S Eryilmaz, Z Turkyilmaz, M Altin, R Karabulut, K Sonmez

Dear Editor,

We wanted to present intramuscular hydatic cyst (HC) without any other primary location. There is only two children cases reported muscules thoracicus longus HC with our case.^1,2

Case Report

A 12-year-old female noticed a swelling on her left flank. After two months, She applied at hospital for this swelling which did not grow. The mass was 7x7 cm, rigid, immobile, painless and not hyperemic on the physical examination. Other systemic exeminations and laboratory findings such as white blood cell account: 8.67/mm³, eosinophil count 0.65/mm³ were normal. Indirect haemagglutination for hytatid disease: negative. In ultrasonograpy (USG) and MRI scans a bilobule cyst measuring 3x3.5x7.5 cm in size, with a thin and smooth wall, without solid component between thoracicus longus muscle fibers at the level of L4-L5. On diagnosis stage, any cyst is not detected in other liver, lung or brain. Patient was referred to interventional radiology department, but they refused the drainage of the cyst. They diagnosed it as a benign cystic lesion. At operation the cystic lesion was approached directly via a 5 cm long left lumbar transverse incision. Cyst was made from the musles as to leave circumfarentially (Figure 1). The cystic contents were aspirated which revealed enfected cystic material. The germinative membrane was seen. Three percent NaCl solution was used as scolicidal agent. Retroperitoneal HC extending from the muscle was excised as unblock. The postoperative period was uneventfull. Preoperatively begun albendazole (10 mg/kg) was administered for 3 cures. No problem was detected in the follow-up period.

Discussion

The incidence of HC has been reported as 1/2000 in Turkey.³ HC's are usually detected in the liver and lungs, but can affect any part of the body.^1-4 HC, through the contiguity may spread nearby organs or with blood flow to distant organs from the liver. The less common form of HC is the involvement of subcutaneous tissue and muscle. The high lactic acid level in muscle tissue is considered unfavourable for parasite survival. Moreover, muscular contractions prevent fixation of larvae to the tissue. However, only in cases where muscle involvement without the internal organ involvement have been reported very rarely at the literature.³

The diagnosis is mainly on history, physical examination. Radiological imaging methods such as USG and MRI are preferred in diagnosis because they give quick results-, aspiration and serological tests.⁵ In this case, indirect haemagglutination test was negative. A differential diagnosis should include cystic lesions (such as lipoma, lymphangioma, soft tissue tumours, and haematoma).^3,4 We consulted the patient with conducted examinations and radiologic examinations because of the swelling on lumber region to interventional radiology, but they had not seen any indication. Therefore, while the patient is taken to surgery, the cyst was tried to be removed unblock, by keeping in mind the differantial diagnosis of HC.

In present conditions not only endemic areas but also due to increased migration because of wars in other developed countries, hydatid disease, intramuscular placement outside the liver and the lung involvement should be considered in the differential diagnosis and contamination must be avoided in the treatment.

Figure 1 Intraoperative image of intramuscular hydatid cyst.

Declaration of Interest

The author declare that there is no conflict interest.

References

1. Teke M, Göçmez C, Hamidi C, et al. Imaging features of cerebral and spinal cystic echinococcosis. Radiol Med 2015;120:458-65.

2. Brunetti E, Kern P, Vuitton DA; Writing Panel for the WHO-IWGE. Expert consensus for the diagnosis and treatment of cystic and alveolar echinococcosis in humans. Acta Trop 2010;114:1-16.

3. Haþlak A, Uysal E. Left lumbar subcutenous hydatid cyst disease: a case report. Turkiye Parazitol Derg 2014;38:55-7.

4. Türkyilmaz Z, Sönmez K, Karabulut R, Göl IH, Baklar AC, Kale N. Unusual localization of hydatid cyst. Acta Chir Belg 2006;106:443-4.

5. Garg R, Nahar U, Mandal AK. A rare case of primary renal hydatid cyst. Ann Parasitol 2015;61:129-31.