Hydatid Cysts in Children

Abstract

Hydatid disease is one of the important health problems in developing countries. Can affect any part of the human body, it commonly affects lungs and liver. Because of poor data and preventive measures in Sub-Saharan Africa, cystic echinococcosis (CE) is regarded as endemic disease. This is a retrospective study of children ages of 3 to 12 years admitted in pediatric surgical unit at Nelson Mandela Academic Hospital (NMAH), from April 2015 to aril 2020. We studied groups of age, sex, organs affected, treatment and complications. We studied 56 children; the group of age most affected was 5 to 10 years, females accounted for 51.8%, and male for 48.2%, lung hydatid cysts in 44.6% of cases, 41.1% had liver cysts, 8.9% of the patients had cysts in multiple locations. In 46 cases (82%), the treatment was surgical: punction-aspiration-injection and respiration (PAIR) removing the germinal layer, following in the post operatory with Albendazole and Praziquantel. In 10 cases (18//%) was given only medical treatment. Females were most affected, and the lungs were the organs most affected followed by liver.

1. Introduction

The Echinococcosis is a zoonotic disease caused by a parasitic infection with the larval stage of the tapeworm Echinococcus genus [1]. Among the recognized species, two are of medical importance – E. granulosus and E. multilocularis – causing cystic echinococcosis (CE) and alveolar echinococcosis (AE) in humans respectively. Cystic echinococcosis is the most common form of the disease [2].

The Echinococcus can infect domestic animals, the adult tapeworms are carried by the definitive host (dogs) asymptomatically and can transmit the worms through defecation contaminating humans if ingest affected intermediate host meat (sheep, cattle, goats, and pigs). Human hydatid cyst is a health problem in some developing countries [3], this disease is usually asymptomatic for years until develop complications: such as compressive symptoms or rupture of the cyst causing anaphylactic shock. In most of the patients the symptoms are non-specific for the disease [4].

2. Course of infection

Have been reported in Ultrasound (US) surveys that the cysts may grow 1–50 mm per year or persist without changes according with [5, 6]; these cysts may spontaneously rupture or collapse and also disappear [5, 7].

The sequence of the changes during the natural history of this cysts is not well define [8], the Liver cysts appear to grow at a lower rate than the lung cysts [6]. The symptoms appear in this disease usually when the cyst compresses or ruptures into neighboring structures [6].

The diagnosis of CE is based on symptoms when they are present, Ultrasound, CT imaging techniques, and serology. The Proof of the presence of protocolises could be given by microscopic examination of the fluid and histology [9].

Source: Expert consensus for the diagnostic and treatment of cystic and alveolar echinococcosis in humans, 2010 [5].

The ultrasound (US) examination is the basis for the diagnosis and the WHO classification of the disease in abdominal locations of the cysts, this technique could visualize cysts in other locations no suspected, such as lung when the cysts are located peripherally [9].

The WHO-IWGE classification; in 1995 standardized and allowed a natural grouping of the cysts into three relevant groups of CE [Cystic echinococcosis]: active, transitional, and inactive; this classification added a “cystic lesion” (CL), to Gharbi classification [9, 10].

The transitional cysts according with WORL HEALTH classification, can be differentiated into with detached endocyst and (predominantly solid with daughter vesicles. The inactive Cysts are late stages of the disease.

The Computed tomography (CT), magnetic resonance (MR) imaging, and cholangiopancreatography (MRCP) are indicated in [1] subdiaphragmatic location, [2] disseminated disease, [3] extra abdominal locations, [4] in complicated cysts (abscess, cysto-biliary fistulae) and [9] in some cases when is necessary in the pre-surgical evaluation. MRI imaging should be preferred to CT due to better visualization of liquid areas.

3. Serology of the echinococcus granuloses

According with some authors [9] the Sensitivity of the serum antibody detection using indirect hemagglutination, ELISA, or latex agglutination, in the hydatid cyst fluid antigens, is between 85 and 98% for liver cysts, 50–60% for lung cysts and 90–100% for multiple organ cysts.

Other cestode infections such as E. multilocularis and Taenia solium, malignancies, liver cirrhosis and presence of anti-P1 antibodies limits the Specificity of all those tests due to this possibility, so a confirmatory test should be used as: (arc-5 test; Antigen B (AgB) 8/12 kDa subunits or EgAgB8/1 immunoblotting) [9].

Any organ could be affected by Echinococcal cysts, including the muscles but the commonest organs affected are lungs, liver, and spleen. If the liver is affected, might cause a compartmental abdominal Syndrome, and might cause obstructive jaundice when there is compression to the biliary system. When the lungs are affected, the patients could present with productive cough, weight loss and poor appetite (Figures 1 and 2).

Figure 1.

Hydatid cysts in the liver and left lung. Source: Author’s record.

Figure 2.

Hydatid cyst right lung lower lobe. Source: Author’s record.

Rupture of the cyst into pleural cavity can with shortness of breath and on chest x-ray it can be confused with pleural effusion, that could wrongly make the doctors to insert a chest drain into the cyst for mistake, founding later in another chest x-ray/or CT-chest a cystic cavity [5, 6, 8] (Figure 3).

Figure 3.

Intercostal drainage into a cyst cavity of a hydatid cyst in the right lung, mistakenly for parapneumonic pleural effusion. Source. Author’s record.

The main aim of our study was to find out the prevalence of the Hydatid Cysts in children and found up the organs more common affected in children.

4. Method

We performed a retrospective study of every child of 3 to 12 years of age admitted in our surgical pediatric ward (N 56), suffering from hydatid cyst. We studied patients with this diagnosis from April 2015 to April 2021. Were studied 56 patients: analyzing the age, sex, localization of the cyst, treatment, and complications. The diagnosis was based on clinical history, physical examination, serology test, abdominal ultrasound, chest X ray, Computer Tomography (CT) and histology. The ultrasound ad CT scans were the most useful investigations in the diagnostics.

The decision to perform a surgical treatment was based on the size of the cyst when it was 6 cm or more, and when the patient having compressive symptoms and signs of complicated hydatid cyst. In hydatid cysts on the liver the compressive symptoms and sings were jaundice, itchiness, abnormal liver function testes; In Hydatid cyst on the lung; the patient could present productive cough, shortness of breath, when there is a bronchial communication, and ruptured of the cyst to the pleural cavity.

Patients with hydatid liver cyst and those with lung hydatid cysts where was showed in the CT no communication of the cyst cavity to a bronchus were performed PAIR (puncture – aspiration- injection and re aspiration, through laparotomy and thoracotomy on those with cysts in the lung. Was use 5% hypertonic saline solution for the injection considering that this concentration of the saline solution is enough to kill the Ovo’s; after the PAIR, the cyst was opened and removed the germinal layer (endocyst) and taken it for histopathology examination as a confirmation of the disease; a capitonage was done in every cyst and a drain was let in the cystic cavity. In case of lung hydatic cyst was let an intercostal drain into the cyst cavity and also into the pleural space.

In the post-operative time, we continued the children with Albendazole (20-50 mg/kg/day) and Praziquantel (30-40 mg/kg/day) for 3 months; depending on the resolution of the cysts in some cases the Albendazol was given more than 3 months, depending on the result of the liver function tests performed monthly to rule out hepatic toxicity.

Patients with hydatid cyst size of 5 cm or less, and with no signs of compression or any other complications were treated conservatively with the combination of Albendazole and Praziquantel this treatment was given for 3 months or more depending on the resolution of the cysts.

Full Blood Count and liver function test were performed before the initiation of the treatment and every month after starting with medical treatment to find out drug toxicity.

5. Results

Were analyzed 56 children, 25 of them (44.6%) had Cysts in the liver, 23 (41%) had lung Cysts. Some patients 8.9% had cysts affecting liver, lung, spleen and in other organs shown in Table 1.

	Liver Hydatic		Lung Hydatic		Soft Tissue		Multiple		Total
Ages	No	%	No	%	No	%	No	%	No	%
< 1 year	—	—	—	—	—	—	—	—	—	—
1–5 years	5	8.9	2	3.6	0	0	0	0	7	12.5
5–10 years	12	21.4	17	30.4	0	0	0	0	29	51.8
> 10 years	8	14.3	4	7.1	1	1.8	7	12.5	20	35.7
Total	25	44.6	23	41.1	1	1.8	7	12.5	56	100

Table 1.

Patients’ age vs. organs location of the cyst.

Source: Patient files.

As it can be seen in the Table 1, the most affected group of age was the one of patients from 5 to 10 years for 52% of the patients, the group of children with more than 10 years was the second in frequency with 36%.

The presentation of hydatid cysts in liver were more frequent in male with 28.6% than in females 16%; on the other hand; lung hydatid cysts were more frequent in female affecting 26.8%, as is showing in Table 2.

Gender	Cyst Location
	Liver Hydatic		Lung Hydatic		Soft Tissue		Multiple		Total
	No	%	No	%	No	%	No	%	No	%
Male	16	28.6	8	14.3	1	1.8	2	3.6	27	48.2
Female	9	16.1	15	26.8	0	0.0	5	8.9	29	51.8
Total	25	44.6	23	41.1	1	1.8	7	12.5	56	100.0

Table 2.

Cysts location vs. gender.

Source: Patient files.

In 40 cases (70%) was performed a surgical treatment (PAIR and enucleation of the endocyst); in 27% of the patients with Lung Hydatid cysts to whom were performed this procedure developed in the post operatory a bronchus pleural fistula that closed by Itself mostly in the first week (Table 3).

Complications	Liver Hydatic	Lung Hydatic	Soft Tissue	Total
	No	No	No	No	%
Biliary Fistula	1			1	1.8
Bronchopleural Fistula		15		15	26.8
Wound infection			1	1	1.8
Total	1	15	1	17	30.4

Table 3.

Complications vs. cyst’s location.

Source: Patients files.

In 18% of our cases the treatment was medical treatment without surgery during a period of 6 to 8 months, expressed in Table 4.

Treatment
	PAIR			Medical alone			Total
	N	%		N	%		100%
Patients	46	82		10	18	56

Table 4.

Patient vs. treatment performed.

The histopathology examination of the germinal layer confirmed the echinococcus granulosus.

6. Discussion

In endemic countries the Hydatid disease is still a national health problem and needs prevention for its eradication or its control [3]. Symptoms of hydatid disease depend on which organs are affected and only are evident when the complications arise, but most patients with hydatid cysts are asymptomatic, and the diagnosis is usually made incidentally during clinical or radiological examination for unrelated reasons [11, 12].

In our study of 56 cases, 29 (52%) were females and 27 (48%) were males in other studies the statistical analyses indicate that in children males are more likely to be infected with lung hydatid, while females were infected more with liver hydatid cysts [9, 13], result found also in our study; in total we found that the hydatid cyst disease in our children was no significative differences of affectation between the liver 41% and the lung 45%.

Hydatid cyst can affect any organ, but the two organs most involved are liver and lungs. The involvement of lungs, liver and other organs in the same patient in our study accounted in 8.9% of the cases.

The group of age commonest affected was from 5 to 10 years, in 32 patients (64%).

In human hydatid cysts Echinococcus granulosus is the most common cause as it was in our children, confirmed with histopathology of the endocyst (germinal, layer) this finding were also reported by other authors [13, 14, 15, 16, 17].

7. Conclusions

The incidence of hydatid disease in children increase with age.

The organs more frequently involved were liver and lungs.

As can be affected for hydatid cyst in the same patient lung and liver, we recommend that when a hydatid cyst of the liver is diagnosed a chest x-ray should be done to rule out lung involvement specially in endemic regions.

The most common cause of human hydatid cyst is the Echinococcus granulosus as it was diagnosed with echinococcus Elisa and confirmed with endocyst (germinal layer) taken for histopathology.

In most case a conservative surgical technique (PAIR) and total or partial enucleation of the endocyst is sufficient, followed by medical treatment post operatively with Albendazol and Praziquantel for no less than 3 months.