Introduction
Spinal hydatid disease is a rare form of hydatid disease caused by the larval form of Echinococcus granulosus (Baysefer et al., 297). Dogs are primarily the definitive hosts of E. granulosus with man and sheep serving as intermediary hosts. Hence, the disease is prevalent in sheep-rearing communities (Emara & Elhameed, 12). Hydatid disease in man begins with ingestion of ova-contaminated water or food. The egg hatches in the intestines and the larvae migrate into the lungs and liver via the portal venous system. According to Prabhakar et al. (426), osseous hydatid disease is a rare secondary disease with an incidence of 0.5-2%. Spinal HD accounts for less than 1% of all hydatid disease cases and 44% of all skeletal hydatid disease cases (Suslu et al., 186). We report a case of spinal HD involving the cervical region managed by laminectomy.
A 64-year-old man presented with complaints of painful swallowing for three days, abdominal pain accompanied by bilious vomitus, and urine retention in a known case of hydatid disease and diabetes mellitus. Physical examination revealed oral candidiasis and bilateral decrease in power to grade three in hip, knee and ankle joint. Neurological assessment of the lower extremities revealed bilateral +1 knee reflexes, bilateral areflexia at the ankle and bilateral Babinski positive. Additionally, sensory system was intact in both limbs and there were no cerebellar signs.
The patient was initially managed symptomatically using intravenous normal saline, nystatin oral drops and antibiotics. Besides, patient was catheterized to relieve urine retention and the bilious fluid drained with help of respiratory therapist pending MRI results. Upon receiving results, diagnosis of acute pancreatitis, intraspinal and retroperitoneal cyst was made. Patient was put on nil-per-oral and intravenous fluids intensified for nutritional support awaiting laminectomy of the cyst. However, the patient developed hypotension that was treated using inotropes prior to laminectomy. The procedure was successful and a sample was taken for histopathology to confirm diagnosis. However, bowel and bladder incontinence developed after laminectomy while lower limb weakness persisted. The patient was discharged on Mebendazole 1g daily for 3 months. Follow up plans are underway to track progress.
Discussion
Spinal HD is perhaps the worst form of parasitic infestations associated with morbidity requiring surgical correction. We concur with Benazgmont et al. (82) that spinal HD has a male preponderance but report that it may occur at any age and not merely below 30 years. In fact, both age (64 years) and anatomical location (cervical) makes this case unique given that spinal HD involving the cervical spine accounts for <10% of all spinal HD cases (Sharma et al. 90). Importantly, all spinal HD cases including those involving the cervical spine manifest with symptoms of cord compression with chief complaints of low back pain accompanying motor weakness and/or paresis.
MRI appears to be the gold standard in diagnosis and treatment requires laminectomy and chemotherapy using mebendazole or albendazole (Benazgmont et al., 82). Notably, both history and eusinophil count may be insignificant. Unfortunately, risk for recurrence is high (>30%) given that radical resection around the spine is unfeasible (Al-Ghnimi, 3). Importantly, lavage with 3% saline prior to closure and mebendazole therapy for at least 3 months reduces the risk (Suslu et al., 188). Neurologic improvement after surgery is gradual and screw stabilization of the vertebrae remains optional depending on extent of bone removed (Rabi, 1). In conclusion, spinal HD is a rare high morbidity disease and an important differential diagnosis in all patients presenting with low back pain, radicular pain and any degree of paresis.
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