C-197. Extra-Hepatic Hydatid Disease: A Pericardial and Intracranial Cysts Pose a Diagnostic Dilemma!

P. R. Hira1, F. Al-Ali2, N. Khalid2, F. A. Al-Shelahi2, A. A. Abdulla3, A. H. Ali2, S. Al-Eneizi2, S. Hebbar2, D. Al-Refaai2;
1Faculty of Med., Kuwait Univ., Kuwait City, KUWAIT, 2Farwania Hosp., Kuwait City, KUWAIT, 3Ibn Sina Hosp., Kuwait City, KUWAIT.

Aim: Hydatid disease due to the larvae of the dog tapeworm Echinococcus granulosus is endemic in sheep-rearing areas of the Middle East including Kuwait. The majority of the cysts manifest in the liver followed by the lung and abdomen. We report a patient harboring a pericardial and multiple intracranial cysts, rare sites of affliction, posing a problem in diagnosis. Case study: An 18-year old Syrian male presented with complaints of repeated attacks of headaches, vomiting and seizures. After two weeks his condition deteriorated further with general weakness and fatigue. The full blood count was normal with no eosinophilia. On a chest x-ray though, a calcified cyst was detected in the pericardium. A CT scan further identified several cysts in both hemispheres of the cerebrum, and one in the cerebellum. Results and Discussion: Hydatid disease was not included as a differential diagnosis since the locations of cysts were in such rare sites. Serology for echinococcosis however, was in the significant range. Albendazole was prescribed. A suboccipital craniotomy and a left temporal craniotomy were performed to remove the cysts. Later, a right temporal craniotomy yielded five cysts, two of which were ruptured. Histopatholgy showed the laminated membrane and the germinal layer typical of a hydatid cyst. However, no scolices or hooklets were identified in the cyst or in the fluid. The patient was on a ventilator for several weeks but without any improvement. The presentation of a cardiac and multiple intracranial cysts is indeed rare, posing a diagnostic dilemma. Many differential diagnoses were proposed but the possibility of hydatid cysts extra-hepatically was not a priority. We discuss further the limitations in diagnosis compared to cysts in the liver and lungs. Conclusions: We emphasize the need to include hydatid disease as a differential diagnosis even if the cystic mass is lodged extra-hepatically, especially in endemic areas. Serology is a valuable diagnostic tool. We also discuss the predilection for organs affected in extra-hepatic cystic hydatid disease, the factors determining such locations and the problems encountered in endemic areas.