eMedicine Specialties > Infectious Diseases > Parasitic Infections

Echinococcosis Hydatid Cyst: Differential Diagnoses & Workup

Author: Enrico Brunetti, MD, Assistant Professor, Department of Internal Medicine, Division of Infectious and Tropical Diseases, University of Pavia School of Medicine, Italy
Coauthor(s): Carlo Filice, MD, Chief of Ultrasound Unit, Adjunct Professor, Department of Internal Medicine, Division of Infectious and Tropical Diseases, IRCCS S Matteo Hospital, University of Pavia, Italy
Contributor Information and Disclosures

Updated: Mar 28, 2008

Differential Diagnoses

Adrenal Adenoma
Lung Cancer, Non-Small Cell
Amebic Hepatic Abscesses
Lung Cancer, Small Cell
Breast Cancer, Ultrasonography
Lung, Metastases
Breast, Benign Calcifications
Metastatic Cancer, Unknown Primary Site
Cholangiocarcinoma
Pseudocyst, Pancreatic
Cysticercosis, CNS
Pyogenic Hepatic Abscesses
Hepatic Adenoma
Pyonephrosis
Hepatic Carcinoma, Primary
Splenic Abscess
Hepatic Cysts

Other Problems to Be Considered

Abscess
Epidermoid cyst
Neoplasm
Simple cyst

Workup

Laboratory Studies

  • Generally, routine laboratory tests do not show specific results.  
    • In patients with rupture of the cyst in the biliary tree, marked and transient elevation of cholestatic enzyme levels occurs, often in association with hyperamylasemia and eosinophilia (up to 60%).
    • In most cases, eosinophilia is limited (<15%) or absent.
  • Cystic echinococcosis is one of the few parasitic infections in which the basis for laboratory diagnosis is primarily serology.  
    • Indirect hemagglutination test and enzyme-linked immunosorbent assay are the most widely used methods for detection of anti-Echinococcus antibodies (immunoglobulin G [IgG]).
    • Depending on the test system used and other parameters, approximately 10% of patients with hepatic cysts and 40% with pulmonary cysts do not produce detectable serum IgG antibodies and exhibit false-negative results.
    • Cysts of the brain or eye and calcified cysts often induce no or low antibody titers.
    • Children aged 3-15 years may produce minimal serologic reactions.
  • No standard, highly sensitive, and specific serologic test exists for cystic echinococcosis antibody detection. In specialized laboratories, the arc 5 test or detection of cestode-specific antibodies can be used to exclude cross-reactions caused by noncestode parasites.

Imaging Studies

  • Radiographic examination is useful for cysts in the lungs, bone, and muscle and for detecting calcified cysts.
  • Ultrasonography is the procedure of choice when making the diagnosis of asymptomatic cystic echinococcosis because it is safe, noninvasive, and relatively inexpensive. Ultrasonography is an imaging technique that uses the reflection of ultrasound waves emitted by a probe on the bodily organs to build images of the organs explored.  
    • Any abnormality can be viewed using ultrasonography from an infinite number of angles and positions. Cysts in every part of the abdomen and in muscles can be imaged with ultrasonography.
    • Ultrasonography is useful in longitudinal studies, such as monitoring the response of cysts to treatment and recording cyst growth rate.
    • Ultrasonography has also been used extensively in endemic areas for mass screening, often using portable machines that can work without an electrical distribution system by running on batteries or on a generator.
    • Many authors consider ultrasonographic mass surveys to be the best way to assess prevalence.
  • Various classifications exist of the ultrasonographic picture in cystic echinococcosis, the most widely used being the one proposed by Gharbi in the early 1980s.2 In 2003, the World Health Organization Informal Working Group on Echinococcosis (WHO-IWGE) proposed a standardized ultrasound classification based on the active-transitional-inactive status of the cyst as suggested by its sonographic appearance.3 The standardized classification scheme is intended to promote uniform standards of diagnosis and treatment and may be applied to the clinical treatment of patients as well as to field diagnostic surveys. Whatever the classification used, general consensus exists about the following:  
    • Simple cysts with well-defined borders and uniform anechoic contents are not pathognomonic for echinococcal cysts (nonparasitic cysts have the same appearance).
    • Cysts with a visible split wall inside (floating membrane or water lily sign) are pathognomonic.
    • Septated cysts, or cysts with a honeycomb pattern, are likely to be echinococcal.
    • A solid heterogeneous mass is difficult to differentiate from granulomas or tumors, although calcification suggests echinococcal cyst.
  • Echocardiography may be used to detect cardiac lesions.
  • CT scanning has the advantage of inspecting any organ (lungs cannot be explored with ultrasonography), detecting smaller cysts when located outside the liver, locating cysts precisely, and sometimes differentiating parasitic from nonparasitic cysts. Measurement of cyst density appears to be an additional tool to differentiate parasitic from nonparasitic cysts and for follow-up studies during chemotherapy. However, the cost of CT scanning is prohibitive in several endemic countries.
  • MRI may have some advantages over CT scanning in the evaluation of postsurgical residual lesions, recurrences, and selected extrahepatic infections, such as cardiac infections.4 It is also superior in identifying changes of the intrahepatic and extrahepatic venous system.

Other Tests

  • Endoscopic retrograde cholangiopancreatography may be indicated in patients with cholestatic jaundice. This technique may also be a therapeutic intervention when cysts communicating with the biliary tree can be basketed out.

Procedures

  • Fine-needle aspiration biopsy of the cyst performed under ultrasonographic guidance, by the transhepatic approach, and under anthelmintic coverage is generally safe and diagnostically useful for differentiation of cystic echinococcosis, malignancy, and abscesses. It may be particularly helpful in cases with no detectable anti-Echinococcus serum antibodies and inconclusive imaging appearance. The hooks are usually numerous and can be found even in bacteriologically infected and/or degenerating cysts. Rostellar hooklets are seen in the image below.

  • Viable scolices (note rostellar hooklets).

    Viable scolices (note rostellar hooklets).

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    Viable scolices (note rostellar hooklets).

    Viable scolices (note rostellar hooklets).

More on Echinococcosis Hydatid Cyst

Overview: Echinococcosis Hydatid Cyst
Differential Diagnoses & Workup: Echinococcosis Hydatid Cyst
Treatment & Medication: Echinococcosis Hydatid Cyst
Follow-up: Echinococcosis Hydatid Cyst
Multimedia: Echinococcosis Hydatid Cyst
References
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References

  1. Nagpal V, Kohli K, Chowdhary A, Kumar A, Andley M, Ravi B. Breast lump as a presentation of a hydatid disease. Trop Doct. Jan 2006;36(1):57-8. [Medline].

  2. Gharbi HA, Hassine W, Brauner MW, Dupuch K. Ultrasound examination of the hydatic liver. Radiology. May 1981;139(2):459-63. [Medline].

  3. WHO Informal Working Group. International classification of ultrasound images in cystic echinococcosis for application in clinical and field epidemiological settings. Acta Trop. Feb 2003;85(2):253-61. [Medline].

  4. Dursun M, Terzibasioglu E, Yilmaz R, Cekrezi B, Olgar S, Nisli K, et al. Cardiac hydatid disease: CT and MRI findings. AJR Am J Roentgenol. Jan 2008;190(1):226-32. [Medline].

  5. Liu Y, Wang X, Wu J. Continuous long-term albendazole therapy in intraabdominal cystic echinococcosis. Chin Med J (Engl). Sep 2000;113(9):827-32. [Medline].

  6. Dionigi G, Carrafiello G, Recaldini C, Sessa F, Boni L, Rovera F, et al. Laparoscopic resection of a primary hydatid cyst of the adrenal gland: a case report. J Med Case Reports. Aug 6 2007;1:61. [Medline].

  7. Hosseini SV, Ghanbarzadeh K, Barzin J, Sadjjadi SM, Tanideh N, Mehrabani D. In vitro protoscolicidal effects of hypertonic glucose on protoscolices of hydatid cyst. Korean J Parasitol. Sep 2006;44(3):239-42. [Medline].

  8. Smego RA Jr, Bhatti S, Khaliq AA, Beg MA. Percutaneous aspiration-injection-reaspiration drainage plus albendazole or mebendazole for hepatic cystic echinococcosis: a meta-analysis. Clin Infect Dis. Oct 15 2003;37(8):1073-83. [Medline].

  9. Biyik I, Acar S, Ergene O. Left atrial mobile hydatid cyst mimicking left atrial myxoma and mitral stenosis and causing heart failure and arrhythmia. Int J Cardiovasc Imaging. Apr 2007;23(2):193-5. [Medline].

  10. Bouraoui H, Trimeche B, Mahdhaoui A, Majdoub A, Zaaraoui J, Hajri Ernez S, et al. Echinococcosis of the heart: clinical and echocardiographic features in 12 patients. Acta Cardiol. Feb 2005;60(1):39-41. [Medline].

  11. Bron JL, van Kemenade FJ, Verhoof OJ, Wuisman PI. Long term follow-up of a patient with disseminated spinal hydatidosis. Acta Orthop Belg. Oct 2007;73(5):678-82. [Medline].

  12. Brunetti E, Filice C. Radiofrequency thermal ablation of echinococcal liver cysts. Lancet. Oct 27 2001;358(9291):1464. [Medline].

  13. Brunetti E, Filice C, Meroni V. Comment on percutaneous treatment of liver hydatid cysts. AJR Am J Roentgenol. Apr 2006;186(4):1198-9; author reply 1199-200. [Medline].

  14. Brunetti E, Gulizia R, Garlaschelli AL, Filice C. Cystic echinococcosis of the liver associated with repeated international travels to endemic areas. J Travel Med. Jul-Aug 2005;12(4):225-8. [Medline].

  15. Brunetti E, Troia G, Garlaschelli AL, Gulizia R, Filice C. Twenty years of percutaneous treatments for cystic echinococcosis: a preliminary assessment of their use and safety. Parassitologia. Dec 2004;46(4):367-70. [Medline].

  16. Budke CM. Global socioeconomic impact of cystic echinococcosis. Emerg Infect Dis. Feb 2006;12(2):296-303. [Medline].

  17. Cunha BA. Antibiotic Essentials. Royal Oak, Mich: Physicians Press; 2005.

  18. Eckert J, Deplazes P. Biological, epidemiological, and clinical aspects of echinococcosis, a zoonosis of increasing concern. Clin Microbiol Rev. Jan 2004;17(1):107-35. [Medline].

  19. Filice C, Pirola F, Brunetti E, Dughetti S, Strosselli M, Foglieni CS. A new therapeutic approach for hydatid liver cysts. Aspiration and alcohol injection under sonographic guidance. Gastroenterology. May 1990;98(5 Pt 1):1366-8. [Medline].

  20. Franchi C, Di Vico B, Teggi A. Long-term evaluation of patients with hydatidosis treated with benzimidazole carbamates. Clin Infect Dis. Aug 1999;29(2):304-9. [Medline].

  21. Giorgio A, Tarantino L, de Stefano G, Francica G, Mariniello N, Farella N, et al. Hydatid liver cyst: an 11-year experience of treatment with percutaneous aspiration and ethanol injection. J Ultrasound Med. Jul 2001;20(7):729-38. [Medline].

  22. Horton J. Albendazole for the treatment of echinococcosis. Fundam Clin Pharmacol. Apr 2003;17(2):205-12. [Medline].

  23. Kabaalioglu A, Ceken K, Alimoglu E, Apaydin A. Percutaneous imaging-guided treatment of hydatid liver cysts: do long-term results make it a first choice?. Eur J Radiol. Jul 2006;59(1):65-73. [Medline].

  24. Khuroo MS, Wani NA, Javid G, Khan BA, Yattoo GN, Shah AH, et al. Percutaneous drainage compared with surgery for hepatic hydatid cysts. N Engl J Med. Sep 25 1997;337(13):881-7. [Medline].

  25. Macpherson CN, Milner R. Performance characteristics and quality control of community based ultrasound surveys for cystic and alveolar echinococcosis. Acta Trop. Feb 2003;85(2):203-9. [Medline].

  26. Magistrelli P, Masetti R, Coppola R, Messia A, Nuzzo G, Picciocchi A. Surgical treatment of hydatid disease of the liver. A 20-year experience. Arch Surg. Apr 1991;126(4):518-22; discussion 523. [Medline].

  27. McManus DP, Zhang W, Li J, Bartley PB. Echinococcosis. Lancet. Oct 18 2003;362(9392):1295-304. [Medline].

  28. Men S, Yucesoy C, Edguer TR, Hekimoglu B. Percutaneous treatment of giant abdominal hydatid cysts: long-term results. Surg Endosc. Oct 2006;20(10):1600-6. [Medline].

  29. Paksoy Y, Odev K, Sahin M, Arslan A, Koc O. Percutaneous treatment of liver hydatid cysts: comparison of direct injection of albendazole and hypertonic saline solution. AJR Am J Roentgenol. Sep 2005;185(3):727-34. [Medline].

  30. Paksoy Y, Odev K, Sahin M, Dik B, Ergül R, Arslan A. Percutaneous sonographically guided treatment of hydatid cysts in sheep: direct injection of mebendazole and albendazole. J Ultrasound Med. Aug 2003;22(8):797-803. [Medline].

  31. Rogan MT, Hai WY, Richardson R, Zeyhle E, Craig PS. Hydatid cysts: does every picture tell a story?. Trends Parasitol. Sep 2006;22(9):431-8. [Medline].

  32. Sayek I, Tirnaksiz MB, Dogan R. Cystic hydatid disease: current trends in diagnosis and management. Surg Today. 2004;34(12):987-96. [Medline].

  33. Schipper HG, Kager PA. Diagnosis and treatment of hepatic echinococcosis: an overview. Scand J Gastroenterol Suppl. 2004;(241):50-5. [Medline].

  34. Schipper HG, Laméris JS, van Delden OM, Rauws EA, Kager PA. Percutaneous evacuation (PEVAC) of multivesicular echinococcal cysts with or without cystobiliary fistulas which contain non-drainable material: first results of a modified PAIR method. Gut. May 2002;50(5):718-23. [Medline].

  35. Tsaroucha AK, Polychronidis AC, Laftsidis PA, Pitiakoudis MS, Fotakis SN, Simopoulos CE. Primary adrenal hydatid cyst: a case report. Acta Chir Iugosl. 2007;54(2):115-7. [Medline].

  36. Tutar N, Cakir B, Geyik E, Tarhan NC, Niron EA. Hydatid cysts in breast: mammography and ultrasound findings. Br J Radiol. Oct 2006;79(946):e114-6. [Medline].

  37. Türkmen C, Unal SN, Berberoglu K, Genchellac H, Unal Z, Cantez S. Acute pulmonary embolism due to hydatid cyst. Clin Nucl Med. Nov 2004;29(11):760-1. [Medline].

  38. Ustunsoz B, Ugurel MS, Uzar AI, Duru NK. Percutaneous treatment of hepatic hydatid cyst in pregnancy: long-term results. Arch Gynecol Obstet. Oct 31 2007;[Medline].

  39. WHO Informal Working Group on Echinococcosis. Guidelines for treatment of cystic and alveolar echinococcosis in humans. WHO Informal Working Group on Echinococcosis. Bull World Health Organ. 1996;74(3):231-42. [Medline].

  40. Yuksel BC, Ozel H, Akin T, Avsar FM, Hengirmen S. Primary hydatid cyst of the breast with elevated CA 19-9 level. Am J Trop Med Hyg. Aug 2005;73(2):368-70. [Medline].

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Further Reading

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Keywords

hydatid cyst, cystic echinococcosis, hydatidosis, CE, echinococcal cysts, taeniid-type tapeworm, Echinococcus granulosus, E granulosus, Echinococcus multilocularis, E multilocularis parasites, protoscolices, alveolar echinococcosis, Echinococcus species, primary echinococcosis, secondary echinococcosis, liver echinococcosis, lung echinococcosis, heart echinococcosis

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Contributor Information and Disclosures

Author

Enrico Brunetti, MD, Assistant Professor, Department of Internal Medicine, Division of Infectious and Tropical Diseases, University of Pavia School of Medicine, Italy
Enrico Brunetti, MD is a member of the following medical societies: American Society of Tropical Medicine and Hygiene
Disclosure: Nothing to disclose.

Coauthor(s)

Carlo Filice, MD, Chief of Ultrasound Unit, Adjunct Professor, Department of Internal Medicine, Division of Infectious and Tropical Diseases, IRCCS S Matteo Hospital, University of Pavia, Italy
Disclosure: Nothing to disclose.

Medical Editor

Mark R Wallace, MD, FACP, FIDSA, Clinical Professor of Medicine, Florida State University College of Medicine; Infectious Disease Fellowship Director, Orlando Regional Medical Center
Mark R Wallace, MD, FACP, FIDSA is a member of the following medical societies: American College of Physicians, American Medical Association, American Society of Tropical Medicine and Hygiene, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

John W King, MD, Professor of Medicine, Chief, Section of Infectious Diseases, Director, Viral Therapeutics Clinics for Hepatitis, Louisiana State University Health Sciences Center; Consultant in Infectious Diseases, Overton Brooks Veterans Affairs Medical Center
John W King, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Federation for Medical Research, American Society for Microbiology, Association of Subspecialty Professors, Infectious Diseases Society of America, and Sigma Xi
Disclosure: emedicine $50.00 author of chapter

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

 
 
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