Three cases of infected liver hydatid cysts are presented with varying clinical presentations: 1) A ruptured infected cyst presenting with abdominal pain and localized mass, later developing peritonitis. 2) A cyst ruptured into the peritoneum, presenting as an iliac fossa abscess. 3) An electively operated cyst found to be infected, with 2 liters of pus drained. All three cases were treated with prolonged external drainage of the cyst cavity, with or without removal of daughter cysts, and medical treatment with albendazole. The report discusses variations in clinical presentation of infected hydatid cysts and emphasizes surgical drainage and medical management as adequate treatment.

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ABSTRACT
We report three cases of infected and complicated liver hydatid cyst with various presentations; two
of which are ruptured infected hydatid cysts and another one case of unruptured infected hydatid cyst
with biliary communication. All these cases were managed by prolonged external drainage with or
without removal of daughter cyst and Albendazole. It was observed that the allergic and anaphylactic
manifestations were not very much pronounced in the case of infected hydatid cyst.
Key words: Echinococcus granulosus, Infected Hydatid cyst, external drainage.
Infected Hydatid Cyst: Various Presentations
Joshi A*, Shrestha K**, Shah LL***
*Lecturer, PAHS, **Assistant Professor, NAMS, *** Professor, NAMS
Correspondence :
Dr. Arbin Joshi, Patan Hospital
joshi_arbin@yahoo.com
INTRODUCTION
Patients of Hydatid cyst come to physician’s attention
with various presentations. Though complicated
Hydatid cyst is a rarity in the western world, it is not
uncommon in our part of the world. Here, we report
three cases of infected Hydatid cysts presented in
General Surgery Unit I of Bir Hospital in the month of
Jestha 2065.
Hydatid cyst is the larval cystic stage of Echinococcus
granulosus that affect man, its accidental intermediate
host.1,2
Epidemiological cycle of Echinococcus
granulosus parasite is dog-pig-dog cycle; however,
dog-sheep-dog, dog-goat-dog and dog-buffalo-dog
cycle have also been reported in Nepal. 2
Complicated
disease is defined as: infected cysts, cysts with a
hyperechoic solid pattern or calcified walls, or cysts
with biliary rupture.3
The incidence of infected Hydatid
cyst in the literatures is around 11%. 4
A study spanning
11 years and including 970 cases of hydatid cyst
reported incidence of acute intraperitoneal rupture of
the hydatid cyst to be just 1.75%. 5
Here, in this paper,
we present to you two cases of acute intraperitoneal
rupture of infected Hydatid cyst, which was treated
in the emergency basis and a case of infected Hydatid
cyst diagnosed at the time of elective surgery.
AIM OF THE PAPER
• To depict the varied clinical presentation of the
infected hydatid cyst.
• To discuss the mode of management of the
infected hydatid cyst.
CASE # 1:
A 78 years old man, smoker from Sarlahi, was
presented to us with the complaints of pain and
localized fluctuating mass in the upper abdomen for
the duration of 2 weeks who developed generalized
abdominal pain with distention of abdomen on the
next day of admission during USG examination, which
revealed free fluid in the abdomen and a cystic mass
in the right lobe of liver measuring 19 X 19 cm. The
patient also developed shortness of breath with
audible wheeze which responded well to Salbutamol
nebulization. Immediate laparotomy revealed about
2 litres of pus in the abdomen with a bulge in the
anterior surface of right lobe of liver with a small hole
measuring 0.5 cm with pus oozing out of it. The cyst
cavity revealed another 1 litre of pus and daughter
cysts floating on it. The peritoneal cavity was washed
with Normal Saline and the cyst cavity was unroofed,
washed with 10% Pividone Iodine and external drain
was kept. The drain was accidentally removed on
post op day 12. Apart from post operative atelectasis,
patient had smooth recovery and was discharged from
the hospital on post op day 18 with Albendazole for 3
months.
Case Report

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CASE # 2
A 24 years old girl from Rupandehi was operated
in the local hospital for pelvic abscess (? Secondary
to appendicular perforation) and 800 ml of pus
was drained and was referred to our centre for
development of right sided pleural effusion in the post
operative period. Patient was toxic with high grade
fever and high respiratory rate. She was dehydrated
and there was frank pus coming out from the drain.
Ultrasound Examination on the next day of admission
revealed a complex mass measuring 8 X 8 cm on right
lobe of liver suggestive of Hydatid cyst of liver and free
fluid in the abdomen with bilateral pleural effusion.
However, her ELIZA test for Ecinococcus was negative.
On aspiration, pus came out of pleural space which
was managed with wide bore chest tube drainage. No
further intervention was carried out in the abdomen
and the drain was removed after 12 days once it was
dry. Chest tube was also removed 6 days after insertion
and patient was discharged on 18th
post admission day
on Albendazole for 3 months. She was readmitted
after one month with fever and upper abdominal pain
and was diagnosed as sub-phrenic abscess which was
drained with USG guided aspiration.
CASE # 3
A 50 years old lady from Ramechhap, ultrasonologically
and serologically diagnosed Gharbi type 1 Hydatid cyst
of liver was being treated medically with Albendazole
for 2 months without any benefit was planned
for surgery in elective basis. During operation, on
aspiration of the cyst, about 2 Litre of purulent pus was
obtained.
Table 1: Clinical presentation of the infected hydatid
liver cyst
1st case
2nd case
3rd case
Painful localized hepatic mass progressing
to generalized peritonitis with allergic
chest symptoms
Right iliac fossa abscess, was diagnosed
as ruptured infected hydatid cyst after
drainage of the abscess
Painful liver mass operated electively and
was diagnosed as infected hydatid cyst
per-operatively.
10% Pividone Iodine was injected in the cyst cavity
and after instilling it for 10 minutes it was re-aspirated
and the cyst was emptied of its daughter cyst. External
drainage was kept in the cyst space without unroofing
it. Drain in the cavity showed bilious content. ERCP and
sphichterectomy was carried out on 14th
post-operative
day and she was discharged on 18th
post-operative day
with the drain tube. The drain was removed on 30th
post-operative day when it became dry.
DISCUSSIONS
First and foremost, presentation of the Hydatid
cyst from three different regions of Nepal shows its
prevalence across Nepal. In a study done in Kathmandu
Valley with slaughtered buffaloes and stray dogs
around the slaughter houses, occurrence of hydatid
cyst was found in 6.7 & 12.5% of slaughtered buffaloes
in slaughter houses and individual butcher’s places
respectively and 12.5% of stray dogs’ faeces sample
revealed hydatid eggs. 6
Prevalence of Echinococcus
granulosus infection was found to be 5.7% in domestic
dogs in the Valley by another study. 7
This shows high
prevalence of hydatidosis in the Kathmandu Valley. In a
hospital where Hydatid cyst is not one of the commonly
encountered problem, three cases of complicated
infected Hydatid cyst in a period of one month directs
us to keep this pathology as a differential diagnosis in
all cases of acute abdomen.
Rupture into the abdominal cavity is a rare but
serious complication of hydatid disease. The cysts
may rupture after a trauma, or spontaneously as a
result of increased intracystic pressure. Rupture of the
hydatid cyst requires emergency surgical intervention.
But there has been paucity of data regarding specific
surgical management of ruptured hydatid cyst.
However, a retrospective study of 16 cases of traumatic
intraperitoneal and intrabiliary rupture of Hydatid cyst
showed lack of single accepted method of surgical
management of such patients. 8
Usually, cysts do not
induce clinical symptoms before they have reached a
size sufficient to exert pressure on adjacent organs and
cyst which have already ruptured always attain such
a huge size before they get ruptured that procedures
like Capitonization, Omental patch, Pericystectomy or
Liver resection are practically impossible in such cases.
Since adequate information regarding management
of complicated infected Hydatid cyst is lacking, our
experience shows immediate surgical intervention
with peritoneal lavage, removal of daughter cysts,
drainage of the cyst cavity and peritoneal cavity are
adequate for these cases. Literatures are also not
in favor of the medical management once the cyst
becomes complicated.9
Hence, as procedures like
pericystectomy, capitonization and omentoplasty are
Infected Hydatid Cyst: Various Presentations

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not feasible, removal of daughter cyst and simple tube
drainage of the infected cyst should be considered as
a curative surgery not a palliative surgery as suggested
by literatures. 1
Duration of the drainage is not well
established in literatures. As we can see in the above
mentioned cases, drain needs to be kept for at least 2
weeks until it becomes dry. Lavage and prolonged tube
drainage of hepatic cavity is recommended by other
authors for free rupture in the peritoneal cavity.10
Though spontaneous rupture of the hepatic hydatid
cystintotheperitoneumwithoutanyserioussymptoms
is unusual, there have been several reports 11
reporting
rupture of hydatid cyst in to the peritoneum causing
only mild abdominal pain. In contrary, both of the
ruptured hydatid cyst in our series had features of
peritonitis. Infection in the cyst could be the cause for
that. It has been noted that asymptomatic perforation
can result in the development of echinococcic
pseudotuberculosis of the peritoneum characterized
by a progressive ascites, cachexia and anemia.12
Another noteworthy fact regarding ruptured infected
hydatid cyst was the incidence of anaphylaxis as a
result of intraperitoneal spillage are not as common as
once believed. Case # 1 showed some bronchospasm,
otherwise there were no other signs of allergic
reactions in both cases of ruptured infected hydatid
cyst. Similar observation was made by other authors.7
However, lethal anaphylactic shock was reported in
0.047% of patients during percutaneous aspiration of
the Hydatid cyst.1
Similarly, morbidity and mortality
in the post operative period after open surgical
intervention was noted to be as high as 35% and 24%
respectively and the intraperitoneal recurrence about
8%. 8
Recurrence was observed in a patient whose
abdomen had not been washed during surgery.13
Lastly, we hope that the findings of this paper will be
helpful to those esp surgical residents and surgeons
who do not have considerable experience in liver
surgeries while managing the cases of complicated
hydatid cysts in emergency basis.
CONCLUSION
• Clinical presentations of infected hydatid cyst are
varied.
• Management plan varies according to clinical
manifestation.
• Allergic manifestations are not present in all cases
and are less severe.
• Removal of daughter cyst and external drainage of
cyst along with medical management may be the
adequate treatment.
ACKNOWLEDGEMENTS
We acknowledge the contributions from Dr. Samar
P Magar, Dr. Manish Roy during the management of
these cases.
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Infected Hydatid Cyst: Various Presentations