Hydatid cyst (b)

1982 - Two hydatid cysts removed from subscapular region
This patient is a known case of of hydatid cyst of the intermuscular tissue in the right subscapular region. It was removed completely in July 1988 in Sanna, Yemen. There were two cysts both of them were infected and contained green pus. The pus was aspirated and the walls were removed completely. Post operative period was uneventful.

CT scan showing right paravertebral shadow.
image1, image2, image3, image4, image5, image6, image7

1983 - first recurrence of the cyst
The cyst recurred after one and half year in the same subscapular region and again had secondary infection. It was completely excised in Sanna.

3/7/1988- second recurrence
Patient attended surgical clinic with a 3rd recurrence of cystic swelling in the same subscapular area without signs of infection. Patient was given R/ mebendazole 500 mmg BD for 2 weeks then 2 cysts were completely removed which proved to be also infected.

6/12/1989 - Third recurrence
She had another cystic lesion in the left subscapular region which was removed.
Histopathological exam did not show any E. granulosus scolices. patient was discharged in good condition on albendazole 400 mg B.D.


18/12/1989 - posterior mediastinum lesion
Patient came for follow up in surgical OPD, routine chest x-ray showed an ill-defined opacity on the right side of the cardiac border inferiorly. P-A chest1, 2,3,4, lateral view.

CT scan of chest was performed a paravetrebral soft tissue mass lesion of the right side which is isodense. it had a well-defined convex antero-lateral border border while the medial border is not separated from the thoracic cage. There was also extensive bone destruction of vertebral bodies ( D8 -to- D9) together with destruction of the adjacent areas of the corresponding ribs.

    CT images

    D7 involved
    image1, image2, image3

   
D7- D8 space
    CT image

    D8, The main bulk of destruction
    image1, image2

    D8-D9 space (heavily involved)
    CT image

    D9, the main bulk of destruction
    image1, image2, image3, image4.

    D9-D10 space
    image
 

    D6, not involved. CT image
    D6-d7 space, not involved. CT image
    D10, not involved. CT image1, CT imag2

Impression:

    Mutifocal hydatid cysts  
    Neurogenic tumor 

The patient received three courses of albendazole therapy

14/3/1990 -removal of retro-pleural lesion
Operation:
Through right poster-lateral thoracotomy, the lesion was found retro-pleural in the posterior mediastinum. It was firm inconsistency and while trying to find a line of cleavage for dissection it ruptured and thick yellow pus came out. The lesion was found eroding the right side of the vertebral bodies and the rib heads. The lesion was removed completely with scooping of the necrotic tissue and irrigation with amicacin.

Microbiological exam of the pus material did no show any organism growth including AFB

She was discharged on
    R/Amicacin  500 mg
    R/Flagyl 400 mg BD

1991 - recurrence of the spinal lesion
Patient appeared again but she was in very poor general condition and she needs parental nutrition to recover
Chest x-ray showed recurrence of the spinal lesion with destruction of D8, D9 bodies and adjacent rib segments.

Patient was disharged home till her general condition improve but when improved she went to Germany, Bonn. MRI showed subtotal destruction of D8 and D9 with compression of the dural sac. The lesion extends to both paravertebral spaces.

15/3/1994 in Bonn, Germany
An external titanium fixator was implanted from D7 to D10 via dorsal access. The patient was mobilized with supporting corset and treated with Eskazole tablets BD till ineternal fixation done.

3/4/1994 in Bonn, Germany
Through right poster-lateral thoracotomy, the parasitic cyst was removed with resection of D8 and D9 vetrbral bodies and a rib bundle graft was put and fixed with titanium plate. P-A chest showing fixation.
The cyst infiltrating the soft tissue and lung in proximity was also removed. Patient was kept on Vermox tab 1X2 for 9/12

13/4/1996 - first neurological deterioration
Patient attended neurosurgical clinic because of  pain and numbness in the legs. She had no neurological deficit, so elective radiological investigations were requested. After one week she returned to A/E with UMNL weakness of both lower limbs.

Myelo CT scan done which showed complete stop at D7-D8 level and soft tissue mass compressing the cord at the same level. Patient offered urgent decompression surgery but she was reluctant. After few days she deteriorated more and became almost paraplegic with urine retention.

24/4/1996 - Laminectomy in UAE
She underwent laminectomy D6,7 and D8 with removal of the daughter cysts from epidural space. She was kept on:
    Albendazole 400 mg bd
    Praziquantel 600 mg tds

The neurological condition of the patient started to improve after surgery and postoperatie physiotherapy. She became able to walk with help of walker. Amazingly patient regained full control of sphincters.

Postoperative MRI did not show any spinal cord compression. Patient was sent to Tawam Hospital in Alin for possible radiotherpay.

October 1996 in Germany again
She underwent surgery for removal of paravertebral multiple hydatid cysts on both sides and refixation of the segment from D6 to D10 was done.

8/11/1997 - neurological condition improved
Patient neurological condition continued to improve and she became able to walk with little assistance. She had also epigastric pain and LFT was impaired so, Eskazole was stopped.

27/3/2002 MRI dorsal Spines showed intact cord and no recurrence
MRI, saggital view showed intact spinal cord without any compression and no recurrence of hydatid cyst

1/11/2005 - follow up in clinic
Patient attended the clinic on regular basis at 6 month interval and in her last visit she was in good general condition, walking alone and unaided, no signs of recurrence and liver function test are within normal limits.
 

Histopathology proved to be : Hydatid cyst