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Table of Contents
CASE REPORT
Year : 2018  |  Volume : 11  |  Issue : 2  |  Page : 84-86

A large isolated hydatid cyst of the left adrenal gland: A case report – Treated by transabdominal laparoscopic approach by reflecting the descending colon and review of the literatures


1 Department of Surgery, Rashid Hospital Dubai, UAE
2 Department of Pathology, Dubai Hospital, Dubai, UAE

Date of Web Publication26-Jun-2018

Correspondence Address:
Abdul Jabbar Mehdi Salih
Department of Surgery, Rashid Hospital Dubai, Dubai
UAE
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/HMJ.HMJ_12_18

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  Abstract 


Hydatid cyst of adrenal gland is rare and is usually incidentally discovered as a part of disseminated disease. Herein, we report a rare case of primary large adrenal gland hydatid cyst who presented with a palpable mass on the left loin, with dull pain only.

Keywords: Adrenal gland, hydatid cyst, laparoscopic adrenalectomy


How to cite this article:
Mehdi Salih AJ, Al-Jazeri A, Sandal M, Taha Makki MM, Hotait H. A large isolated hydatid cyst of the left adrenal gland: A case report – Treated by transabdominal laparoscopic approach by reflecting the descending colon and review of the literatures. Hamdan Med J 2018;11:84-6

How to cite this URL:
Mehdi Salih AJ, Al-Jazeri A, Sandal M, Taha Makki MM, Hotait H. A large isolated hydatid cyst of the left adrenal gland: A case report – Treated by transabdominal laparoscopic approach by reflecting the descending colon and review of the literatures. Hamdan Med J [serial online] 2018 [cited 2018 Jul 23];11:84-6. Available from: http://www.hamdanjournal.org/text.asp?2018/11/2/84/235227




  Introduction Top


Hydatid disease (HD) is an accompaniment of infestation by echinococcosis granulosus (EG) Larva, which is endemic in many countries such as the Middle East, Africa and Latin America. The echinococcosis has a complex lifecycle requiring two mammalian hosts; dogs are the definitive host while sheep, cattle, horses and humans are the intermediate hosts. Infestation is conveyed by the use of food and water contaminated with eggs of the parasite in dog's faeces. After swallowing, the eggs are degraded in the digestive system and the larvae freed, which then pass through the hepatic filtration system and reach the lungs.[1] Larvae that not trapped by the lungs' filtration system can be established in other organs of the body such as the spleen, kidneys, brain, heart, bones, muscles, pancreas, breasts, subcutaneous tissue, retroperitoneum, thyroid and adrenal glands, through the arterial circulation.[2] Sometimes, larvae may directly enter the systemic circulation through the lymphatic vessels, without entering the portal vein. Rarely, they can also enter the surrounding tissue by adjacent contact.[1]

Most common locations for hydatid cysts are the liver (59%–75%) and lungs (27%). They are generally asymptomatic lesions, and commonly detected incidentally, such as during radiological examination for other reasons.[3]

Adrenal hydatid cyst (AHC) occurs with an incidence of 0.5% of all cases, even in endemic areas.[3] AHCs are rarely complicated and become symptomatic mainly from pressure (dull pain), or a loin mass.[4]

The size and localisation of the cyst together with the presence of complications are the most important clinical findings taken into consideration in establishing the diagnosis of hydatid cyst disease.[5]

Diagnosis of AHC disease is dependent on imaging methods, such as ultrasonography, computed tomography (CT) scan and magnetic resonance imaginings. The serological tests include the indirect haemagglutination test and enzyme-linked immunosorbent assay (IgG and IgE). In the recent years, 18F-FDG positron emission tomography/CT analysis employed to exclude malignancy in adrenal lesions.[6]

The most effective curative treatment of AHC is by surgical removal of the whole mass including the adrenal gland.[3] During surgery, special attention is paid to avoid spilling the contents. Fluid that contains the scoleces and/or the daughter cysts, that helps in the dissemination of the disease and may lead to severe allergic reactions.

Antiseptic precautions are used, using packs soaked in 10% formaldehyde, hypertonic saline (20%) or dextrose (20%) solution. Before that, the cyst is also injected with the same solution to ensure the death of any living components i.e., (the daughter cysts and scoleces as well as the mother cyst). In keeping with technological improvements, in cases of uncomplicated AHC disease, the current surgical procedures are laparoscopic or retroperitoneal endoscopic techniques.[7] Since some of the AHCs grow to great size and lead to the destruction of the adrenal gland, resection of the adrenal gland together with the cyst may be required.[8]

The medical treatment with albendazole, mebendazole and/or praziquantel, in the pre-operative period for (2–4 weeks) and postoperatively for (4–6 weeks) highly recommended.[5] The treatment aims lower cystic pressure, reduce the viability of cystic components, decreasing anaphylactic reactions and preventing the development of post-operative recurrence.


  Case Report Top


A 48-year-old woman was referred to our department with a large palpable mass located in the left loin, possibly arising from the left kidney.

The patient was the wife of a stock farmer who bred sheep and goats. She had a 2-month history of moderate pain in the left loin, radiating to the left lumbar region.

On examination, she had minimal tenderness in the left upper quadrant of the abdomen and bimanually palpable, rounded mass.

Laboratory studies showed a mild leukocytosis with a normal differentiation count. Echinococcal antibodies were negative.

Plain chest X-ray was normal. Plain abdominal films demonstrated a large mass, with calcification, in the left paravertebral gutter [Figure 1], sonography of the abdomen suggested the presence of a hydatid cyst situated on the left kidney. CT of the abdomen, revealed a 7.22 cm × 7.00 cm cystic mass, some calcification of the wall, arising from the upper pole of the left kidney, displacing the adrenal gland anteriorly without any other pathology [Figure 2].
Figure 1: Plain abdomen X-ray (RKUB) showing the left loin rounded shadow above the left kidney with calcification

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Figure 2: Computed tomography scan abdomen, showing the hydatid cyst of the left adrenal gland, shelling out the gland outward, with calcification

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On laparoscopic approach, the splenic flexure and the descending colon was reflected medially, to expose the retroperitoneal mass, which was easily identified as a rounded mass over the upper pole of the left kidney. Meticulous dissection around the mass, by clipping the adrenal veins, led to freeing the mass and delivered by using a secured plastic bag from the retroperitoneal space.[7]

The gross specimen showed a rounded mass with a cross-sectional diameter of 7.22 cm [Figure 3]a with a thick fibrous wall and rim of golden yellow edge, indicating the pushed out left suprarenal gland cortex [Figure 3]b. The cavity filled with a lump of necrotic hydatid endocyst with no hydatid fluid or daughter cysts [Figure 3]b.
Figure 3: (a) Whole removed (outer view) of 7.22 cm, showing the outer rim of the adrenal gland tissue. (b) The cross-section of the removed specimen contents of the degenerated endocyst, the cyst wall of the ectocyst and the golden colour rim of the pushed out suprarenal gland

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Histological examination of the resected specimen showed a hydatid cyst of the adrenal gland with the membranous endocyst, and laminated membrane (ectocyst) and the compressed adrenal gland tissue [Figure 4]a and [Figure 4]b. The patient had uninterrupted post-operative recovery and was discharged home.
Figure 4: (a) Microscopic section of H and E, at low power of 4 × 0.15, showing the degenerated endocyst, the fibrous ectocyst and the outer shell of the suprarenal cortex. (b) Microscopic section of H and E, at higher power of 100 × 1.30 showing the fibrous ectocyst and the rim of pushed suprarenal tissue

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  Discussion Top


Cystic lesions of adrenal glands are rare, and most commonly seen in the fifth and sixth decades,[1] but they also seen at any age group.[2] They are usually (92%) unilateral and benign, showing no special predilection for either side.

HD accounts for 6%–7% of all adrenal gland cysts.[3] Other types of adrenal gland cysts include endothelial cysts (lymph angiomatous and angiomatous cysts) (45%); pseudocysts (39%) and epithelial cysts (true glandular retention cysts, embryonal cysts and cystic adenoma (9%).

Hydatid cysts involving the adrenals are usually secondary to generalised echinococcosis and occur in about 0.5% of all patients.[1]

The clinical presentation variable, it is most commonly asymptomatic. However, they can present with a wide variety of symptoms. Often, they are vague and non-specific. The most commonly seen clinical features are dull pain in the renal area and a palpable mass.[3]

As adrenal cysts are usually asymptomatic, they discovered as an incidental finding (incidentaloma), on imaging or during surgery carried out for different abdominal pathologies.[1]

HD should be considered in the differential diagnoses of any cystic lesion of the body, particularly in endemic geographic regions. Hydatid cysts involving the adrenals are most of the time part of generalised echinococcosis, which requiring surgical treatment.[4]

In this case report, a laparoscopic procedure performed, since it is large (7.22 cm.) and located in the left loin laparoscopic approach is feasible, by reflecting the descending colon. Resection of the cyst with preservation of the adrenal gland was not possible, because it is difficult to identify the components.

Indications for surgery of adrenal cysts include large size, complicated, parasitic, functioning cysts and neoplasm with cystic degeneration.

Access to the adrenal gland can be obtained by anterior transabdominal or, for small lesions, by a posterior retroperitoneal. Recently, transabdominal laparoscopic and endoscopic retroperitoneal adrenalectomy, have been performed with less morbidity and good results (7/8). The operation of choice is the removal of the cyst with preservation of the ipsilateral kidney and if possible the adrenal gland, but in our case, the adrenal gland was compressed by the large cyst and become part of its ectocyst [Figure 1]b. It is important; the cyst should be removed intact since intraoperative rupture can cause spillage of the content and dissemination of the disease. With a laparoscopic approach, the risk of spillage of infectious material is higher, so we preferred the approach of a retroperitoneal exposer, by creating a well-isolated retroperitoneum space by reflecting the descending colon, where we achieved, complete removal of the AHC.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Pedrosa I, Saíz A, Arrazola J, Ferreirós J, Pedrosa CS. Hydatid disease: Radiologic and pathologic features and complications. Radiographics 2000;20:795-817.  Back to cited text no. 1
    
2.
Geramizadeh B. Unusual locations of the hydatid cyst: A review from Iran. Iran J Med Sci 2013;38:2-14.  Back to cited text no. 2
    
3.
Geramizadeh B, Maghbou M, Ziyaian B. Primary hydatid cyst of the adrenal gland: A case report and review of the literature. Iran Red Crescent Med J 2011;13:346-7.  Back to cited text no. 3
    
4.
Schoretsanitis G, de Bree E, Melissas J, Tsiftsis D. Primary hydatid cyst of the adrenal gland. Scand J Urol Nephrol 1998;32:51-3.  Back to cited text no. 4
    
5.
Ozarmagan S, Erbil Y, Barbaros U, Salmaslioglu A, Bozbora A. Primary hydatid disease in the adrenal gland: A case report. Braz J Infect Dis 2006;10:362-3.  Back to cited text no. 5
    
6.
Metser U, Miller E, Lerman H, Lievshitz G, Avital S, Even-Sapir E, et al. 18F-FDG PET/CT in the evaluation of adrenal masses. J Nucl Med 2006;47:32-7.  Back to cited text no. 6
    
7.
Assalia A, Gagner M. Laparoscopic adrenalectomy. Br J Surg 2004;91:1259-74.  Back to cited text no. 7
    
8.
Mellon MJ, Sethi A, Sundaram CP. Laparoscopic adrenalectomy: Surgical techniques. Indian J Urol 2008;24:583-9.  Back to cited text no. 8
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