ª Springer Science+Business Media New York 2014
Abdominal Imaging
Abdom Imaging (2014) DOI: 10.1007/s00261-014-0152-7
Hepatic cysticercosis: a rare entity Vikas Chaudhary,1 Shahina Bano,2 Praveen Kumar,3 Mahender Kaur Narula,3 Rama Anand3 1
Department of Radiodiagnosis, Employees’ State Insurance Corporation (ESIC) Model Hospital, Sector-9A, Gurgaon 122001, Haryana, India 2 Department of Radiodiagnosis, Post Graduate Institute of Medical Education & Research (PGIMER), Dr. Ram Manohar Lohia Hospital, New Delhi 110001, India 3 Department of Radiodiagnosis, Lady Hardinge Medical College and Associated Hospitals, New Delhi 110001, India
Abstract Hepatic cysticercosis is a very rare entity; only four cases have been reported to date. High-resolution ultrasonography of the abdomen is the initial and most reliable modality for evaluation of hepatic cysticercosis. Medical therapy is the mainstay of treatment. We report a case of hepatic cysticercosis in a 28-year-old male who presented with right upper quadrant pain, fever, and jaundice. The article also describes the imaging patterns of hepatic cysticercosis based on different stages of evolution. Key words: Albendazole—Hepatic cysticercosis—Jaundice—Right upper quadrant pain—Ultrasound
Cysticercosis is the most common parasitic infection reported in human beings. Cysticercosis is endemic in Africa, Latin America, East Asia, Eastern Europe, India, Indonesia, Mexico, and China [1]. Cysticercosis can affect various organs including the brain, spinal cord, orbit, muscle, subcutaneous tissue, and heart [2]. Liver and spleen involvements are extremely rare. Only four cases of hepatic cysticercosis have been reported to date [3–6]. We report a case of hepatic cysticercosis who presented with right upper quadrant pain, fever, and jaundice. We also describe the various imaging patterns of hepatic cysticercosis corresponding to the different stages of evolution.
Case report A 28-year-old male presented with a 2-month history of recurrent right upper abdominal pain, fever, and jaunCorrespondence to: Vikas Chaudhary; email: dr_vikaschaudhary@yahoo. com
dice. The patient was a chronic alcoholic and smoker. Physical examination revealed mild hepatomegaly and yellowish discoloration of sclera and skin. Laboratory examination revealed a high ESR (54 mm at the end of 1 hour) and peripheral eosinophilia (750 cells/cu mm). Liver function tests showed elevated serum bilirubin (>3 gm/dL) and liver enzymes (transaminases; AST was 133 IU/L and ALT was 116 IU/L). Urine bilirubin was positive. Ultrasound abdomen (Fig. 1) showed mild hepatomegaly and multiple liver cysts. The cysts were randomly distributed within the liver parenchyma and were of variable sizes (1 mm to 3 cm size) and shapes (round to oval). Majority of them showed the presence of the scolex. The cysts were seen in various stages of evolution—live, dead, degenerating, and calcified. Liver echotexture appeared normal. Additional imaging workup failed to show the presence of cyst at other sites. Radiological diagnosis of hepatic cysticercosis was suggested. Serology test (ELISA) for anti-cysticercal antibodies (IgG) was strongly positive and supported the diagnosis of hepatic cysticercosis. The patient was managed with a course of albendazole and steroid therapy. His pain, fever, and jaundice gradually subsided. Biweekly follow-up ultrasounds showed complete resolution of the cysts over a period of 6 weeks.
Discussion Human cysticercosis is caused by the larval form of Taenia solium or pork tapeworm called cysticercus cellulosae. It is acquired by ingestion of food, water, and vegetables contaminated with the ova of Taenia solium. Cysticercus cellulosae may become encysted at various sites within the body, usually involving the central nervous system, eyes, muscles, and subcutaneous tissues. Liver and spleen may rarely be involved. The clinical
V. Chaudhary et al.: Hepatic cysticercosis
V. Chaudhary et al.: Hepatic cysticercosis
A Ultrasound image of the abdomen showing a mildly enlarged liver with multiple cysts randomly distributed within the liver parenchyma. The cysts are of variable sizes (1 mm to 3 cm size) and shapes (round to oval). Majority of them show the presence of the eccentric scolex. The cysts are seen in various stages of evolution. Liver echo texture appears normal. Radiological diagnosis of hepatic cysticercosis was suggested. Additional imaging workup failed to show the presence of cyst at other sites. B High-resolution ultrasound image of the liver in the same patient showing cysts in various stages of evolution—live, dead, degenerating, and calcified. Live cyst (thick white arrows) with typical imaging characteristics: a well-circumscribed, round to oval, fluid-filled structure with an eccentric mural nodule (corresponding to the invaginated protoscolex). The cystic fluid appears anechoic as the larva is alive. An irregular cyst with no scolex and minimal surrounding edema (white arrowhead). Note that nonvisualization of the scolex may be due to partial collapse of cyst following larval death or escape of scolex outside the cyst following rupture. A degenerating cyst with thick turbid fluid and no scolex (thin white arrows). Note that after parasitic death, turbidity and gelling of the fluid reduce the contrast between the nodule and the cystic fluid. A degenerating cyst with thick turbid fluid, mineralized nodule, and peripheral wall calcification (black arrowheads). Multiple elliptical (millet-shaped) calcified cysticercus cysts (thin black arrows).
b Fig. 1.
manifestations vary depending on the site of larval encystment. The dead parasite produces an immunologic reaction with intense inflammatory response [5]. Hepatic cysticercosis is extremely rare and hence of clinical importance. Only four patients with hepatic cysticercosis have been documented in human beings till date [3–6]. The first case was reported in a 62-year-old man with colon adenocarcinoma [4]. In hepatic cysticercosis, a solitary lesion may remain asymptomatic, while multinodular lesions may manifest as acute or chronic hepatitis [6]. Clinical manifestations of liver damage may result in significant morbidity [4]. High-resolution ultrasonography (USG) is the initial and most reliable diagnostic modality for evaluation of liver and soft tissue cysticercosis. It is readily available, inexpensive, noninvasive, and a nonionizing imaging modality [1–7]. Ultrasound helps us evaluate the cyst size, shape, and margin, the presence or absence of scolex, surrounding inflammation, abscess/pseudomass formation, and location of the lesion. Follow-up USG is performed to look for resolution of the lesion following medical therapy [1]. Computed tomography (CT) and magnetic resonance imaging (MRI) also help in the detection of hepatic cysticercosis. Liver cysts may be present in various stages of evolution—live, dead, degenerating, and calcified. Based on the stage of evolution, different imaging patterns have
been recognized. These patterns are similar to those imaging patterns which are found with cysticercosis elsewhere in the body. Live cysts have a typical imaging appearance, identified as a well-circumscribed, round to oval, nonenhancing fluid-filled structure with an eccentric mural nodule (corresponding to the invaginated protoscolex). If larva is alive, then the cystic fluid would appear clear. Parasite death (and leakage of fluid from the cyst) incites a host immune response and pericystic inflammatory reaction characterized by a variable degree of edema around the cyst and intense cyst wall enhancement. After parasitic death, turbidity and gelling of the fluid reduce the contrast between the nodule and the cystic fluid. Chronic inflammation may lead to the formation of an inflammatory mass that may mimic a pseudotumor. Inflammatory changes are best observed on fat-suppressed T2-weighted and contrast-enhanced MR image. Varying imaging characteristics of the mural nodule and the cystic fluid are demonstrated by a degenerating cyst. Subsequently, over a variable period of time, the disintegrating larva evolves into a granulomatous abscess and eventually into a mineralized nodule. When in multiple, millet-shaped elliptical calcified cysts give a starry night appearance on CT. Nonvisualization of the scolex may be due to partial collapse of cyst following larval death or escape of scolex outside the cyst following rupture [1, 7]. Serology test (ELISA) for anti-cysticercal antibodies (IgG) strongly supports the diagnosis of cysticercosis. The test has 80% sensitivity and 94% specificity [6]. The diagnosis of cysticercosis can be confirmed by fine-needle aspiration cytology (FNAC) or biopsy, which shows detached hooklets, scolex, and fragments of the spiral wall of cysticercosis cellulosae [7]. Cysts not associated with edema are treated conservatively with antihelminthic medications such as albendazole or praziquantel. Surgical excision is usually reserved for isolated cysticercosis associated with abscess formation. Biweekly follow-up USG is generally recommended over a period of about 4–6 weeks following initiation of medication to evaluate resolution of the cyst and inflammatory changes [1, 6, 7].
Conclusion Cysticercosis should always be included in the differential diagnosis of liver cysts in endemic countries like India. The appearance on high-resolution US is pathognomonic of cysticercosis and a definitive diagnosis can be made with greater confidence. The knowledge of different imaging patterns of hepatic cysticercosis (based on the stage of evolution) is essential for a radiologist to guide the correct therapy. Conflict of interest The authors declare that they have no conflict of interest.
V. Chaudhary et al.: Hepatic cysticercosis
References 1. Vijayaraghavan SB (2004) Sonographic appearances in cysticercosis. J Ultrasound Med 23:423–427 2. Chaudhary V, Bano S, Parmar PR, Bidasaria N, Bajaj S (2013) Extraocular muscle cysticercosis mimicking as pseudotumor orbit: a clinical dilemma. Neurol India 61:665–667 3. Singh N, Singh DK, Parihar A, Singh R (2012) Disseminated cysticercosis: rare manifestation of a common disease. BMJ Case Rep . doi:10.1136/bcr-2012-007876
4. Sickel JZ, Fultz PJ, Penwarden B, Laczin J (1995) Hepatic cysticercosis. Report of an unusual case. J Clin Gastroenterol 20:160–163 5. Figurnov VA, Churin AN, Lenshin AV, et al. (2002) A case of isolated hepatic cysticercosis in a nine-year-old girl. Med Parazitol (Mosk) 1:56–57 6. Vishwanath S, Charudutt S, Kavitha S, et al. (2011) A rare case of hepatic cysticercosis. Asian Pac J Trop Biomed 1:139–140 7. Naik D, Srinath MG, Kumar A (2011) Soft tissue cysticercosis-ultrasonographic spectrum of the disease. Indian J Radiol Imaging 21:60–62
Abdominal Imaging
Abdom Imaging (2014) DOI: 10.1007/s00261-014-0152-7
Hepatic cysticercosis: a rare entity Vikas Chaudhary,1 Shahina Bano,2 Praveen Kumar,3 Mahender Kaur Narula,3 Rama Anand3 1
Department of Radiodiagnosis, Employees’ State Insurance Corporation (ESIC) Model Hospital, Sector-9A, Gurgaon 122001, Haryana, India 2 Department of Radiodiagnosis, Post Graduate Institute of Medical Education & Research (PGIMER), Dr. Ram Manohar Lohia Hospital, New Delhi 110001, India 3 Department of Radiodiagnosis, Lady Hardinge Medical College and Associated Hospitals, New Delhi 110001, India
Abstract Hepatic cysticercosis is a very rare entity; only four cases have been reported to date. High-resolution ultrasonography of the abdomen is the initial and most reliable modality for evaluation of hepatic cysticercosis. Medical therapy is the mainstay of treatment. We report a case of hepatic cysticercosis in a 28-year-old male who presented with right upper quadrant pain, fever, and jaundice. The article also describes the imaging patterns of hepatic cysticercosis based on different stages of evolution. Key words: Albendazole—Hepatic cysticercosis—Jaundice—Right upper quadrant pain—Ultrasound
Cysticercosis is the most common parasitic infection reported in human beings. Cysticercosis is endemic in Africa, Latin America, East Asia, Eastern Europe, India, Indonesia, Mexico, and China [1]. Cysticercosis can affect various organs including the brain, spinal cord, orbit, muscle, subcutaneous tissue, and heart [2]. Liver and spleen involvements are extremely rare. Only four cases of hepatic cysticercosis have been reported to date [3–6]. We report a case of hepatic cysticercosis who presented with right upper quadrant pain, fever, and jaundice. We also describe the various imaging patterns of hepatic cysticercosis corresponding to the different stages of evolution.
Case report A 28-year-old male presented with a 2-month history of recurrent right upper abdominal pain, fever, and jaunCorrespondence to: Vikas Chaudhary; email: dr_vikaschaudhary@yahoo. com
dice. The patient was a chronic alcoholic and smoker. Physical examination revealed mild hepatomegaly and yellowish discoloration of sclera and skin. Laboratory examination revealed a high ESR (54 mm at the end of 1 hour) and peripheral eosinophilia (750 cells/cu mm). Liver function tests showed elevated serum bilirubin (>3 gm/dL) and liver enzymes (transaminases; AST was 133 IU/L and ALT was 116 IU/L). Urine bilirubin was positive. Ultrasound abdomen (Fig. 1) showed mild hepatomegaly and multiple liver cysts. The cysts were randomly distributed within the liver parenchyma and were of variable sizes (1 mm to 3 cm size) and shapes (round to oval). Majority of them showed the presence of the scolex. The cysts were seen in various stages of evolution—live, dead, degenerating, and calcified. Liver echotexture appeared normal. Additional imaging workup failed to show the presence of cyst at other sites. Radiological diagnosis of hepatic cysticercosis was suggested. Serology test (ELISA) for anti-cysticercal antibodies (IgG) was strongly positive and supported the diagnosis of hepatic cysticercosis. The patient was managed with a course of albendazole and steroid therapy. His pain, fever, and jaundice gradually subsided. Biweekly follow-up ultrasounds showed complete resolution of the cysts over a period of 6 weeks.
Discussion Human cysticercosis is caused by the larval form of Taenia solium or pork tapeworm called cysticercus cellulosae. It is acquired by ingestion of food, water, and vegetables contaminated with the ova of Taenia solium. Cysticercus cellulosae may become encysted at various sites within the body, usually involving the central nervous system, eyes, muscles, and subcutaneous tissues. Liver and spleen may rarely be involved. The clinical
V. Chaudhary et al.: Hepatic cysticercosis
V. Chaudhary et al.: Hepatic cysticercosis
A Ultrasound image of the abdomen showing a mildly enlarged liver with multiple cysts randomly distributed within the liver parenchyma. The cysts are of variable sizes (1 mm to 3 cm size) and shapes (round to oval). Majority of them show the presence of the eccentric scolex. The cysts are seen in various stages of evolution. Liver echo texture appears normal. Radiological diagnosis of hepatic cysticercosis was suggested. Additional imaging workup failed to show the presence of cyst at other sites. B High-resolution ultrasound image of the liver in the same patient showing cysts in various stages of evolution—live, dead, degenerating, and calcified. Live cyst (thick white arrows) with typical imaging characteristics: a well-circumscribed, round to oval, fluid-filled structure with an eccentric mural nodule (corresponding to the invaginated protoscolex). The cystic fluid appears anechoic as the larva is alive. An irregular cyst with no scolex and minimal surrounding edema (white arrowhead). Note that nonvisualization of the scolex may be due to partial collapse of cyst following larval death or escape of scolex outside the cyst following rupture. A degenerating cyst with thick turbid fluid and no scolex (thin white arrows). Note that after parasitic death, turbidity and gelling of the fluid reduce the contrast between the nodule and the cystic fluid. A degenerating cyst with thick turbid fluid, mineralized nodule, and peripheral wall calcification (black arrowheads). Multiple elliptical (millet-shaped) calcified cysticercus cysts (thin black arrows).
b Fig. 1.
manifestations vary depending on the site of larval encystment. The dead parasite produces an immunologic reaction with intense inflammatory response [5]. Hepatic cysticercosis is extremely rare and hence of clinical importance. Only four patients with hepatic cysticercosis have been documented in human beings till date [3–6]. The first case was reported in a 62-year-old man with colon adenocarcinoma [4]. In hepatic cysticercosis, a solitary lesion may remain asymptomatic, while multinodular lesions may manifest as acute or chronic hepatitis [6]. Clinical manifestations of liver damage may result in significant morbidity [4]. High-resolution ultrasonography (USG) is the initial and most reliable diagnostic modality for evaluation of liver and soft tissue cysticercosis. It is readily available, inexpensive, noninvasive, and a nonionizing imaging modality [1–7]. Ultrasound helps us evaluate the cyst size, shape, and margin, the presence or absence of scolex, surrounding inflammation, abscess/pseudomass formation, and location of the lesion. Follow-up USG is performed to look for resolution of the lesion following medical therapy [1]. Computed tomography (CT) and magnetic resonance imaging (MRI) also help in the detection of hepatic cysticercosis. Liver cysts may be present in various stages of evolution—live, dead, degenerating, and calcified. Based on the stage of evolution, different imaging patterns have
been recognized. These patterns are similar to those imaging patterns which are found with cysticercosis elsewhere in the body. Live cysts have a typical imaging appearance, identified as a well-circumscribed, round to oval, nonenhancing fluid-filled structure with an eccentric mural nodule (corresponding to the invaginated protoscolex). If larva is alive, then the cystic fluid would appear clear. Parasite death (and leakage of fluid from the cyst) incites a host immune response and pericystic inflammatory reaction characterized by a variable degree of edema around the cyst and intense cyst wall enhancement. After parasitic death, turbidity and gelling of the fluid reduce the contrast between the nodule and the cystic fluid. Chronic inflammation may lead to the formation of an inflammatory mass that may mimic a pseudotumor. Inflammatory changes are best observed on fat-suppressed T2-weighted and contrast-enhanced MR image. Varying imaging characteristics of the mural nodule and the cystic fluid are demonstrated by a degenerating cyst. Subsequently, over a variable period of time, the disintegrating larva evolves into a granulomatous abscess and eventually into a mineralized nodule. When in multiple, millet-shaped elliptical calcified cysts give a starry night appearance on CT. Nonvisualization of the scolex may be due to partial collapse of cyst following larval death or escape of scolex outside the cyst following rupture [1, 7]. Serology test (ELISA) for anti-cysticercal antibodies (IgG) strongly supports the diagnosis of cysticercosis. The test has 80% sensitivity and 94% specificity [6]. The diagnosis of cysticercosis can be confirmed by fine-needle aspiration cytology (FNAC) or biopsy, which shows detached hooklets, scolex, and fragments of the spiral wall of cysticercosis cellulosae [7]. Cysts not associated with edema are treated conservatively with antihelminthic medications such as albendazole or praziquantel. Surgical excision is usually reserved for isolated cysticercosis associated with abscess formation. Biweekly follow-up USG is generally recommended over a period of about 4–6 weeks following initiation of medication to evaluate resolution of the cyst and inflammatory changes [1, 6, 7].
Conclusion Cysticercosis should always be included in the differential diagnosis of liver cysts in endemic countries like India. The appearance on high-resolution US is pathognomonic of cysticercosis and a definitive diagnosis can be made with greater confidence. The knowledge of different imaging patterns of hepatic cysticercosis (based on the stage of evolution) is essential for a radiologist to guide the correct therapy. Conflict of interest The authors declare that they have no conflict of interest.
V. Chaudhary et al.: Hepatic cysticercosis
References 1. Vijayaraghavan SB (2004) Sonographic appearances in cysticercosis. J Ultrasound Med 23:423–427 2. Chaudhary V, Bano S, Parmar PR, Bidasaria N, Bajaj S (2013) Extraocular muscle cysticercosis mimicking as pseudotumor orbit: a clinical dilemma. Neurol India 61:665–667 3. Singh N, Singh DK, Parihar A, Singh R (2012) Disseminated cysticercosis: rare manifestation of a common disease. BMJ Case Rep . doi:10.1136/bcr-2012-007876
4. Sickel JZ, Fultz PJ, Penwarden B, Laczin J (1995) Hepatic cysticercosis. Report of an unusual case. J Clin Gastroenterol 20:160–163 5. Figurnov VA, Churin AN, Lenshin AV, et al. (2002) A case of isolated hepatic cysticercosis in a nine-year-old girl. Med Parazitol (Mosk) 1:56–57 6. Vishwanath S, Charudutt S, Kavitha S, et al. (2011) A rare case of hepatic cysticercosis. Asian Pac J Trop Biomed 1:139–140 7. Naik D, Srinath MG, Kumar A (2011) Soft tissue cysticercosis-ultrasonographic spectrum of the disease. Indian J Radiol Imaging 21:60–62
