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Letters to the Editor |
Indian Pediatrics 2000;37: 111-112 |
| Hydatiduria |
Echinococcosis or hydatid disease is a cyclo-zoonotic parasitic infestation caused by the cestode Echinococcus granulosus. Kidney involvement in echionococcosis is exremely rare, constituting only 2-3% of all cases, even in the areas where hydatid disease is endemic. There are no specific symptoms that really establish the diagnosis of renal echinococcosis. The presence of a flank mass, hematuria, dysuria, pyuria, renal colic, ureteral colic, persistent fever, calculi, hypertension and so forth are all non specific(1). However, if the renal cyst ruptures into the collecting system of the kidneys, daughter cysts can pass into urine and that is pathognomic of the disease. We report a case of disseminated echinococcosis, involving the lung and kidneys, presenting primarily with long standing hydatiduria. This 9 year old boy presented with history of intermittent passage of small, white, grape sized, balloon like structures in the urine for last 8 months. On further inquiry, he also complained of having intermittent cough, and vague pain in chest and abdomen for last two years. The child also had 3 episodes of hemoptysis in last 3 months. There was no history of fever. Examination revealed mild respiratory distress. Chest examination was suggestive of left pleural effusion. Abdominal examination did not reveal any hepatospleno-megaly or any other palpable lump. Rest of the systemic examination was normal. Gross examination of a single balloon like structure in the urine revealed a membraneous cyst measuring 2�1 cm; histopathology showed an outer laminated layer with an internal germinal layer showing calcification in multiple areas. Scolioces could not be demonstrated although the laminated structure was consistent with a hydatid cyst. Sonography and CT scan revealed a solitary large parenchymal cyst occupying almost whole of the left lung and multiple renal hydatid cysts. Spleen and liver were normal. Absolute eosino-phil count was 950/cu mm. Kidney function tests were normal. Pyogenic cultures of the urine, sputum and blood were sterile. Sputum and gastric aspirate were negative for acid fast bacilli. Tuberculin test was negative. Micro-scopic examination of the stool failed to demonstrate any ova or cyst. Echinococcus antibdoy titer were less than 1: 16 on indirect hemagglutination test. It is not clear how the hydatid embryo reached the kidney but it is postulated that it must pass through the portal system into the liver and retroperitoneal lymphatics. A small percentage of organisms may escape entrapment in the liver and lungs, enter the systemic circu-lation and infect any organ in the human body. Renal hydatid cysts usually remain asymptomatic for many years. The passage of gelatinous material (grape skins) in urine is caused by rupture of the cyst into the renal pelvis. Eosinophilia is noted in about 50% cases. Serological tests are usually negative. Advanced radiological techniques like CT scan and MRI remain the mainstay of diagnosis(2,3). Hydatiduria accompanies 10-20% of cases of renal hydatidosis and is basically micro-scopic. Gross passage of hydatid cysts in the urine is reported infrequently, being rather uncommon, but has a tremendous diagnostic utility(2,4). It offers little scope for a second differential diagnosis, specially in children with multisystem involvement. Diagnosis can be confirmed with characteristic radiological appearances(3). Echinococcal disease of the kidney and the retroperitoneal structures is usually treated with partial or total nephrectomy(5). Since the child had multisystem involvement and secondly parents refused surgery, he was treated with albendazole 20 mg per kg per day given in a cyclical fashion for 28 days with a 2 week drug free interval between cycles. Six such courses were repeated with marked improve-ment in the condition. Hydatiduria disappeared and child gained weight. Repeat CT after 6 months showed a marked reduction in the size of the lung cyst and disappearance of renal cysts. Vikas Loiwal, References 1. Afsar H, Yagci F, Meto S, Aybasti N. Hydatid disease of the kidney: Evaluation and features of diagnostic procedures. J Urol 1994; 151: 567-570. 2. Von Sinner WN, Hellstrom M, Kagevi I, Norlen BJ. Hydatid disease of the urinary tract. J Urology 1993; 149: 577-580. 3. Odev K, Kilinc M, Arslan A, Aygun E, Gungor S, Durak AC, et al. Renal hydatid cysts and the evaluation of their radiologic images. Eur Urol 1996; 30: 40-49. 4. Saxena S, Gupta R, Nigam DK, Tahiliani ND, Saxena KN. Hydatid cyst of kidney presenting as hydatiduria. J Assoc Phys India 1990; 38: 359-360. 5. Tryfonas GJ, Avtzoglou PP, Chaidos C, Zioutis J, Gavopoulos S, Limas C. Renal hydatid disease: Diagnosis and treatment. J Pediatr Surg 1993; 28: 228-231. |
