Isolated
renal Echinococcosis is a rare acquired disease of the kidney caused
by the parasite Echinococcosus. The kidneys are involved in less than
2 % of all human hydatidosis; isolated renal involvement is even rarer.
We present a case of a 30 year old male patient who presented to us
with vague abdominal pain of one year duration with no significant
physical findings Ultrasonography of the abdomen picked up a multiloculated
cystic lesion of the upper pole of the left kidney, which was more
clearly displayed in the CT Scan, IVU displayed the area as a filling
defect. There was no hydatid involvement of other visceral organs
as displayed by the investigations.
Based on the clinical and radiological findings a diagnosis of isolated
renal Echinococcosis was made, a rare case. The diagnosis was confirmed
by surgery and histopathology.
Introduction
Renal Echinococcosis also called, the hydatid cyst of the kidney is
a very rare condition caused by the parasite Echinococcus. Kidney
is the third commonest organ involved after the liver and the lungs.
The incidence of renal involvement is about 2% of all hydatid disease
in man and isolated renal involvement is very rare. It is endemic
in parts of Eastern Europe, Middle East, South America, Australia,
New Zealand, Alaska and Canada.
Here we present a case of a 30-year-old male, who presented with isolated
renal Echinococcosis, a very rare presentation.
Case Report
A 30-year-old male patient presented with vague abdominal pain of
1-year duration, insidious in onset, nonprogressive and dull aching
in type. There were no other symptoms associated with the pain.
General physical examination revealed no abnormality and systemic
examination revealed no lump or any other abdominal signs.
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Fig.
1 : Intravenous urogram showing a filling defect in the
upper pole of left kidney
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Fig.
2 : CT scan showing a multilocular cyst in the upper
pole of the left kidney
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Fig.
3 : Intraoperative photograph showing evacuated hydatid
cyst at the upper pole of the left kidney |
Routine blood examinations
were normal. The X-ray of the abdomen and chest were normal. The Ultrasonography
of the abdomen picked up a thin walled multilocular cyst in the upper
pole of the left kidney measuring 6.4 X 6.2 X 5.6 cm in size, rest of
the urinary system was normal. An Intravenous Urogram (Fig. 1) was performed
and it showed a filling defect, in the nephrogram phase on the left
side, which was not communicating with the ductal system. A CT Scan
(Fig. 2) of the abdomen was done and displayed a multilocular cyst at
the upper pole of the left kidney. There were no similar leisions in
other abdominal viscera. A diagnosis of Isolated Renal Echinococcosis
was made while keeping in mind the possibility of a polycystic kidney
disease.
The patient was
explored under general anaesthesia under the cover of antihistaminics
and steroids via a sub costal incision and the diagnosis of a hydatid
cyst involving the upper pole of the left kidney was confirmed (Fig.
3). The cyst was not in communication with the renal tubular system.
The endocyst and ectocyst were removed after isolating the cyst from
the peritoneal cavity with cetavlon soaked mops. Approximation of
the pericyst, Capitonnage was done and the patient was put on a course
of oral Albendazole therapy, 10 mg/kg for 21 days for three cycles
with an intervening period of two weeks. Histopathology confirmed
the diagnosis of hydatid cyst. Post-operative follow-up of the patient
for 3 months by Ultrasonography of the abdomen has shown the patient
to be disease free.
Discussion
Renal echinococcosis also called hydatid cyst of the kidney is an
acquired disease of the kidney caused by the parasite, echinococcus.
Renal echinococcosis comprises about 2% of all hydatid disease in
man.1 Two variants of the disease occur, Classic hydatid
disease caused by echinococcus granulosus and the rarer2
multilocular variant caused by echinococcus multilocularis, which
is more aggressive because it infiltrates the organ, involved and
hence cannot be easily removed.
Echinococcus also called the flat worm belongs to the order cestoda
and the family taenia is about 5 mm long and the adult resides in
the large bowel of foxes and dogs in case of E. granulosus and small
rodents in case of E. multilocularis.
Man is the intermediate host and gets the disease by ingesting vegetables
and water contaminated by the affected dogs. The embryos hatch in
the duodenum and migrate into the small bowel wall to enter the mesenteric
circulation and are filtered in the liver or the lungs or the kidney,
where the embryo becomes a small vesicle with an inner germinal epithelium
called the lamillated membrane that produces secondary or daughter
brood cysts containing scolices. The brood cysts float freely in the
hydatid fluid and are called hydatid sand. The cyst is slow growing
and many years may elapse before a significant size is reached. The
surrounding parenchyma gets thickened to form a pericyst
The patients usually present with vague pain in the lumbar region.3
Some may present with a mass palpable in the loin and rarely some
present with a history of passing whitish material also called as
the “grape skin”, the scolices, in the urine.3
Radiography (X-rays) may identify an occasional calcified cyst. USG
and CT scan are required to identify the loculated nature of the lesion
and may demonstrate a floating membrane, which confirms the diagnosis.
CT scan is more accurate than a USG.3 Hypo intense rim
and multicystic appearance is distinctive in MRI scan which also delineates
anatomy well.4 Intravenous urogram must be done to rule
out a communication with renal ductal system. Serology may be helpful
when in doubt and consists of doing immunoelectrophoresis, immunohaemagglutination
test, and compliment fixation test. Casoni test has been largely abandoned,
as it is unreliable. A combination of investigations will yield a
diagnosis in only 50% of cases.5
Management is mainly surgery in view of the catastrophic complications
that a cyst rupture can cause. Conservative management with oral Albendazole
is unreliable being successful in only 40% of cases. Radiological
intervention in the form of Percutaneous Aspiration Injection Re-aspiration
followed by Percutaneous drainage (PAIR-PD),6 has been
described,7 but is again successful in only 70% of cases
of unilocular cysts. Hence, surgery is the main form of treatment
especially so for the multilocular variant of the disease for which
surgery is the only form of treatment. Surgical management consists
of various options. TOTAL EXCISION consists of either wedge resection
or partial nephrectomy and PARTIAL EXCISION includes partial pericystectomy
followed by Capitonnage, re-approximation of the pericyst or marsupialisation.
Renal sparing surgery by way of partial excision is possible in 75%
cases8 and is the most adapted treatment whenever possible.1
Partial excision should be preceded by the injection of scolicidal
agents into the cyst which include 20% hypertonic saline, Chlorhexidine,
80% Ethanol, 0.5 % Cetrimide, 3% H2O2 and 0.5% Silvernitrate.9
Patient has to be operated under the cover of antihistaminics and
steroids for the fear of anaphylaxis if cyst rupture occurs during
surgery. No intervention is needed when the cyst walls are calcified.10
Patient can be started on a course of oral Albendazole after surgery.
Acknowledgements
We would like to acknowledge Dr. Girish D Bakhshi, Lecturer, Department
of General Surgery, Grant Medical College, Mumbai 400 008 for his
help in preparing this manuscript.
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