papillary orifice. This material had given rise to the filling defects in the duct, as contrast instillation at the termination of the procedure showed a dilated PD but no filling defects. The patient improved clinically, only to return with pancreatitis again, and surgery was consulted. At laparotomy, a cystic mass was present in the body and tail of the pancreas that was adherent to the spleen. A partial pancreatectomy followed by pancreaticojejunostomy was performed. Opening of the cystic mass disclosed a hydatid cyst containing multiple daughter cysts (Fig. 3), and the histopathologic findings were consistent with Echinococcus granulosus. There was a communication between the cyst cavity and the main PD through a defect in the cyst wall. Postoperatively the patient was treated with albendazole at an oral dose of 400 mg BID for 12 weeks. He has remained symptom free to date (12 months).

Controversy in the Management of Cholangitis Secondary to Hydatid Daughter Cysts

A 36 year old Cypriot woman, resident in the U.K. since the age of three years, presented with pyrexia, jaundice and upper abdominal pain. On ultrasound examination the biliary tree was dilated, contained sludge and a cystic lesion was present in the liver. An endoscopic cholangiogram showed multiple filling defects in the bile duct which were not felt to be removable endoscopically and a nasobiliary drain was therefore inserted. On resolution of the cholangitis with drainage and antibiotics a laparotomy was performed. The right lobe of the liver was largely replaced by a multiloculated cyst and the bile duct contained multiple hydatid daughter cysts. A right hepatectomy was performed with t-tube drainage of the evacuated bile duct. She made an uneventful recovery and has had no problems on subsequent follow up. Histology confirmed an intrabiliary rupture of a hydatid liver cyst. Cholangitis secondary to daughter cysts is a rare but recognised complication of hydatid liver cysts. Management of hydatid liver cysts by formal resection is controversial but may be preferable in this situation.