Abstract
Primary pelvic hydatidosis is a rare finding (incidence 0.2–2.25%). An 80-year-old, P6L6, lady presented to our hospital with complaints of PMB and abdominal pain of 5 days with a radiological diagnosis of an ovarian tumor. On pervaginal examination, a firm mobile mass of 6 × 6 cm was palpated in the anterior fornix. Suspecting torsion, semi-elective laparotomy was performed. A mass of 6 × 6 cm was seen arising from the pelvis, adherent to bowel loops, omentum, and bladder peritoneum. Hysterectomy with bilateral salpingo-oophorectomy was performed. No evidence of hydatid cyst was found in liver or any other organs. Final HP report was consistent with ovarian hydatid cyst.
Keywords: Hydatid cyst, Pelvic, Echinococcus, Albendazole
Introduction
Hydatidosis is a zoonotic parasitosis. It is caused by Echinococcus granulosus larva, which reaches any tissue of the body to mature into a hydatid cyst [1]. Uncommon sites with atypical symptoms of this parasitosis causes diagnostic dilemmas leading to treatment delays. Although any organ maybe affected, primary pelvic hydatid cyst is a rare finding with the reported incidence being 0.2–2.25%. The ovary is the most common site of affection followed by the uterus in 80% cases of pelvic hydatid cyst [2]. A rare case of pelvic hydatid cyst in a postmenopausal elderly lady, mimicking an ovarian tumor, has been presented in this case report.
Case Report
An 80-year-old P6L6 female was referred to our hospital with complaints of postmenopausal bleeding for 2 months, lower abdominal pain of 5 days with a radiological diagnosis of an ovarian tumor. Per abdomen, there is no evidence of tenderness, mass, or free fluid. Uterus was atrophic (probably as postmenopausal) on per vaginal examination; a 6 *6-cm firm mobile mass, moving separately from the uterus, was palpated in the anterior fornix.
Her investigations including serum CA-125 and CEA levels were normal. MRI pelvis done in the previous hospital revealed a well-defined 6*5.5-cm cystic lesion with multiple septations within seen in pelvis, in the midline, and extending to the right side (Fig. 1e). Uterus was atrophic and left adnexa normal. Endometrial tissue was reported as non-secretory endometrium on HP study.
Fig. 1.
A-B: Intraoperative pictures C-D: Histolopathology pictures E: Mri picture
Due to sudden worsening of pain, semi-elective laparotomy was performed suspecting torsion. A solid cystic mass (6 × 6 cm approximately) was seen arising from the pelvis, adherent to bowel loops, omentum, and bladder peritoneum (Fig. 1a). By sharp dissection, the cyst wall was separated from bladder, omentum, and gut wall. The cyst felt free once all adhesions were released and were removed in toto without rupture. Uterus was atrophic, bilateral tubes, and ovaries appeared normal. Another small cystic mass (2 × 2 cm) was seen freely occupying the pouch of Douglas. Upon cutting open the thick-walled cyst, multiple cystic masses emerged (Fig. 1b). Suspicion of hydatid cyst was raised at that point. The mass was sent for intraoperative pathology which was reported as hydatid cyst. Whole of peritoneal cavity and solid organs were examined for any daughter cysts or lesions. TAH BSO was performed. Post-surgery, it was revealed that there was history of contact with cattle as they owned a cowshed.
Postoperative antibiotics were given and the recovery was uneventful. Albendazole (400 mg) was given as definitive treatment, twice daily for 1 month. Final histopathology was consistent with ovarian hydatid cyst (Fig. 1c, d).
Discussion
Echinococcus granulosus completes its lifecycle in two hosts with man being an accidental intermediate host [3]. Intraperitoneal hydatid cysts are usually secondary to the rupture of a cyst in spleen, liver, or mesentery. A solitary hydatid cyst in the pelvis can be considered primary only by exclusion of cysts at other sites [4]. The main diagnostic aids are the serological and radiological investigations [5]. But, in this case, she was referred to our institute as a case of ovarian tumor with an MRI pelvis report, and since she complained of sudden onset of pain, suspecting it to be a torsion of ovarian cyst, we proceeded for a laparotomy without further radiological evaluation. Intraoperatively, it was diagnosed as a case of hydatid cyst. Hence, following surgery, we advised for an ultrasound abdomen and pelvis to rule out other involved organs. As liver and other organs did not have cysts on sonography and there was also no history of hepatic hydatid cyst, this case was labeled as primary pelvic hydatid cyst. Due to non-specific symptoms and atypical radiological image, we missed the diagnosis preoperatively. The most recommended surgical approach for hydatid disease as was done in our case is in toto resection of cysts preventing spillage and spread of the daughter cysts [6, 7]. Cyst rupture has a small but definite risk of toxic anaphylactic reactions, infections, and recurrences. In females, because of rich vascular supply from infundibulopelvic ligaments and direct invasions from the peritoneum of POD, pelvic organs, i.e., uterus with adnexa are at risk of parasitosis. So we proceeded with TAH BSO when intraoperatively ovarian hydatid cyst with another daughter cyst in POD was diagnosed. Postoperatively, recurrence rate of approximately 2%, with survival rate of 95%, has been reported; hence, follow-up is crucial.
Conclusion
Anamnestic data and a high grade of suspicion for primary pelvic hydatidosis can lead to its diagnosis. It is important to differentiate between hydatid cysts, ovarian neoplasms, and polycystic ovaries. Sonography and CECT abdomen and pelvis are the best radiological investigations to get a preoperative diagnosis so as to avoid an intraoperative spill and optimize management.
Sony Nanda
Declarations
Conflict of Interest
The authors declare no competing interests.
Footnotes
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References
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