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Echinococcus cyst of muscle
ECHINOCOCCUS CYST OF MUSCLE REPORT
OF A CASE OCCURRING
ANDREW MCNALLY, M.D. Associate Urologist, St. Lukes HospitaI
IN THE LEFT PSOAS MUSCLE
AND
JAMES B.
CASE,
M.D.
ClinicaI Assistant in UroIogy, St. Lukes Hospital
CHICAGO, ILLINOIS
U
and rare diseases, especiaIIy when they are met as a compIete surprise, instiI1 a new interest in the daiIy routine of the cIinician. Echinococcus infestation is rare in the United States and particularly so when the cyst has formed in muscIe tissue. A patient recentIy seen by us in the out-patient department of St. Lukes HospitaI, presented an interesting probIem in differential diagnosis as we11 as this unusua1 Iocation of an echinococcus cyst. NUSUAL
CASE REPORT
J. C., an ItaIian white male of 47 years, was first seen in the out-patient department on ApriI I I, 1937. He compIained of pains all over the body, weakness, headaches, dizziness and a cough which had lasted al1 winter and was productive of puruIent material. He had no chest pain and no night sweats. His weakness was so severe that he was unabIe to work. Even Iight work caused marked perspiration. Loss of weight was 18 pounds in eighteen months. The physica examination was essentiaIIy negative except for an occasiona raIe in the Ieft hiIus. There was aIso some tenderness of the Iarge muscIes of the back. The bIood pressure was 130/80. X-ray of the chest showed cIear costophrenic angIes; the diaphragm on the right was somewhat noduIar. There was no evidence of free fluid in either pIeura1 sac. The termina1 bronchioles in the right Iobe, Iower portion, were dilated. The root shadows were moderateIy increased on both sides. There was evidence of oId pathoIogy aIong the first and second interspaces on both sides. The clinica diagnosis was bronchiectasis and myositis. The patient did not return unti1 August 8, I 939, when he complained of low back pain and a mass in the Ieft side which had been present for two years and was graduaIIy increasing in 419
size. He was then referred to the uroIogic department. A Iarge mass couId be readiIy seen on the Ieft side, apparentIy extending from the kidney region. It was not movabIe on respiration, was smooth, not tender, and a sweIIing visible in the Ieft abdomen seemed to be a smaIIer projection from the main mass in the flank. Retrograde pyeIograms showed the Ieft kidney Iarger than normal, with an opaque shadow opposite the transverse process of the second Iumbar vertebra on the Ieft side, apparentIy media1 to the shadow of the left kidney. IrreguIar caIcification Ied to the belief that it was due to a caIcified Iymph gIand. The peIvis and upper portion of the Ieft ureter were dispIaced IateraIIy and upward, and onIy a smaI1 amount of dye had entered the Iower caIyces. These were apparentIy cut off and it appeared possibIe that the mass was pushing the kidney upward. A diagnosis of tumor or large cyst invoIving the Iower pole of the Ieft kidney was made. On cIose scrutiny of the fiIms the faint outIine of a mass couId just be discerned. (Fig. 2.) A barium enema showed the mass definitely posterior to the descending coIon. The coIon was freeIy movable and couId be separated from the mass. The patient entered the hospita1 September 7. UrinaIysis was negative. The bIood showed 13 Gm. hemoglobin per IOO c.c.; red bIood ceIIs 5,300,ooo; Ieucocytes 5000; coaguI&tion time 2.5; bIeeding time 1.3. DifferentiaI count 24; monocyte I; polywas : Iymphocytes morphonucIear neutrophiIes 72; eosinophiIes 3. The diagnosis was not cIearIy estabIished, but a retroperitonea1 tumor or a soIitary cyst of the kidney was considered most likely. ExpIoration of the Ieft renaI area was performed after the usua1 obIique muscIe-cutting Ioin incision. The mass was found to originate from and seemed firmly attached to the Ieft psoas muscIe. The norma Ieft kidney couId be seen above. We thought we were deaIing with
420
American Jocund of Surgery
McNalIy,
Case-Echinococcus
a Iarge retroperitonear tumor which we considered inoperable. However, an incision to remove a portion for microscopic diagnosis
Cyst
FEBRUARY. ,941
tinued chest compIaints with unchanged physical and x-ray findings. The roentgenogram also reveaIs a Iarge smooth Iiver shadow and the
FIG. I. Left pyelogram showing relation of mass, which has been retouched, to the Ieft kidney.
caused numerous daughter cysts to be extruded from the mass, and the opening was therefore enIarged so that the cyst contents couId be evacuated. Then the entire cyst waI1 was mobiIized and removed in toto. The pathoIogic report reveaIed echinococcus cyst of the Ieft psoas muscIe. (Fig. F.) The wound was cIosed, Ieaving ampIe space for drainage. The postoperative course was miId and the patient Ieft the hospita1 September 24, feeIing better than he had for a Iong time. He was seen in the out patient department and an intraderma1 test (Casoni) was performed. BIood was withdrawn for a compIement fixation test, but both of these proved negative. Further questioning elicited the fact that the patient was born and Iived for the first thirteen years of his life in a Iarge town in ItaIy. He was then brought to America and the rest of his Iife has been spent in New York City and Chicago. He had never spent any time on a farm and his family never kept dogs as far as he couId remember. Further observation is being carried on in the out-patient department because of con-
possibility of invoIvement Iungs must be considered.
of the
liver
and
Etiology. Echinococcosis in human bewith the ings is caused by infestation Ecbinococcus granulosusl or dog tape worm in its Iarval form. Human beings are onIy accidentally an intermediate host and constitute a bIind pocket as far as further dissemination is concerned. The dog, woIf, and jacka are the idea1 definitive hosts and they infect the food and water suppIy of the intermediate hosts by feca1 contamination. The ovum passed by the dog, when swallowed by the intermediate host, passes into the duodenum where its chitinous she11 is digested. The embryo attaches itseIf to the mucosa by its hooklets and penetrates it. The embryo is then carried passiveIy until it lodges in one of the capiIIary fiIters or passes through them to the organ in which it Iocates. The first filter is the Iiver; the second the Iung.
NEW
SERIES VOL.. LI, No.
2
McNaIIy,
Case-Echinococcus
The embryo may be destroyed or it may deveIop into an echinococcus cyst. The cyst has a definite Iaminated outer Iayer or ectocyst, an inner germina1 Iayer which deveIops the brood capsuIes, the endocyst and a capsuIe or pericyst which is derived from the tissues of the host. The scoIices, which are the heads of future worms, deveIop inside the brood capsules. Portions of the germina1 layer may become separated, forming daughter cysts. When a cyst containing viable scoIices is ingested by the dog, woIf, or jackal, the scoIices become attached to the waI1 of the intestine and deveIop into compIete worms. Occurrence. Hydatid disease is of rare occurrence in North America. Riley2 states that up to 1933 approximately 430 cases were seen in the United States and Canada. PracticalIy a11 of these were in individuaIs of foreign birth. In rg2r Magath3 reported twenty-five cases seen at the Mayo Clinic, four occurring in patients American born. The IocaIization of the cysts is accounted for in the Iife history of the embryo in the intermediate host, the sites of most frequent occurrence being the liver and then the Iung, because of the IiItering effect of these organs. Devk,4 in reporting 2,727 cysts, gave the percentage occurrence as foIIows : Iiver 76.6; Iung 9.4; muscIe and ceIIuIar tissue 3.2; kidney 2.3; spIeen 2. I ; and bone 0.9. In Magath’s report of twenty-five cases seen at the Mayo CIinic and eighty-seven cases cohected from the Iiterature after rgo2, one cyst of muscIe was found in the anterior abdomina1 waI1 with cysts in the Iiver as weI1, and two were retroperitonea1. Kneebone, in a survey of sixty cases in AustraIia, found three IocaIized in muscle, one of them in the Ieft psoas muscle. Diagnosis. To diagnose the presence of echinococcus cyst cIinicaIIy before surgica1 exposure, the possibiIity of its occurrence must, of course, be thought of. Specific tests for the presence of echinococcus cyst are not infaIIibIe. The precipitin test using the patient’s serum and prepared hydatid ffuid is positive in 65 per cent of cases. 6 The
Cyst
A mericanJournalof Surgery
421
compIement fixation test using a procedure simiIar to the Wassermann technique is positive in 52.4 per cent. The cutaneous
FIG.
2.
Photomicrograph of scolices rosteIIum of hooklets.
showing
test,
simiIar to the Mantoux, injecting 0.2 of hydatid fluid intracutaneousIy, is positive in 56 per cent of the cases. Some reliance can be pIaced on an eosinophilia if other causes can be ruIed out. It may be possibIe to demonstrate the cyst roentgenoIogicaIIy. The pericyst derived from the host tissue may cast a shadow, depending upon the organ involved. The ectocyst with its contained ffuid may cast a shadow like any cavity containing Auid. The endocyst does not cast a shadow. If the cyst dies, calcium is deposited in its waI1 and a definite shadow may then be shown. The combination of the various Iaboratory tests and x-ray wiIl aIIow a positive diagnosis of echinococcus cyst to be made in approximately go per cent of cases. C.C.
SUMMARI
Infestation with the echinococcus granuIosa is uncommon in this country and the Iocalization of a cyst in muscIe rareIy
422
American hrd
0f surgery
McNaIIy,
Case-Echinococcus
occurs. This case is presented because of its cIinica1 interest, and because of this unusua1 IocaIization of the echinococcus cyst. In this instance the diagnosis was not made preoperativeIy, nor couId it have been made even if considered, as the specific tests were found to be negative immediateIy after operation. The entire cyst waI1 was removed at operation, and the patient’s condition since then has been one of gradua1 improvement. Because of the chest findings and the enIargement of the Iiver, the patient is being kept under observation, but there has been no recurrence of the
condition organ.
FEBRUARY.1941
Cyst either
IocaIIy
or in any
other
REFERENCES
I.
FAUST, E. C. Human HeIminthoIogy. PhiIadeIphia, 1929. Lea Bi Febiger. 2. RILEY, W. A. Reservoirs of echinococcus in Minnesota. Minnesota Med., 16: 744. 1925. disease. M. Clin. 3. MAGATH, T. B. Echinococcus North America, 5: 549, 1921. 4 DEVI?, F. Echinococcus primitive experimentaIe; kystes hydatidiques de Ia pIkvre. Compt. rend. Sot. de biol., 64: 587, 1908. $. KNEEBONE, J. LEM. Hydatid disease. M. J. Australia, I: 201, 1937. GODFREY, M. F. Hydatid disease, clinical, Iaboratory 6* and roentgenographic observations. Arch. Int. Med., 60: 783, 1937.
OUR view (regarding injuries of the liver) is that of FairchiId (1931) who cIas.sified injuries of the abdomina1 viscera as conditions which demand immediate exploration, on the basis of our inabiIity to say that certain Iesions do not exist rather than on our abiIity to say that they are present. From-“The RBIe of the Liver in Surgery” by Boyce (CharIes C. Thomas).
OF A CASE OCCURRING
ANDREW MCNALLY, M.D. Associate Urologist, St. Lukes HospitaI
IN THE LEFT PSOAS MUSCLE
AND
JAMES B.
CASE,
M.D.
ClinicaI Assistant in UroIogy, St. Lukes Hospital
CHICAGO, ILLINOIS
U
and rare diseases, especiaIIy when they are met as a compIete surprise, instiI1 a new interest in the daiIy routine of the cIinician. Echinococcus infestation is rare in the United States and particularly so when the cyst has formed in muscIe tissue. A patient recentIy seen by us in the out-patient department of St. Lukes HospitaI, presented an interesting probIem in differential diagnosis as we11 as this unusua1 Iocation of an echinococcus cyst. NUSUAL
CASE REPORT
J. C., an ItaIian white male of 47 years, was first seen in the out-patient department on ApriI I I, 1937. He compIained of pains all over the body, weakness, headaches, dizziness and a cough which had lasted al1 winter and was productive of puruIent material. He had no chest pain and no night sweats. His weakness was so severe that he was unabIe to work. Even Iight work caused marked perspiration. Loss of weight was 18 pounds in eighteen months. The physica examination was essentiaIIy negative except for an occasiona raIe in the Ieft hiIus. There was aIso some tenderness of the Iarge muscIes of the back. The bIood pressure was 130/80. X-ray of the chest showed cIear costophrenic angIes; the diaphragm on the right was somewhat noduIar. There was no evidence of free fluid in either pIeura1 sac. The termina1 bronchioles in the right Iobe, Iower portion, were dilated. The root shadows were moderateIy increased on both sides. There was evidence of oId pathoIogy aIong the first and second interspaces on both sides. The clinica diagnosis was bronchiectasis and myositis. The patient did not return unti1 August 8, I 939, when he complained of low back pain and a mass in the Ieft side which had been present for two years and was graduaIIy increasing in 419
size. He was then referred to the uroIogic department. A Iarge mass couId be readiIy seen on the Ieft side, apparentIy extending from the kidney region. It was not movabIe on respiration, was smooth, not tender, and a sweIIing visible in the Ieft abdomen seemed to be a smaIIer projection from the main mass in the flank. Retrograde pyeIograms showed the Ieft kidney Iarger than normal, with an opaque shadow opposite the transverse process of the second Iumbar vertebra on the Ieft side, apparentIy media1 to the shadow of the left kidney. IrreguIar caIcification Ied to the belief that it was due to a caIcified Iymph gIand. The peIvis and upper portion of the Ieft ureter were dispIaced IateraIIy and upward, and onIy a smaI1 amount of dye had entered the Iower caIyces. These were apparentIy cut off and it appeared possibIe that the mass was pushing the kidney upward. A diagnosis of tumor or large cyst invoIving the Iower pole of the Ieft kidney was made. On cIose scrutiny of the fiIms the faint outIine of a mass couId just be discerned. (Fig. 2.) A barium enema showed the mass definitely posterior to the descending coIon. The coIon was freeIy movable and couId be separated from the mass. The patient entered the hospita1 September 7. UrinaIysis was negative. The bIood showed 13 Gm. hemoglobin per IOO c.c.; red bIood ceIIs 5,300,ooo; Ieucocytes 5000; coaguI&tion time 2.5; bIeeding time 1.3. DifferentiaI count 24; monocyte I; polywas : Iymphocytes morphonucIear neutrophiIes 72; eosinophiIes 3. The diagnosis was not cIearIy estabIished, but a retroperitonea1 tumor or a soIitary cyst of the kidney was considered most likely. ExpIoration of the Ieft renaI area was performed after the usua1 obIique muscIe-cutting Ioin incision. The mass was found to originate from and seemed firmly attached to the Ieft psoas muscIe. The norma Ieft kidney couId be seen above. We thought we were deaIing with
420
American Jocund of Surgery
McNalIy,
Case-Echinococcus
a Iarge retroperitonear tumor which we considered inoperable. However, an incision to remove a portion for microscopic diagnosis
Cyst
FEBRUARY. ,941
tinued chest compIaints with unchanged physical and x-ray findings. The roentgenogram also reveaIs a Iarge smooth Iiver shadow and the
FIG. I. Left pyelogram showing relation of mass, which has been retouched, to the Ieft kidney.
caused numerous daughter cysts to be extruded from the mass, and the opening was therefore enIarged so that the cyst contents couId be evacuated. Then the entire cyst waI1 was mobiIized and removed in toto. The pathoIogic report reveaIed echinococcus cyst of the Ieft psoas muscIe. (Fig. F.) The wound was cIosed, Ieaving ampIe space for drainage. The postoperative course was miId and the patient Ieft the hospita1 September 24, feeIing better than he had for a Iong time. He was seen in the out patient department and an intraderma1 test (Casoni) was performed. BIood was withdrawn for a compIement fixation test, but both of these proved negative. Further questioning elicited the fact that the patient was born and Iived for the first thirteen years of his life in a Iarge town in ItaIy. He was then brought to America and the rest of his Iife has been spent in New York City and Chicago. He had never spent any time on a farm and his family never kept dogs as far as he couId remember. Further observation is being carried on in the out-patient department because of con-
possibility of invoIvement Iungs must be considered.
of the
liver
and
Etiology. Echinococcosis in human bewith the ings is caused by infestation Ecbinococcus granulosusl or dog tape worm in its Iarval form. Human beings are onIy accidentally an intermediate host and constitute a bIind pocket as far as further dissemination is concerned. The dog, woIf, and jacka are the idea1 definitive hosts and they infect the food and water suppIy of the intermediate hosts by feca1 contamination. The ovum passed by the dog, when swallowed by the intermediate host, passes into the duodenum where its chitinous she11 is digested. The embryo attaches itseIf to the mucosa by its hooklets and penetrates it. The embryo is then carried passiveIy until it lodges in one of the capiIIary fiIters or passes through them to the organ in which it Iocates. The first filter is the Iiver; the second the Iung.
NEW
SERIES VOL.. LI, No.
2
McNaIIy,
Case-Echinococcus
The embryo may be destroyed or it may deveIop into an echinococcus cyst. The cyst has a definite Iaminated outer Iayer or ectocyst, an inner germina1 Iayer which deveIops the brood capsuIes, the endocyst and a capsuIe or pericyst which is derived from the tissues of the host. The scoIices, which are the heads of future worms, deveIop inside the brood capsules. Portions of the germina1 layer may become separated, forming daughter cysts. When a cyst containing viable scoIices is ingested by the dog, woIf, or jackal, the scoIices become attached to the waI1 of the intestine and deveIop into compIete worms. Occurrence. Hydatid disease is of rare occurrence in North America. Riley2 states that up to 1933 approximately 430 cases were seen in the United States and Canada. PracticalIy a11 of these were in individuaIs of foreign birth. In rg2r Magath3 reported twenty-five cases seen at the Mayo Clinic, four occurring in patients American born. The IocaIization of the cysts is accounted for in the Iife history of the embryo in the intermediate host, the sites of most frequent occurrence being the liver and then the Iung, because of the IiItering effect of these organs. Devk,4 in reporting 2,727 cysts, gave the percentage occurrence as foIIows : Iiver 76.6; Iung 9.4; muscIe and ceIIuIar tissue 3.2; kidney 2.3; spIeen 2. I ; and bone 0.9. In Magath’s report of twenty-five cases seen at the Mayo CIinic and eighty-seven cases cohected from the Iiterature after rgo2, one cyst of muscIe was found in the anterior abdomina1 waI1 with cysts in the Iiver as weI1, and two were retroperitonea1. Kneebone, in a survey of sixty cases in AustraIia, found three IocaIized in muscle, one of them in the Ieft psoas muscle. Diagnosis. To diagnose the presence of echinococcus cyst cIinicaIIy before surgica1 exposure, the possibiIity of its occurrence must, of course, be thought of. Specific tests for the presence of echinococcus cyst are not infaIIibIe. The precipitin test using the patient’s serum and prepared hydatid ffuid is positive in 65 per cent of cases. 6 The
Cyst
A mericanJournalof Surgery
421
compIement fixation test using a procedure simiIar to the Wassermann technique is positive in 52.4 per cent. The cutaneous
FIG.
2.
Photomicrograph of scolices rosteIIum of hooklets.
showing
test,
simiIar to the Mantoux, injecting 0.2 of hydatid fluid intracutaneousIy, is positive in 56 per cent of the cases. Some reliance can be pIaced on an eosinophilia if other causes can be ruIed out. It may be possibIe to demonstrate the cyst roentgenoIogicaIIy. The pericyst derived from the host tissue may cast a shadow, depending upon the organ involved. The ectocyst with its contained ffuid may cast a shadow like any cavity containing Auid. The endocyst does not cast a shadow. If the cyst dies, calcium is deposited in its waI1 and a definite shadow may then be shown. The combination of the various Iaboratory tests and x-ray wiIl aIIow a positive diagnosis of echinococcus cyst to be made in approximately go per cent of cases. C.C.
SUMMARI
Infestation with the echinococcus granuIosa is uncommon in this country and the Iocalization of a cyst in muscIe rareIy
422
American hrd
0f surgery
McNaIIy,
Case-Echinococcus
occurs. This case is presented because of its cIinica1 interest, and because of this unusua1 IocaIization of the echinococcus cyst. In this instance the diagnosis was not made preoperativeIy, nor couId it have been made even if considered, as the specific tests were found to be negative immediateIy after operation. The entire cyst waI1 was removed at operation, and the patient’s condition since then has been one of gradua1 improvement. Because of the chest findings and the enIargement of the Iiver, the patient is being kept under observation, but there has been no recurrence of the
condition organ.
FEBRUARY.1941
Cyst either
IocaIIy
or in any
other
REFERENCES
I.
FAUST, E. C. Human HeIminthoIogy. PhiIadeIphia, 1929. Lea Bi Febiger. 2. RILEY, W. A. Reservoirs of echinococcus in Minnesota. Minnesota Med., 16: 744. 1925. disease. M. Clin. 3. MAGATH, T. B. Echinococcus North America, 5: 549, 1921. 4 DEVI?, F. Echinococcus primitive experimentaIe; kystes hydatidiques de Ia pIkvre. Compt. rend. Sot. de biol., 64: 587, 1908. $. KNEEBONE, J. LEM. Hydatid disease. M. J. Australia, I: 201, 1937. GODFREY, M. F. Hydatid disease, clinical, Iaboratory 6* and roentgenographic observations. Arch. Int. Med., 60: 783, 1937.
OUR view (regarding injuries of the liver) is that of FairchiId (1931) who cIas.sified injuries of the abdomina1 viscera as conditions which demand immediate exploration, on the basis of our inabiIity to say that certain Iesions do not exist rather than on our abiIity to say that they are present. From-“The RBIe of the Liver in Surgery” by Boyce (CharIes C. Thomas).