Echinococcosis, a group of zoonoses caused by cestodes of the genus Echinococcus, is one of currently twenty neglected tropical diseases (NTDs) [1]. With an estimated loss of over one million Disability Adjusted Life Years (DALY’s) annually worldwide, it imposes a high burden on health [2, 3]. Parasitologically, an infected human is a dead-end intermediate host, disrupting the life cycle. Clinically, human echinococcosis presents predominantly in three forms, each requiring a different therapeutic approach. The fox tapeworm Echinococcus multilocularis causes the alveolar type, also endemic to Western Europe [4].

Many hydatid cysts remain asymptomatic, even into advanced age. Data from alveolar echinococcosis registries in Europe show that more than half of the patients are asymptomatic at diagnosis (56.2% in the FrancEchino registry in 2011-2021). ⁽⁵⁾

Vague abdominal (right upper quadrant) pain is the most common presenting symptom (30%) and can last for years before lesions develop.

Jaundice is the most common presenting symptom, especially China. Progressive gradual cancerlike onset of jaundice is observed in most cases that involve symptomatic cholestasis. Intermittent jaundice may also be associated with acute right upper quadrant pain when parasitic material migrates through the common bile duct. Hepatomegaly may be observed.

In the presence of bacterial superinfection, fever and chills may accompany gallstonelike symptoms. Fever and chills may also evoke liver abscess due to superinfection in the central periparasitic necrosis. 'Liver abscess-like' acute pain with or without fever may also reveal rapid growth of the lesions in the liver of immunocompromised patients. (6,7) 

Various symptoms, ranging from dyspnea and bile sputum to seizures and stroke, as well as bone pain or skin tumor, may be the presenting symptoms of a secondary location or metastasis of the parasitic lesions (approximately 10% of cases).

The diagnosis of cystic echinococcus is mainly made on the basis of clinical presentation and imaging and serologic studies. 

Despite the availability of various therapeutic options and the inherent risks (medical, percutaneous or surgical treatments), surgery remains the most frequently performed treatment, particularly in complicated or recurrent cases (8,9).
One of the primary challenges in managing CE is postoperative recurrence, defined as the appearance of new active cysts after surgical intervention. Its estimated incidence is 8% (95% confidence interval [95% CI] 6–10%) (10), and has been associated with factors, such as the presence of multiple cysts (11,12), larger cyst diameter [11, 13], evolutionary complications [12, 13], and the type of surgical procedure performed [14,15,16]. In addition, perioperative benzimidazole therapy is consistently recommended in clinical guidelines as a preventive measure; however, the certainty of evidence remains low and consistent effect estimates are lacking (17,18,19).

Percutaneous drainage PAIR described by Ben- Amour et al. (20,21). PAIR means the abbreviation of puncture, aspiration of cyst content, injection of hypertonic saline solution or ethanol 75%-95% and reaspiration of all fluid after 5 to 15 minutes. PAIR technique may be carried out by either only US guidance or US and Flouroscopy guidance in combination. PAIR is the preferred treatment for WHO-IWGE type CE1 and CE3a hepatic cysts.

Main indication for percutaneous treatment of liver CE cysts includes viable CE types such as CE1, CE2, CE3a and CE3b according to WHO classification.There is a direct relation between the type of liver CE

cysts and the percutaneous technique which will be employed. Therefore, CE1 and CE3a are treated by either PAIR or Catheterization techniques while CE2 and CE3b are treated by MoCaT technique.

The infected hydatid cysts are treated by percutaneous drainage and antibiotics like other liver abscesses (22). Recurrent hydatid cysts are also treated by percutaneous techniques (23). Suspected postoperative fluid collections are also treated bypercutaneous approach

Percutaneous treatment in the ruptured liver hydatid cysts into biliary system may be performed together with endoscopic interventions. In this case,a catheter is placed into the cavity of the ruptured cyst to the biliary system as a first step. On the second step, the patient is referred to gastroenterology for endoscopic intervention in order to clean main bile duct by a balloon catheter during ERCP after papillotomy.

The procedure is ended up with insertion of plastic stents into the main bile duct. By both intervention fistulae between CE cyst cavity and biliary system ceased in a short period of time. Surgery is and alter-

native option for these cases (24,25). The size, number or localization of the hydatid cysts in the liver are not deemed to be contraindications for percutaneous treatment. Any treatment is

unnecessary in patients with CE4 and CE5 liver hydatid cysts as these types are managed by ‘Wait and Watch approach (26) .

We report Two cases of hydatid infections have been documented an unusual clinical presentation of recurrent hydatid cyst of liver. A 33-year-old female patient presented to us with complaints of pain in abdomen for months. The patient gave history of being previously operated for hydatid cyst of liver 6 years back. His abdominal radiograph and computed tomography scan revealed a cystic lesion in the right lobe of liver. And a 44-year-old woman reported experiencing intermittent abdominal pain and discomfort over the past five months, primarily centered in the right upper quadrant his abdominal radiograph and computed tomography scan a subcapsular hydatid cyst with no signs of cyst rupture or secondary infection. The two patients managed by percutaneous drainage the so-called PAIR (Puncture, Aspiration, Instillation, and Reaspiration) technique and received chemotherapy for 6 months and the patient had a good recovery.

Case Report

Case 1 A 33-year-old female patient presented to my clinic complains of pain in abdomen for months. She was a housewife in a rural area

The patient living in rural area containing cats and dogs.

 She also stated that she had undergone surgery to remove a hydatid cyst from her liver six years prior.

On clinical examination, there was a scar in right subcostal region. A lump was felt in the right hypochondrium, which was tender on palpation. His ultrasonography abdomen revealed a hydatid cyst in right lobe of liver (Fig.A 1 )Computed Tomography (CT) scan of abdomen and chest was done which helped to exclude cases of tumors and other benign cysts. It showed a fairly well-defined rounded lesion with septae and multiple cysts in right lobe of liver. Size of the cyst was 13.5 × 11.0 cm. CT scan of chest showed no cystic lesions (Fig.A 2). His haemoglobin percentage was 13.2 gm/dl and total leucocyte count was 9.6 × 10⁹/L with no eosinophila. Liver function tests showed Total bilirubin was 0.8mg/dl with direct bilirubin 0.4 mg/dl    and indirect bilirubin 0.4 mg/dl. SGOT (46 IU/L), SGPT (25 IU/L) and Alkaline Phosphatase (86 IU/L) levels were normal. Following a radiological finding and past history of operative hydatid cyst the diagnosis recurrent of hydatid cyst was made and the patient was planned for hepatic cyst.

Informed consent was taken from the patient for percutaneous drainage called PAIR (Puncture, Aspiration, Instillation, and Reaspiration) technique. The patients are given Albendazole (10 –15 mg/kg/day) one week before the procedure for the aim of prophylaxis in order to reduce the risk of the abdominal dissemination [31]. patients fast overnight

for approx. 8 h before the procedure Done under  US ,Under local anaesthesia cyst is punctured as first step using a spinal needle  18 gauge  , second step CE cyst content is aspirated as much as possible. The amount which aspirated 350 ml then the third step injected the scolicidal agent as ethanol (90%) into the cyst cavity. The volume of these agents should be 30% of aspirated volume, ethanol should be kept within the cavity at 15 min is needed to follow separation of endocyst from adventitia (pericyst) which generally occurs within 15 min, then a last step respiration of the cyst fluid and after respiration, an ultrasound examination of the cyst is done to confirm complete detachment of the laminated membrane from the cyst wall. Before needle withdrawal, normal saline is installed into the cyst cavity. the needle is withdrawn after respiration of all the cyst content, Procedure success is defined if the laminated membranes are detached in toto, and the scolex viability test shows the scoleces in the reaspirated fluid are nonmotile on light microscopy and take up the color on vital dye staining. As figure (A 3 a,b)

figure (A 3a, b)

A routine abdominal ultrasound examination is performed within 24 h to observe cyst appearances and rule out any cyst leak, and if uneventful, the patient was discharged on a regime including Albendazole (10mg/kg/day) for 6 months, as it was a case with recurrence. He wase regular follow up from last 12months to the clinic. After three years there is no further recurrence and the patient has shown good recovery as figure (A 4)

Case 2 A 44-year-old woman reported experiencing intermittent abdominal pain and discomfort over the past five months, primarily centered in the right upper quadrant. Her medical history is notable for its lack of significant issues or known allergies. During the physical examination, mild tenderness was observed in the right upper quadrant, though she showed no signs of acute distress or rebound tenderness, indicating a non-urgent condition.

Ultrasound: Revealed a subcapsular hydatid cyst in the right liver lobe, approximately 6 cm in diameter. The cyst appeared to be near the liver capsule, raising concerns about the risk of rupture (Figure B 1).

CT scan: Confirmed the presence of a subcapsular hydatid cyst with no signs of cyst rupture or secondary infection. The liver is mildly enlarged, measuring 17 cm in the cranio-caudal direction. The parenchymal texture is homogeneous. A large cystic mass is seen in segments V and VI of the liver, measuring approximately 57.6×42.2 ×38.7 mm (Figure B 2). The lesion shows peripheral calcifications but no perifocal reaction. The interface between the liver and the suprarenal gland is normal. The portal venous system is normal in calibre, and intra-hepatic biliary radicles are not dilated. The porta hepatis is free of lymph nodes.

USG-guided catheter drainage of a right lobe hydatid cyst. The procedure involved insertion of an 18G LP needle into the cyst, with subsequent placement of an 18 Fr. The cyst contents were aspirated. Absolute alcohol was used as a scolicidal agent as ethanol (90%) to sterilize the cavity, followed by reaspiration after 15 minutes and repeated injection of ethanol and followed by reaspiration after 15 minutes for complete evacuation (Figure B 3). Sand samples taken pre- and post-procedure showed no motility, indicating successful treatment. The procedure was performed under aseptic conditions and was uneventful.

Follow-up imaging (ultrasound and CT) at 3- and 6-months post-procedure showed significant reduction in cyst size with no evidence of residual disease or complications.