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148 Parasitic Infestations of Surgical Importance in Children

sure effects, antigenic reaction, or rupture. The cyst may remain silent Treatment
for a long time and regress without causing any symptoms. Patients Management of patients with hydatid disease has changed significantly
usually have nonspecific symptoms such as cough, abdominal discom- over the past few decades. Initially, surgery was considered the only
fort, low-grade fever, and malaise. In liver hydatid, the patient may option for hydatid cysts, but now medical management is useful in
present with abdominal discomfort, painful abdomen, palpable mass, many cases. The drugs of choice are albendazole (12–15 mg/kg/day for
and sometimes jaundice due to compression of the biliary ductal sys- 28 days) and praziquantel (50 mg/kg/day for 6-8 weeks). Mebendazole
tem. In the lungs, the hydatid cyst manifests as coughing, haemoptysis, (200 mg/kg/day in 3 divided doses for 16 weeks) is also effective.
and passage of white flakes in sputum, or incidental findings on a chest Although primary surgery can eradicate hydatid cyst in most cases,
x-ray. Bone hydatid cysts present with bone pains and pathological there is always fear of daughter cyst formations. Furthermore, treatment
fractures. Hydatid cysts in the brain usually present with features of a with long-term albendazole can cure hydatid cyst in more than half the
space-occupying lesion in the brain. cases. The general consensus now is that patients with multiple hydatid
The rupture of a hydatid cyst may occur secondary to infections or cysts and having cysts less than 6 cm in diameter shall be treated medi-
trauma and can cause serious allergic reactions and even anaphylactic cally, and any residual cysts may be tackled with surgery. In the case of
shock. The rupture of an untreated hydatid cyst can cause seedling and a solitary cyst larger than 6 cm, surgery should be planned. Adjuvant
formation of multiple daughter cysts, especially in wide cavities such medical therapy in these patients should be done to avoid recurrence of
as the peritoneum and pleural cavities. cysts and seedlings in adjacent tissue. PAIR (percutaneous aspiration,
Diagnosis instillation [of hypertonic saline], and re-aspiration [after 15 minutes])
In the endemic areas the diagnosis is often easy due to the prevalence is another technique of treating hydatid cysts of the liver and lungs.
of the disease. Patients with hapatomegaly should be properly inves- These patients should also be treated with albendazole to avoid any
tigated. Ultrasound evaluation is a useful tool in differentiating solid recurrence. Recently, laparoscopic-assisted drainage of hydatid cysts
and cystic masses and can make a confident diagnosis in liver hydatid has been performed with good results, but its advantage over PAIR and
cysts. Simple liver cysts and abscesses are not uncommon in develop- other procedures needs to be evaluated by long-term studies.
ing countries; the ultrasound evaluation can easy differentiate internal Evidence-Based Research
membrane and floating hydatid sand (scolices). In a ruptured hydatid Table 23.1 presents an evidence-based study of intestinal parasitic
cyst, the laminated membrane floats on the fluid surface and can be infection among children in Karachi, Pakistan.
detected by ultrasound. A multilocular hydatid cyst can be diagnosed
by its classic ultrasound appearance but may be confused with cystic Table 23.1: Evidence-based research.
tumours. In these cases a CT scan may be helpful in making a diagno- Title Prevalence and factors associated with intestinal
sis. A lung hydatid cyst is suggested by the well-circumscribed homog- parasitic infection among children in an urban slum in
Karachi
enous opacity in the lung (Figure 23.5). A ruptured pulmonary hydatid
cyst shows as a rounded cavity with air fluid level and floating lami- Authors Mehraj V, Hatcher J, Akhtar S, Rafique G, Beg MA
nated membrane and may give the appearance of the so-called “water Institution Department of Pathology & Microbiology, Aga Khan University,
lily” sign. Patients with hydatid cysts have moderate eosinophilia, Karachi, Pakistan. Awolowo University, Ile-Ife, Ilesa, Nigeria.
and their immunoglobulin levels are elevated. The diagnosis may be Reference PLoS ONE 2008; 3(11):e3680.
confirmed by serological tests. Countercurrent immunoelectrophoresis Problem Intestinal parasitic infections are endemic worldwide and have
(CIE) for scolex antigen and enzyme-linked immunosorbent assay been described as constituting the greatest single worldwide
(ELISA) can confirm the diagnosis in most cases. The Casoni test is cause of illness and disease. Poverty, illiteracy, poor hygiene,
lack of access to potable water, and a hot and humid tropical
performed by intradermal injection of crude sterile hydatid fluid, but it climate are the factors associated with intestinal parasitic
is not a reliable test. infections.
Intervention The study aimed to estimate the prevalence and identify
factors associated with intestinal parasitic infections among
1- to 5-year-old children residing in an urban slum of Karachi,
Pakistan.
Comparison/ A cross-sectional survey was conducted from February to June
control 2006 in Ghosia Colony, Gulshan Town, Karachi, Pakistan. A
(quality of simple random sample of 350 children aged 1–5 years was
collected. The study used a structured pretested questionnaire,
evidence) anthropometric tools, and stool tests to obtain epidemiological
and disease data. Data were analyzed by using appropriate
descriptive, univariate, and multivariable logistic regression
methods. The mean age of participants was 2.8 years,
and 53% were male. The proportions of wasted, stunted,
and underweight children were 10.4%, 58.9%, and 32.7%,
respectively. The prevalence of intestinal parasitic infections
was estimated to be 52.8% (95% CI: 46.1; 59.4). Giardia
lamblia was the most common parasite, followed by Ascaris
lumbricoides, Blastocystis hominis, and Hymenolepis nana.
About 43% of the children were infected with a single parasite,
and 10% with multiple parasites. Age {Adjusted Odds Ratio
(aOR) = 1.5; 95% CI: 1.1; 1.9}, living in rented households
(aOR = 2.0; 95% CI: 1.0; 3.9) and a history of excessive crying
(aOR = 1.9; 95% CI: 1.0; 3.4) were significantly associated with
intestinal parasitic infections.
Outcome/ Intestinal parasites are highly prevalent in this setting, and poverty
effect was implicated as an important risk factor for infection. Effective
Figure 23.5: X-ray of hydatid disease of the lung. poverty reduction programmes and promotion of deworming
could reduce intestinal parasite carriage. There is a need for mass
campaigns to create awareness about health and hygiene.