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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 15  |  Issue : 1  |  Page : 57-58

Ruptured hydatid cyst: An unusual cause of pneumobilia


Department of Internal Medicine, Christian Medical College and Hospital, Vellore, Tamil Nadu, India

Date of Web Publication17-Feb-2017

Correspondence Address:
Ajay Kumar Mishra
Department of Internal Medicine, Christian Medical College and Hospital, Vellore - 632 004, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cmi.cmi_7_16

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  Abstract 

Echinococcosis or hydatid disease caused by the larval stage of cestodes of the genus Echinococcus granulosus, produces cystic lesions in various organs, the liver being the most common site. Symptoms are produced by mass effect, biliary obstruction, or secondary infection in most instances. Cystic rupture is an uncommon cause of symptoms. We report the uncommon occurrence of pneumobilia in the setting of hydatid cyst rupture with secondary infection by gas producing organisms.

Keywords: Echinococcosis, hydatid cyst, internal medicine


How to cite this article:
Koshy M, Mishra AK, Iyadurai R. Ruptured hydatid cyst: An unusual cause of pneumobilia. Curr Med Issues 2017;15:57-8

How to cite this URL:
Koshy M, Mishra AK, Iyadurai R. Ruptured hydatid cyst: An unusual cause of pneumobilia. Curr Med Issues [serial online] 2017 [cited 2019 Nov 19];15:57-8. Available from: http://www.cmijournal.org/text.asp?2017/15/1/57/200313


  Introduction Top


Hydatid disease is a parasitic infestation caused by the larval stage of Echinococcus granulosus, also known as dog tapeworm. The disease is found in all parts of the world, with a high prevalence in Central Asia, the Middle East, the Mediterranean, East Africa, and some parts of South America. It is a public health concern and may be regarded as a reemerging disease.[1] The parasite produces cystic lesions in various organs, the liver being the most common site. Symptoms are produced by mass effect, biliary obstruction, secondary infection, or rarely cystic rupture. We report the uncommon occurrence of pneumobilia in the setting of hydatid cyst rupture with secondary infection by gas producing organisms.


  Case Report Top


A 40-year-old male complained of the right upper abdominal pain and early satiety for 1 month. He presented to the emergency department with worsening of abdominal pain, fever, and vomiting for 1 day. He had no comorbid illnesses other than poorly controlled diabetes and chronic consumption of alcohol. On general examination, he was febrile and tachycardic. Systemic examination was unremarkable apart from tender hepatomegaly (18 cm) and intercostal tenderness.

Investigations revealed leukocytosis with neutrophilia (18,000/mm [3]; neutrophils - 85%) and direct hyperbilirubinemia (total/direct bilirubin - 4.1/3.5 mg%) and elevated alkaline phosphatase (455 mg%). Computed tomography of the abdomen showed a thin-walled cystic lesion, measuring 9 cm × 9 cm × 12 cm, in segment VI and VII of the liver with calcification and a large air pocket communicating with the hepatic duct [Figure 1]a and [Figure 1]b. A diagnosis of infected ruptured hydatid cyst with aerobilia was made. The patient underwent endoscopic retrograde cholangiopancreatography with sphincterotomy, and the bile culture grew extended spectrum beta-lactamase  Escherichia More Details coli. His symptoms resolved following treatment with meropenem and albendazole.
Figure 1: (a and b) Computed tomography of the abdomen showed a thin-walled cystic lesion in liver with calcification and a large air pocket communicating with the hepatic duct.

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  Discussion Top


Echinococcosis in humans is caused by the larval stage of cestodes of the genus Echinococcus. The two most important forms of the disease in humans are cystic echinococcosis (caused by E. granulosus) and alveolar echinococcosis (caused by Echinococcus multilocularis). The life cycle of the parasite involves a definitive host and an intermediate host. Canines are the definitive host which house the adult worm in their intestines and shed eggs in the feces. The intermediate host is often herbivores such as sheep, goats, cattle, and camels which ingest the eggs from contaminated ground. The eggs develop within the intermediate host and oncospheres are released in the gut. These oncospheres penetrate the intestinal wall to enter the circulatory system and thereafter migrate to various organs. Oncospheres develop into cysts, especially in the lungs and liver of these animals. The ingestion of infected meat with cysts by the definitive host results in completion of the cycle.[1],[2]

Humans are accidental intermediate hosts and become infected by the ingestion of food contaminated with canine feces containing the eggs. The disease is endemic among those involved with rearing livestock and dogs. Human infection with E. granulosus leads to the development of one or more hydatid cysts located in several organs. The liver is the most common organ of involvement (>65%) followed by the lung (25%).[3] Less frequently, cysts may be found in the kidney, spleen, heart, bone, or central nervous system. Although infections are acquired in childhood, individuals become symptomatic as adults due to the slow rate of growth (1–5 cm/year).

The imaging technique of choice is ultrasonography, for both cystic echinococcosis and alveolar echinococcosis. Computed tomography and/or magnetic resonance imaging scans help in validating the findings and provide greater detail.

Hydatid cyst, caused by Echinococcus, can produce symptoms due to mass effect or complications secondary to rupture.[1] Hepatic echinococcosis presents with abdominal pain, palpable mass, enlarged liver, obstructive jaundice, nausea and vomiting. Rupture of the cyst can result in allergic reactions and anaphylaxis. Rupture into the biliary tree causes cholangitis and obstructive jaundice while secondary infection results in the formation of an abscess.[3]

Pneumobilia refers to air within the biliary system. Pneumobilia occurs in the setting of biliary instrumentation, incompetent  Sphincter of Oddi More Details, and spontaneous or surgical biliary-enteric communication [3] (an abnormal communication between the biliary tree and the intestinal tract) or if there is infection by gas-forming organisms. Other conditions associated with pneumobilia include an incompetent sphincter of Oddi, recent biliary instrumentation, and biliary-enteric anastomosis or fistulae.[4]

In this case, the hydatid cyst had ruptured into the biliary tree and became secondarily infected with gas-forming organisms resulting in pneumobilia. Similarly, pulmonary hydatid cysts may rupture into the bronchial tree and manifest with symptoms of cough, chest pain, hemoptysis, and dyspnea.

Diagnosis is established by imaging with demonstration of well-defined cysts, daughter cysts. and “hydatid sand.” Serological testing and aspiration of cyst contents may also be done. Treatment modalities include chemotherapy with benzimidazole compounds, percutaneous aspiration injection, and re-aspiration and surgery.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Moro P, Schantz PM. Echinococcosis: A review. Int J Infect Dis 2009;13:125-33.  Back to cited text no. 1
    
2.
Echinococcosis. World Health Organization Fact Sheet. Available from: http://www.who.int/mediacentre/factsheets/fs377/en/. [Last accessed on 2016 Dec 19; Last updated on 2016 Apr].  Back to cited text no. 2
    
3.
Tinsley B, Abbara A, Kadaba R, Sheth H, Sandhu G. Spontaneous intraperitoneal rupture of a hepatic hydatid cyst with subsequent anaphylaxis: A case report. Case Reports Hepatol 2013;2013:320418.  Back to cited text no. 3
    
4.
Sherman SC, Tran H. Pneumobilia: Benign or life-threatening. J Emerg Med 2006;30:147-53.  Back to cited text no. 4
    


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