Treatment of a giant hepatic echinococcal cyst with percutaneous drainage and in vivo assessment of the protoscolicidal effect of praziquantel

Abstract

Therapy choices for cystic echinococcisis (CE) are stage-specific: surgical, minimally invasive, medical or observation without intervention. PAIR (percutaneous aspiration, instillation of a scolicide, and re-aspiration) has been considered the treatment of choice for uncomplicated echinococcal liver cysts. However, PAIR carries the risk of toxic cholangitis or hypernatremia and that the cyst frequently refills with bile after withdrawing the catheter. We treated a patient with a giant CE 1 liver cyst with puncture drainage (PD) under albendazole coverage. Drainage enabled us to monitor the morphology of protoscolices under praziquantel (PZQ) co-medication. Protoscolices degenerated within 5 days of PZQ 50 mg/kg/d. The cyst cavity solidified with no evidence of reactivation or secondary spread. Percutaneous treatments can replace surgery in a significant number or cases with hepatic CE. PD allows to assess microscopically the viability of protoscolices under co-medication with PZQ-albendazole and to avoid the instillation of topical scolicides.

Keywords: Albendazole; Cystic echinococcosis; Echinococcus granulosus; Percutaneous drainage; Praziquantel.

Fig. 1

WHO-IGWE-classification of hepatic echinococcal cysts¹

Fig. 2

a Magnetic resonance imaging of the giant hepatic echinococcal cyst; b Computed tomography reconstructed in maximum intensity projection (MIP) after catheter placement. The cyst is partially filled with contrast medium

Fig. 3

Microscopy of the cyst fluid: a.multitude of viable protoscolices at puncture, 21 days after starting albendazole monotherapy; b single protoscolex; c intact rostellum with hooklets; d degenerating protoscolex; e disintegrated rostellum five days after adding praziquantel

Fig. 4

a–c Abdominal ultrasonography: subsequent evolution of the liver cyst after aspiration and combined albendazole—praziquantel therapy. a after having 13 withdrawn 1500 ml of cyst fluid; b one week after removal of the catheter; c twenty-three months after PD