- Case report
- Open Access
Primary para-vertebral hydatid cyst in the sub-occipital area of the neck: an unusual case of echinococcosis
© The Author(s) 2018
- Received: 15 September 2017
- Accepted: 29 June 2018
- Published: 7 September 2018
Hydatid disease is a parasitic infectious disease caused by Echinococcus granulosus. The parasite can form cysts in any part of the body with the liver and lung being the most commonly involved organs. It can rarely occur in other organs like the muscle, bone, pericardium, myocardium, spleen, spine, and neck. Para-vertebral hydatid cyst is very rare and can present with a variable clinical presentation. Surgical excision is the treatment modality of choice and accepted to be curative with a very low recurrence.
We here present a case of primary hydatid cyst in the para-vertebral space in sub-occipital area of the neck who presented with complaints of pain and swelling in the right posterior-lateral side of the neck. X-ray cervical spine revealed suspicious lesion in the sub-occipital area. Magnetic resonance imaging (MRI) was suggestive of multi-loculated cystic lesion. There were no such cysts found in peritoneal viscera or any other organ. Patient was planned for surgery and the cyst was excised. Histopathological examination confirmed the hydatid disease. Post-operatively, the patient was put on albendazole and patient’s symptoms disappeared after surgery.
Cysts in any part of the body should be evaluated for hydatid disease especially in the endemic areas. Radiological imaging and serology are important for diagnosis, and surgical excision is the best modality of treatment.
- Hydatid cyst
- Para-vertebral space
Hydatid disease is caused by larval form of Echinococcus granulosus. It is commonly seen in cattle rearing areas like Australia, New Zealand, South America, Mediterranean countries, and countries with poor socio-economic conditions [1–3]. It is commonly seen in the liver and lung [4–6] and rarely involves some unusual locations such as the bones, heart, brain, spleen, pericardium, myocardium, and muscles [7–10]. Primary hydatid cyst of muscle is very rare because of the presence of lactic acid creating unfavorable environment for its growth [11, 12]. It constitutes only 2–3% of all cases . We present a case of hydatid cyst in para-vertebral space in sub-occipital area of cervical region in a 50-year-old male presented to our neurosurgery outpatient clinic at our institute.
Hydatid cyst generally remains asymptomatic with a very slow growth rate. The latency period ranges from 5 to 20 years [22, 23]. Clinical manifestation depends on the anatomical site involved and size of the cyst. Clinical symptoms are usually due to the pressure on adjacent structures or obstruction. Secondary infections and anaphylactic reaction to ruptured cystic fluid are the most common complications . Our case presented with neck swelling in the sub-occipital area with neck pain.
Hydatidosis being asymptomatic is usually diagnosed by imaging done for other reasons. X-ray, USG, computed tomography (CT), and magnetic resonance imaging (MRI) are the main investigations used for the detection of cysts. CT and MRI have very high accuracy in establishing diagnosis of hydatid cyst [25, 26]. Diagnose is confirmed by serological tests. Various serological tests are used to detect specific serum antibodies and circulation antigens: hemagglutination test, immunoelectrophoresis (IEP), ELISA for echinococcal IgG, etc. ELISA have sensitivity-95% and specificity-94% . Serological tests can have false negative and false positive results; therefore, positive tests do not confirm the diagnosis and negative test do not exclude the disease . In the present case, X-ray cervical spine showed a suspicious lesion in the sub-occipital area, posterior to C1 and C2 cervical vertebrae. The diagnosis was then made by MRI and confirmed by ELISA.
Treatment for the hydatid disease depends on the location of the cyst, size, and health status of the patient. Surgical excision is the optimal treatment of large and symptomatic hydatid cysts . Other modalities of treatment include anti-helminthic drugs (for small and asymptomatic cysts) and scolecidal agents. Depending on the clinical situation, radical or conservative approach can be adopted. Total cystectomy has the least recurrence rate but is associated with high morbidity. Cyst in the intraperitoneal viscera can be approached by simple deroofing and enucleation, but care should be taken to prevent the spillage. Residual cavity can be managed by various methods . Puncture-aspiration-injection-reaspiration (PAIR) is an ultrasound-guided technique consisting of puncture of the hydatid cyst and evacuation of the contents, injection of scolecidal agents such as 95% ethanol, and reaspiration of the contents of the cyst. Although this technique has long been discouraged because of the potential complications such as iatrogenic spread of disease and anaphylactic shock, there is an expanding literature suggesting that PAIR is effective for the treatment of primary uncomplicated hepatic cysts . This technique has also been used as a modality of treatment in muscular hydatid cyst . In the present case, we have performed total cystectomy with captionage of the residual cavity.
Hydatid cyst can occur in any part of the body, so cysts in any part of the body should be evaluated for hydatid disease especially in the endemic areas. The radiological imaging and hydatid serology play an important role in diagnosis with high accuracy. Treatment varies from medical management to surgical excision. We consider surgical excision as the best modality of treatment.
We are very thankful to the patient for his time and consent for the publication of this case report.
Availability of data and materials
The data and material used during the current study is available with the corresponding author on reasonable request.
DPMUD, WAA, and MLA conceived and designed the manuscript. DPMUD, MLA, and GBA helped in the definition of the intellectual content. DPMUD, WAA, KAR, GBA, and WNG contributed in the literature search. DPMUD, WAA, and MLA provided the clinical studies. DPMUD, MLA, and WNG involved in data acquisition. DPMUD, WAA, MLA, and GBA analyzed the data. DPMUD, MLA, and KAR gave statistical analysis. DPMUD, WAA, MLA, and GBA prepared the manuscript. DPMUD, MLA, KAR, and WNG edited the manuscript. DPMUD, WAA, MLA, and KAR reviewed the manuscript. DPMUD, WAA, MLA, KAR, GBA, and WNG are guarantors of the manuscript. All authors read and approved the final manuscript.
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Written informed consent was obtained from the patient to participate in the treatment and publication.
The authors declare that they have no competing interests.
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