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Table of Contents
CASE REPORT
Year : 2019  |  Volume : 10  |  Issue : 2  |  Page : 108-110

Worm causing diabetes


1 Department of Medicine, Postgraduate Institute of Medical Education and Research, Dr. RML Hospital, New Delhi, India
2 Department of Biochemistry, Postgraduate Institute of Medical Education and Research, Dr. RML Hospital, New Delhi, India

Date of Submission26-Dec-2018
Date of Decision19-Feb-2019
Date of Acceptance08-Apr-2019
Date of Web Publication24-May-2019

Correspondence Address:
Prof. Ajay Chauhan
Postgraduate Institute of Medical Education and Research, Dr. RML Hospital, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/INJMS.INJMS_42_18

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  Abstract 


Hydatid disease or echinococcosis is one of the oldest known zoonotic diseases. Although known to be found in liver and lungs, these cysts are rarely found in the pancreas. We report a patient who not only had hydatid cyst in the pancreas but also pancreatitis and subsequently diabetes because of it.

Keywords: Diabetes, echinococcosis, pancreatitis


How to cite this article:
Singh A, Chauhan A, Singh A, Goyal P, Jain P. Worm causing diabetes. Indian J Med Spec 2019;10:108-10

How to cite this URL:
Singh A, Chauhan A, Singh A, Goyal P, Jain P. Worm causing diabetes. Indian J Med Spec [serial online] 2019 [cited 2019 Jun 26];10:108-10. Available from: http://www.ijms.in/text.asp?2019/10/2/108/258992




  Introduction Top


Cystic echinococcosis is a zoonosis caused by adult or larval stages of cestode parasites belonging to the genus Echinococcus and the family Taeniidae and phylum Platyhelminthes. Humans act as an accidental intermediate host. The liver and lungs are the organs most often (90% of cases) involved in human echinococcosis. Pancreatic involvement by hydatid cyst is rare (<0.2%).[1],[2] Pancreatitis caused by hydatid cyst is even rarer.[3],[4],[5] We hereby report a case of a young man who presented with acute on chronic pancreatitis associated with hydatid cyst. On subsequent evaluation, he was found to have associated diabetes.


  Case Report Top


A 30-year-old male, auto-rickshaw driver by occupation, presented with complaints of pain in the abdomen and multiple episodes of vomiting for 7 days. The pain in the abdomen was in the epigastric region and nonradiating. The pain was dull and boring in nature. The patient had a history of similar pain in the abdomen (although less severe in intensity) along with occasional fever on and off for the past 8 months. The patient was afebrile for the past 20 days. The patient was a nonalcoholic and a nonsmoker. There was no significant family history. The patient's parents and none of the patient's siblings (brothers aged 55 and 38 years and sister aged 27 years) had diabetes. On examination, the patient was thin built with a body mass index of 22.6 kg/m2. On per abdominal examination, tenderness was present in the epigastric region. Bowel sounds were diminished. There was no shifting dullness or organomegaly. Rest of the systemic examination was normal.

The patient had hemoglobin of 11.9 g/dl, with a total leukocyte count of 7000/mm3 and a platelet count of 1.7 lakh/mm3. Random blood sugar, kidney function tests, and serum electrolytes were normal. Serum amylase (592 U/L) and serum lipase (69.75 U/L, normal range: 0–64 U/L) levels were raised. Erythrocyte sedimentation rate (38) was raised. Alkaline phosphatase level was increased (244 U/l). Serum calcium and lipid profile were normal. Ultrasound of the abdomen showed anechoic cystic lesion at the porta hepatis (suggestive of hydatid cyst). Contrast-enhanced computed tomography (CECT) of the abdomen was suggestive of acute or chronic pancreatitis with a cystic lesion in the pancreatic head (12.3 mm × 12.2 mm) [Figure 1]. The pancreas appeared diffusely bulky and hypoechoic with focal areas of calcification seen in the region of the head and uncinate processes. Echinococcosis serology (enzyme-linked immunosorbent assay [ELISA] immunoglobulin G) was done which was positive, i.e., 0.7 OD (normal – 0.3 OD). In urine examination, it showed sugar positive with ketones positive. In view of sugar positive in urine examination, fasting blood sugar of the patient was done which was 137 mg/dl. Oral glucose tolerance test (75 g of glucose) showed values of 213 mg/dl and 214 mg/dl (at 1 h and 2 h). HbA1c was 10.74%. His fasting serum insulin levels were 8 IU/ml (normal: <25), and fasting serum C-peptide levels were 0.4 ng/ml (normal: 0.8–3.1 ng/ml).
Figure 1: Contrast-enhanced computed tomography of the abdomen showing hydatid cyst of the pancreas (arrow)

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After all these investigations, we concluded that hydatid cyst led to acute on chronic pancreatitis. Owing to underlying chronic pancreatitis and high HbA1c, we inferred that the patient has pancreatitis-induced diabetes.

The patient was treated for acute pancreatitis. His blood sugars were monitored and treated with injectable insulin (injection Human Mixtard). For hydatid cyst, the patient was treated with oral albendazole. In view of the location of cyst in the head and uncinate process and areas of calcification along with features suggestive of chronic pancreatitis, surgery was avoided in our case, and he was medically managed. The patient's pain subsided and serum amylase levels settled in 7 days. The patient was treated with oral albendazole for 6 months, and on follow–up, the patient did not show any clinical features of pancreatitis, and his blood sugars were controlled on injectable insulin.


  Discussion Top


Hydatid disease is caused by the cystic stage of Echinococcus granulosus. Dogs act as definitive hosts. Infection begins when the animal eats offal that contains hydatid cysts. The swallowed cysts burst, and the tapeworm heads travel to the gut and attach themselves to the intestine wall. Each mature worm grows and sheds the last segment of its body about every 2 weeks. This last segment contains immature eggs. The eggs are passed from the animal's body in feces and may stick to the animal's hair or contaminate the vegetable garden. Humans act as an intermediate host by accidental ingestion of Echinococcus eggs coming from the feces of infected dogs. The eggs of the parasite can penetrate the intestinal wall, enter the portal system, and then reach various organs.[6] They form watery cysts full of tapeworm heads known as hydatid disease or echinococcosis. Most hydatid cysts occur in the liver (59%–75%), followed in frequency by the lung (27%). Involvement of the kidney (3%), bone (1%–4%), and brain (1%–2%) is rare. Other sites, such as the heart, spleen, pancreas, and voluntary muscle, are very rarely involved.[1] The reported incidence of hydatid cyst of the pancreas is 0.2%. Pancreatic infestation of Echinococcus is mainly by hematogenous dissemination, local spread via the pancreatobiliary ducts, and peripancreatic lymphatic invasion. The hydatid cyst of the pancreas is most commonly located in the head (57%), followed by the body (24%–34), and then tail (16%–19%). Clinical presentation varies according to the anatomic location and complications of the cyst (e.g., infection, rupture, biliary or intestinal fistula, segmental portal hypertension, vascular thrombosis, and acute or chronic pancreatitis).[7] Two hypotheses are postulated for pathogenesis of pancreatitis by hydatid cyst: main pancreatic duct compression caused by the cyst itself[8] and main pancreatic duct obstruction by hydatid scolices' migration from the hydatid cyst.[9],[10]

Although imaging is the primary modality of diagnosing cysts, ELISA is used to differentiate a hydatid cystic lesion from other cystic lesions in the pancreas, with a specificity of 85% and a sensitivity of 90%.[11] Ultrasonography (USG) is a useful tool for diagnosis, treatment, and follow-up of patients with hydatid cysts. CT is indicated in cases in which USG fails.

Ahmed et al.[12] reported a case report of a 40-year-old female who presented with epigastric pain for 3 months. USG and CECT revealed a 55 mm × 57 mm cystic structure in the pancreatic body. During open surgical exploration, it was found to be a hydatid cyst. Postoperative ELISA for echinococcal antigen was positive, similar to our case.

Shah et al.[13] reviewed records of all patients treated for hydatid disease from January 2000 to January 2010 in the Department of Surgical Gastroenterology at Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India. During this 10-year period, a total of 340 patients with hydatidosis were treated, only six (1.8%) of whom had isolated hydatid disease involving the pancreas. Indirect hemagglutination and ELISA tests were positive for the presence of specific hydatid antibodies in four patients.

Treatment may be conservative or radical. Treatment options depend on the location of the hydatid cysts. Hydatid cysts in the tail of the pancreas have been successfully treated with distal pancreatectomy, whereas cysts in the body and head of the pancreas have been treated with proper evacuation, pericystectomy, and omentoplasty.[14] Conservative procedures aim at sterilization and evacuation of cyst content, including the hydatid membrane (hydatidectomy) and partial removal of the cyst. The evacuation and hydatidectomy consist of puncture of cyst and aspiration of part of the content to permit introduction of scolicidal agent and total aspiration (PAIR) thereafter. The risks are anaphylactic shock and chemical cholangitis.[15]

Two benzimidazole drugs, mebendazole and albendazole, are the only antihelminthics effective. Albendazole is more effective than mebendazole. The standard regimen is using three cycles of 1 month with a break of 14 days between courses,[16] but it is no longer recommended. Continuous treatment is recommended. The dose of albendazole is 15 mg/kg which is divided into 2 doses/day. The treatment has to be monitored according to the size of cyst on USG of the abdomen. The treatment can be continued up to 6 months. With albendazole, apparent cure in as many as 30% of patients has been observed with further 40%–50% of patients showing objective evidence of response when observed short term.

WHO Informal Working Group on Echinococcus classification [Table 1] of hydatid cysts (HCs) has important consequences on treatment decision-making and is widely accepted.
Table 1: WHO classification suggested practice by cyst stage

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  Conclusion Top


Hydatid cyst of the pancreas is extremely rare. Isolated involvement of the pancreas by hydatid cyst is even more unusual. Pancreatitis associated with hydatid cyst is a rare etiology of pancreatitis. Radiological examinations may help clinicians in diagnosing cystic masses in the pancreas and help in the detection of hydatid cysts. Surgical treatment is the main modality of treatment for hydatid cyst. Hydatid cyst is a treatable disease and should be kept in mind as one of the rare causes leading to pancreatitis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

None.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Dziri C. Hydatid disease – Continuing serious public health problem: Introduction. World J Surg 2001;25:1-3.  Back to cited text no. 1
    
2.
Khiari A, Mzali R, Ouali M, Kharrat M, Kechaou MS, Beyrouti MI. Hydatid cyst of the pancreas. Apropos of 7 cases. Ann Gastroenterol Hepatol (Paris) 1994;30:87-91.  Back to cited text no. 2
    
3.
Sebbag H, Partensky C, Roche J, Ponchon T, Martins A. Recurrent acute pancreatitis from the rupture of a solitary pancreatic hydatid cyst into Wirsung's canal. Gastroenterol Clin Biol 1999;23:793-4.  Back to cited text no. 3
    
4.
Augustin N, Gamstätter G, Neher M, Schreyer T, Störkel S. Echinococcus cysticus of the pancreas in the clinical picture of acute pancreatitis. Chirurg 1984;55:661-4.  Back to cited text no. 4
    
5.
Katkhouda N, Legoff D, Tricarico A, Castillo L, Bertrandy M, Mouiel J. Hydatid cyst of the pancreas responsible for chronic recurrent pancreatitis. Presse Med 1988;17:2021-3.  Back to cited text no. 5
    
6.
Zhou RX, Hu HJ, Ma WJ, Jiang Y, Li FY. Alveolar echinococcosis in the head of pancreas: A case report. Medicine (Baltimore) 2018;97:e0072.  Back to cited text no. 6
    
7.
Hammad A, Mentouri B. Acute pancreatitis in Algeria. Report of 221 cases. Am J Surg 1985;149:709-11.  Back to cited text no. 7
    
8.
Ozmen MM, Moran M, Karakahya M, Coskun F. Recurrent acute pancreatitis due to a hydatid cyst of the pancreatic head: A case report and review of the literature. JOP 2005;6:354-8.  Back to cited text no. 8
    
9.
Pouget Y, Mucci S, O'Toole D, Lermite E, Aubé C, Hamy A. Recurrent acute pancreatitis revealing a hydatid cyst of the pancreas. Rev Med Interne 2009;30:358-60.  Back to cited text no. 9
    
10.
Diop SP, Costi R, Le Bian A, Carloni A, Meduri B, Smadja C. Acute pancreatitis associated with a pancreatic hydatid cyst: Understanding the mechanism by EUS. Gastrointest Endosc 2010;72:1312-4.  Back to cited text no. 10
    
11.
WHO Informal Working Group. International classification of ultrasound images in cystic echinococcosis for application in clinical and field epidemiological settings. Acta Trop 2003;85:253-61.  Back to cited text no. 11
    
12.
Ahmed Z, Chhabra S, Massey A, Vij V, Yadav R, Bugalia R, et al. Primary hydatid cyst of pancreas: Case report and review of literature. Int J Surg Case Rep 2016;27:74-7.  Back to cited text no. 12
    
13.
Shah OJ, Robbani I, Zargar SA, Yattoo GN, Shah P, Ali S, et al. Hydatid cyst of the pancreas. An experience with six cases. JOP 2010;11:575-81.  Back to cited text no. 13
    
14.
Safioleas MC, Moulakakis KG, Manti C, Kostakis A. Clinical considerations of primary hydatid disease of the pancreas. Pancreatology 2005;5:457-61.  Back to cited text no. 14
    
15.
Vaquerizo A, Sola JL, Bondía A, Opla JM, Madariaga MJ. Intraoperative hydatid anaphylactic shock. Rev Esp Anestesiol Reanim 1994;41:113-6.  Back to cited text no. 15
    
16.
Gil-Grande LA, Rodriguez-Caabeiro F, Prieto JG, Sánchez-Ruano JJ, Brasa C, Aguilar L, et al. Randomised controlled trial of efficacy of albendazole in intra-abdominal hydatid disease. Lancet 1993;342:1269-72.  Back to cited text no. 16
    


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