The Gremlin In My Patient

Here's one for the medical folks: 

She was a G1P1 who presented complaining of an abdominal mass.  We are currently training new ultrasound techs at Tenwek so I was asked to scan the patient.  I saw this:

An odd looking mass, but it was located just lateral and superior to the uterus - where one might expect an ovary to be and there was no ovary to be seen, so an ovarian mass it was.  Whatever it was - it was big (10x8 cm), tender and it needed to be taken out. 

Now from time to time, we find things on pelvic ultrasound that are incorrectly blamed as being of gynecological origin.  This happens in the USA and it happens in Kenya.  In residency, nothing was more frustrating that the patient who complained of abdominal pain and had been found to have a 0.5 cm simple ovarian cyst.  Or the patient with no ultrasound findings who is generally labeled, "PID" or "Chronic pelvic pain."  However, here in Kenya, more often than not - if the problem is not gynecologic in origin - you can be sure it is at least interesting!

OtherDoc and our rotating Surgery Resident took this particular patient to theatre.  I was covering L&D but I stopped by to snoop and see what they found:

 It was NOT an ovarian mass, but it was an abdominal/pelvic mass - it seemed to be growing from the posterior abdominal wall and several small loose "cysts" were found extruding from mass and in the pelvis.

It was Echinococcosis or hydatid cyst - a parasitic disease caused by a tapeworm.  Typically the disease is passed from dogs/wild dogs or foxes to sheep/cattle and then may be passed to humans via soil or animals that are infected.  The incubation period can be months to years before symptoms are noted, depending on the location of the cyst in the body and how fast it is growing.  Generally, the cysts are found inside the liver or intestine.  Strangely though, this one was in its own little capsule that encompassed many, many eggs.  It was totally sci-fi.

It is important to not spill any cyst fluid inside the peritoneal cavity because it may cause seeding of the abdomen with hundreds of these little worm egg cysts or even anaphylaxis (from the cyst fluid).  We had to have epi and steroids close by - just in case.  I felt like I was on House!  After the mass was removed (we called the General Surgeon on-call), I got to cut it open!  Take a look:

The patient endured the surgery without any complications - including anaphylaxis - and will now require long term treatment with albendazole (anti-parasitic).

Very cool.  So gross.  I love it!