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NEURORADIOLOGY Table of Contents   
Year : 2006  |  Volume : 16  |  Issue : 4  |  Page : 771-774
Disseminated hydatid disease a case report with mr spectroscopic correlation


Sri Sathya Sai Institute Of Higher Medical Sciences, Epip Area, Whitefield, Bangalore, India

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Date of Submission28-Apr-2005
Date of Acceptance10-Jun-2006
 

Keywords: Hydatid Cyst, Brain, MRI, MR Spectroscopy

How to cite this article:
Sreedhar M. Disseminated hydatid disease a case report with mr spectroscopic correlation. Indian J Radiol Imaging 2006;16:771-4

How to cite this URL:
Sreedhar M. Disseminated hydatid disease a case report with mr spectroscopic correlation. Indian J Radiol Imaging [serial online] 2006 [cited 2019 Aug 24];16:771-4. Available from: http://www.ijri.org/text.asp?2006/16/4/771/32344
Hydatid cyst is the larval form of echinococcus granularis affecting most of the organs of the body. It mainly affects the liver and lungs. Brain is affected in about 2% of cases and the heart is affected in less than 2% of cases. We present a case of cardiac, cerebral and peritoneal hydatid disease in a 9 year old boy.

A 9 year old boy presented with history of diffuse, episodic headache since 3 months, intensity of headache having increased since 1 1/2 months, associated with nausea, vomiting, and loss of consciousness at the height of headache. History of right hemiparetic gait since one month. No relevant past history.

Positive clinical findings were right 6th nerve paresis, bilateral papilloedema, mildly increased tone.

MRI of the brain showed cystic lesions of CSF intensity, in the right parieto occipital, Rt insular, left fronto parietal regions, posterior aspect of perimedullary cistern on right side, posterolateral to the fourth ventricle (Fig 1a). The cysts were of varying sizes, though generally they were large in size (largest 7x4x4cms and smallest cyst 0.6x0.5x0.7cms). The lesions had thin hypointense walls did not enhance with contrast, showed apparent diffusion coefficient similar to that of CSF. MR Spectroscopy (fig.4) at TE of 144 and 33 showed elevated lactate seen as a doublet at 1.3ppm (lactate peak is inverted at echo time of 144 due to j coupling) and a peak at 2.4 ppm which corresponds to the pyruvate peak and a smaller peak adjacent to lactate at 1.5 ppm suggesting alanine.

CT scan of thorax and abdomen revealed a unilocular cyst arising from the omentum and measuring 3.2 x 3.7 x 3.6 cms with non- enhancing walls, located in the Rt hypogastric region. There was a multi-loculated cystic lesion arising from the lateral wall of the left ventricle. However there were no cysts in the liver.

On echocardiography, multiple cystic lesions attached to the antero-lateral papillary muscles and the lateral wall of left ventricle. There was no flow into the cysts.

RT and LT parietal craniotomy and removal of multiple cysts was done under GA.

Post op MRI showed residual cysts, in the right postero inferior perimedullary cistern, one within the fourth ventricle, one in the right temporal lobe, 2 small cysts in the right parieto occipital areas. Bilateral sub dural effusions and post op changes, no hydrocephalus was seen. The patient was started on albendazole.

A review MRI done 6 wks after albendazole treatment showed no significant diminution of size, though some perilesional edema was observed probably related to degeneration of cysts on treatment.

Hydatid disease is a worldwide zoonosis produced by the larval stage of the Echinococcus tapeworm. The two main types of hydatid disease are caused by E granulosus and E multilocularis. The former is commonly seen in the cattle grazing regions of the world and is the most frequently encountered type of hydatid disease in humans [1]. Dog is the definitive host whereas sheep and humans are intermediate hosts. Human disease is caused by the ingestion of food contaminated with dog feces that contain tapeworm ova. The ingested ova hatch in the gastro intestinal tract and the liberated embryos spread to many organs via portal and systemic circulations. They subsequently develop into cystic larvae, known as hydatid cysts.

. Hydatid disease affects the central nervous system in less than 2% of cases [2] and is usually diagnosed during childhood. Though in other organs they are multiple, they are usually solitary in brain [4],[5],[6]. Although hydatid disease may be located anywhere in the brain, it is most frequently located in both hemispheres, particularly in the middle cerebral artery territory. In young patients, radiography of the skull may demonstrate suture separation, unilateral enlargement of the vault, or erosion of the posterior clinoid processes [1]. Classic CT appearance of E. granulosus intracranial hydatid disease is a spherical cystic lesion with sharply defined border and attenuation similar to that of CSF. MR imaging shows a well-defined oval or cystic mass with signal intensities similar to that of CSF, sometimes with a low intensity rim. MR imaging may also show pericyst as a halo of high signal intensity on T2-weighted images, and in some cases, perifocal edema may be detected. The lesion typically shows no contrast enhancement, and calcifications, usually peripheral, are rare. Cystic lesions with peri focal edema and rim enhancement can be categorized as complicated [8]. When a secondary process occurs in the cyst, such as infection or rupture, the signal intensity tends to be slightly decreased on T2-weighted images and a little higher on T1-weighted images. Proton MR Spectroscopy shows a large succinate peak, in addition to lactate, alanine, and acetate [3], whereas other authors have described pyruvate at 2.4 ppm as a marker metabolite of hydatid cyst [9],[10].

Our patient had shown markedly elevated lactate pyruvate and Myo-inositol [3]. On diffusion weighting, these cysts showed ADC similar to that of CSF. The ADC values of E. granularis and E. alveolaris were entirely different. DWI could not be used differential diagnosis [7].

The lesion seen with E. multilocularis was a well-defined multi-septate mass consisting of solid and cystic components with calcification in the solid portion [8].

Infestation with E. multilocularis is a more malignant disease, referred to as alveolar echinococcosis. CT findings of brain involvement are typically multiseptate multiple iso-attenuated or hyper-attenuated lesions that show contrast enhancement. On MR images, the lesions are heterogeneous, with areas of low signal intensity on both T1- and T2-weighted images, corresponding to calcifications. Extensive perifocal edema and heterogeneous contrast enhancement can be seen [5].

A case of disseminated hydatid disease, secondary to cardiac lesion is described. On diffusion weighted study ADC values were similar to CSF. MRS showed alanine, lactate, pyruvate peaks, correlating with previous reports.

 
   References Top

1.Ivαn Pedrosa, MD, Antonio Saνz, MD, Juan Arrazola, MD, Joaquνn Ferreirós, MD and Cιsar S. Pedrosa, MD. Hydatid disease: Radiologic and Pathologic features and complications. Radiographics. 2000; 20:795-817.  Back to cited text no. 1    
2.Bukte Y, Kemaloglu S, Nazaroglu H, Ozkan U, Ceviz A, Simsek M. Cerebral hydatid disease: CT and MR Imaging findings. Swiss Med Wkly. 2004 Aug 7; 134(31-32):459-67.   Back to cited text no. 2    
3.Zoran Rumboldt, Hrvoje Jedna ak, Jasna Talan-Hranilovi , Tihana Rumboldt and Miljenko Kalousek. An Unusual appearance of cisternal hydatid cyst. American Journal of Neuroradiology 24:112-114, January 2003.  Back to cited text no. 3    
4.Juan M. Taveras, Inflammatory Diseases, Neuroradiology 3rd edition page 303, chapter 6. Williams Wilkins 1996.  Back to cited text no. 4    
5.El-Shamam O, Amer T, El-Atta M.A. Magnetic Resonance Imaging of simple and infected hydatid cysts of the brain. Magn Resonance Imaging. 2001 Sep; 19(7):965-74.  Back to cited text no. 5    
6.Gupta S, Desai K, Goel A. Intracranial hydatid cyst: A report of five cases and review of literature. Neurol India 1999; 47:214-17.  Back to cited text no. 6    
7.Kitis O, Calli C, Yunten N. Report of diffusion-weighted MRI in two cases with different cerebral hydatid disease. Acta Radiol. 2004 Feb; 45(1):85-7.  Back to cited text no. 7    
8.Iyigun O, Uysal S, Sancak R, Hokelek M, Uyar Y, Bernay F, Ariturk E. Multiple Organ involvement hydatid Cysts in a 2-year-old Boy. J Trop Pediatr. 2004 Dec; 50(6):374-6.  Back to cited text no. 8    
9.Kohli A ,Guptha R K ,Poptani.H ,Roy K. In vivo proton spectroscopy in a case of intracranial hydatid cyst. Neurology 1995, March.45 (3 pt 1 ) 562-4.  Back to cited text no. 9    
10.Jay Kumar P N, Srikanth S G, Chandrasekhar H S, Kovoor J M, Shankar S K, Anandh B. Pyruvate: An in vivo marker of cestodal infection in human brain on Proton MR spectroscopy. J of Mag Reson Imaging,2003 Dec 8(6) 675-80.   Back to cited text no. 10    

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Correspondence Address:
M Sreedhar
Chief Radiologist, Sri Sathya Sai Institute Of Higher Medical Sciences, Epip Area, Whitefield, Bangalore
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-3026.32344

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