Introduction:

Hydatid disease results from an infection due to the Echinococcus species, a microscopic tapeworm found in foxes, dogs and cats. Although human cases are rare, infection in humans results in cysts in the liver, lungs, brain and other organs. The disease is common all over India but especially in Kashmir.sacral hydatidosis is rare. No solid data for Ethiopian case.
Presentation of a case:

Sixty-four-year-old male presented with urinary incontinence, and difficulty of flatus control of 2weeks duration. No history of medical illness like tuberculosis or diabetes. Thoracolumbar spine MRI shows sacral encapsulated benign lesion with sacral hiatus involvement possibly chordoma and considering differential diagnosis of anterior meningocele. Surgery was done during which time daughter cyst was seen and sent for histopathology result showing sacral hydatid cyst. The recovery was promising but patient left follow up after 1 month.
Discussion:

Hydatid disease is disease of zoonosis and when it catches human being commonly affect liver and lung. It is too rare to involve sacral vertebrae. Patients went asymptomatic until disease erode and involve deep structures. Better to decompress surgically before and medical management with albendazole chemotherapy will be given. Chance of recurrence is still there though surgical or medical therapy or combined.
Conclusion:

It is wise to consider sacral hydatid disease in patients who present with bowel or bladder incontinence. And good to manage promptely unless complication is devastating aswell.  Follow up is manadatory since recurrence is high to occur.

Background:
Hydatid disease or hydatidosis is the most widespread, serious human cestode infection in the world. It is caused by echinococcus parasite and two species are known for human hydatidosis/echinococos granulosis and echinococcus alveolaris/. This parasite inhabits intestine of dogs,foxes,jackals etc then herbiborus domestic animals graze contaminated grasses and they will be infected. Humans get the parasite through contaminated foods by eggs of echinococcus. Then the parasite hatch mucosa of human intestine and enter to portal circulation then commonly affect liver and lung, less commonly brain, bones and heart. Skeletal hydatidoses occurs in 0.5–2%cases, half of which infest the spine. Among parts of vertebrae thoracic is the commonest to be infected and sacral is rare. I report case of sacral hydatid disease presented with bladder and bowel incontinence.
Case report:

This is 64-year-old male farmer patient from agaw midir presented with bladder and bowel incontinence of 2weeks duration. otherwise, no other complaint or breast swelling. Physically on per rectum examination he has lax anal sphincter otherwise no pertinent findings. Imagings(fig-1)

Open abdominal surgery done and cystic 6cm-4cm mass identified after reflecting peritoneum and rectum laterally attached to body of sacrum with lytic change and mass extended to sacral hiatus and encroached pelvic plexus but not pudendal nerve. Excision of mass done,during manipulation daughter cyst come out and consideration of hydatid cyst entertained and excisional biopsy sent for histopathology. The result showed sacral hydatid cyst. Patient put on albendazole chemotherapy regimen and he appeared for one month on surgical referral clinic with slight improvement on continence meanwhile he disappeared.

Discussion:

Hydatid disease is a zoonosis which predominantly affects liver and lung. Other organs are less commonly affected. In series of 29 cases of brain and spine hydatid cyst no sacral involvement identified. Among 25 case series of spine hydatidosis,3 cervical,11 thoracic,5 lumbar and 6 were sacral. In other case series only one was sacral one. Generally, the spinal hydatidosis was found to be extradural and most of the time involving vertebral body. In our case actually it is typical vertebral body involving one. Since there is no host reaction most of the time it grows large size being asymptomatic. If symptomatic the intial symptom is pain. Gibbus deformity does not occur and the neurologic finding is similar with disc disease or extradural tumor of spine. Hydatid disease of sacrum is not easily detectable and most case reports show delay in diagnosis for average of one year and one delayed up to 12 years, considering other differentials of spinal disease such as epidermoid, dermoid, teratoma, neuromeric and retrorectal cystic hamartoma) anterior sacral meningocele, necrotic sacral chordoma, schwannoma, arachnoid cyst, and aneurysmal bone cyst. In this case as well diagnosis was made post-surgical any of diagnostic tests has not considered diagnosis of sacral hydatid cyst disease.

The management of choice is both surgery and albendazole chemotherapy regimen, though not hundrend percent effective. Surgery is both therapeutic and diagnostic by excising tumor and relieve compression effect of the cyst. If bone is eroded more than 50% it needs stabilization. To decrease recurrence albendazole can be given before surgery, even it facilitates surgery by decreasing intra cystic pressure. Other than albendazole hypertonic saline can be injected during operation to the cyst as scolicidal agent. Despite of actions mentioned above the overall recurrence rate is 30-40%. Surgery can be done again and again for recurrence.
Conclusion:

For patients presented with lower back pain and devastating neurologic complications like incontinence, sacral hydatid cyst should be considered, and prompt management should be started though rare. Radiologists should consider as differential in sacral lytic lesions despite patients are asymptomatic which leads for early diagnosis.
Declaration:
Ethical approval has gained from ethical committee of injibara general hospital. Verbal Consent was taken from patient and he has allowed since it is important to teach and care other patients

Author’s contribution:

The author of this case report is the one who encounterd the patient at referral clinic and sent for better diagnostic imaging and then did surgery and reach to definitive diagnosis by giving chance for histopathology examination of excised mass. And followed the patient until it’s disappearance from follow up.

The author has written more than 4 case reports and is eager for new innovations aswell as contributing a little for medical dynamics. The author is both academician and clinician conducting prospective hospital-based research as well.

Acknowledgement:

I would like to thank a man who help INJIBARA GENERAL HOSPITAL to be established in such case dense strategic area. My gratitude goes to all IGH team from Guard to surgeon, especially SRC team, surgical ward team, operation room team.

Finally, I thank my family for their patiency while I give time for the research but little for them.