|Year : 2013 | Volume
| Issue : 2 | Page : 80-82
Hydatid cyst of axilla masquerading as scrofuloderma
Shantilal M Sisodia, Sameer A. H. Ansari, Surya Kumar Bera, Vinod R Mahajan
Department of Pathology, Grant Government Medical College and Sir J. J. Group of Hospitals, Byculla, Mumbai, India
|Date of Web Publication||19-Jul-2013|
Sameer A. H. Ansari
Department of Pathology, Grant Government Medical College and Sir J. J. Group of Hospitals, Byculla, Mumbai
Hydatid disease is an ancient endemic parasitic infestation caused by Echinococcus granulosus, which results in the formation of hydatid cysts in various parts of the body, the liver, and lungs being the most common sites. However, in 15% to 20% of the cases it may occur in unusual sites. We report a 25-year-old male patient who presented with clinical features similar to scrofuloderma in the axillary region but confirmed from histological examination to have hydatid cyst. This case highlights the uncommon site of hydatid cyst and unusual clinical and histopathological features along with the fact that it should be kept in differential diagnosis of nodules and sinuses in the axillary region. The treatment of choice is excision along with combination of albendazole and praziquantel.
Keywords: Axilla, endoscolex, granulomatous inflammatory reaction, hydatid disease
|How to cite this article:|
Sisodia SM, Ansari SA, Bera SK, Mahajan VR. Hydatid cyst of axilla masquerading as scrofuloderma. Sahel Med J 2013;16:80-2
| Introduction|| |
Hydatid disease or echinococcosis is an ancient endemic disease caused by the larval tapeworm of the genus Echinococcus. Three species of genus Echinococcus which are pathogenic include Echinococcus granulosus, Echinococcus multilocularis, and Echinococcus vogeli . Among these three, E. granulosus is the most common species, but E. multilocularis can also infest humans. Hydatid cysts develop most frequently (80%) in the liver. However, in 15% to 20% of the cases, the embryo passes through the capillary systems and reaches the general circulation thereby making all viscera and tissues vulnerable to infestation.
Hence, hydatid cysts may arise in unusual sites such as the orbit, urinary bladder, chest wall, subcutaneous tissue, tibia, parotid gland, breast, cervicofacial region, and thyroid. , Though no part of human anatomy is invulnerable to hydatid cyst, primary axillary hydatid disease is extremely rare, with only few case reports in the literature.  Still rarer is the presence of granulomatous inflammatory reaction in such cases.
| Case report|| |
A 25-year-old male presented skin and venereal diseases outpatient department with multiple erythematous papules and sinuses in the axilla of 6-month duration. He had no other complaints. Provisional clinical differential diagnoses entertained by the dermatologist were scrofuloderma, actinomycosis, and atypical mycobacterial infection. Skin punch biopsy from the axillary nodule was performed and sent for histopathological examination. Microscopic examination [Figure 1] and [Figure 2] showed epidermis with dermal inflammatory cell infiltrate comprising of multiple foreign body granulomas. In addition, a single scolex of hydatid cyst was seen [Figure 2] and [Figure 3]. Ziehl Nielsen stain for AFB was negative. A diagnosis of hydatid cyst with granulomatous reaction was entertained. Unfortunately, the patient was lost to follow up.
|Figure 1: Low power view showing skin comprised of epidermis and dermis. Deep dermis shows a necrotizing granulomatous infl ammation. (H and E × 40)|
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|Figure 2: High power view showing a necrotizing granulomatous inflammation and a scolex of Echinococcus granulosus. (H and E × 200)|
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|Figure 3: High power view showing a scolex of Echinococcus granulosus (H and E × 400)|
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| Discussion|| |
Hydatid cyst disease still constitutes a major health problem in developing countries accounting for 2-3 million cases per year.  Primary hydatid cyst is the result of a haematogenous dissemination of the embryos of E. granulosus, which pass through the capillary bed of the liver and lung, finally reaching more distant and unusual sites such as the kidney, orbit, heart, bone, spleen, muscle, brain, urinary bladder, chest wall, subcutaneous tissue, tibia, parotid, breast, cervicofacial region, and thyroid. ,, The cyst may remain in an organ for many years without producing any signs or symptoms.  Its symptoms may emerge depending on the host organ, location, its pressure effect on adjacent structures, and complications including rupture, secondary infections, and immunological reactions caused by the cyst.  In the period from the first infection to clinical symptoms, echinococcosis may often display the characteristic symptoms of benign tumor that grows slowly. It may mimics variety of pathologies including benign and malignant tumors, cysts, abscess, hematoma, pseudocyst, and congenital cysts misleading the diagnosis. , The current case clinically mimicked mycobacterial infection because of its presentation. In suspected cases, cross-sectional imaging modalities such as ultrasound (US), computed tomography (CT), or magnetic resonance imaging (MRI) may aid in diagnosis.  Ultrasonography is an easy available and affordable modality with high diagnostic sensitivity for screening of hydatid cyst in endemic areas and nonendemic area.  Grossly it is a unilocular cyst or sometimes multilocular. The cyst contains daughter cysts or has a solid appearance made up of multiple septated cysts. Microscopic examination reveals a cyst lined by three layers. The innermost is a nucleated, germinal layer that is 10-25 um thick and gives rise to broad capsules and daughter cyst. The second layer is the laminated membrane that is 1 mm thick and nonnucleated. It is located immediately beneath the germinal layer and is avascular, eosinophilic, refractile, and chitinous. It stains strongly with PAS, Gomori methenamine silver, and Best carmine. The outer, adventitial layer (pericyst) consists of dense fibrovascular tissue with a varying number of mononuclear inflammatory cells, depending on the age of the cyst.  Very rarely it produces necrotizing granulomatous response as seen in our case. Primary axillary hydatid disease is extremely rare, to the best of our knowledge; there are 17 case reports in the literature till date. 
Though hydatid disease is known to evoke granulomatous inflammation, only one of the 17 reported cases of primary axillary hydatid disease presented with necrotizing granulomatous response. , Hence, the current case presentation is the second in the literature presenting with granulomatous inflammatory reaction. It is also unique as histological diagnosis was made on the basis of the presence of single scolex of echinococcus in the dermis.
Although very rare, possibility of hydatid disease should not be overlooked, in patient presenting as nodules or healed sinuses in the axilla. Serological test (such as indirect hemagglutination, ELISA (enzyme linked immunosorbent assay), immunoblots or latex agglutination) that use antigens specific for E. granulosus are helpful in arriving at the diagnosis.  Cystectomy (surgical excision) is the single effective treatment and is sufficient by itself. The prognosis is excellent in such cases that are treated by removal of cyst totally without rupture. ,, In order to prevent recurrence, the cyst should be excised in toot during operation. Albendazol can be used postoperatively and preoperatively for the purpose of size reduction. , The major limitation of this case is the lost of follow up of the patient, which is a major problem that we face frequently these days while giving proper medical care and treatment to the patient.
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[Figure 1], [Figure 2], [Figure 3]