Q J Med 2015; 108:343–344 doi:10.1093/qjmed/hcu203 Advance Access Publication 19 September 2014
Clinical picture Orbital hydatid cyst A 46-year-old man presented with unilateral proptosis of the right eye for 3 months. The patient was a shepherd and had contact with dogs. Visual acuity was 20/800 in the right eye and 20/25 in the left eye. Physical examination revealed an axile, irreducible and painless proptosis, without breath or thrill, associated with lower chemosis (Figure 1A, asterisk), lagophthalmos and exposure keratitis (Figure 1A, arrowheads). The CT scan showed a right intra conial hypodense mass measuring 42 mm 29 mm, well limited, with sharp and spontaneously hyperdense edges (Figure 1B, asterisk). It pushes forward the eyeball, resulting in a grade III proptosis (figure 1B, arrows). Blood count revealed eosinophilia of 440/mm3 (reference range 40–400). Hydatid serology was negative. This presentation was consistent with an orbital hydatid cyst, which is due to Echinococcus granulosis. Results of liver function revealed a high level of transaminases (ALAT 760 UI/l and ASAT 720 UI/l, reference range 10–40). Abdominal ultrasound objectified a thin-walled cystic formation measuring 75 mm in diameter, located at the segment V–VI of the liver, evoking a hydatid cyst stage I. Cerebral CT and chest radiograph showed no secondary location. Surgery has allowed the puncture and aspiration of the cyst liquid with its germinal membrane. Histological
examination confirmed the diagnosis of orbital hydatid cyst. Proptosis and lagophthalmos decreased since the first postoperative day. The patient underwent hepatic hydatid cyst surgery 1 month later. At 3-month follow-up, proptosis has completely disappeared. The orbital location of hydatid disease is extremely rare.1 It is usually unilateral, affecting mainly the left orbit.2 This can be explained by the path of the left carotid artery. Contamination is from the gastrointestinal tract. The embryo hexacanth borrows the portal venous system, liver and lungs where most larvae are stored. Rarely, these larvae can colonize other organs through general systemic circulation. The association with other visceral involvement, as in the case of our patient, is often not reported. The multicystic forms are exceptional, it is most often a single cyst. Orbital involvement is characterized by the presence of exophthalmos, the most frequent reason for consultation, whether or not preceded by periorbital pain. In case of late diagnosis, the evolution is towards a decrease in visual acuity with total ophthalmoplegia, optic atrophy or papillary hyperemia by compression effect. Radiological investigations help to locate the tumor in relation to ocular and orbital structures, to define the fluid nature of the lesion and guide therapeutic
Figure 1. (A) Physical examination showing the proptosis of the right eye resulting in a lower chemosis (asterisk), lagophthalmos and exposure keratitis (arrowheads). (B) CT scan showing the orbital hydatid cyst (asterisk), which is well limited, with sharp and spontaneously hyperdense edges, resulting in a grade III proptosis (arrows).
! The Author 2014. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For Permissions, please email: [email protected]
344
Clinical picture
intervention. Treatment of orbital hydatidosis is exclusively surgical. It must be as early as possible to avoid any functional damage. The incision must consider the location and size of the cyst. Recurrences are exceptional even in case of release of the cyst content because of the absence of a peritoneum in the orbit. The diagnosis of orbital hydatid cyst should not be misunderstood in case of unilateral exophthalmos. Although rare, this location remains available to surgery. Prevention is based on the careful hand washing after contact with dogs, and extensive washing of fruits and vegetables before consumption. Conflict of interest: None declared.
Photographs and text from: S. Berradi, Z. Hafidi, O. Lezrek, M. Lezrek and R. Daoudi, Mohammed V Souissi University, Teaching Hospital of Rabat, Department A of Ophthalmology, Quartier Souissi 10100, Rabat, Morocco. email: [email protected]
References 1. Benazzou S, Arkha Y, Derraz S, El Ouahabi A, El Khamlichi A. Orbital hydatid cyst: review of 10 cases. J Craniomaxillofac Surg 2010; 38:274–8. 2. Limaiem F, Bellil S, Bellil K, et al. Primary orbital hydatid cyst in an elderly patient. Surg Infect (Larchmt) 2010; 11:393–5.
Clinical picture Orbital hydatid cyst A 46-year-old man presented with unilateral proptosis of the right eye for 3 months. The patient was a shepherd and had contact with dogs. Visual acuity was 20/800 in the right eye and 20/25 in the left eye. Physical examination revealed an axile, irreducible and painless proptosis, without breath or thrill, associated with lower chemosis (Figure 1A, asterisk), lagophthalmos and exposure keratitis (Figure 1A, arrowheads). The CT scan showed a right intra conial hypodense mass measuring 42 mm 29 mm, well limited, with sharp and spontaneously hyperdense edges (Figure 1B, asterisk). It pushes forward the eyeball, resulting in a grade III proptosis (figure 1B, arrows). Blood count revealed eosinophilia of 440/mm3 (reference range 40–400). Hydatid serology was negative. This presentation was consistent with an orbital hydatid cyst, which is due to Echinococcus granulosis. Results of liver function revealed a high level of transaminases (ALAT 760 UI/l and ASAT 720 UI/l, reference range 10–40). Abdominal ultrasound objectified a thin-walled cystic formation measuring 75 mm in diameter, located at the segment V–VI of the liver, evoking a hydatid cyst stage I. Cerebral CT and chest radiograph showed no secondary location. Surgery has allowed the puncture and aspiration of the cyst liquid with its germinal membrane. Histological
examination confirmed the diagnosis of orbital hydatid cyst. Proptosis and lagophthalmos decreased since the first postoperative day. The patient underwent hepatic hydatid cyst surgery 1 month later. At 3-month follow-up, proptosis has completely disappeared. The orbital location of hydatid disease is extremely rare.1 It is usually unilateral, affecting mainly the left orbit.2 This can be explained by the path of the left carotid artery. Contamination is from the gastrointestinal tract. The embryo hexacanth borrows the portal venous system, liver and lungs where most larvae are stored. Rarely, these larvae can colonize other organs through general systemic circulation. The association with other visceral involvement, as in the case of our patient, is often not reported. The multicystic forms are exceptional, it is most often a single cyst. Orbital involvement is characterized by the presence of exophthalmos, the most frequent reason for consultation, whether or not preceded by periorbital pain. In case of late diagnosis, the evolution is towards a decrease in visual acuity with total ophthalmoplegia, optic atrophy or papillary hyperemia by compression effect. Radiological investigations help to locate the tumor in relation to ocular and orbital structures, to define the fluid nature of the lesion and guide therapeutic
Figure 1. (A) Physical examination showing the proptosis of the right eye resulting in a lower chemosis (asterisk), lagophthalmos and exposure keratitis (arrowheads). (B) CT scan showing the orbital hydatid cyst (asterisk), which is well limited, with sharp and spontaneously hyperdense edges, resulting in a grade III proptosis (arrows).
! The Author 2014. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For Permissions, please email: [email protected]
344
Clinical picture
intervention. Treatment of orbital hydatidosis is exclusively surgical. It must be as early as possible to avoid any functional damage. The incision must consider the location and size of the cyst. Recurrences are exceptional even in case of release of the cyst content because of the absence of a peritoneum in the orbit. The diagnosis of orbital hydatid cyst should not be misunderstood in case of unilateral exophthalmos. Although rare, this location remains available to surgery. Prevention is based on the careful hand washing after contact with dogs, and extensive washing of fruits and vegetables before consumption. Conflict of interest: None declared.
Photographs and text from: S. Berradi, Z. Hafidi, O. Lezrek, M. Lezrek and R. Daoudi, Mohammed V Souissi University, Teaching Hospital of Rabat, Department A of Ophthalmology, Quartier Souissi 10100, Rabat, Morocco. email: [email protected]
References 1. Benazzou S, Arkha Y, Derraz S, El Ouahabi A, El Khamlichi A. Orbital hydatid cyst: review of 10 cases. J Craniomaxillofac Surg 2010; 38:274–8. 2. Limaiem F, Bellil S, Bellil K, et al. Primary orbital hydatid cyst in an elderly patient. Surg Infect (Larchmt) 2010; 11:393–5.
![[Inflammatory exophthalmos revealing an orbital hydatid cyst].](/assets/img/hold.png)
