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Ultramar Medical Imaging Centre 06420 Ankara, Turkey
Dr. Sami Ulus Children's Medical Centre 06080 Ankara,
Turkey
Hacettepe University Medical School 06100 Ankara, Turkey
Hydatid disease has a worldwide distribution and causes health problems in endemic countries. The prevalence of primary muscle hydatid disease is reported to be only 0.5-4.7% [1], because muscle is an unfavorable site for infestation as a result of its high levels of lactic acid. We recently encountered an unusual case of intramuscular hydatid cyst in biceps brachii muscle accompanied by a tapeworm in brachialis muscle. To the best of our knowledge, a case of this coexistence has never been reported.
A 31-year-old woman presented with a 4-month history of painful swelling in her left arm without symptoms or signs of an inflammatory process. Sonography revealed a well-defined cystic mass of 4.5 x 4 x 3 cm in the biceps brachii muscle. The diagnosis of hydatid disease was made. Because the differential diagnosis included soft-tissue tumor, MR imaging was performed using a 1.5-T system. The cyst was hypointense on T1-weighted and hyperintense on T2-weighted MR sequences (Fig. 4A) and contained a capsule, which was shown as an enhanced rim in the contrast-enhanced T1-weighted spin-echo images (Fig. 4B). Besides the cystic mass in the biceps brachii muscle, a tapeworm was seen in another cyst (Fig. 4C), on sonography, in the brachialis muscle. The capsule did not enhance, whereas the fluid around the adult tape-worm showed some enhancement (Fig. 4B). Findings from abdominal and pelvic sonography and chest CT were normal, and the diagnosis of primary muscle hydatid disease was made. Serologic findings were strongly positive for Echinococcus organisms. The diagnosis was confirmed by examination of the excised cyst: a double-layered membrane and numerous scolec-es attached to the germinative layer, which are typical of Echinococcus organisms (Fig. 4D), were seen. The tapeworm was identified as Echinococcus granulosus.
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Hydatid disease is easily diagnosed in endemic areas. However, primary intramuscular hydatid cyst presents a diagnostic problem not only because of the unusual location and low prevalence, but also because complicated cysts may imitate solid or complex lesions [2]. The differential diagnosis in those cases must include soft-tissue abscess caused by coccidioidomycosis or epitrochlear lymphadenopathy in cat-scratch disease, chronic hematoma, and malignant soft-tissue tumors such as myxoid liposarcoma.
In the differential diagnosis of an intramuscular cystic mass accompanied by a tapeworm, as seen in our patient, Trichinella spiralis and Strongyloides stercoralis can be considered. T. spiralis larvae are shorter than E. granulosus larvae. Furthermore, a hydatid cyst has a characteristic double-layered wall and contains hydatid sand with scoleces. S. stercoralis, the life cycle of which does not involve muscle, causes colitis.
Humans are known to be accidental intermediate hosts for Echinococcus organisms. The adult form of the parasite is seen only in dogs. The life cycle of the larva in a human ends with the bacterial infection, shrinkage of the cyst, and eventual calcification. We are unable to explain the presence of an adult E. granulosus tapeworm in our patient.
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  M. Said, H. Babba, M. Golli, A. Ganouni, T. Tacal, D. Altinok, Y. T. Yildiz, and G. Altinok Can We Really Have Coexistence of Hydatid Cyst and Tapeworm in Humans? Am. J. Roentgenol., January 1, 2001; 176(1): 252 - 253. [Full Text]
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