Broncho-Hepato-Cutaneous Fistula of Hydatid Origin

Recently, a 55-year-old afebrile female presented to the emergency department of our hospital with serous discharge from a small skin opening in the right hypochondrium. Her medical history included a by removal of a hydatid cyst from the right hepatic lobe laparotomy 16 y previously; since then, occasional discharge was noted. This time, a contrast-enhanced thoraco-abdominal computed tomography scan showed a 10×6-cm hypodense lesion of the right hepatic lobe compatible with abscess (Fig. 1A). Fistulography was carried out by injecting some non-ionic radiopaque contrast medium into the cutaneous opening, permitting the discovery of a communication among the skin, liver, and subsegmental bronchi of the right lower lobe (Fig. 1B). Analysis of the discharge was non-contributory, but serology was weakly positive for echinococcal antigens; a diagnosis of broncho-hepato-cutaneous fistula arising from a liver abscess of hydatid origin was made. Pondering the patient's otherwise good health and the potentially major complications deriving from an extensive resection (liver, lung, and skin), we opted for non-operative management, and the patient was dismissed with a 3-mo antihelmintic treatment course.

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FIG. 1.

Images of abscess. (A) Contrast-enhanced computed tomography scan of abdomen showing large intraparenchymal abscess of right hepatic lobe (within purple ring). (B) Fistulogram depicts broncho-hepato-cutaneous communication (bronchial filling can be observed inside purple ring).

Cystic echinococcosis of the liver is a form of parasitic disease that is endemic world-wide [1]. Generally asymptomatic, on occasion, it can manifest with complications. Rupture and fistulization into the biliary tract, bronchi, or skin are the complications described most frequently [1,2]. The development of a fistula arising from a liver abscess of hydatid origin communicating with the bronchi as well as the skin is a rare phenomenon, as only one previous case has been reported. In that instance, a 70-year-old febrile female was treated with thoracotomy and excision of the entire fistulous complex together with pericystectomy of the liver lesion [3]. In our case, considering both the absence of complaints apart from occasional discharge from the skin and the risk of potentially severe complications following major surgery, we opted for non-operative management. In fact, given its rarity, no standardized algorithm exists for the management of this type of complex fistula of hydatid origin [2,3].