Letters to Editor
REFERENCES 1. Adebayo ET, Hussain NA. Pattern of prescription drug use in Nigerian army hospitals. Ann Afr Med 2010;9:152-8. 2. Ebrahimzadeh MA, Shokrzadeh M, Ramezani A. Utilization pattern of antibiotics in different wards of specialized Sari Emam University Hospital in Iran. Pak J Biol Sci 2008;11:275-9. 3. Hutchinson JM, Patrick DM, Marra F, Ng H, Bowie WR, Heule L, et al. Measurement of antibiotic consumption: A practical guide to the use of the Anatomical Therapeutic Chemical classification and defined daily dose system methodology in Canada. Can J Infect Dis 2004;15:29-35. 4. Miyawaki K, Miwa Y, Tomono K, Kurokawa N. Impact of antimicrobial stewardship by infection control team in a Japanese teaching hospital. Yakugaku Zasshi 2010;130:1105-11. 5. Zhang W, Shen X, Wang Y, Chen Y, Huang M, Zeng Q, et al. Antibiotic use in five children’s hospitals during 2002-2006: The impact of antibiotic guidelines issued by the Chinese Ministry of Health. Pharmacoepidemiol Drug Saf 2008;17:306-11. Access this article online Quick Response Code: Website: www.jgid.org
DOI: 10.4103/0974-777X.127953
A Case of Primary Cervicofacial Hydatidosis Sir, Hydatid disease of the neck region is an extremely rare finding, even in endemic regions, and only a few cases have been reported in the literature.[1-5] A 25-year-old female presented with a 1-month history of gradually progressive swelling in the neck. It was not associated with pain or fever or any other symptom. The swelling was located in the right cervical region, just below thyroid; its size was about 3 × 2 cm and was cystic in consistency. It was non-tender and the overlying skin did not show any signs of inflammation. A submandibular lymph node was also palpable, size approximately 1 × 1cm. X-ray demonstrated a mass in the neck without involvement of deeper structures. Ultrasonography showed a loculated cystic lesion with internal septae near the lower pole of thyroid under the strap muscles of the neck. An excisional biopsy of the mass was performed followed by irrigation by hypertonic saline [Figure 1]. Hematoxylin and eosin (H and E) stained slides were examined which showed all the three layers namely outermost pericyst, laminated layer and the inner germinal layer (which together
a
b
c
d
Figure 1: (a) Ultrasound showing a loculated cystic lesion with internal septa near the lower pole of thyroid under the strap muscles of neck. (b) Hematoxylin and Eosin (H and E) stained section of a part wall of hydatid cyst showing laminated layer and outermost pericyst layer composed of granulation tissue (H and E ×40). (c) H and E stained section of a part of cyst wall showing laminated layer and innermost germinal layer (H and E ×100). (d) High power view showing both laminated and innermost germinal layer (H and E ×400)
comprise the endocyst) [Figure 1]. Thus a final diagnosis of hydatid cyst in the neck was made. Biopsy of the lymph node revealed features of reactive lymphadenitis. The patient underwent further investigations and further thorough examination was done. There was no evidence of primary illness anywhere else. Since there was no evidence of primary lesion anywhere else, a final diagnosis of primary hydatid disease of the neck was made. The patient was given 4-week albendazole therapy (400 mg twice a day) and since the cyst was completely excised, no further surgical intervention was done. Presently, she is doing well and there is no evidence of recurrence. Due to its rarity, the diagnosis of cervicofacial hydatid disease is difficult.[1-4] However, diagnosis can be aided by taking proper history and combining different diagnostic modalities like radiology and serology. Serological tests, include immune hemagglutination, complement fixation, immunoelectrophoresis, skin tests (Casoni intradermal test), enzyme-linked immunosorbent assay (ELISA) and western blot serology. Radiology is a better diagnostic tool than serology.[2] Ultrasonography can clearly demonstrate the hydatid sands in purely cystic lesions, as well as floating membranes, daughter cysts, and vesicles. Some authors discourage the use of fine needle aspiration (FNA) in diagnosing Hydatid disease due to danger of spillage and anaphylaxis.[2] Histopathology is unanimously the preferred and definitive diagnostic option.[2,3] It consists
Journal of Global Infectious Diseases / Jan-Mar 2014 / Vol-6 / Issue-1
43
Letters to Editor
of an inner germinal layer of cells supported by a characteristic acidophilic-staining, acellular, laminated membrane of variable thickness. Each cyst is surrounded by a host-produced layer of granulomatous adventitial reaction tissue, which is a thick fibrous tissue.[2,3] The most effective and gold standard treatment of hydatid cyst is surgical excision.[1,5]
Noorin Zaidi, Nishat Afroz, Kiran Alam, Imran Rizvi1 Departments of Pathology, Medicine, J N Medical College, A.M.U., Aligarh, Uttar Pradesh, India 1
Address for correspondence: Dr. Noorin Zaidi, E-mail: [email protected]
REFERENCES 1.
Iynen I, Sogut O, Guldur ME, Kose R, Kaya H, Bozkus F. Primary hydatid cyst: An unusual cause of a mass in the supraclavicular region of the neck. J Clin Med Res 2011;3:52-4. 2. Sultana N, Hashim TK, Jan SY, Khan Z, Malik T, Shah W. Primary cervical hydatid cyst: A rare occurrence. Diagn Pathol 2012;7:157. 3. Ahmad S, Jalil S, Saleem Y, Suleman BA, Chughtai N. Hydatid cysts at unusual sites: Reports of two cases in the neck and breast. J Pak Med Assoc 2010;60:232-4. 4. Kumar K, Khanna AK, Misra MK. Hydatid cyst of the neck. Postgrad Med J 1992;68:152. 5. Katilmiş H, Oztürkcan S, Ozdemir I, Adadan Güvenç I, Ozturan S. Primary hydatid cyst of the neck. Am J Otolaryngol 2007;28:205-7.
Over the next 3-4 months she progressively worsened and became a non-walker with an obvious progression of kyphotic deformity in the upper back. MRI showed an increase in the size of abscess and cord compression. She was again empirically started on secondline treatment with injectable streptomycin and restart of AKT-4 drug. At this stage she was referred to us for further management. Based on worsening inspite of AKT, evidence of ‘spine at risk’[1] signs and significant cord compression on MRI [Figures 1-4], decision was made for decompression, instrumentation and deformity correction. On culture and sensitivity testing with the BACTEC-MGIT 960[2] system she was found to be infected with extensively drug resistant (XDR) tuberculosis resistant to all first line drugs. The only drugs susceptible were Ethionamide, PAS and Clofazimine. She was started with PAS, Ethionamide, Clofazimine, Linezolid, Clarithromycin and Amoxicillin Clavulanatein order to include atleast fournew sensitive drugs which were not used in the past.[3-5] Within two weeks of surgery her neurology started improving progressively with the ability to walk with support. After completing 8 months of second line treatment, repeat MRI showed decrease in size of abscess and clinically she could walk without support.
Access this article online Quick Response Code: Website: www.jgid.org
DOI: 10.4103/0974-777X.127954
Figure 1: Preoperative CT
De-novo XDR Tuberculosis Spine in a 3-year-old Girl Sir, We report the case of a 3-year-old girl who had been diagnosed with tuberculosis of the spine with paraparesis based on clinical and radiological signs. She had received empirical therapy with standard AKT-4 drug and steroids; which were tapered on completion of 2 months of intensive phase with signs of neurological and clinical improvement. 44
Figure 2: Postoperative CT showing kyphosis correction
Journal of Global Infectious Diseases / Jan-Mar 2014 / Vol-6 / Issue-1
Copyright of Journal of Global Infectious Diseases is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
REFERENCES 1. Adebayo ET, Hussain NA. Pattern of prescription drug use in Nigerian army hospitals. Ann Afr Med 2010;9:152-8. 2. Ebrahimzadeh MA, Shokrzadeh M, Ramezani A. Utilization pattern of antibiotics in different wards of specialized Sari Emam University Hospital in Iran. Pak J Biol Sci 2008;11:275-9. 3. Hutchinson JM, Patrick DM, Marra F, Ng H, Bowie WR, Heule L, et al. Measurement of antibiotic consumption: A practical guide to the use of the Anatomical Therapeutic Chemical classification and defined daily dose system methodology in Canada. Can J Infect Dis 2004;15:29-35. 4. Miyawaki K, Miwa Y, Tomono K, Kurokawa N. Impact of antimicrobial stewardship by infection control team in a Japanese teaching hospital. Yakugaku Zasshi 2010;130:1105-11. 5. Zhang W, Shen X, Wang Y, Chen Y, Huang M, Zeng Q, et al. Antibiotic use in five children’s hospitals during 2002-2006: The impact of antibiotic guidelines issued by the Chinese Ministry of Health. Pharmacoepidemiol Drug Saf 2008;17:306-11. Access this article online Quick Response Code: Website: www.jgid.org
DOI: 10.4103/0974-777X.127953
A Case of Primary Cervicofacial Hydatidosis Sir, Hydatid disease of the neck region is an extremely rare finding, even in endemic regions, and only a few cases have been reported in the literature.[1-5] A 25-year-old female presented with a 1-month history of gradually progressive swelling in the neck. It was not associated with pain or fever or any other symptom. The swelling was located in the right cervical region, just below thyroid; its size was about 3 × 2 cm and was cystic in consistency. It was non-tender and the overlying skin did not show any signs of inflammation. A submandibular lymph node was also palpable, size approximately 1 × 1cm. X-ray demonstrated a mass in the neck without involvement of deeper structures. Ultrasonography showed a loculated cystic lesion with internal septae near the lower pole of thyroid under the strap muscles of the neck. An excisional biopsy of the mass was performed followed by irrigation by hypertonic saline [Figure 1]. Hematoxylin and eosin (H and E) stained slides were examined which showed all the three layers namely outermost pericyst, laminated layer and the inner germinal layer (which together
a
b
c
d
Figure 1: (a) Ultrasound showing a loculated cystic lesion with internal septa near the lower pole of thyroid under the strap muscles of neck. (b) Hematoxylin and Eosin (H and E) stained section of a part wall of hydatid cyst showing laminated layer and outermost pericyst layer composed of granulation tissue (H and E ×40). (c) H and E stained section of a part of cyst wall showing laminated layer and innermost germinal layer (H and E ×100). (d) High power view showing both laminated and innermost germinal layer (H and E ×400)
comprise the endocyst) [Figure 1]. Thus a final diagnosis of hydatid cyst in the neck was made. Biopsy of the lymph node revealed features of reactive lymphadenitis. The patient underwent further investigations and further thorough examination was done. There was no evidence of primary illness anywhere else. Since there was no evidence of primary lesion anywhere else, a final diagnosis of primary hydatid disease of the neck was made. The patient was given 4-week albendazole therapy (400 mg twice a day) and since the cyst was completely excised, no further surgical intervention was done. Presently, she is doing well and there is no evidence of recurrence. Due to its rarity, the diagnosis of cervicofacial hydatid disease is difficult.[1-4] However, diagnosis can be aided by taking proper history and combining different diagnostic modalities like radiology and serology. Serological tests, include immune hemagglutination, complement fixation, immunoelectrophoresis, skin tests (Casoni intradermal test), enzyme-linked immunosorbent assay (ELISA) and western blot serology. Radiology is a better diagnostic tool than serology.[2] Ultrasonography can clearly demonstrate the hydatid sands in purely cystic lesions, as well as floating membranes, daughter cysts, and vesicles. Some authors discourage the use of fine needle aspiration (FNA) in diagnosing Hydatid disease due to danger of spillage and anaphylaxis.[2] Histopathology is unanimously the preferred and definitive diagnostic option.[2,3] It consists
Journal of Global Infectious Diseases / Jan-Mar 2014 / Vol-6 / Issue-1
43
Letters to Editor
of an inner germinal layer of cells supported by a characteristic acidophilic-staining, acellular, laminated membrane of variable thickness. Each cyst is surrounded by a host-produced layer of granulomatous adventitial reaction tissue, which is a thick fibrous tissue.[2,3] The most effective and gold standard treatment of hydatid cyst is surgical excision.[1,5]
Noorin Zaidi, Nishat Afroz, Kiran Alam, Imran Rizvi1 Departments of Pathology, Medicine, J N Medical College, A.M.U., Aligarh, Uttar Pradesh, India 1
Address for correspondence: Dr. Noorin Zaidi, E-mail: [email protected]
REFERENCES 1.
Iynen I, Sogut O, Guldur ME, Kose R, Kaya H, Bozkus F. Primary hydatid cyst: An unusual cause of a mass in the supraclavicular region of the neck. J Clin Med Res 2011;3:52-4. 2. Sultana N, Hashim TK, Jan SY, Khan Z, Malik T, Shah W. Primary cervical hydatid cyst: A rare occurrence. Diagn Pathol 2012;7:157. 3. Ahmad S, Jalil S, Saleem Y, Suleman BA, Chughtai N. Hydatid cysts at unusual sites: Reports of two cases in the neck and breast. J Pak Med Assoc 2010;60:232-4. 4. Kumar K, Khanna AK, Misra MK. Hydatid cyst of the neck. Postgrad Med J 1992;68:152. 5. Katilmiş H, Oztürkcan S, Ozdemir I, Adadan Güvenç I, Ozturan S. Primary hydatid cyst of the neck. Am J Otolaryngol 2007;28:205-7.
Over the next 3-4 months she progressively worsened and became a non-walker with an obvious progression of kyphotic deformity in the upper back. MRI showed an increase in the size of abscess and cord compression. She was again empirically started on secondline treatment with injectable streptomycin and restart of AKT-4 drug. At this stage she was referred to us for further management. Based on worsening inspite of AKT, evidence of ‘spine at risk’[1] signs and significant cord compression on MRI [Figures 1-4], decision was made for decompression, instrumentation and deformity correction. On culture and sensitivity testing with the BACTEC-MGIT 960[2] system she was found to be infected with extensively drug resistant (XDR) tuberculosis resistant to all first line drugs. The only drugs susceptible were Ethionamide, PAS and Clofazimine. She was started with PAS, Ethionamide, Clofazimine, Linezolid, Clarithromycin and Amoxicillin Clavulanatein order to include atleast fournew sensitive drugs which were not used in the past.[3-5] Within two weeks of surgery her neurology started improving progressively with the ability to walk with support. After completing 8 months of second line treatment, repeat MRI showed decrease in size of abscess and clinically she could walk without support.
Access this article online Quick Response Code: Website: www.jgid.org
DOI: 10.4103/0974-777X.127954
Figure 1: Preoperative CT
De-novo XDR Tuberculosis Spine in a 3-year-old Girl Sir, We report the case of a 3-year-old girl who had been diagnosed with tuberculosis of the spine with paraparesis based on clinical and radiological signs. She had received empirical therapy with standard AKT-4 drug and steroids; which were tapered on completion of 2 months of intensive phase with signs of neurological and clinical improvement. 44
Figure 2: Postoperative CT showing kyphosis correction
Journal of Global Infectious Diseases / Jan-Mar 2014 / Vol-6 / Issue-1
Copyright of Journal of Global Infectious Diseases is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
