Hydatid Cyst Co-infection with Hepatitis B
Dushyant Singh Gaur,Amit Varma,Ramjee Prasad
Department of Pathology
Himalayan Institute of Medical Sciences
Jolly Grant, Dehradun 248140, Uttaranchal, India

Address for Correspondence:
Dr. Dushyant Singh Gaur MD
Additional Professor
Department of Pathology
Himalayan Institute of Medical Sciences
Jolly Grant, Dehradun 248140, Uttaranchal, India
e-mail: dugaur@yahoo.com
Phone: 09837020745

 

Abstract:
The co-infection of Echinococcus ( Hydatid cyst ) with Hepatitis B virus (HBV) infection is a very rare entity. We came across this rare co-infection in a 56 years old female with jaundice, gradually progressive abdominal distension, generalized weakness and decreased appetite. There was no history of any blood transfusion or intravenous medication.

Key Words: Co-infection ; Echinococcus infestation ; Hepatitis B virus .


Introduction:
Hydatid cyst, or Echinococcosis, is caused by Echinococcus granulosus, a tapeworm that infests the intestines of dogs and other canine species. Man is the accidental intermediate host that harbours the larval cysts most commonly in liver, lungs and brain. Echinococcosis is found worldwide and has been endemic in India (1). This case is being presented because of its unusual association with Hepatitis B Virus (HBV) infection.


Case Summary:
A 56 year old female presented with gradually progressive distension of abdomen for last 3 months with heaviness and dragging sensation in the upper abdomen. She also developed yellow discoloration of eyes and urine for last one and half months. This was associated with generalized weakness and decreased appetite. There was no history of any blood transfusion or intravenous medication. General examination revealed jaundice. Her vitals were normal. There was no lymphadenopathy or engorgement of neck veins. On abdominal palpation, she was found to have hepatomengaly. There was no splenomegaly or free fluid in the abdominal cavity. The examination of cardio-vascular, respiratory, locomotor and central nervous systems was normal. On detailed clinical investigation, her hemoglobin was 8.8 grams/dl, Total leucocyte count was 6,800/cu.mm, Polymorphs were 65%, lymphocytes 27% and eosinophils 8%. Peripheral blood had normocytic mildly hypochromic picture and adequate platelets. Her total Bilirubin was 6.8mg/dl, ALT= 157 U/L, AST= 171 U/L, ALP= 108 U/L; total serum Proteins= 6.6 g/dl, total serum albumin= 3.4 g/dl. Renal function tests and X-ray chest were normal. Abdominal ultrasonography showed multiple loculated cysts of varying sizes. There was no free fluid in abdomen or retroperitoneal lymphadenopathy. MRI scan confirmed multiple loculated cysts with daughter cysts in few of them, together measuring about 55mm. Enzyme Linked Immunosorbent Assay (ELISA) test was positive for Echinococcus and Hepatitis B. ELISA for Human Immunodeficiency Virus (HIV) infection was negative.


Discussion:
Echonicoccosis can involve practically any organ of the body but liver & lung together constitute 90% of the cases. In liver, most of the signs and symptoms produced are due to constantly increasing size of the Hydatid cyst that gradually compresses the hepato-biliary system, producing features of obstructive jaundice, chronic cough with pleuritic chest pain and hemoptysis. Secondary complications may occur as a result of infection or leakage of contents from the cyst, producing anaphylactic shock (1). Specific humoral and cellular responses of the host confer a significant level of resistance to the parasite, causing a proportion of hydatid cysts to die soon after initial infestation and get calcified. The inflammatory response restricts the growth and metastasis of the cyst mass in the host (2).

At the time of clinical examination, patient appeared to be a case of obstructive jaundice, produced by the Hydatid cyst. Discovery of co-infection of the patient by HBV gave a new dimension to our diagnosis.

Co-infection is a phenomenon which was not reported very frequently till the era of Acquired Immuno-deficiency Syndrome (AIDS), caused by HIV, came in existence. Immuno-compromised patients of HIV hosted co-infection by various Opportunistic agents like Mycobacterium tuberculosis, viruses like Hapatitis B, C and D viruses, Cytomegalovirus, Rickettsial, fungal, protozoal and certain helminthic infections (3). Many of these were noticed as human pathogens for the first time during research on AIDS patients (4).Thus we tried to explore presence of HIV infection, besides Hydatid cyst and HBV infection in this case, but the ELISA test for HIV was reported as negative.

Individuals infected with HBV, progressing to Chronic Hepatitis B seem to have diminished CD4+ and CD8+ cellular responses in peripheral blood, contributing to the viral persistence in liver cells (3). Probably in the present case, infection by HBV immuno-compromised the patient in such a way that echinococcus co-infection flourished in a liver already suffering for hepatitis caused by HBV. This resulted in the unrestricted growth of Hydatid cyst to a size large enough to compress the host hepato-biliary system and produce obstructive jaundice.
It appears that, just as HIV, HBV too is capable of producing immunosuppression of host to a certain extent, which is an aspect that needs a higher level exploration
The co-infection of Echinococcus with Hepatitis B virus (HBV) infection is a very rare entity that has probably never been reported in medical literature. We hope this unusual case will trigger the scientific minds to explore the interesting link of echinococcus co-infection with HBV, bringing more such cases to the medical limelight.

References:
01. Chakraborty P. Text book of Medical Parasitology. Ist Ed. India. New Central Book Agency (P) Ltd. 2004:239-247.
02. Flisser A. Larval cestodes. In: Collier L, Balows A, Sussman M. eds. Topley & Wilson’s Microbiology Vol. 5: Parasitology. IXth Ed. Arnold publishers. 1998: 539-560.
03. Lucas SB. Other viral and infectious diseases and HIV-related liver disease. In: MacSween RNM, Burt AD, Portmann BC, Ishak KG, Scheuer PJ, and Antony PP. eds. Pathology of Liver. 4th ed. China. Churchill Livingstone. 2002: 363-414.
04. Abbas AK. Diseases of Immunity. In: Kumar V, Abbas AK, Fausto N. Robbins and Cotran Pathologic Basis of Disease. 7th ed. India. WB Saunders Company 2004: 193-268.

 

Fig. 1 : Liver M.R.I. showing multiple Hydatid Cysts