|Year : 2017 | Volume
| Issue : 2 | Page : 64-66
Primary hydatid cyst of the kidney presenting as a complex renal mass
Siraj Fouzia1, Shruti Sharma1, Vasudeva Pawan2
1 National Institute of Pathology (Indian Council of Medical Research), Safdarjung Hospital, New Delhi, India
2 Department of Urology, Safdarjung Hospital, New Delhi, India
|Date of Submission||19-Dec-2016|
|Date of Acceptance||20-Feb-2017|
|Date of Web Publication||21-Sep-2017|
National Institute of Pathology, Indian Council of Medical Research, Safdarjung Hospital Campus, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
Hydatid disease caused by Echinococcus granulosus is a rare parasitic disease mainly involving the liver and lungs. Renal involvement is uncommon and accounts for 2–3% of all cases. However, primary involvement of the kidney with sparing of liver and lungs is extremely rare. We report a case of primary renal hydatid disease in a 45-year-old woman who presented with left flank pain and a well-defined multicystic mass in the mid-pole of the left kidney. As it can clinically mimic malignancy, a high index of suspicion should be kept in mind when encountering a cystic renal mass in people from endemic areas.
Keywords: Echinococcus spp, hydatid disease, kidney
|How to cite this article:|
Fouzia S, Sharma S, Pawan V. Primary hydatid cyst of the kidney presenting as a complex renal mass. J Egypt Soc Nephrol Transplant 2017;17:64-6
|How to cite this URL:|
Fouzia S, Sharma S, Pawan V. Primary hydatid cyst of the kidney presenting as a complex renal mass. J Egypt Soc Nephrol Transplant [serial online] 2017 [cited 2018 Jun 19];17:64-6. Available from: http://www.jesnt.eg.net/text.asp?2017/17/2/64/215227
| Introduction|| |
Hydatid disease (HD) is caused by a parasite Echinococcus granulosus in humans and can afflict any organ system of the body. However, the most common sites are liver (55–70%), followed by lung (18–35%), with incidence in unusual sites accounting for 8–10% of cases. Kidneys may be simultaneously infected with liver and lung; however, isolated renal involvement is extremely rare and seen in only 1–3% of cases .
In spite of being a benign disease, it can cause substantial morbidity and mortality. The present case highlights primary renal hydatidoses with sparing of commonly affected organs such as liver and lung. It also emphasizes the need to suspect this entity while encountering a cystic renal mass in people from endemic areas.
| Case report|| |
A 33-year-old woman, living in a rural environment, presented to our hospital with chief complaints of left flank pain for the past 4 months. The patient’s consent could not be obtained as she was lost to follow-up. Pain was associated with intermittent gross hematuria. Her medical and family history was unremarkable. On physical examination, there was only mild tenderness in the left lumbar region and no mass was palpable in the abdomen. Rest of the systemic examination was normal. Routine hematological and biochemical investigations were within normal limits, except for peripheral eosinophilia (30% of the total white blood cell count). Urine analysis showed the presence of red blood cells, and urine culture was sterile. The chest radiograph was normal. Ultrasound abdomen revealed a multiseptate cystic mass measuring 50×52 mm in diameter in the mid-pole of the left kidney. Other abdominal organs were normal. This was followed by MRI, which showed a well-defined multicystic lesion in the mid-pole of the left kidney with a thin hypointense wall on T2-weighted images. The mass was seen lateral to and inseparable from the cortex in the mid-pole with splaying of pelvicalyceal system ([Figure 1]). Diethylene triamine pentaacetic acid scan revealed glomerular filtration rate of 44.9 ml/min in the right kidney and 14.9 ml/min in the left kidney with a total glomerular filtration rate of 59.8 ml/min.
|Figure 1 MRI showing a well-defined multicystic lesion in the mid-pole of the left kidney|
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With a clinical diagnosis of left nonfunctioning kidney with an associated cystic mass, the patient was taken up for laparoscopic nephrectomy. Intraoperatively, the kidney appeared enlarged showing a solid cystic mass.
Gross examination revealed a cystic mass in the kidney measuring 9×5 cm with normal renal parenchyma in the periphery ([Figure 2]). It was filled with gelatinous material and associated with multiple small cysts ([Figure 3]). Microscopic examination showed a hydatid cyst with all three layers. Pericyst adherent to the renal parenchyma was the outermost thick, fibrotic, and hyalinized layer followed by ectocyst in the form of acellular lamellated membrane ([Figure 4]). Inner germinal layer with the presence of brood capsule and scolices comprised the endocyst ([Figure 5]). A final diagnosis of primary HD of left kidney was rendered. Postoperative period was uneventful and the patient was discharged in a stable condition. She was prescribed a course of albendazole (dose: 10 mg/kg/day) for a period of 28 days and advised regular follow-up. Two years postoperatively, the patient is disease free.
|Figure 2 Gross photograph showing a cystic mass in the kidney with normal renal parenchyma in the periphery|
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|Figure 3 The mass comprises gelatinous material, multiple small cysts, and membranes|
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|Figure 4 Photomicrograph showing a pericyst (P) adherent to the renal parenchyma and an ectocyst in the form of an acellular lamellated membrane (E). Haematoxylin and eosin, ×200|
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|Figure 5 Photomicrograph showing the presence of brood capsule and scolices (endocyst). Haematoxylin and eosin, ×400|
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| Discussion|| |
HD has been known since ancient times and was recognized by early scholars such as Hippocrates who described it in the liver. It is more prevalent in endemic areas such as Middle East Asia, South America, Australia, and New Zealand, where people raise sheep and cattle. HD is seen in many developing countries  including India, where it is commonly encountered in Andhra Pradesh, Tamil Nadu, and Jammu and Kashmir . It is caused by larval stage of Echinococcus spp. (most commonly E. granulosus), which is a 5-mm-long hermaphroditic tapeworm that has dogs and foxes as the definitive host, and sheep, swine, and cattle as the intermediate host. Infection of humans occurs accidently wherein they act as intermediate hosts and represent a dead-end for the parasite. The ingested eggs hatch in the duodenum to release the true larvae (oncospheres) that infiltrate the duodenal mucosa and enter the portal circulation . Liver is the most commonly affected site (75%) and plays a major role in the body’s defense mechanism against this disease. The second common site of involvement are the lungs (15%), and thereafter it can disseminate to any anatomical location in the body. However, the occurrence of isolated primary renal hydatid cyst is very rare as seen in our case ,. Although it is not well established, the hydatid larva is believed to reach the kidney through retroperitoneal lymphatics .
The clinical picture varies depending upon the involved organs, its effects on surrounding structures, complications due to secondary infection, rupture, and anaphylaxis caused by hydatid cyst. The most common symptoms of renal hydatidosis are palpable mass, flank pain, hematuria, malaise, and fever. Hydaturia is a pathognomonic sign with passage of grape-like material in the urine on rupture of the cysts into the collecting system. It is seen in 5–25% of patients with renal HD. In a study of 11 patients with renal hydatidoses, seven (63.6%) presented with flank pain, followed by postejaculation pain in one (9.1%) patient, whereas three (27.3%) were asymptomatic .
Routine laboratory tests can only reveal eosinophilia, as was observed in our case. Diagnosis is established by imaging and serological tests. Abdominal ultrasonography, computed tomography scan, and MRI are highly sensitive and specific in revealing the morphological details of a cyst and in distinguishing it from other lesions . Other highly sensitive and specific serological tests include enzyme-linked immunosorbent assay, indirect hemagglutination test, latex agglutination test, double diffusion test, immunoelectrophoresis, and radioallergosorbant test .
In about half of the cases, medical treatment alone is found to be beneficial. It is highly effective in pulmonary hydatidoses, less for liver infection, and essentially ineffective in infection of other sites. Surgery remains the mainstay of treatment, and special care is taken to avoid any spread of hydatid with subsequent secondary echinococcosis. Some authors advocate preoperative use of antihelmenthics to sterilize the cyst, reduce the chances of spillover, anaphylactic reaction, and dissemination during surgery . Disease recurrence is a late complication and can be avoided by using postoperative medical treatment and keeping the patient on regular follow-up .
| Conclusion|| |
Primary renal involvement by E. granulosus is rarely seen. There may be a striking clinical resemblance between a hydatid cyst and malignant disease of the kidney. However, a high index of suspicion should be kept in mind when encountering a cystic renal mass in people from endemic areas.
Fouzia Siraj contributed to the study concept and design; Fouzia Siraj and Shruti Sharma contributed to drafting of the manuscript; Fouzia Siraj, Shruti Sharma, and Dr Pawan Vasudeva contributed to critical revision of the manuscript for important intellectual content; Fouzia Siraj and Dr Pawan Vasudeva contributed to clinical, technical, or material support; Shruti Sharma and Fouzia Siraj contributed to study supervision; Fouzia Siraj, Shruti Sharma, and Dr Pawan Vasudeva contributed to manuscript editing and manuscript review.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]