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Primary multiple peritoneal hydatid cysts in 12 years old child

Article  in  Journal of Pediatric Surgery Case Reports · December 2021

DOI: 10.1016/j.epsc.2021.102153

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 Journal of Pediatric Surgery Case Reports 77 (2022) 102153

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Journal of Pediatric Surgery Case Reports

journal homepage: www.elsevier.com/locate/epsc

Primary multiple peritoneal hydatid cysts in 12 years old child

Menawar Dajenah a, Anessa Thabet b, Faisal Ahmed c, *, Qasem Alyhari a,
Abdu Al-hajri a, Waleed Aljbri d
a
Department of General Surgery, School of Medicine, Ibb University of Medical Science, Ibb, Yemen
b
Department of Gynecology, School of Medicine, Ibb University of Medical Science, Ibb, Yemen
c
Urology Research Center, Al-Thora General Hospital, Department of Urology, School of Medicine, Ibb University of Medical Science, Ibb, Yemen
d
Department of Urology, School of Medicine, 21 September University, Sana’a, Yemen

A R T I C L E I N F O A B S T R A C T

Keywords: The hydatid cyst (HC) is a parasitic infection produced by cysts comprising Echinococcus gran­
Primary ulosus larval stage. It is higher in rural areas in some underdeveloped countries, Yemen. Primary
Peritoneal hydatid cyst peritoneal and mesenteric HC are uncommon without a precise mechanism of manifestation.
Mesentery hydatid cyst Hence, we report a 12-year-old boy was presented with recurrent abdominal pain and gradual
growth of abdominal mass in the last three months. Abdominal Computed tomography confirmed
three large calcified lesions (one in the left hypochondrium, one in the right and midabdominal
region, and the last one in the pelvis, which caused a pressure effect on the urinary bladder).
Surgical excisions were made, and the patient left the hospital with oral medication on the sixth
postoperative day. Pathological specimen examinations confirmed cystic hydatidosis. In conclu­
sion, primary peritoneal and mesentery HCs are rare. In the case of abdominal mass, HC must be
considered in the differential diagnosis, particularly in endemic areas.

1. Introduction
Hydatid cyst (HC) is a parasitic helminthic disease of Echinococcus granulosus, which is chronic and cystic in nature. Mature
Echinococcus granulosus lives in the intestine of the dogs as a definitive host. Gravid proglottids excrete eggs, which incubate in the
small intestine after being consumed by an intermediate host such as sheep, goats, and humans. These eggs penetrate the small bowel
wall and migrate to different organs [1,2].
The prevalence rate of HC is about 1%–7%, with higher occurrence in females and the elderly. Because of the slow growth and
development of the HC, it is usually asymptomatic. The symptoms, however, vary according to the size and location of HC lesions [3,
4].
The rarest sites of HCs are the peritoneal and mesenteric regions. Mesenteric HCs prevalence is one in 100,000 adults and one in
20,000 children [5]. We present a case of a 12-year-old child with multiple intraperitoneal HCs (one in the mesentery) treated with
open surgery, which is rarely present in children.

1.1. Case report

On March 2021, a 12 years old child presented to our outpatient clinic at Almnar hospital, Ibb, Yemen, with abdominal pain and
palpable mass in the abdominal region, which had begun to expand in the last three months. He lived in a neighborhood with dogs and

* Corresponding author.
E-mail address: fmaaa2006@yahoo.com (F. Ahmed).

https://doi.org/10.1016/j.epsc.2021.102153
Received 12 December 2021; Accepted 14 December 2021
Available online 16 December 2021
2213-5766/© 2021 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
M. Dajenah et al. Journal of Pediatric Surgery Case Reports 77 (2022) 102153

cheeps kept in the house. There was no mention of pica or abdominal trauma.
The mass was located in the right lower hypochondrium region and gradually expanded to the pelvic area on physical exam. It had
limited mobility but moved with respiration without tenderness on palpation (Fig. 1).

1.2. Diagnostic assessment

The white blood cell count was 12300 cells/mm3, the hemoglobin level was 12 g/dl, and mild eosinophilia (6%). The positive
results of the Echinococcus latex hemagglutination test and the indirect hemagglutination test were 1:7000 and 1:3300, respectively.
The liver and kidney function tests came back normal.
An abdominal CT revealed a sizeable intra-abdominal cyst (9.6 × 7.4 × 7.8 cm) with a high-density wall and various inner cal­
cifications. There is another cyst concerning a bowel loop in the left hypochondrium (7.9 × 4.4 × 5.1 cm). Another cyst, measuring
approximately (6.6 × 6.5 × 5.4 cm) in the pelvic area, caused a pressure effect on the urinary bladder—additionally, incidental finding
of the left hypoplastic kidney (Fig. 2). Albendazole (12 mg/kg/day) twice a day for one week was recommended.

1.3. Therapeutic interventions

After general anesthesia, the abdomen was opened with an abdominal midline incision. All cysts were identified, opened. The
daughter cysts were evacuated and removed (Fig. 3). To prevent potential contamination, we washed out the abdominal cavity with
hypertonic saline (15%) [6]. A catheter size 18 Fr was inserted into the abdominal cavity as a drainage tube. Finally, the fascia and skin
were sutured.

1.4. Follow-up and outcome

The postoperative period was uneventful, and the patient was left the hospital on the 6th postoperative day. Histopathological
findings of the mesenteric cyst were possible for primary HC; it is formed of three layers, inner germinative layer with scolices, in­
termediate lamellar chitinous layer, and outer fibrous layer with extensive inflammatory cell infiltrate, mainly eosinophils (Fig. 4).
We advise the patient to continue taking albendazole at 14-day intervals for three months following surgery. After three months of
postoperative follow-up, abdominal ultrasonography relived no signs of recurrence. For the first three months, the patient followed
every two weeks with a complete blood cell (CBC) and a liver enzyme evaluation, and then every four weeks. Follow-up was advised
every six months for the first two years.

Fig. 1. Preoperative image showed the abdominal mass (arrow).

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M. Dajenah et al. Journal of Pediatric Surgery Case Reports 77 (2022) 102153

Fig. 2. Abdominal computed tomography relived: (A); Intra-abdominal hydatid cyst (9.6 × 7.4 × 7.8 cm) (arrow). (B); Mesenteric Hydatid cyst concerning a bowel
loop (7.9 × 4.4 × 5.1 cm) (arrow). (C); Hydatid cyst near the right side of the urinary bladder (6.6 × 6.5 × 5.4 cm) (arrow).

Fig. 3. Intraoperative image showing the multiple hydatid cysts.

Fig. 4. Histopathological specimen of hydatid cysts (The scolex contained hydatid micronuclei).

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M. Dajenah et al. Journal of Pediatric Surgery Case Reports 77 (2022) 102153

2. Discussion
HC is a common disease in farming communities, including Yemen. Mesenteric HC is a rare occurrence even in endemic areas. The
liver (approximately 70%) and respiratory system (15–47%) have been the most common organs of HC. The disease is infrequent in
other organs, such as the heart, spleen, pancreas, mesentery, and muscles. Multiple organs are involved in approximately 5–13% of all
cases [1].
It is exceptionally uncommon to have primary peritoneal HC. Primary peritoneal HC is very rare, with an occurrence rate of 2%.
Secondary HC of the peritoneum is usually caused by the rupture of a hepatic, splenic, or mesenteric cyst, either traumatically or
surgically. When the endocyst and the pericyst are torn, cystic contents escape into the peritoneal space via a non-anatomic route [7].
Our patient had not previously shown signs of anaphylaxis, history of abdominal surgery, or trauma to abdomen.
Individuals are typically asymptomatic for an extended period while the cysts grow slowly. Symptoms are determined by the HC
numbers and sizes and the pressure of surrounding organs. The signs of mesenteric HC are abdominal pain and abdominal discomfort
due to traction on the mesentery and pressure effect on adjacent organs, As seen in our patient [1,7].
Because of mesenteric HC rarity, lack of clear manifestations, varied imaging appearances, preoperative diagnosis of HC from other
abdominal masses is challenging. Sandhya Mittal et al. described a 35-year-old female with mesenteric HC. The presurgical diagnosis
was right Tuboovarian mass, and the final diagnosis was HC after surgical intervention and histopathological examination [4,8].
Radiological images, such as ultrasound, computed tomography (CT) scans, and magnetic resonance imaging have greatly
improved diagnostic accuracy, allowing clinicians to make the exact diagnosis. Furthermore, antibody assays can be used to confirm
the radiologic diagnosis [5]. The antibody assays and CT scan have confirmed the diagnosis in our patient.
The goal of treatment for HC disease is to eliminate the parasite. Recurrence prevention and mortality reduction are critical. The
benzimidazole compounds used to treat hydatid disease are mebendazole and albendazole. Albendazole is the preferred medication
with high bioavailability and optimal gastrointestinal absorption. Albendazole is typically administered orally in two divided doses of
10–15 mg/kg per day [9].
The World Health Organization suggested that albendazole be administered post-operatively for at least one month. However, the
risk of peritoneal relapses determines whether or not the treatment is continued [1].
Invasive treatment aims to inactivate infectious scolices and germinative membranes. It is critical to avoid intraoperative
contamination of the peritoneal cavity, as ruptured cysts can result in systemic anaphylaxis. Recognizing and managing complicated
cysts necessitates the use of an experienced surgical team [1].
The primary therapeutic interventions are radical surgery (pericystectomy and organ resection) or conservative management
(unroofing and capitonnage). Other options are minimally invasive surgery, such as laparoscopy and percutaneous puncture-guided
sonography with liquid aspiration and injection of a protoscolicidal agent [1,7]. Open surgical resection was the optimal choice in our
patient due to the presenting multiple big sizes of HCs, which was similar to previous reports [1,8].
The size of mesenteric HC in previous reports was 5.3 × 3.6 × 9 cm by Paramythiotis et al. [1] and 10 × 6 cm reported by Mittal
et al. [8]. in our case, the HC size was 9.6 × 7.4 × 7.8 cm and 7.9 × 4.4 × 5.1 cm.
We recommended our patient continue the albendazole in the postoperative period. Similarly, Paramythiotis et al. reported a case
of multiple HC in the liver and mesenteric area in 39 years old man. All cysts were treated with open surgical intervention, and the
patient has received albendazole in the preoperative and postoperative period [1].

3. Conclusions
The existence of HC in multiple locations simultaneously is uncommon, and their presence in the mesentery is unusual. This entity
should be considered in the differential diagnosis of abdominal cysts in endemic areas. Radiological investigations are helpful to make
an accurate diagnosis. The surgical excision of HC is the optimal choice treatment for our patients.

Financial disclosure statement

None of the authors on this manuscript have any conflicts of interest to disclose, financial, or otherwise.

Patient consent
Consent to publish the case report was not obtained. This report does not contain any personal information that could lead to the
identification of the patient.

Funding
No funding or grant support.

Authorship
All authors attest that they meet the current ICMJE criteria for authorship.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to

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M. Dajenah et al. Journal of Pediatric Surgery Case Reports 77 (2022) 102153

influence the work reported in this paper.

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(6):385–94.
[3] Budke CM, Carabin H, Ndimubanzi PC, Nguyen H, Rainwater E, Dickey M, et al. A systematic review of the literature on cystic echinococcosis frequency
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[6] Ghabisha S, Ahmed F, Al-Wageeh S, Al-Shami E, Al-Naggar K, Chowdhury U, et al. Isolated giant primary splenic hydatid cyst in a 10-year-old boy: a case report.
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[7] Geramizadeh B. Isolated peritoneal, mesenteric, and omental hydatid cyst: a clinicopathologic narrative review. Iran J Med Sci 2017;42(6):517–23.
[8] Mittal S, Taneja BK, Goel A, Puri M, Pandey P. Mesenteric hydatid cyst: an unusual presentation. Korean J Obstet Gynecol 2012;55(5):358–60.
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