Biyabani, S R

Memon, A

Nandwani, G M

English

eCommons@AKU

eCommons@AKUSection of Urology Department of SurgeryAugust 2004Incidental intrarenal-pelvic hydatid cyst discoveredduring percutaneous Nephrolithotomy (PCNL)G M. NandwaniS R. BiyabaniAga Khan University, raziuddin.biyabani@aku.eduA MemonFollow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_surg_urolPart of the Urology CommonsRecommended CitationNandwani, G. M., Biyabani, S. R., Memon, A. (2004). Incidental intrarenal-pelvic hydatid cyst discovered during percutaneousNephrolithotomy (PCNL). Journal of Pakistan Medical Association, 54(8), 436-438.Available at: https://ecommons.aku.edu/pakistan_fhs_mc_surg_urol/117Case ReportsIncidental Intrarenal-pelvic Hydatid Cyst discovered during PercutaneousNephrolithotomy (PCNL)G. M. Nandwani, S. R. Biyabani, A MemonDepartment of Surgery, The Aga Khan University, Karachi.Echinococcosis is an infestation caused in humansby the larval form of tenia echinococcus (E. granulosus).Humans are accidental intermediary hosts. The incidence ofhydatid disease is 0.4/100,000, and renal infestation occursin 2% to 3% of all cases.1,2 Most cases are symptomatic. Wepresent a case of incidentally discovered hydatid diseaseencountered during percutaneous nephrolithotomy (PCNL)managed without sacrificing the kidney. Case ReportA 32-years old housewife presented with left lumbarpain and hematuria for 6 months. On examination she hadmoderate tenderness in left lumbar region. Laboratoryinvestigations revealed hemoglobin: 12.5 gm/dl (11.1-14.5gm/dl), white cell count: 11.1 x 10E9 per liter (4-10 x 10E9per liter), neutrophils: 74.9% (40-75 %), lymphocytes:19.8% (20 - 45 %), platelets: 409 x 10E9 per liter (150 - 400x 10E9 per liter), random blood sugar: 87 mg/dl (80-160mg/ dl), sodium: 143 mmol/ L (136 - 148 mmol/L), potassi-um 3.9 mmol/L (3.6 - 5 mmol/ L), creatinine: 0.7 mg/dl(0.65 - 1.1 mg/dl), calcium: 9.6 mg/dl (8.6 - 10.5 mg/dl),phosphorous: 2.8 mg/dl (2.7 - 4.8 mg/dl), uric acid 3.6 mg/dl (2.4 - 7.2 mg/dl), urinalysis showed red blood cells: 2 andleukocytes: 18 per high power field. Urine culture showedgrowth of Proteus mirabilis. Intravenous urogram and ultra-sound kidneys showed a 3cm radio opaque calculus in theleft renal pelvis with multiple small daughter calculi withevidence of partial obstruction leading to moderatehydronephrosis (Figure 1). After treating the urinary tractinfection, she underwent a PCNL for her renal stones. Atsurgery multiple flimsy membranous structures embeddedin gelatinous material along with small mushy stones anddebris was found that raised suspicion of renal hydatid dis-ease (Figure 2). Histopathology revealed extensively  calci-fied  cystic tissue, lamellations  and  focal necrosis of surrounding tissue. Echinococcal antibody titerswere <1:16 (normal <1:32). She was put on albendazoletreatment regimen and ultrasound abdomen repeated after 10months showed no recurrence of cyst.DiscussionHydatid disease is endemic in cattle and sheep raisingregions of the world. Although hydatid disease is endemic inareas of well known geographical distribution, increasedtravel and migration have led to spontaneous occurrence inunexpected regions. In our population an intense period ofcontact with cattle occurs during the Holy month of Zilhaj,during which the ritual of sacrificing cattle (goats, sheep,cows and camels) is performed, which could be a risk factorfor contracting the disease.1 Moreover, breaking of the chainbetween primary and secondary hosts for E granulosus is notvery effective, poor surroundings of slaughterhouses and useof natural fertilizers may be an influencing factor.3 The Echinococcal larvae penetrate the intestine toenter the blood stream and lymphatics, and travel to the liver,lungs and other organs. Direct invasion of the organs from anadjacent source may also occur.1 The larvae may reach thekidneys through the bloodstream, lymph glands or by directinvasion. The kidney is usually involved as part of dissemi-nated disease and isolated renal echinococcus is uncommon. The usual presentation of renal hydatid disease isflank pain and mass. Hydatiduria, the passage of grape skin-like debris in the urine is reported in up to 29% of cases andserology is positive in half.2,4Eosinophilia is detected in 20% to 50% of patientswith renal hydatid disease. The poor efficacy of Eosinophiliais due to a high incidence of false-positive results with otherparasitic infestations. Negative serology does not excludehydatid disease and positive serology does not confirm thediagnosis.2On plain x-ray 0.9% of calcified renal masses haverenal hydatidosis. IVP reveals mostly distortion of the calicesor caliceal ectasia as a result of a renal mass involving thecollecting system. Ultrasonography usually demonstrates thetypical appearance of an echinococcal cyst that may beunilocular or multilocular. The determination of daughtercysts, which is characteristic of hydatid disease, is also pos-sible on ultrasonography. Of radiologic investigations, CThas some advantages. CT can more easily detect calcifica-tions and daughter cysts, and it is more sensitive and accuratethan ultrasonography. Also, CT provides more detailed infor-mation about communication with the urinary tract andextrarenal disease. Magnetic resonance imaging has noadvantages over CT.2Histopathologically, there is an outer non-nucleatedlayer having laminations made up of many layers of gelatin.Outside this opaque layer is inflammatory reaction that overa period of time makes a dense fibrous capsule. The daugh-ter cysts develop from the inner germinal layer. These cystseventually become leaky, resulting in sterile inflammation ofthe cyst or bacterial super infection. This causes shrinkage,fibrosis and eventual calcification of the cyst and destructionof the parasite structure, with only the pathognomic, hookletbearing degenerated scolices remaining intact amid the pastelike yellow, cholesterol rich debris.4Surgical removal of intra-pelvic renal hydatid cystwithout sacrificing kidney has been reported in the past.5In our case the cyst was discovered incidentally onpercutaneous surgery and was entirely intra-pelvic with noevidence of extra renal hydatid disease and patient did notexperience anaphylactic reaction or dissemination postoper-atively.Hydatid disease may present in unusual ways andlead to diagnostic difficulty and management problems. Ahigh index of suspicion for hydatid disease should be main-tained while evaluating complex cystic renal masses.Preoperative diagnosis is highly desirable and albendazolemay be useful to prevent anaphylactic reactions and diseaserecurrence. During percutaneous surgery intra-pelvic renalhydatid cyst can be encountered and may be managed percu-taneously in combination with medications.  References1. Biyabani SR, Abbas F, Ghaffar S, et al. Unusual presentations of hydatid dis-ease of the urinary tract. J Urol 2000;163:896-8.2. Gogus C, Safak M, Baltaci S, et al. Isolated renal hydatidosis: experience with20 cases. J Urol 2003;169:186-9. 3. Nandwani GM, Malik KA. Infrequent sites for hydatid cyst:. case report. J SurgPak 2001;6:36-7.4. Ramzi SC, Vinay K.  Robins SR. Pathologic basis of disease, 4th ed.Philadelphia: WB Sanders, 1989, pp.421-2.5. El Khader K, Koutani A, El Mamoun M, et al. Endoscopic percutaneousdrainage of a renal echinococcal cyst during percutaneous nephrolithotomy.Acta Urol Belg 1998;66:43-6.

Incidental intrarenal-pelvic hydatid cyst discovered during percutaneous Nephrolithotomy (PCNL)

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Incidental intrarenal-pelvic hydatid cyst discovered during percutaneous Nephrolithotomy (PCNL)

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