Letters to Editor
Hydatid cyst of urinary bladder Sir, Hydatid cyst of liver and lungs are common, but hydatid cysts have been seen on rare occasions at unusual sites, spleen, kidney, muscle, brain, spine, breast, thyroid, peritoneal cavity, and retroperitoneum.[1] Hydatid cyst of urinary bladder (UB) is very rare.[2,3]
a
b
Figure 1: (a, b) 48-year-old man with hydatid cyst urinary bladder. USG shows multilocular cystic lesion “with cyst within cyst appearance” (UB: Urinarybladder, H: Hydatid cyst)
A 48‑year‑old-male, known case of carcinoma larynx (post‑laryngectomy) presented with a history of lower abdominal pain, urgency and feeling of incomplete urination for last 2 years. There was no history of fever, hematuria or pyuria. However, he had a history of hydatid cyst liver for which he had undergone surgery 10 years back. On examination, routine blood tests and chest X‑ray were normal. Ultrasound abdomen showed multi‑loculated cystic lesion measuring 5.2 cm × 4.8 cm arising from the left antero‑lateral wall of UB [Figure 1a and b]. The lesion had typical “cyst within cyst appearance,” also called “spoke in wheel” appearance. Ultrasound (USG) guided fine needle aspiratioon (FNA) was carried out, which showed clear fluid, but microscopy was inconclusive. Based on the typicall USG findings, a provisional diagnosis of hydatid cyst of UB was made. Surgical excision of the cyst was carried out [Figure 2]. Post‑operative period was uneventful. Histopathology confirmed the diagnosis. The pathogenesis of bladder hydatid cyst is explained by hematogenous spread with development of cyst in the wall of UB. The bladder hydatid cyst clinically remains silent for long periods.[4] However, patient may present with acute retention of urine, lower abdomen pain urgency or hydaturia. In our case, patient had lower abdominal pain, urgency, and sense of incomplete urination. USG is effective in the diagnosis of hydatid cysts. USG findings in hydatid cysts are of five types; (1) simple cyst with no internal architecture, (2) cyst with echogenic sand, (3) cyst with floating membranes (detached endocyst) also called as “water Lily sign,” (4) multi‑locular cyst, which gives “cyst within cyst appearance” and (5) calcified cyst. Aspiration of fluid under USG guidance is safe, simple, and effective in reaching out provisional diagnosis.[5] Serological test are helpful in difficult cases. 462
November 2013 / Vol 23 / Issue 6
Figure 2: Excisied hydatid cyst
The treatment of hydatid cyst is primarily surgical. However, both pre‑ and post‑operative medical treatment facilitates the operation and decrease the recurrence. F. A. Ganie, O. H. Dar1, A. Kaleem2, S. Hassan3, M. Gani3 1
Departments of Cardiovascular and Thoracic Surgery, Radiology, and 2General Medicine, SKIMS, Soura, Kashmir, 3 J and K Health Services, Jammu and Kashmir, India Address for correspondence: Mr. F. A. Ganie, Department of Cardiovascular and Thoracic Surgery, SKIMS, Soura ‑ 190 011, Kashmir, India. E‑mail: [email protected]
References 1. Joshi M. Surgical Diseases in the Tropics. Bombay, Calcutta, Madras: Macmillan India Ltd.; 1982. p. 151‑69. 2. Amir‑Jahed AK, Fardin R, Farzad A, Bakshandeh K. Clinical echinococcosis. Ann Surg 1975;182:541‑6. 3. Deodhar SD, Patel VC, Kirloskar MS. Hydatid disease of urinary bladder (a case report). J Postgrad Med 1986;32:46B‑8. 4. Horchani A, Nouira Y, Kbaier I, Attyaoui F, Zribi AS. Hydatid cyst of the kidney. A report of 147 controlled cases. Eur Urol Indian Journal of Nephrology
Letters to Editor
5.
2000;38:461‑7. McCorkell SJ. Unintended percutaneous aspiration of pulmonary echinococcal cysts. AJR Am J Roentgenol 1984;143:123‑6. Access this article online Quick Response Code:
Website: www.indianjnephrol.org DOI: 10.4103/0971-4065.120348
35 30 25 20 15 10 5 0
Misc. Co-arc Tx
norma l Misc. 2 Co-arc 1 Tx 1 Scar 5 single kidney 5 CKD 10 incidental 7
WCH
MH
1 1 0 3 3 2 9
0 0 1 0 0 2 0
PRE HT 0 0 0 0 0 0 7
AMB HT 0 0 0 0 0 0 5
SEVER E 0 0 0 0 1 0 3
Scar single kidney CKD
incidental
Figure 1: Outcomes of the ambulatory blood pressure monitoring. ABPM = ambulatory blood pressure monitoring, CKD = Chronic Kidney Disease, Co – arc = co-arctation, HT = hypertension, MH= masked hypertension, Misc = miscellaneous, Tx = Renal transplant
Prospective analysis of utility and feasibility of ambulatory blood pressure monitoring service in a pediatric nephrology set up Sir, Despite ambulatory blood pressure monitoring (ABPM) becoming standard of care in adult practice[1] as well as its strong recommendation in pediatric hypertension (HT) guidelines[2,3] there are very few reports on its utility and feasibility in children from emerging economy and none from Indian subcontinent.[4] We hereby present a prospective analysis of an ABPM service initiated in February 2012. Pediatric ABPM service was initiated with Welch Allyn 6100 monitor using appropriate blood pressure (BP) cuff sizes. It was offered to all children above 5 years of age with incidental (without any obvious underlying reason for HT) clinic blood pressure (CBP) persistently ≥95th percentile (p) but ≤99th p +5 mm Hg or as a standard of care for children with chronic kidney disease (CKD) (≥stage 3), post renal transplant (RTx), solitary kidney, renal scar, and post‑op for coarctation of the aorta. The American Heart Association (AHA) recommendation[2] was taken as standard and ABPM limits were set accordingly. Height was used for estimating the ABPM limits or age if height was less than 120 cm.[2,3] Interpretation was as per AHA suggestions‑normal: (CBP < 95th p, mean ABPM < 95th p and systolic load (SL) 95th p, mean ABPM < 95th p and SL < 25%), masked hypertension (MH): (CBP < 95th p, mean ABPM > 95th and SL < 25%), pre‑HT: (CBP > 95th p, mean ABPM < 95th p and SL > 25% but < 50%), ambulatory hypertension (AH): (CBP > 95th p, mean ABPM > 95th p and SL > 25%, Indian Journal of Nephrology
but < 50%) and severe AH: (CBP < 95th p, mean ABPM < 95th p and SL > 50%). Until 31st March 2013; 69 children had ABPM (26% female) with the median age of 9.2 years (range 5‑18). As per the AHA recommendation all of them had at least one reading per hour and the total number of readings were greater than 40 (median number of total reading was 52 with range 41‑72). Sleep diary was used to ascertain day and night time. Underlying reason for undertaking ABPM and the outcome are shown in Figure 1. Incidental HT was the most common underlying reason. WCH was found in 27% (n = 19) of the total subjects and MH in 4% (n = 3). On analysis of utility; ABPM resulted in definite change in management in 36% of the cases (n = 25). Whereas WCH was detected in 19 children MH was detected in three cases (all three cases were of CKD including one post RTx). In addition, anti‑hypertensive medications were increased in another three cases of known hypertensive wherein ABPM showed severe ambulatory HT although CBP was only around 95th percentile. In conclusion, similar to western literature[2] we also found a high incidence of WCH (27%) as well as MH (21% among CKD and RTx). Diagnosis of WCH does avoid further costly investigation as well as use of anti‑hypertensive medications,[5] whereas diagnosis of MH can result in more effective control of BP, which is likely to result in improved renal outcome. Although small in numbers, our study supports the use of pediatric ABPM even in Indian circumstances and should encourage its increased utilization. R. Sinha Departments of Paediatric Nephrology, AMRI Group of Hospitals and Paediatric Medicine, Institute of Child Health, Kolkata, West Bengal, India Address for correspondence: Dr. Rajiv Sinha, 37, G Bondel Road, Kolkata ‑ 700 019, West Bengal, India. E‑mail: [email protected] November 2013 / Vol 23 / Issue 6
463
Copyright of Indian Journal of Nephrology 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.
Hydatid cyst of urinary bladder Sir, Hydatid cyst of liver and lungs are common, but hydatid cysts have been seen on rare occasions at unusual sites, spleen, kidney, muscle, brain, spine, breast, thyroid, peritoneal cavity, and retroperitoneum.[1] Hydatid cyst of urinary bladder (UB) is very rare.[2,3]
a
b
Figure 1: (a, b) 48-year-old man with hydatid cyst urinary bladder. USG shows multilocular cystic lesion “with cyst within cyst appearance” (UB: Urinarybladder, H: Hydatid cyst)
A 48‑year‑old-male, known case of carcinoma larynx (post‑laryngectomy) presented with a history of lower abdominal pain, urgency and feeling of incomplete urination for last 2 years. There was no history of fever, hematuria or pyuria. However, he had a history of hydatid cyst liver for which he had undergone surgery 10 years back. On examination, routine blood tests and chest X‑ray were normal. Ultrasound abdomen showed multi‑loculated cystic lesion measuring 5.2 cm × 4.8 cm arising from the left antero‑lateral wall of UB [Figure 1a and b]. The lesion had typical “cyst within cyst appearance,” also called “spoke in wheel” appearance. Ultrasound (USG) guided fine needle aspiratioon (FNA) was carried out, which showed clear fluid, but microscopy was inconclusive. Based on the typicall USG findings, a provisional diagnosis of hydatid cyst of UB was made. Surgical excision of the cyst was carried out [Figure 2]. Post‑operative period was uneventful. Histopathology confirmed the diagnosis. The pathogenesis of bladder hydatid cyst is explained by hematogenous spread with development of cyst in the wall of UB. The bladder hydatid cyst clinically remains silent for long periods.[4] However, patient may present with acute retention of urine, lower abdomen pain urgency or hydaturia. In our case, patient had lower abdominal pain, urgency, and sense of incomplete urination. USG is effective in the diagnosis of hydatid cysts. USG findings in hydatid cysts are of five types; (1) simple cyst with no internal architecture, (2) cyst with echogenic sand, (3) cyst with floating membranes (detached endocyst) also called as “water Lily sign,” (4) multi‑locular cyst, which gives “cyst within cyst appearance” and (5) calcified cyst. Aspiration of fluid under USG guidance is safe, simple, and effective in reaching out provisional diagnosis.[5] Serological test are helpful in difficult cases. 462
November 2013 / Vol 23 / Issue 6
Figure 2: Excisied hydatid cyst
The treatment of hydatid cyst is primarily surgical. However, both pre‑ and post‑operative medical treatment facilitates the operation and decrease the recurrence. F. A. Ganie, O. H. Dar1, A. Kaleem2, S. Hassan3, M. Gani3 1
Departments of Cardiovascular and Thoracic Surgery, Radiology, and 2General Medicine, SKIMS, Soura, Kashmir, 3 J and K Health Services, Jammu and Kashmir, India Address for correspondence: Mr. F. A. Ganie, Department of Cardiovascular and Thoracic Surgery, SKIMS, Soura ‑ 190 011, Kashmir, India. E‑mail: [email protected]
References 1. Joshi M. Surgical Diseases in the Tropics. Bombay, Calcutta, Madras: Macmillan India Ltd.; 1982. p. 151‑69. 2. Amir‑Jahed AK, Fardin R, Farzad A, Bakshandeh K. Clinical echinococcosis. Ann Surg 1975;182:541‑6. 3. Deodhar SD, Patel VC, Kirloskar MS. Hydatid disease of urinary bladder (a case report). J Postgrad Med 1986;32:46B‑8. 4. Horchani A, Nouira Y, Kbaier I, Attyaoui F, Zribi AS. Hydatid cyst of the kidney. A report of 147 controlled cases. Eur Urol Indian Journal of Nephrology
Letters to Editor
5.
2000;38:461‑7. McCorkell SJ. Unintended percutaneous aspiration of pulmonary echinococcal cysts. AJR Am J Roentgenol 1984;143:123‑6. Access this article online Quick Response Code:
Website: www.indianjnephrol.org DOI: 10.4103/0971-4065.120348
35 30 25 20 15 10 5 0
Misc. Co-arc Tx
norma l Misc. 2 Co-arc 1 Tx 1 Scar 5 single kidney 5 CKD 10 incidental 7
WCH
MH
1 1 0 3 3 2 9
0 0 1 0 0 2 0
PRE HT 0 0 0 0 0 0 7
AMB HT 0 0 0 0 0 0 5
SEVER E 0 0 0 0 1 0 3
Scar single kidney CKD
incidental
Figure 1: Outcomes of the ambulatory blood pressure monitoring. ABPM = ambulatory blood pressure monitoring, CKD = Chronic Kidney Disease, Co – arc = co-arctation, HT = hypertension, MH= masked hypertension, Misc = miscellaneous, Tx = Renal transplant
Prospective analysis of utility and feasibility of ambulatory blood pressure monitoring service in a pediatric nephrology set up Sir, Despite ambulatory blood pressure monitoring (ABPM) becoming standard of care in adult practice[1] as well as its strong recommendation in pediatric hypertension (HT) guidelines[2,3] there are very few reports on its utility and feasibility in children from emerging economy and none from Indian subcontinent.[4] We hereby present a prospective analysis of an ABPM service initiated in February 2012. Pediatric ABPM service was initiated with Welch Allyn 6100 monitor using appropriate blood pressure (BP) cuff sizes. It was offered to all children above 5 years of age with incidental (without any obvious underlying reason for HT) clinic blood pressure (CBP) persistently ≥95th percentile (p) but ≤99th p +5 mm Hg or as a standard of care for children with chronic kidney disease (CKD) (≥stage 3), post renal transplant (RTx), solitary kidney, renal scar, and post‑op for coarctation of the aorta. The American Heart Association (AHA) recommendation[2] was taken as standard and ABPM limits were set accordingly. Height was used for estimating the ABPM limits or age if height was less than 120 cm.[2,3] Interpretation was as per AHA suggestions‑normal: (CBP < 95th p, mean ABPM < 95th p and systolic load (SL) 95th p, mean ABPM < 95th p and SL < 25%), masked hypertension (MH): (CBP < 95th p, mean ABPM > 95th and SL < 25%), pre‑HT: (CBP > 95th p, mean ABPM < 95th p and SL > 25% but < 50%), ambulatory hypertension (AH): (CBP > 95th p, mean ABPM > 95th p and SL > 25%, Indian Journal of Nephrology
but < 50%) and severe AH: (CBP < 95th p, mean ABPM < 95th p and SL > 50%). Until 31st March 2013; 69 children had ABPM (26% female) with the median age of 9.2 years (range 5‑18). As per the AHA recommendation all of them had at least one reading per hour and the total number of readings were greater than 40 (median number of total reading was 52 with range 41‑72). Sleep diary was used to ascertain day and night time. Underlying reason for undertaking ABPM and the outcome are shown in Figure 1. Incidental HT was the most common underlying reason. WCH was found in 27% (n = 19) of the total subjects and MH in 4% (n = 3). On analysis of utility; ABPM resulted in definite change in management in 36% of the cases (n = 25). Whereas WCH was detected in 19 children MH was detected in three cases (all three cases were of CKD including one post RTx). In addition, anti‑hypertensive medications were increased in another three cases of known hypertensive wherein ABPM showed severe ambulatory HT although CBP was only around 95th percentile. In conclusion, similar to western literature[2] we also found a high incidence of WCH (27%) as well as MH (21% among CKD and RTx). Diagnosis of WCH does avoid further costly investigation as well as use of anti‑hypertensive medications,[5] whereas diagnosis of MH can result in more effective control of BP, which is likely to result in improved renal outcome. Although small in numbers, our study supports the use of pediatric ABPM even in Indian circumstances and should encourage its increased utilization. R. Sinha Departments of Paediatric Nephrology, AMRI Group of Hospitals and Paediatric Medicine, Institute of Child Health, Kolkata, West Bengal, India Address for correspondence: Dr. Rajiv Sinha, 37, G Bondel Road, Kolkata ‑ 700 019, West Bengal, India. E‑mail: [email protected] November 2013 / Vol 23 / Issue 6
463
Copyright of Indian Journal of Nephrology 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.
