A seven year old boy with a tumour on his right upper leg
Öz
Case A 7 year old boy living in a rural area presented with a complaint of swelling in the right upperleg which was present for 1 5 years but increased in size in the last 3 months and caused pain and difficulty in walking On physical examination a soft mass of 4x6 cm without erythema was found in the adductor region of the right thigh The patient had no history of trauma surgery or disease Eosionphilia 15 4 leucocytosis 14000 mm3 and a CRP value of 37 7 mg dL were found in the laboratory tests Ultrasonography USG revealed a lesion area with a size of 24x44 mm including extensive internal septations with a thick capsule localized in the muscle in the anterior medial region of the right thigh compatible with cystic criteria At this stage necessary blood tests and magnetic resonance imaging were performed Diagnosis: Hydatic cyst Elisa test performed for echinococcus was found to be positive Magnetic resonance MR imaging revealed a cystic lesion with regular borders with a size of 28x44 mm including internal septations in the anterior medial region of the right thigh Hydatic cyst? The lesion was hypodense on T1 weighted images hyperdense on T2 weighted images and showed no marked contrast uptake following IV contrast injection Contrast uptake was observed in the peripheral region of the lesion inflammation Picture 1 Postoperatively 10 mg kg albendazole was given for 10 days After obtaining informed consent from the patient operation was performed under general anesthesia and it was observed that the cyst was localized between adductor and sartorius muscles The cystic mass was excised completely without damaging the mass Picture 2 and the area was rinsed with hypertonic saline Afterwards the mass was opened and it was observed that germinative membrane and hydatid fluid were present Picture 3 No problem occured postoperatively The patient was given 10 mg kg day albendazole for three months Discussion Hydatosis is a parasitic infection known since the old times Four different parasites lead to this disease These include Echinococcus granulosus E Multilokularis E Vogeli ve E oligarthrus The first two have clinical significance The other two parasites rarely cause infection in humans 1 The disease is endemic in many regions including Mediteranean countries the Middleeast Australia and South America The annual incidence in Turkey is 12 100000 2 Hydatic cyst is found with a rate of 64 in the lungs and with a rate of 28 in the liver in children In addition the brain peritoneal cavity spleen heart and bone can also be involved 3 It is believed that primary infection occuring in the muscle tissue in the childhood is due to E Granulosus It is observed rarely in children and frequently in the adulthood because the cyst grows slowly and symptoms arise in later years 4 Primary skeletal muscle hydatic cyst is observed rarely with a rate of 0 5 4 7 The cyst uses oxygen to grow However muscles contain lactic acid and this environment is not appropriate for the growth of the cyst 4 The pathogenesis related to skeletal muscle localization of hydatic cyst has not been elucidated fully Some authors propose that it occurs by bite of an infected dog and some others propose that the embryio reaches the skeletal muscle after passing two organs acting as filters namely the lungs and liver 7 There are approximately 60 cases of primary skeletal muscle hydatic cyst reported in the literature and the patients are mostly adults 5 It occurs very rarely in children 69 It is difficult to diagnose primary intermuscular hydatic cyst except for endemic areas Abscess hematoma soft tissue tumor and other lesions should be considered in the differential diagnosis Biopsy should not be performed since it would be harmful in terms of leading live scolexes to enter the circulation and causing anaphylaxis by extending and infecting other compartments Therefore primarily imaging is very important in swellings 8 Our patient is the second pediatric case reported in the literature with its intermuscular localization and a size of 5 cm Although muscular hydatic cyst is observed rarely it is still important in urban regions in endemic areas Radiologic imaging tests and serologic tests may be helpful in the diagnosis of muscular hydatic cyst with an extraordinary localization It may sometimes be confused with abscess on ultrasonography Marked hypodense borders of the hydatic cyst can be observed on MRI 9 Serologic tests can be used to confirm the diagnosis The common techniques used include indirect immunoflourescence antibody test ELISA immunoelectrophoresis and immunoblast tests 10 The diagnosis of our patient was confirmed radiologically serologically and histopathologically Conclusively hydatic cyst should not be ignored in patients presenting with cystic mass in areas where hydatic cyst occurs endemically and radiologic and serologic tests for hydatic cyst would be performed before performing biopsy If hydatic cyst is considered the cyst should be excised totally and drainage should not be done Ad shy;dress for Cor shy;res shy;pon shy;den shy;ce: Mehmet Hanifi Okur MD Dicle University Medical Faculty Department of Pediatric Surgery Diyarbakır Turkey E mail: m hanifi okur@hotmail com Re shy;cei shy;ved: 05 15 2012 Ac shy;cep shy;ted: 06 18 2012 References 1 Merkle EM Schulte M Vogel J Tomczak R Rieber A Kern P Goerich J Brambs HJ Sokiranski R Musculoskeletal involvement in cystic Echinococcosis: report of eight cases and review of the literature AJR Am Roentgenol 1997;168:1531 1534 2 Republic of Turkey Ministry of Health Health statistics Ankara: Research planning and Coordination Council; 1997 3 Tsakayiannis E Papis C Moussatos G Late result of the conservative surgical procedures in hydatid disease of the lung in children Surgery 1970; 68: 379 382 4 Garc iacute;a D iacute;ez AI Ros Mendoza LH Villacampa VM C oacute;zar M Fuertes MI MRI evaluation of soft tissue hydatid disease Eur Radiol 2000; 10: 462 466 5 Mseddi M Mtaoumi M Dahmene J Ben Hamida R Siala A Moula T Ben Ayeche ML Hydatid cyst in muscles: eleven cases Rev Chir Orthop Reparatrice Apar Mot 2005; 91: 267 271 6 Cankorkmaz L Ozturk H Koyluoglu G Atalar MH Arslan MS Intermusculer hydatid cyst in a 4 year old child: a case report J Pediatr Surg 2007; 42: 1946 1948 7 Melis M Marongiu L Scintu F Pisano M Capra F Zorcolo L Casula G Primary hydatid cyst of psoas muscle ANZ J Surg 2002; 72: 443 445 8 Duncan GJ Tooke SM Echinococcus infestation of the biceps brachii A case report Clin Orthop Relat Res 1990; 261: 247 250 9 Pedrosa I Saiz A Arrazola J Ferreiros J Pedrosa CS Hydatid disease: radiologic and pathologic features and complications Radiographics 2000; 20: 795 817 10 Zhang W Li J McManus DP Consept in immunology and diagnosis of hydatid disease Clin Microbial Rev 2003; 16: 18 36
Anahtar Kelimeler
Sağ uyluk bölgesinde şişlik olan yedi yaşında erkek çocuk
Öz
Olgu Kırsal bölgede yaşayan yedi yaşında bir erkek çocuk sağ uyluk bölgesinde 1 5 yıldan beri var olan ancak son üç aydır boyutları artan ağrıya ve yürüme güçlüğüne neden olan şişlik yakınması ile başvurdu Hastanın fizik muayenesinde sağ uyluk adduktör bölgesinde 4x6 cm çapında yumuşak kıvamlı eritemsiz kitle saptandı Hastanın travma cerrahi veya herhangi bir hastalık öyküsü yoktu Laboratuvar tetkiklerinde eozonofili 15 4 lökositoz 14 000 mmc ve CRP 37 7 mg dL saptandı Ultrasonografide USG sağ uyluk anterior medialde kas içi yerleşimli kalın kapsüllü yaygın internal septasyonlar içeren 27x44 mm boyutlarında kistik ölçütlerde lezyon alanı saptandı Bu aşamada gerekli kan tahlili ve manyetik görüntüleme yapıldı
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