Primary Hydatid Cyst of the Spleen : Unusual Location

Hydatidosis is a parasitic disease caused mostly by Echinococcus granulosis in human and many other mammals. It is characterized by a worldwide spread but is endemic mainly around the Mediterranean Sea (FernándezRuiz, M., 2008). The liver followed by the lung are the most common sites of the disease (Arikanoglu, Z., 2012). However, other sites such as the heart and spleen are rarely affected. Primary and isolated involvement of the spleen is unusual. It has an incidence of 0.5 4%. The rarity of splenic hydatid disease may pose a diagnostic challenge for clinicians, especially in non endemic areas (FernándezRuiz, M., 2008). Herein we report the case of a 65-year-old female presenting with moderate fever and heaviness in the left upper abdomen and found to have isolated splenic hydatidosis.


Introduction
Hydatidosis is a parasitic disease caused mostly by Echinococcus granulosis in human and many other mammals.It is characterized by a worldwide spread but is endemic mainly around the Mediterranean Sea (Fernández-Ruiz, M., 2008).The liver followed by the lung are the most common sites of the disease (Arikanoglu, Z., 2012).However, other sites such as the heart and spleen are rarely affected.Primary and isolated involvement of the spleen is unusual.It has an incidence of 0.5 -4%.The rarity of splenic hydatid disease may pose a diagnostic challenge for clinicians, especially in non endemic areas (Fernández-Ruiz, M., 2008).Herein we report the case of a 65-year-old female presenting with moderate fever and heaviness in the left upper abdomen and found to have isolated splenic hydatidosis.

Case Presentation
A 65-year-old female resident of Jemmel (Monastir -Tunisia) was presented with five months history of moderate fever and gradual increasing sensation of heaviness in her left hypochondrium.Patient complained of malaise with nausea, vomiting and intermittent fever since 2 months.There was no history of dyspepsia, or weight loss or other complaints.Physical examination was unremarkable except for the presence of a palpable painless tip of spleen.There was no ___________________________________________________________________________________________________________________ ______________ C. Loussaïef, H. Ben Brahim, W. Ben Abdessalem, A. Toumi, A. Aouam and M. Chakroun (2013), International Journal of Case Reports in Medicine, DOI: 10.5171/2013.916777 hepatomegaly or lymphadenopathy.Chest, cardiovascular, central nervous, and the musculoskeletal systems were normal on examination.Ultrasonographic examination of the abdomen revealed an enlarged spleen (13 cm) with well encapsulated cystic lesion measuring 9 cm x 7 cm.The contrast enhanced computed tomography (CT) scan revealed splenomegaly (14 cm) with well defined homogenous hypodense lesion with an enhancing capsule measuring 93 mm x 88 mm in size (Figure).The liver and other abdominal organs and the chest were not involved.
White blood cells count was 5400/mm 3 and Creactive protein level was normal.Renal function test, liver function test and electrolytes revealed no abnormalities.Blood cultures were negatives.IgM Ecchinococcus antibodies were positives.A diagnosis of primary splenic hydatidosis was retained.Oral albendazole therapy was applied one month before surgery at 10 mg/kg/day in two divided doses.Then splenectomy was performed.Histopathological examination of the spleen confirmed the diagnosis of hydatidosis since there was acellular fibrous wall cyst with germinal layer and scolices in the center.Postoperatively, the patient continued on oral albendazole for 6 months without any side effects.One year later, the patient remains symptom free and no longterm complications were observed during the follow-up.preoperative administration should begin between 1 month and 4 days before surgery for albendazole and 3 months before surgery for mebendazole (Arikanoglu, Z et al., 2012).WHO also recommends albendazole after surgery to reduce the risk of preoperative dissemination of hydatic scolices.In our case, albendazole therapy was taken before and after surgery with good outcomes and with no recurrence through the period of follow-up.

Conclusion
Primary splenic hydatid cyst is a rare clinical condition which must be considered in the differential diagnosis of a cystic lesion of spleen in endemic areas like Tunisia.Owing to the potential risk of threatening complications, surgery should be advised to the patient.

Figure :
Figure: Abdominal CT Scan: Splenomegaly (14 cm) with well defined homogenous hypodense lesion with an enhancing capsule measuring 93 mm x 88 mm in size Discussion Hydatic disease is common in areas where sheep and cattle rearing are important, particularly in Tunisia.It is a zoonotic infection caused by the tapeworm of the genus Echinococcus (Hariqbal, S., 2003).The most common form is cystic hydatid disease that is caused by Echinococcus granulosus, whereas the alveolar type is caused by E. multilocularis (Ibrahim, A., 2011).The primary hosts are the members of the canidae family, usually dogs, wolves and coyotes.The life cycle of this worm may also involve other animals called