Cutaneous fistula of liver echinococcal cyst previously misdiagnosed as fistulizated rib osteomyelitis

Management of a primary retroperitoneal hydatid cyst ruptured in the abdominal wall: A case report

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Hydatid disease is endemic in North Africa countries such as Tunisia.

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Retroperitoneal location is scarce.

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Parietal complications are rarely described even in endemic geographic locations.

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Management of parietal complications of hydatid cysts is not consensual.

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Surgical drainage remains the gold standard.

Introduction

Hydatid disease is a global zoonosis. Any organ of the human body can be involved. Single or multiple locations are reported. However, retroperitoneal hydatid cysts are uncommon. Furthermore, parietal complications are rarely reported in literature. Therefore, the management of hydatid cysts ruptured in the abdominal wall remains challenging.

Presentation of case

In this case report, we aim to describe our experience in treating a primary retroperitoneal hydatid cyst with rupture into abdominal wall in an 87-year-old woman who presented with a 15-centimeter mass of the right flank. Hydatid serology test was positive. An abdominal CT scan showed a 20-centimeter cystic mass of retroperitoneum extended to the abdominal wall with several septa within and enhanced thick wall. The patient underwent a surgical elective drainage with perioperative antiparasitic chemotherapy. Follow-up showed no recurrence.

Discussion

Primary retroperitoneal hydatid cyst with parietal complications is scarce and barely described in literature. We performed a review of the recent relevant literature that deals with this subject. None of the hydatid cysts reported in 55 cases was located in retroperitoneum. The top seven countries of origin are located in Mediterranean region except for India. Imaging is compulsory for the diagnosis along with patient’s history, physical examination and hydatid serology. The treatment is surgical and must be must be covered by antiparasitic chemotherapy.

Conclusion

Primary retroperitoneal hydatid cyst extended to the abdominal wall remains a rare and challenging diagnosis that must be considered in endemic countries.

Parietal complication of the hydatid disease: Comprehensive literature review

BACKGROUND

The aim of the study was to provide an overview of the medical literature on parietal complications of hydatid disease (HD).

METHODS

A literature search was conducted on PubMed, Medline, Google Scholar, and Google databases in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, using keywords to identify articles related to parietal complications of HD in the thoracic and abdominal cavities. The following keywords were used: HD, hydatid cyst, cystic echinococcosis, alveolar echinococcosis, abdominal HD, thoracic HD, parietal complication, cutaneous fistulization, cystocutaneous fistulization, cutaneous involvement, external rupture, external fistulization, subcutaneous involvement, and subcutaneous abscess. The language of publication, journal, or country was not included as limitation criteria, and publications dated before August 1, 2016, were considered. Articles or abstracts containing adequate information, such as age, sex, cyst size, cyst location, clinical presentation, fistula opening location, and management were included in the study, whereas articles with insufficient clinical and demographic data were excluded.

RESULTS

The literature review included 52 articles involving 55 patients with parietal complications of HD. Thirty-two articles were written in English, 15 in French, 2 in Spanish, 1 in Italian, 1 in German and 1 in Russian. All 55 patients (women, 30; men, 23; unknown, 2) involved in the study were aged 7 to 93 (mean ± standard deviation, 54.5 ± 20.2) years. A total of 24 patients had cysto-cutaneous fistula (Echinococcus granulosus), 12 had subcutaneous rupture, 10 had cutaneous fistula (E multilocularis), 3 had cystosubcutaneous abscess, 3 had cysto-cutaneo-bronchial fistula, 2 had cysto-cutaneo-bronchio-biliary fistula, and 1 had cutaneo-bronchial fistula. E granulosus were detected in 43 and E multilocularis in 12 patients through clinical, radiological, or histopathological examinations.

CONCLUSION

Parietal complications such as cysto-cutaneous fistulization are a rare complication of HD. Complicated HD should be considered in the differential diagnosis of patients presenting with cutaneous involvement, especially in HD endemic regions.

Superinfection of a Dead Hepatic Echinococcal Cyst with a Cutaneous Fistulization

Cystic echinococcosis (CE), also known as "hydatid disease" (HD), is a zoonotic infection caused by the larval stage of Echinococcus granulosus, which infects humans as intermediate hosts through the orofecal route. Carried by the intestinal venous blood, the embryos released by the eggs of the tapeworms can reach every organ, especially the liver, turning into a hydatid cyst. Usually asymptomatic, the cysts can be incidentally detected through radiological examinations performed for other reasons. We show an unusual case of superinfection of a hydatid cyst with typical radiological features of inactivity (WHO-type CE5) with an even rarer skin fistulization passing through a subcutaneous-abdominal abscess involving the right iliac muscle.

Cutaneous fistulization of the hydatid disease: A PRISMA-compliant systematic review

AIM

To provide an overview of the medical literature on cutaneous fistulization in patients with hydatid disease (HD).

METHODS

According to PRISMA guidelines a literature search was made in PubMed, Medline, Google Scholar, and Google databases were searched using keywords to identify articles related to cutaneous fistulization of the HD. Keywords used were hydatid disease, hydatid cyst, cutaneous fistulization, cysto-cutaneous fistulization, external rupture, and external fistulization. The literature search included case reports, review articles, original articles, and meeting presentations published until July 2016 without restrictions on language, journal, or country. Articles and abstracts containing adequate information, such as age, sex, cyst size, cyst location, clinical presentation, fistula opening location, and management, were included in the study, whereas articles with insufficient clinical and demographic data were excluded. We also present a new case of cysto-cutaneous fistulization of a liver hydatid cyst.

RESULTS

The literature review included 38 articles (32 full text, 2 abstracts, and 4 unavailable) on cutaneous fistulization in patients with HD. Among the 38 articles included in the study, 22 were written in English, 13 in French, 1 in German, 1 in Italian, and 1 in Spanish. Forty patients (21 males and 19 females; mean age ± standard deviation, 54.0 ± 21.5 years; range, 7-93 years) were involved in the study. Twenty-four patients had cysto-cutaneous fistulization (Echinococcus granulosus); 10 had cutaneous fistulization (E multilocularis), 3 had cysto-cutaneo-bronchio-biliary fistulization, 2 had cysto-cutaneo-bronchial fistulization; and 1 had cutaneo-bronchial fistulization (E multilocularis). Twenty-nine patients were diagnosed with E granulosis and 11 had E multilocularis detected by clinical, radiological, and/or histopathological examinations.

CONCLUSION

Cutaneous fistulization is a rare complication of HD. Complicated HD should be considered in the differential diagnosis of cases presenting with cutaneous fistulization, particularly in regions where HD is endemic.

[Spontaneous cutaneous fistula of hydatid liver cysts]

BACKGROUND

Spontaneous cutaneous fistula of hydatid liver cysts is a rare complication. Its genesis involves anatomic factors as well as other local factors.

AIMS

An exhaustive literature review was conducted to identify the characteristics of this complication, treatment modalities and the results obtained.

PATIENTS AND METHODS

An exhaustive bibliographic search was made for all articles published in French and English relating to parietal complications of hydatid liver cyst, from which we retained only those involving cases of cutaneous cyst fistulas (communicating rupture), to which we added our own case.

RESULTS

Seventeen cases of cystocutaneous fistula have been reported. The reason for consultation was productive cutaneous fistula. Morphological investigations were highly evocative of the diagnosis. Thirteen patients were treated by surgery, two underwent percutaneous debridement, and two declined treatment.

DISCUSSION

Cutaneous fistula constitutes a rare mode of discovery of hydatid cyst. Fistulography and CT scan are extremely useful for diagnosis. Percutaneous debridement of the hydatid cyst represents a debatable alternative to surgical therapy.

Development of a cutaneous fistula following hepatic cystic echinococcosis

Hydatid cyst is an infectious disease characterized by cysts formed primarly within the gastrointestinal tract by echinococci. Hepatic hydatid disease, which is the most common form, remains asymptomatic until complications occur. In this report, we present an 80 years old patient who presented with a hepatic hydatid cyst which fistulized to the abdominal skin into the Emergency Department. Computed tomography of the abdomen showed inactive grade 5 cyst. Drainage without removal of the cyst failed to reveal active disease but the microbiological examination showed Klebsiella pneumonia that was sensitive to ampicillin-sulbactam as the causative agent. The treatment of the cyst with a combination of surgical and medical treatment was the successful treatment of Hepatic Hydatid Disease presenting with a cutaneous fistula.