Sonographic changes of hydatid cyst of the liver after treatment with mebendazole and albendazole. By T. Singcharoen, M.D., *N. Mahanonda, M.D., *L W.
1985, The British Journal of Radiology, 58, 905-907
SEPTEMBER
1985
Case reports and R. Doshi for assistance with the histopathology and photomicrographs. I am also grateful to the Department of Medical Photography, Brook General Hospital for preparing the illustrations and to Mrs. Pat Saunders for typing the manuscript.
Primary malignant neoplasms of the spleen. Gynecology & Obstetrics, 120, 947-960.
HERMANN, G. G., FOGH, J., GRAEM, N., HANSEN, O. P. &
HIPPE, E., 1984. Primary hemangiosarcoma of the spleen with angioscintigraphic demonstration of metastases. Cancer, 53, 1682-1685. MAHONY,
REFERENCES ARBONA, G. L., LLOYD, T. V., LUCAS, J. & SHARMA, H. M.,
1982. Computed tomographic demonstration of angiosarcoma of the spleen. Southern Medical Journal, 75, 348-350. CHEN, K. T.
K.,
BOLLES, J. C. & GILBERT, E. F.,
1979.
Angiosarcoma of the spleen. Archives of Pathology and Laboratory Medicine, 103, 122-124. DAS GUPTA, T.,
COOMBES, B. & BRASFIELD, R.
D.,
1965.
Surgery,
B.,
JEFFREY,
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FEDERLE,
M.
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Spontaneous rupture of hepatic and splenic angiosarcoma demonstrated by CT. American Journal of Roentgenology, 138, 965-966. MONTEMAYOR, P. & CAGGIANO, V., 1980. Primary Hemangio-
sarcoma of the spleen associated with leukocystosis and abnormal spleen scan. International Surgery, 65, 369-373. PIEKARSKI, J., FEDERLE, M. P., Moss, A. A. & LONDON, S. S.,
1980. Computed tomography of the spleen. Radiology, 135, 683-689.
Sonographic changes of hydatid cyst of the liver after treatment with mebendazole and albendazole By T. Singcharoen, M.D., *N. Mahanonda, M.D., * L W. Powell, M.D., Ph.D., F.R.A.C.P. and H. Baddeley, M.B.B.S., F.R.C.R., F.R.A.C.R. Department of Radiology and 'Department of Medicine, University of Queensland, Clinical Sciences Building, Royal Brisbane Hospital, Herston 4029, Queensland, Australia (Received January 1985)
Hydatid disease is a tape-worm infection caused by either Echinococcus granulosus or Echinococcus multilocularis. The disease is endemic in many countries throughout the world. In man, the liver is the most common organ involved by this parasite because the route of entry of the larvae is the portal venous system (Sherlock, 1981). The radiological appearances of hydatid disease have been described previously, including ultrasound and computed tomography (Itzchak et al, 1980; Gharbi et al, 1981; Niron & Ozer, 1981; Hadidi, 1982; Choliz et al, 1982; Beggs, 1983). Not many reports have mentioned the changes after medical treatment (Bekhti et al, 1977; Morris et al, 1983, 1984). We report the serial sonographic changes in a patient with a hepatic hydatid cyst who has been treated with mebendazole and albendazole during a five-year period.
refused surgical treatment, mebendazole had been given and the patient felt better following treatment. The follow-up sonogram one month later showed that the daughter cysts had disappeared and the whole lesion became diffusely echogenic (Fig. 2). She continued on mebendazole treatment for three years but this had to be discontinued because of duodenal ulceration. During these three years, four sonograms were performed each showing the same appearance (Fig. 2).
CASE REPORT
A 70-year-old Yugoslav woman, who had lived in Australia for 36 years, had a very long history of hepatomegaly. The diagnosis of hydatid liver disease had been made six years previously on the basis of a high hydatid antibody titre, sonographic demonstration of cystic lesions in the liver and the past history of living in an endemic area. The first hepatic sonogram six years ago showed a very large space-occupying lesion in the right hepatic lobe with many daughter cysts peripherally and an echogenic area centrally (Fig. 1). Since she 905
FIG. 1. First hepatic sonogram in July 1978 shows a centrally echogenic lesion and the peripheral daughter cysts.
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FIG. 2. Hepatic sonogram in May 1979, one month after mebendazole therapy, shows disappearance of the peripheral daughter cysts.
FIG. 4. Hepatic sonogram in September 1984, two months after albendazole therapy, shows a return to a diffusely echogenic lesion.
Four months after stopping mebendazole, the sonogram showed the reappearance of daughter cysts but the echogenic central part was unchanged (Fig. 3). The patient had no specific treatment for hydatid disease for two years and during this period three sonograms showed progressive increase in the size of the peripheral daughter cysts. When albendazole became available she was treated with this new drug and a sonogram taken after two months' treatment (Fig. 4) showed dramatic reduction in peripheral daughter cysts and a return to the appearance seen prior to ceasing mebendazole treatment (Fig. 2). The patient is continuing on albendazole therapy. DISCUSSION
The common sonographic features of hydatid liver disease are those of cystic lesions with or without septa due to daughter cysts (Itzchak et al, 1980; Gharbi et al, 1981; Niron & Ozer, 1981). Mixed echo pattern, as in
this case, or a diffusely echogenic lesion is uncommon, and might be confused with other conditions such as neoplasm or abscess. At first it was thought that secondary infection accounted for this atypical appearance (Niron & Ozer, 1981). However, diffusely echogenic hydatid cysts without secondary infection have recently been reported (Barriga et al, 1983; Schulman et al, 1983). Surgery is generally accepted as the primary treatment for hydatid disease, but in patients who refuse, or are unfit for surgery, medical treatment is necessary. Mebendazole has been used to treat hydatid disease for several years and has been replaced recently by albendazole which is claimed to have better intestinal absorption and therapeutic effect (Morris et al, 1983). Changes in radiological or sonographic appearances of hydatid liver disease after medical treatment are complete collapse or gradual shrinkage of the cyst (Bekhti et al, 1977; Morris et al, 1983, 1984). Transformation from a cystic to echogenic appearance on ultrasound has been described by Morris et al (1984) in cases after treatment with albendazole. In this patient, this event has happened on two occasions, firstly after treatment with mebendazole and then with albendazole. The reappearance of daughter cysts after three years treatment with mebendazole indicated that the drug had only a static effect upon the parasite. From this experience, long-term follow-up is needed for albendazole, and ultrasound seems to be the best investigation for this purpose. REFERENCES
3. Hepatic sonogram in July 1982, four months after stopping mebendazole, shows reappearance of the daughter cysts. FIG.
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BARRIGA, P., CRUZ, F., LEPE, V. & LATHROP, R., 1983.
An
ultrasonographically solid, tumor-like appearance of echinococcal cysts in the liver. Journal of Ultrasound in Medicine, 2, 123-125.
1985, The British Journal of Radiology, 58, 907-909
SEPTEMBER 1985
Case reports BEGGS, I., 1983. The radiological appearances of hydatid disease of the liver. Clinical Radiology, 34, 555-563.
MORRIS, D. L., DYKES, P. W., DICKSON, B., MARRINER, S. E., BOGAN, J. A. & BURROWS, F. G. O., 1983. Albendazole in
BEKHTI, A., SCHAAPS, J. P., CAPRON, M., DESSAINT, J. P., SANTORO, F. & CAPRON, A., 1977. Treatment of hepatic
MORRIS, D. L., SKENE-SMITH, H., HAYNES, A. & BURROWS,
hydatid disease. British Medical Journal, 286, 103-104.
hydatid disease with mebendazole: preliminary results in four cases. British Medical Journal, ii, 1047-1051.
F. G. O., 1984. Abdominal hydatid disease: computed tomographic and ultrasound changes during albendazole therapy. Clinical Radiology, 35, 297-300.
CHOLIZ, J. DE D., OLAVERRI, F. J. L., CASAS, T. F. & ZUBIETA,
S. O., 1982. Computed tomography in hepatic echinococcosis. American Journal of Roentgenology, 139, 699-702.
NIRON, E. A. & OZER, H., 1981. Ultrasound appearances of
GHARBI, H. A., HASSINE, W., BRAUNER, M. W. & DUPUCH, K.,
SCHULMAN, A . , VAN JAARSVELD, J., LOXTON, A . J. & GROVE,
1981. Ultrasound examination of the hydatid liver. Radiology, 139, 459^63. HADIDI, A., 1982. Sonography of hepatic echinococcal cysts. Gastrointestinal Radiology, 7, 349-354.
W. H., 1983. Pseudosolid appearance of simple and echinococcal cysts on ultrasonography: a report of 2 cases. South African Medical Journal, 63, 905-906. SHERLOCK, S., 1981. Hydatid disease. In Disease of the Liver and Biliary System. (Blackwell Scientific Publications, Oxford), pp. 447-452.
ITZCHAK, Y., RUBINSTEIN, Z., HEYMAN, Z. & GERZOF, S., 1980.
Role of ultrasound in the diagnosis of abdominal hydatid disease. Journal of Clinical Ultrasound, 8, 341-345.
liver hydatid 335-338.
disease. British Journal of Radiology,
54,
Ultrasound in the diagnosis of granulomatous orchitis By R. F. Scott, M.B., B.Ch., D.M.R.D. and A. P. Bayliss, D.M.R.D., F.R.C.R. Department of Diagnostic Radiology, Aberdeen Royal Infirmary, Aberdeen (Received January 1985)
Granulomatous orchitis is a rare and unusual disease which was first described by Grunberg in 1926. Since then there have been approximately 150 cases reported (Mazzolli et al, 1976; Sporer & Seebode, 1982). The diagnosis of granulomatous orchitis is a difficult one, and according to Sporer and Seebode (1982), the disease has never been diagnosed prior to surgery. Ultrasound may have a role to play in the preoperative diagnosis. To our knowledge the sonographic features of granulomatous orchitis have not been described. A patient referred to the ultrasound department for evaluation, with symptoms referable to the testis, was found to have uniformly decreased echogenicity of that testis when compared to the contralateral normal testis. This was later histologically confirmed to be granulomatous orchitis. CASE REPORT
A 59-year-old man complaining of right testicular swelling and discomfort was referred by his general practitioner to the urology clinic for assessment. On examination he was found to have a small hydrocoele and an enlarged and irregular testis. There was minimal associated tenderness and no signs of acute inflammation. The patient was subsequently referred for an ultrasound scan of the testis which showed the right testis to be larger than the left and comparatively hypoechogenic. The reduced internal echopattern was completely uniform with no focal abnormalities demonstrable. At the time of the scan the appearances were thought not to be wholly characteristic of a tumour and orchitis was given as a differential diagnosis.
DISCUSSION
Granulomatous orchitis presents with symptoms of an inflammatory process involving the testis, namely localised swelling, tenderness and pyrexia. The acute symptoms usually subside after several weeks and the end result is a hard irregular testis and indurated epididymis which is clinically indistinguishable from a carcinoma (Sporer & Seebode, 1982). Patients usually present between the ages of 40 and 70 years although younger patients have been reported (Librach & Regan, 1983). The disease process is usually unilateral, but bilateral involvement has been suggested (Sporer & Seebode, 1982). The precise aetiology of granulomatous orchitis remains unknown. Mazzolli et al (1976) have been able to produce it experimentally in guinea pigs. Trauma has been suggested as an initiating factor (Librach & Regan, 1983) which may cause extravasation of sperm into the testis resulting in the formation of a sperm granuloma. Ultrasound has become increasingly useful in the diagnosis and management of intrascrotal pathology. Important contributions which have been made by ultrasound are (1) to determine which intrascrotal lesions require urgent surgical management and (2) to hasten the initiation of medical treatment as in the case of acute inflammation (Orr & Skolnick, 1980). Solid lesions are readily distinguished from cystic lesions (Orr & Skolnick, 1980; Gottesman et al, 1977)
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