Multilocated hydatid cysts involving the liver, the spleen and the scapula

A 75-year-old healthy woman presented with mild, right hypochondral discomfort and heaviness present for at least 2 days before admission to the hospital. She also complained of pain in the region of her left shoulder, which was moderate in nature and of approximately 1 year's duration. Shoulder pain had led to the limited use of her left arm. The patient had a history of intimate contact with sheep and dogs. Clinical examination revealed a tender, enlarged liver (5 cm below the right costal margin), as well as a tender scapula on palpation. Laboratory tests showed the white blood cell count to be 7000/mm3 with 8% eosinophils. The erythrocyte sedimentation rate was 30 mm per hour. Serological tests for Echinococcus granulosus, which included immunoelectrophoresis and indirect immunohaemagglutination assay, were strongly positive (IHA 1/800). A plain abdominal radiograph showed the enlarged hepatic shadow and a curvilinear calcification lying within it (Figure 1). An ultrasound study was then performed to further characterize the lesion. A hyperechoic band located in the right lobe of the liver associated with an acoustical shadow representing dense calcification was found (Figure 2). Two roundish, hypoechoic areas located in the enlarged spleen were found incidentally during the ultrasound examination of the abdomen (Figure 3). The diagnosis of splenic hydatid disease was favoured because of the simultaneous presence of the cystic lesion in the liver. The roentgenographic examination of the left scapula showed multiple, variously sized, round or oval osteolytic lesions, giving a honeycomb appearance of the inferior part of the scapula (Figure 4). On the basis of clinicoradiological features and laboratory findings a diagnosis of hydatid disease was proposed. A thorough clinical, radiological and ultrasonographic search did not reveal any other sites of hydatid cysts. The patient proceeded to surgery where she underwent local hepatic resection, splenectomy and local total excision with a wide healthy margin in the scapula. Histological examination of the material excised from the liver, the spleen and the scapula confirmed the diagnosis of hydatid disease. The patient made an uneventful postoperative recovery and was discharged 1 week later. Pain subsided totally following surgery. At follow-up examination 6 and 12 months later, the patient remained asymptomatic, and had no clinical or radiological evidence of the disease in the primary sites or elsewhere.