Letter to the Editor


September 2007

Dear Editor,


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.

Figure 1.

Ultrasound showing multi-cystic areas in abdomen.

Figure 2.

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.