Unusual case of disappearing hepatic hydatid cyst: COVID-19
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Complicated hydatid disease of the liver is always treated with surgery and closing the cystobiliary communication. This report shows an emergency drainage procedure of the common bile duct (CBD) due to cholangitis and pharmacotherapy alone could be curative. This is relevant in very sick patients.

A young patient had presented with a short history of right upper abdominal pain, high-grade fever with chills/rigor and deep jaundice. He also gave a history of high coloured urine but not associated with pale stools or bleeding tendency. On further questioning, he had non-specific dyspeptic symptoms lasting for more than a year. Being from a village background, the joint family depended on agriculture for their livelihood. They also had cows and goats at home many years back. He would regularly take the goats for grazing in the neighbouring forest along with his dog. Examination revealed a toxic looking patient with fever of 38.3°C, tachycardia at 112/min, blood pressure was 126/84 mm Hg, a respiratory rate of 18/min. He had significant icterus and a tender hepatomegaly with localised signs of peritonism in the right upper quadrant. Per rectal examination was normal. The systemic examination was normal.

The routine blood workup had shown neutrophilic leucocytosis, an obstructive liver function test with a total bilirubin of 11 mg/dL and direct of 8.04 mg/dL. Ultrasonography (USG) of the abdomen had shown a large cyst in the liver with intrahepatic biliary radicle dilatation and no gallstones. With a normal serum creatinine, an urgent contrast-enhanced CT (CECT) scan of the abdomen had shown a large hepatic hydatid cyst (HHC) measuring 12×8 cm enclosing multiple daughter cysts involving segment IV, VIII, caudate lobe with dilatation of the intrahepatic and extrahepatic biliary system.

The patient had undergone a diagnostic and therapeutic Endoscopic Retrograde Cholangiopancreatography (ERCP) with endoscopic sphincterotomy and extraction of hydatid elements along with drainage of purulent bile from the CBD using a 7F double pig tail stent. Bile aspiration during ERCP had grown Escherichia coli sensitive to piperacillin/tazobactum.

The patient had undergone a therapeutic ERCP with endoscopic sphincterotomy and extraction of hydatid elements along with drainage of purulent bile using a 7F double pig tail stent. Intravenous piperacillin/tazobactam antibiotic was administered for 7 days. Simultaneously pulse therapy of albendazole 400 mg two times per day for 21 days was started for two cycles with 1?week rest in between.

This would sterilise the HHC and prevent anaphylaxis during laparoscopic evacuation. However in the ensuing 2?months the patient came back once with cholangitis secondary to a blocked stent. A repeat ERCP with stent exchange was done under antibiotic cover. Unfortunately, SARS-CoV-2 pandemic broke out and all elective surgeries were postponed as per government guidelines. As a result, we had advised him to continue with pulse therapy of albendazole through teleconsultation.

Source: https://casereports.bmj.com/content/14/8/e243533?rss=1