|Year : 2015 | Volume
| Issue : 2 | Page : 161-163
Primary renal hydatid disease: An unusual case report and review of literature
Nidhi Verma1, Suresh Babu1, Poojan Agarwal2, Vishwajeet Singh3
1 Department of Pathology, King George's Medical College, Lucknow, Uttar Pradesh, India
2 Department of Pathology, PGIMER, Dr. Ram Manohar Lohia Hospital, New Delhi, India
3 Department of Urology, King Georges' Medical College, Luckhnow, Uttar Pradesh, India
|Date of Web Publication||6-May-2015|
Department of Pathology, King George's Medical University, Lucknow, Uttar Pradesh
Hydatid disease is caused by Echinococcus granulosus; a parasitic infestation commonly affecting liver and lung. Isolated renal involvement is rare. Unusual locations, absence of specific diagnostic tests and varied clinical and radiological presentations may pose a diagnostic challenge. High index of suspicion of this disease should be kept for any space-occupying lesion in the kidney. Early pre-operative diagnosis in combination with medical and surgical treatment may prevent dreaded complications. This case is presented here due to its rarity and to highlight the gross, microscopic, and radiological features of isolated renal hydatid disease.
ملخص البحث :
يصيب المرض الطفيلي العدارى الكبد والرئة في أغلب الأحيان وقلما يصيب الكلية. ويشكل وجود المرض في المواقع غير العادية تحديًا في تشخيصه. ولذا يجب الاشتباه في المرض عند وجود تغيرات غير طبيعية في الكلية. يجب التأكد من التشخيص ويشمل العلاج الدوائي والجراحي مما يقلل من مضاعفات المرض الخطيرة. يستعرض الباحثون حالة لمرض العدارى بالكلية لندرة حدوثها وبين الخصائص المجهرية والإشعاعية لمثل هذه الحالات.
Keywords: Echinococcus, hydatid disease, renal involvement
|How to cite this article:|
Verma N, Babu S, Agarwal P, Singh V. Primary renal hydatid disease: An unusual case report and review of literature. Saudi J Med Med Sci 2015;3:161-3
|How to cite this URL:|
Verma N, Babu S, Agarwal P, Singh V. Primary renal hydatid disease: An unusual case report and review of literature. Saudi J Med Med Sci [serial online] 2015 [cited 2021 Feb 27];3:161-3. Available from: https://www.sjmms.net/text.asp?2015/3/2/161/156433
| Introduction|| |
Hydatidosis (cystic echinococcus) is a zoonotic disease caused by ingestion of food infested by the eggs of cestode echinococcus. The adult parasite is found in jackals and canines in all continents.  Hydatid disease (HD) is endemic in sheep farming and cattle farming areas of Asia, North and East Africa, South America, Australia, and Middle East.  The highest prevalence of human HD in India has been reported from Andhra Pradesh, Saurashtra, and Tamil Nadu.  Hydatid cyst may occur in localized or disseminated form, the former being more common. Common sites of involvement are liver (55-60%) and lungs (30%). Primary renal involvement by HD is a relatively rare and accounts for only 2.5% of the cases reported world-wide. 
| Case report|| |
A 23-year-old female patient presented with lethargy and dull aching right flank pain for 1 year. No lump was palpable per abdomen. There was no history of dysuria or discoloration of urine. There were no similar complaints in the family. Her total and differential blood counts and urinary findings were within normal limits. Renal function tests were in normal range. Ultrasound abdomen was done and revealed a multiseptate multilocular well-defined complex cystic mass. A contrast enhanced computed tomography scan abdomen correlation showed enlarged right kidney with a well-defined hypodense peripherally enhancing lesion measuring 6 cm × 5.3 cm near the lower pole. Multiple thin septations were noted within this lesion on post contrast images [Figure 1]. No evidence of hydronephrosis or cortical scarring was seen. Based on the radiological findings, a presumptive diagnosis of hydatid cyst was offered. The indirect hemagglutination and other serological assays could not be performed in our case. The patient was planned for surgery and right nephroureterectomy was performed. The specimen was subsequently sent for histopathology. Grossly, a large cyst measuring approximately 7 cm × 6 cm × 3 cm at the lower pole and approaching renal pelvis, filled with numerous tiny glistening white cysts ranging in size from 0.5 to 5 cm was noted [Figure 2]. Adjoining renal parenchyma was compressed; however, pelvis and ureter were unremarkable. On microscopy multiple sections revealed numerous tiny daughter cysts composed of laminated membrane. Brood capsules and scolices with hooklets were also identified [Figure 3] and [Figure 4]. Adjacent renal parenchyma showed tubulo-interstitial inflammation and granulation tissue. Ureter and major blood vessels were normal. Thus, a final diagnosis of HD of right kidney was made.
|Figure 1: Contrast enhanced computed tomography (axial image) showing a well-defined complex cystic mass in right kidney|
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|Figure 2: Gross picture of hydatid cyst of kidney showing multiple tiny glistening white daughter cysts involving lower pole and approaching renal pelvis along with a separately sent large cyst wall (shown by arrow)|
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|Figure 3: Microphotograph showing wet mount image of Cyst fluid showing parasitic hooklets (×10). Inset showing scolex with suckers (shown by arrow ×40)|
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|Figure 4: Microphotograph showing acellular laminar cyst wall (thin arrow). Parasitic scolex is also seen (thick arrow) (H and E, ×40)|
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| Discussion|| |
Hydatidosis is a zoonotic disease caused by Echinococcus granulosus. Dogs and other carnivorous animals are definitive hosts, while sheep, cattle, horses, and goats are intermediate host. Man is an accidental and dead end intermediate host. In general, infection is acquired due to intimate association with dogs or ingestion of contaminated food. The ova penetrate the intestine and pass via the portal vein to the liver. After filtration by the liver, larvae seed and form a reactive cyst in the end-organ.  Hydatid cyst usually locate in liver and lung, but several studies have been reported from ectopic sites such as appendix, spleen, spinal, orbit, ovary, parotid glands, pancreas, skin, lymphatic glands, uterus, and tonsil except nails, teeth, and hair.  Renal hydatid cysts usually remain asymptomatic for many years. Typical hydatid cyst demonstrates germinal layer with protoscolices and brood capsules surrounded by a parasite derived laminated layer. The outermost pericystic layer is formed as a result of tissue response. The cyst is considered closed if all three layers (pericyst, ectocyst, and endocyst) are intact. Rupture of any of the layers may result in free communication with pelvi-calyceal system. Cyst rupture into the collecting system resulting in hydatiduria is rare (10-20% of renal hydatidosis). Cyst rupture can lead to complications like anaphylactic shock or disseminated echinococcosis. No laboratory test is specific to HD. Eosinophilia is nonspecific and reported in 25-50% of cases. Serological tests in primary renal hydatidosis are usually negative. The immunological study consists of immunoelectrophoresis, indirect immunofluorescence, and ELISA and is neither sensitive nor specific. Advanced radiological techniques like computed tomography (CT) scan and magnetic resonance imaging remain the mainstay of pre-operative diagnosis. Although abdominal sonography is helpful in the diagnosis, a CT is more accurate and sensitive.  The sonographic findings may show anechoic lesions with well-defined margins, while a CT may demonstrate a cyst with a thick or calcified wall, a unilocular cyst with a detached membrane, a multiloculated cyst with mixed internal density, and daughter cysts with lower density than the maternal matrix. HD may mimic renal tumors in half the cases and should be considered in the differential diagnosis of renal space-occupying lesions.  The combination of clinical history, laboratory, and imaging studies may give clue to the diagnosis.
Surgery remains the main stay of treatment. Various modalities used in the literature are percutaneous drainage and instillation of scolicidal, enucleation, cystectomy, de-roofing, nephrectomy and partial nephrectomy. During kidney-sparing surgery scolicidal solutions such as hypertonic saline should be used before opening the cavities to kill the daughter cysts and therefore prevent further spread or anaphylactic reaction. Pre-treatment with albendazole alone or in combination with praziquantel is very important as the cyst material becomes non-antigenic, cyst tension is reduced and thus reducing the risk of spillage.  Post-operatively albendazole has shown to reduce the risk of implantation of scolices.
A pre-operative accurate diagnosis is important to avoid unnecessary radical surgery and take intraoperative precautions to prevent parasite dissemination. Appropriate pre-treatment with antihelmenthics may also be started.
| Conclusion|| |
Isolated HD of the kidney is a rare entity. Clinical, serologic and radiological findings can give clue to diagnosis, but confirmation is only possible by histopathology. HD may also mimic renal tumors and should be considered in the differential diagnosis of renal space-occupying lesions. Surgical excision of renal HD is successful in providing a long-lasting cure. This case report aims at raising the awareness isolated renal HD in the differential diagnosis of space-occupying lesions of the kidney. A correct pre-operative diagnosis protects against dissemination of the parasite and avoids unnecessary radical surgery.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]