Prof Sebastian Lucas

Case 11
• Male Turk, aged 29yr
• No past medical history
• Involved in a fracas at
Heathrow Airport, and
punched in the stomach
• Collapsed shortly after, in
shock
• Admitted to a liver unit,
and scanned – image
attached
Case 11
• Clinical diagnosis: ?liver cancer, ?what
• Taken to operating theatre and liver area
explored; bleeding and a cystic mass.
• Radiological angio-obliteration attempted, and
failed
• Needle core biopsy of liver lesion – this slide
• Follow-up: after supportive care and appropriate
chemotherapy, recovered and discharged
Diagnosis
• Typical scolices of Echinococcus
granulosus
• In the hepatic venules
• From a classical hydatid cyst in the liver
– Post-trauma
• Clinically anaphylactic shock from release
of antigen-rich cyst fluid
Collateral damage – ischaemic degeneration
Case 11
• Submitting pathologist’s diagnosis:
– Schistosomiasis
• Other small egg-like parasites in liver:
– Ascaris lumbricoides egg granuloma
– Clonorchis & Opisthorcis egg granuloma
– Enterobius vermicularis worm/egg granuloma
Schisto in liver
Liver Enterobius – eosinophilic necrotic
granuloma
Echinococcus life cycle
Hydatid cysts
E.granulosus
E.multilocularis (alveolar)
Contrasting imaging
E.granulosus
E.multilocularis
Contrasting pathologies
E.granulosus
Emultilocularis
How do pathologists diagnose
hydatid cysts?
•
•
•
•
•
FNA
BAL
Surgical biopsy
Surgical resection
At autopsy
Dead cysts – no scolices,
only laminated membrane
Case 10
Brain biopsy
Case 10
• Female 40yr
Ghanaian
• Presented
with
headache and
visual
disturbance
• Neuroimaging
showed a
cystic lesion
in the suprasellar space
Case 10
• Clinico-imaging diagnosis
= ?craniopharyngioma
• Biopsy of the lesion (unclear whether
completely removed or not) – this H&E
slide
• Thanks to Dr Leslie Bridges, St George’s
Hospital neuropathology.
Differential diagnosis
• Taenia solium
– Cellulose cysticercosis
• Obviously a larval
cestode
• Racemose cysticercus
• Proliferating larval
cestode NOS
• Taenia crassiceps
– Rodent host usually
• Taenia multiceps
– (coenurus cyst)
• But which one?
• …or none of these?
Cellulose cysticercus
And another one..
Coenurus
T.multiceps – multiple scolices in one
cyst
Taenia crassiceps in a patient with
Hodgkin lymphoma
Taenia crassiceps
Heldwein et al
Am J Trop Med Hyg
2006, 75:108-111
Lucas S et al
Abnormal development
of Hymenolepis nana larvae
in immunosuppressed mice
J Helminthology 1980
&
Lancet letter 1979
Differential diagnosis
•
Taenia solium
– Cellulose cysticercosis
•
Racemose cysticercus
• Typical location
• No scolices within
•
•
• But which one?
Proliferating larval cestode
NOS
Taenia crassiceps
– Rodent host usually
•
• Obviously a larval
cestode
Taenia multiceps
– (coenurus cyst)
• …or none of these?
Question of the hour
• Are racemose and
cellulose cysticerci:
– The same species
(T.solium) under
different host
circumstances?
• Location
• Immune response
– Different species?
• “Genetic similarity between
cysticerci of T.solium isolated
from human brain and from
pigs”
• Hinojosa-Juarez et al; Infect
Genet Evol 2008, 8:653-656
• Human or pig [Mexico]
• Cellulose or racemose
• = genetically identical
metacestodes of T.solium.
Life cycle of Taenia solium
CDC apeing ET?
Case 10: Follow up
• Cyst probably removed in toto
• Rx: praziquantel
• Hydrocephalus persisted
• V-P shunt inserted
• Intra-abdominal problems ?abscess