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OJHAS Vol. 11, Issue 1:
(Jan-Mar 2012) |
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A Rare Primary Pelvic Hydatid Cyst Presenting as Sciatica |
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Praveen S Rathod, Assistant Professor,
Pallavi V Reddihalli, Assistant Professor,
Uma K Devi, Associate Professor,
Uttam D Bafna, Professor and Head,
Department
of Gynaecologic Oncology, Kidwai Memorial Institute of Oncology, Bangalore. |
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Address for Correspondence |
No. 5, AB Type, Block- 1,
Kidwai Memorial Institute of Oncology Campus,
Dr. MH Marigowd Road,
Bangalore - 560029.
E-mail:
rathodps2003@yahoo.com |
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Rathod PS, Reddihalli PV, Devi UK, Bafna UD. A Rare Primary Pelvic Hydatid Cyst Presenting as Sciatica. Online J Health Allied Scs.
2012;11(1):17 |
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Submitted: Feb 28,
2012;
Accepted: Mar 24, 2012; Published: Apr 15, 2012 |
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| Abstract: |
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Primary hydatid cyst in the pelvis is rare, and usually
presents with pressure symptoms affecting the adjacent abdominal organs.
We describe a rare hydatid cyst which was eroding the sacral hallow,
protruding into the right sciatic foramen and presenting as a radiating
pain and weakness of right lower limb due to compression of the lumbosacral
nerve roots. Laparotomy with removal of cyst and postoperative treatment
with albendazole is effective in controlling the disease and preventing
recurrence.
Key Words:
Lower limb paresis; Primary pelvic hydatid cyst;
Sciatica.
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Echinococcosis is an infection caused in humans by
the larval stage of the Echinococcus granulosus
complex, These parasites are found on all continents,
with areas of high prevalence in China, central Asia, the Middle East,
the Mediterranean region, eastern Africa, and parts of South America. Echinococcal species have both intermediate and definitive
hosts. The definitive hosts are canines that pass eggs in their feces
and the intermediate hosts are sheep, cattle, humans, goats, camels,
and horses for the E. granulosus complex.
After humans ingest the eggs, embryos escape from the eggs, penetrate
the intestinal mucosa, enter the portal circulation, and are carried
to various organs, most commonly the liver and lungs. Larvae develop
into fluid-filled unilocular hydatid cysts that consist of an external
membrane and an inner germinal layer. Daughter cysts develop from the
inner aspect of the germinal layer, as do germinating cystic structures
called brood capsules. New larvae,
called protoscolices, develop
in large numbers within the brood capsule. The cysts expand slowly over
a period of years.[1] Rarely, spread may occur by the lymphatic
system of the bowel wall or, alternatively, by the venous circulation
when the parasite has passed the liver and lungs.[2] Cysts
are found in the liver (55% to 60%), lungs (30%), kidneys (2.5%), heart
(2.5%), bones (2%), muscles (1%), brain (0.5%) and in other organs such
as the spleen (1.5%).[3] Other rare sites include the omentum,
ovaries, parametrium, pelvis[4,5], thyroid, orbit or retroperitoneum.[6] In man, infection is usually acquired in childhood. The symptoms
present several years after exposure and it may take ?ve to 20 years
before a diagnosis is made.
We describe a rare case of a primary pelvic hydatid
cyst presenting like sciatica with right lower limb paresis. A Medline
search on PubMed using the key word “primary pelvic hydatid cyst case
reports” found 51 cases reported and only 5 cases have been described
with a neurological deficit like sciatica.
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A 38 years old lady presented with a radiating pain
and parasthesia of right lower limb. The radiating pain started as intermittent
in nature and progressively increased in intensity over a period of
3 years. Numbness and weakness involving the right lower limb had been
present for 15 days. There was no associated fever, loss of appetite,
backache or history of tuberculosis. The clinical examination revealed
no swelling or mass in the abdomen and there was no spinal tenderness
or deformity. The bimanual pelvic examination revealed a fixed mass
of size 10x15x15 cms, adherent to right pelvic wall and sacrum. A
normal sized uterus felt separately and bilateral parametrium, rectal
mucosa appeared free. Neurological examination showed weakness of the
hip extensors and abductors (4/5), the hamstrings (4/5), and the muscles
of the ankle and foot (3/5) on the right side as measured on the Medical
Research Council (MRC) scale. There was diminished sensation in the
distribution of the L5, S1 and S2 roots on the affected side. The clinical
diagnosis was that of a benign retroperitoneal pelvic tumour. Possibilities
considered were a cystic neuroma arising from the sciatic nerve or the
lumbosacral plexus, a sacral teratoma, or ovarian tumor or haemangioma.
Ultrasonography of the abdomen revealed a large (10.7 x 15.6 cm) hypoechoic
mass with echogenic septations in the presacral area posterolateral
to the uterus and extending into the right sacral foramen. There was
minimal right sided hydroureteronephrosis and the urinary bladder appeared
normal. MRI revealed a large cystic mass in the right adnexa, presacral
region with well-defined walls, situated posterior to the bladder and
extending to spinal cord through right sacral foramen (Figure 1). |
Figure 1: MRI of the pelvis
showing a large cystic mass extending into the sacral foramen on
the right side with well defined walls |
The
possible radiological diagnosis suspected was ovarian cyst, teratoma,
hydatid cyst, or cystic neuroma. Aspiration of the swelling yielded
approximately 15 ml of clear to straw-coloured fluid. Smear and cytospin
preparation from the fluid showed acellular material with no evidence
of any atypical cells or parasites. No acid-fast bacilli could be visualised
in the smears. The tumor markers were within normal limits. Radiological
examination of the chest was normal. We performed a laparotomy through
a midline incision on the presumptive diagnosis of cystic neuroma, sacral
teratoma, and hydatid cyst. A dumb-bell-shaped retroperitoneal cystic
mass was found occupying and eroding the hollow of the sacrum with extending
into the right sacral foramen, causing stretching of the lower lumbar
and sacral nerve roots adherent to the wall of the cyst. The cyst was
mobilized and it got ruptured during the process revealing multiple
hydatid daughter cysts (Figure 2). The germinal layer or the endocysts
were removed completely and as much of the ectocyst as possible (Figure
3). The cyst and the surgical field were washed with hypertonic saline
and povidone iodine solution. The pelviabdominal organs appeared normal.
Histological examination revealed the diagnosis of a hydatid cyst. The
patient had considerable neurological recovery with the hip extensors
and abductors and the hamstrings showing power of 5/5 on seventh postoperative
day. The patient was discharged on seventh postoperative day and advised
to continue per oral albendazole 400mg two times a day for 6 months.
Figure 2 (above): An
Intra-operative picture of a large hydatid cyst showing multiple
daughter cysts within
Figure 3
(right): The germinal layer and multiple daughter cysts after
saline wash appeared like marbles |
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The involvement of female pelvic organs by hydatid
disease is extremely rare and usually not thought of until operation
in the majority of reported cases. Primary pelvic hydatid disease originates
in the connective tissue immediately beneath the peritoneum of the pouch
of Douglas. It spreads to the uterus, ovaries, Fallopian tubes, bladder
and rectum after contact. Nearly all the cases described as developing
from the ovary or Fallopian tubes are really invasions from the broad
ligament.[7] Our case, with a pelvic mass in right adnexal
region and symptoms of nerve compression in the form of sciatica, is
rare and unique. Only five such cases of primary pelvic hydatid cyst
leading to a neurological deficit like sciatica are found reported
on Medline search in PubMed. It is of the utmost importance that a correct
preoperative diagnosis is made since all precautions must be taken to
prevent dissemination and seeding of the surgical field. Deaths have
been reported due to anaphylactic shock resulting from spillage during
excision or biopsy after a mistaken diagnosis of a retroperitoneal tumour.
In endemic regions, because of the diversity of its presentation the
possibility of hydatid disease should always be borne in mind for any
growing mass in the body. Diagnostic techniques such as radiography,
ultrasonography, CT, MRI, and immunological tests are of value. Comparison
of the Casoni and IHA tests suggests that the former is unreliable.[8,9]
- Eckert J, Deplazes P. Biological, epidemiological,
and clinical aspects of echinococcosis, a zoonosis of increasing concern. Clin Microbiol Rev. 2004;17(1):107–135.
- Manouras AJ, Tzardis PJ, Katergiannakis VA, Apostolidis
NS. Unusual primary locations of hydatid disease: case report. Acta Chir Scand 1989;155:217-219.
- Barret NR, Thomas D. Pulmonary hydatid disease. Br J Surg. 1952;40:222-244.
- Seenu V, Misra MC, Tiwari SC, Jain R, Chandrashekhar
C. Primary pelvic hydatid cyst presenting with obstructive uropathy
and renal failure. Postgrad Med J 1994;70:930-932.
- Unal S, Kayhan B, Balos F, Gorgul A. Primary pelvic
hydatid cyst. J Clin Gastroenterol 1996;23:303-304.
- Mukerjee S, Nigam M, Saraf JC. Primary retroperitoneal
hydatid cyst. Br J Surg 1973;60:916-918.
- Emamy H, Asadian A. Unusual presentation of hydatid
disease. Am J Surg 1976;132:403-405.
- Agarwal S, Shah A, Kadhi SKM, Rooney RJ. Hydatid
bone disease of the pelvis: a report of two cases and review of the
literature. Clin Orthop 1992;280:251-255.
- Fuller GK, Fuller DC. Hydatid disease in Ethiopia:
clinical survey with some immunodiagnostic test results. Am J Trop Med Hyg 1981;30:645-652.
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