An 18-year-old female presented with complaints of generalized edema of three months duration in January 2008. She also had loss of appetite, low grade fever, and right-sided upper abdominal pain for the same duration. She did not have any discoloration of urine, joint pain, skin rash, or hair loss. She had no history of allergies, tuberculosis, or hypertension.
On admission to the hospital she had pallor and anasarca with ascites. She was afebrile with normal blood pressure. Her liver was enlarged and extended 4 cm below the costal margin in midcalvicular line. Liver was firm and tender. No other organomegaly was noted.
Urine was positive for protein on dipstick and contained red cells, pus cells, and proteinaceous casts. She was excreting 3.2 g of urinary protein in 24 hours. Renal function was normal. Her hemoglobin was 9.8 g/dL with normochromic, normocytic picture with no evidence of hemolysis. Her complete blood count was normal and autoantibody screen (antinuclear and antineutrophil cytoplasmic) was negative. The complement levels C3 and C4 were normal. The liver function was normal except for that serum albumin level was significantly low with a value of 1.8 g/dL and total protein was 4.3 g/dL. The serum cholesterol level was elevated and was 465 mg/dL.
Chest X-ray revealed a raised right hemidiaphragm. Renal ultrasound showed normal kidneys except for slightly increased echogenecity. Liver ultrasound showed fluid filled cavity of 9.3 x 8.1 cm with multiple cysts within it in the left lobe of liver. Ultrasound also revealed mild ascites. Serology for Echinococcus granulosus (IgG/IgM) was positive. Computed tomography (CT) scan of the abdomen showed an 11 x 10 x 6 cm cystic lesion with areas of rim calcification and few small cysts within it in the left lobe of liver which was extending into the lesser sac (Figure 1). Mild ascites were also noted. The above findings confirmed the diagnosis of hydatid disease of liver. The patient was subjected to renal biopsy as it was a nephrotic presentation. Renal biopsy revealed mesangial proliferation with acute on chronic tubulo-interstitial nephritis (Figures 2, 3). Electron microscopy was not done as there was no in-house facility.
Treatment was started with diuretics, albumin infusion, and high protein diet. The patient was also initiated with albendazole 400 mg twice a day. After three weeks of preparation, hepatic cyst resection was done. The laparotomy was uneventful and histopathological evaluation of the resected specimen confirmed the diagnosis of hydatid cyst.
Two weeks after surgery, the serum albumin had only marginal improvement to 2.2 g/dL and 24-hour urine protein excretion was 2.5 g. One month after surgery, the 24-hour urine protein excretion decreased to less than 1 g. Two months after surgery, the serum albumin level became 3.6 g/dL and 24-hour urine protein excretion became less than 300 mg. Follow-up urine examination and ultrasound was normal for one year after surgery, which confirmed good renal recovery and absence of residual hepatic Echinococcus disease. Albendazole was given for a total of twelve weeks. The patient was never treated with steroids or any other immunosuppressant.