A previously asymptomatic 46–year–old male presented with acute onset of sharp right upper quadrant (RUQ) pain. Patient denied nausea, vomiting, fever or similar symptoms before. The patient is Lebanese and had moved to USA 5 years ago. He appeared not to be fluent in English. At presentation patient was stable, afebrile but in moderate distress due to pain. Physical exam showed hepatomegaly, RUQ tenderness, positive Murphy’s sign but no rebound tenderness. There was a Leukocytosis of 16.2K cells/mL. The liver function tests were unremarkable. A CT scan showed an enormous 14 × 12 × 10 cm rim enhancing lesions compatible with a hepatic abscess (Figure 1). A fluoroscopy guided drainage was planned without prior consultation to hepatology, hepatobiliary surgery or infectious diseases. The aspiration was unsuccessful. Immediately, after the needle was retracted the patient developed severe hypoxia, hypotension, angioedema and a severe anaphylactic shock. Patient was intubated and admitted to the ICU. An extensive urticarial rash with hives developed in skin and mucosal surfaces. Antihistamines, steroids, fluids and vasopressors were started as well as empiric albendazole for a suspected hydatid cyst. Clinical improvement and extubation occurred 48 hours later. A later exploratory laparotomy showed a liver cyst aspirating 1 L of straw colored fluid, which showed no cells or organisms. Serology came back positive for Echinococcus granulosus (5.83 IU; Positive test > 1.20 IU). Pathology showed a hydatid cyst membrane, daughter cysts and scolices. Using a translator the patient confirmed that “the dog cyst” was frequent among his relatives in Lebanon. The hospital course was complicated by the development of a biliary fistula and superimposed resistant bacterial and fungal peritonitis and multiple surgeries. The length of stay was 3 months.
The proper treatment of a hydatid cyst depends on an adequate diagnosis and a multidisciplinary assessment. For simple cases of cystic echinococcosis, the most common treatment is surgical removal of the cysts combined with albendazole. PAIR (puncture–aspiration–injection–reaspiration) is used for cysts in risky locations. A wrong assessment could cause catastrophic outcomes that include anaphylaxis (spillage of hydatid fluid into the peritoneum or the bloodstream), infection and biliary fistulas.
In this case of a superficially located simple but large hepatic hydatid cyst, puncture or aspiration of any kind should have been avoided due to the high risk of rupture. A surgical excision would have been the best treatment. The use of a translator and consultations to other specialties could have prevented this catastrophic outcome.
Figure 1Abdominal CT scan at presentation. It shows a single and large (14 × 12 × 10 cm) rim enhancing hepatic cystic lesion of homogeneous content. Patient moved from Lebanon to US 5 years ago. During these 5 years the patient did not have any symptoms related to this liver cyst until presentation.