Case reports
1990, The British Journal of Radiology, 63, 652-653
tis include air in the bowel wall. Barium examination demonstrates diffuse ulceration with or without thumbprinting. Computed tomography, as in this case, shows gross bowel wall thickening (Bankoffet al, 1985; Taylor et al, 1985). Fortunately in this case a rapid and specific diagnosis was made by stool microscopy. The presentation following her course of chemotherapy was interesting and is typical of strongyloidiasis which has been reported in a number of cases to arise following immune suppression. (Pagliuca et al, 1988; Maayan et al, 1987) To our knowledge, the CT appearances of colonic strongyloidiasis have not previously been reported. References
BERRY, A. J., LONG, E. G., SMITH, J. H., GOURLEY, W. K. &
FINE, D. P., 1983. Chronic relapsing colitis due to strongyloides stercoralis. American Journal of Tropical Medicine and Hygiene, 32, 1289-1293. CARP,
N.
Z.,
NEJMAN,
J.
H.
&
KELLY,
J.
Strongyloidiasis. An unusual cause of pseudopolyposis and gastrointestinal bleeding. Endoscopy, 3, 175-177.
J.,
1987.
colonic Surgical
DRASIN, G. F., MOSS, J. P. & CHENG, S. H., 1976. Strongyloides
stercoralis colitis: findings in four cases. Radiology, 126, 619-621. MAAYAN, S., WORMSER, G. P., WIDERHORN, J., SY, E. R., KIM,
Y. H. & ERNST, J. A., 1987. Strongyloides stercoralis hyperinfection in a patient with AIDS. American Journal of Medicine, 83, 945-948. PAGLIUCA, A., LAYTON, D. M., ALLEN, S. & MUFTI, G. J., 1988.
Hyperinfection with strongyloides after treatment for adult T-cell leukaemia-lymphoma in an African immigrant. British Medical Journal, 297, 1456-1457.
BANKOFF, M. S., SARNO, R. C. & BONICI, A. J., 1985. CT
TAYLOR, A. J., DODDS, W. J., GONYO, J. E. & KOMOROWSKI, R.
detection of necrotising enterocolitis. British Journal of Radiology, 58, 495.
A., 1985. Typhlitis in adults. Gastrointestinal Radiology, 10, 363.
Epidermoid cyst of the spleen: a case report and review of the literature By Kirsten A. Younger, M B , BS, BSc and Christine M. Hall, M B , BS, FRCR The Department of Radiology, The Hospital for Sick Children, Great Ormond Street, London WC1 (Received October 1989 and in revised form January 1990)
True cysts of the spleen are rare, those caused by the parasite Taenia ecchinococcus accounting for over two thirds of the world's cases. In non-endemic areas, benign non-parasitic cysts prevail, and only 10 % of these are epidermoid. Pseudocysts, resulting from trauma, haemorrhage or infarct are four times as common as true cysts, the latter being defined as those with an epithelial lining. Epidermoid cysts of the spleen usually present in the second to fourth decades, 60 % are in females, 80 % are unilocular and solitary and only 10% calcify (Robbins et al, 1978). There are few reports of epidermoid cysts of the spleen in British radiological literature (Zimmerman et al, 1972; Bhimji et al, 1977; Daneman & Martin, 1982). Case report A 10-year-old Caucasian boy was transferred to The Hospital for Sick Children, Great Ormond Street with a 2-day history of abdominal pain, distension, retching and constipation. The history dated back 4 months, when he presented to his general practitioner following a heavy and spontaneous epiAddress correspondence to Dr Kirsten A. Younger, The Department of Radiology, St Georges' Hospital, Blackshaw Road, London SW17 0QT.
652
staxis. After this he developed myalgia and polyarthralgia for which a diagnosis of reactive arthralgia was made. This slowly resolved with non-steroidal anti-inflammatory medication. During investigation he was found to have splenic enlargement and ultrasound showed a well defined, relatively echopoor lesion, 10 cm in diameter, arising from the spleen. This was thought to represent either a large splenic haematoma or haemorrhage into a splenic cyst (Fig. 1). The patient admitted to having sustained a fall onto his left side 3 months previously. He was admitted for observation and his condition remained stable. A computed tomographic (CT) scan was performed which showed a 10 cm diameter, low density, non-enhancing mass medial to the spleen. Other abdominal organs were normal (Fig. 2). The patient was discharged to his home for strict rest with planned monthly follow-up examinations and ultrasound scans. Events culminated in emergency admission as described. On admission he was well with no signs of circulatory embarrassment. The abdomen was soft with a palpable spleen 4 cm below the left costal margin. The ultrasound appearance was unchanged from the initial scan, and plain abdominal films confirmed an enlarged spleen together with normal bowel gas pattern. At laparotomy a partial splenectomy was performed to include the splenic cyst. This was noted to contain nonhaemorrhagic fluid, and histopathology showed a unilocular, coarsely trabeculated, fibrotic-walled cyst lined by stratified squamous epithelium adjacent to normal splenic tissue. Postoperative recovery was uneventful.
The British Journal of Radiology, August 1990
Case reports
Figure 2. Computer tomographic scan of spleen, showing a 10 cm low density, non-enhancing mass. Figure 1. Ultrasound of spleen, showing a well defined 10 cm lesion.
Discussion
(1967) report cases of rupture with severe localized granulomatous inflammation. Pre-operative pneumovac immunization should be given in case splenectomy is unavoidable. Pathologically the epidermoid cyst is lined with pearly white trabeculations. Microscopically there are focal areas of stratified squamous epithelium in varying amounts. The aetiology is unknown but is thought to be congenital and current theories are of metaplasia of coelomic epithelium which is mesodermal in origin or a heterotopic endodermal inclusion within the spleen. Ahlgren and Beardmore (1984) have reported familial occurrence of solitary epidermoid splenic cysts and postulated a genetic transmission.
This case demonstrates one of the most common presentations, that of incidental finding of a solitary cyst. Twenty-five per cent are discovered after trauma which is often trivial and coincidental. Others present with a feeling of fullness or pain in the left upper quadrant. After haematological investigation has excluded other causes of an enlarged spleen, such as myeloproliferative and infective diseases, the diagnosis relies upon radiological assessment (Ross et al, 1977). The aim of the pre-operative evaluation is to localize the mass to the spleen, assess whether it is cystic or solid References and to exclude secondary splenic involvement by a AHLGREN, L. S. & BEARDMORE, H. E., 1984. Solitary epiderprimary systemic disorder. moid splenic cysts. Occurrence in sibs. Journal of Paediatric Ultrasound is the most valuable single investigation Surgery, 19, 56-58. for splenic epidermoid cysts, showing, as in this case, a BHIMJI, S. D., COOPERBERG, P. L., MAIMAN, S., MORRISON, R. T. & SHERGILL, P., 1977. Ultrasound diagnosis of splenic well circumscribed echo-poor lesion not changing over a cysts. Radiology, 122, 787-789. period of time. When the lesion is not completely DANEMAN, A. & MARTIN, D. J., 1982. Congenital epithelial anechoic, Goldfinger et al (1986) have advocated that splenic cysts in children. Paediatric Radiology, 12, 119-125. splenic aspiration should be performed to exclude a M., COHEN, M. M., STEINHARDT, M. I., neoplasm or lymphoma. The dangers are of rupture, GOLDFINGER, ROTHBERG, R. & ROTHER, I., 1986. Sonography and percutaperitonitis and seeding in hydatid disease. In nonneous aspiration of splenic epidermoid cyst. Journal of endemic areas this risk is extremely small. Computed Clinical Ultrasound, 14, 147-149. tomography will also demonstrate the nature of the LIPPIT, W. H., AKHAVAN, T. & CAPLAN, G. E., 1967. Epiderlesion, but often no additional useful information is moid cyst of the spleen with rupture and inflammation. Archives of Surgery, 95, 74. obtained. Nuclear medicine scans are generally nonspecific and angiography will display an avascular mass ROBBINS, F. G., YELLIN, A. E., LINGUA, R. W., CRAIG, J. R., TURRILL, F. L. & MIKKELSEN, W. P., 1978. Splenic epiderwith vessels stretched around it. This information can be moid cysts. Annals of Surgery, 3, 231-234. particularly important in determining the feasibility of a Ross, M. E., ELLWOOD, R., YOUNG, S. S. & LUCAS, R. J., 1977. partial splenectomy. Epidermoid splenic cysts. Archives of Surgery, 122, 596-599. The advocated treatment is elective surgical removal ZIMMERMAN, O., SCHENKEN, J. R., SCHULTZ, L. & PAUSTIAN, F., of the cyst, conserving the spleen if possible, because of 1972. Epidermoid cyst of the spleen. An unusual case of potential splenic infection, rupture following trauma, Massive Splenomegaly. Journal of Paediatric Surgery, 7, massive haemorrhage or abscess formation. Lippit et al 374-377.
Vol. 63, No. 752
653
1990, The British Journal of Radiology, 63, 652-653
tis include air in the bowel wall. Barium examination demonstrates diffuse ulceration with or without thumbprinting. Computed tomography, as in this case, shows gross bowel wall thickening (Bankoffet al, 1985; Taylor et al, 1985). Fortunately in this case a rapid and specific diagnosis was made by stool microscopy. The presentation following her course of chemotherapy was interesting and is typical of strongyloidiasis which has been reported in a number of cases to arise following immune suppression. (Pagliuca et al, 1988; Maayan et al, 1987) To our knowledge, the CT appearances of colonic strongyloidiasis have not previously been reported. References
BERRY, A. J., LONG, E. G., SMITH, J. H., GOURLEY, W. K. &
FINE, D. P., 1983. Chronic relapsing colitis due to strongyloides stercoralis. American Journal of Tropical Medicine and Hygiene, 32, 1289-1293. CARP,
N.
Z.,
NEJMAN,
J.
H.
&
KELLY,
J.
Strongyloidiasis. An unusual cause of pseudopolyposis and gastrointestinal bleeding. Endoscopy, 3, 175-177.
J.,
1987.
colonic Surgical
DRASIN, G. F., MOSS, J. P. & CHENG, S. H., 1976. Strongyloides
stercoralis colitis: findings in four cases. Radiology, 126, 619-621. MAAYAN, S., WORMSER, G. P., WIDERHORN, J., SY, E. R., KIM,
Y. H. & ERNST, J. A., 1987. Strongyloides stercoralis hyperinfection in a patient with AIDS. American Journal of Medicine, 83, 945-948. PAGLIUCA, A., LAYTON, D. M., ALLEN, S. & MUFTI, G. J., 1988.
Hyperinfection with strongyloides after treatment for adult T-cell leukaemia-lymphoma in an African immigrant. British Medical Journal, 297, 1456-1457.
BANKOFF, M. S., SARNO, R. C. & BONICI, A. J., 1985. CT
TAYLOR, A. J., DODDS, W. J., GONYO, J. E. & KOMOROWSKI, R.
detection of necrotising enterocolitis. British Journal of Radiology, 58, 495.
A., 1985. Typhlitis in adults. Gastrointestinal Radiology, 10, 363.
Epidermoid cyst of the spleen: a case report and review of the literature By Kirsten A. Younger, M B , BS, BSc and Christine M. Hall, M B , BS, FRCR The Department of Radiology, The Hospital for Sick Children, Great Ormond Street, London WC1 (Received October 1989 and in revised form January 1990)
True cysts of the spleen are rare, those caused by the parasite Taenia ecchinococcus accounting for over two thirds of the world's cases. In non-endemic areas, benign non-parasitic cysts prevail, and only 10 % of these are epidermoid. Pseudocysts, resulting from trauma, haemorrhage or infarct are four times as common as true cysts, the latter being defined as those with an epithelial lining. Epidermoid cysts of the spleen usually present in the second to fourth decades, 60 % are in females, 80 % are unilocular and solitary and only 10% calcify (Robbins et al, 1978). There are few reports of epidermoid cysts of the spleen in British radiological literature (Zimmerman et al, 1972; Bhimji et al, 1977; Daneman & Martin, 1982). Case report A 10-year-old Caucasian boy was transferred to The Hospital for Sick Children, Great Ormond Street with a 2-day history of abdominal pain, distension, retching and constipation. The history dated back 4 months, when he presented to his general practitioner following a heavy and spontaneous epiAddress correspondence to Dr Kirsten A. Younger, The Department of Radiology, St Georges' Hospital, Blackshaw Road, London SW17 0QT.
652
staxis. After this he developed myalgia and polyarthralgia for which a diagnosis of reactive arthralgia was made. This slowly resolved with non-steroidal anti-inflammatory medication. During investigation he was found to have splenic enlargement and ultrasound showed a well defined, relatively echopoor lesion, 10 cm in diameter, arising from the spleen. This was thought to represent either a large splenic haematoma or haemorrhage into a splenic cyst (Fig. 1). The patient admitted to having sustained a fall onto his left side 3 months previously. He was admitted for observation and his condition remained stable. A computed tomographic (CT) scan was performed which showed a 10 cm diameter, low density, non-enhancing mass medial to the spleen. Other abdominal organs were normal (Fig. 2). The patient was discharged to his home for strict rest with planned monthly follow-up examinations and ultrasound scans. Events culminated in emergency admission as described. On admission he was well with no signs of circulatory embarrassment. The abdomen was soft with a palpable spleen 4 cm below the left costal margin. The ultrasound appearance was unchanged from the initial scan, and plain abdominal films confirmed an enlarged spleen together with normal bowel gas pattern. At laparotomy a partial splenectomy was performed to include the splenic cyst. This was noted to contain nonhaemorrhagic fluid, and histopathology showed a unilocular, coarsely trabeculated, fibrotic-walled cyst lined by stratified squamous epithelium adjacent to normal splenic tissue. Postoperative recovery was uneventful.
The British Journal of Radiology, August 1990
Case reports
Figure 2. Computer tomographic scan of spleen, showing a 10 cm low density, non-enhancing mass. Figure 1. Ultrasound of spleen, showing a well defined 10 cm lesion.
Discussion
(1967) report cases of rupture with severe localized granulomatous inflammation. Pre-operative pneumovac immunization should be given in case splenectomy is unavoidable. Pathologically the epidermoid cyst is lined with pearly white trabeculations. Microscopically there are focal areas of stratified squamous epithelium in varying amounts. The aetiology is unknown but is thought to be congenital and current theories are of metaplasia of coelomic epithelium which is mesodermal in origin or a heterotopic endodermal inclusion within the spleen. Ahlgren and Beardmore (1984) have reported familial occurrence of solitary epidermoid splenic cysts and postulated a genetic transmission.
This case demonstrates one of the most common presentations, that of incidental finding of a solitary cyst. Twenty-five per cent are discovered after trauma which is often trivial and coincidental. Others present with a feeling of fullness or pain in the left upper quadrant. After haematological investigation has excluded other causes of an enlarged spleen, such as myeloproliferative and infective diseases, the diagnosis relies upon radiological assessment (Ross et al, 1977). The aim of the pre-operative evaluation is to localize the mass to the spleen, assess whether it is cystic or solid References and to exclude secondary splenic involvement by a AHLGREN, L. S. & BEARDMORE, H. E., 1984. Solitary epiderprimary systemic disorder. moid splenic cysts. Occurrence in sibs. Journal of Paediatric Ultrasound is the most valuable single investigation Surgery, 19, 56-58. for splenic epidermoid cysts, showing, as in this case, a BHIMJI, S. D., COOPERBERG, P. L., MAIMAN, S., MORRISON, R. T. & SHERGILL, P., 1977. Ultrasound diagnosis of splenic well circumscribed echo-poor lesion not changing over a cysts. Radiology, 122, 787-789. period of time. When the lesion is not completely DANEMAN, A. & MARTIN, D. J., 1982. Congenital epithelial anechoic, Goldfinger et al (1986) have advocated that splenic cysts in children. Paediatric Radiology, 12, 119-125. splenic aspiration should be performed to exclude a M., COHEN, M. M., STEINHARDT, M. I., neoplasm or lymphoma. The dangers are of rupture, GOLDFINGER, ROTHBERG, R. & ROTHER, I., 1986. Sonography and percutaperitonitis and seeding in hydatid disease. In nonneous aspiration of splenic epidermoid cyst. Journal of endemic areas this risk is extremely small. Computed Clinical Ultrasound, 14, 147-149. tomography will also demonstrate the nature of the LIPPIT, W. H., AKHAVAN, T. & CAPLAN, G. E., 1967. Epiderlesion, but often no additional useful information is moid cyst of the spleen with rupture and inflammation. Archives of Surgery, 95, 74. obtained. Nuclear medicine scans are generally nonspecific and angiography will display an avascular mass ROBBINS, F. G., YELLIN, A. E., LINGUA, R. W., CRAIG, J. R., TURRILL, F. L. & MIKKELSEN, W. P., 1978. Splenic epiderwith vessels stretched around it. This information can be moid cysts. Annals of Surgery, 3, 231-234. particularly important in determining the feasibility of a Ross, M. E., ELLWOOD, R., YOUNG, S. S. & LUCAS, R. J., 1977. partial splenectomy. Epidermoid splenic cysts. Archives of Surgery, 122, 596-599. The advocated treatment is elective surgical removal ZIMMERMAN, O., SCHENKEN, J. R., SCHULTZ, L. & PAUSTIAN, F., of the cyst, conserving the spleen if possible, because of 1972. Epidermoid cyst of the spleen. An unusual case of potential splenic infection, rupture following trauma, Massive Splenomegaly. Journal of Paediatric Surgery, 7, massive haemorrhage or abscess formation. Lippit et al 374-377.
Vol. 63, No. 752
653
