Endgames Picture Quiz

A farmer with fever and right upper quadrant pain

BMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e3426 (Published 01 June 2012) Cite this as: BMJ 2012;344:e3426
  1. Vivek Chhaya, registrar in gastroenterology,
  2. Sanjay Gupta, consultant gastroenterologist
  1. 1Croydon University Hospital, Croydon CR7 7YE, UK
  1. Correspondence to: S Gupta sanjay.gupta{at}mayday.nhs.uk

A 22 year old Asian man presented with right upper quadrant pain and associated nausea, fever, and dark urine. He had worked as a farmer in Pakistan before moving to the United Kingdom in 2004. He was icteric with a 3 cm hepatomegaly. His blood tests showed a white blood cell count of 10.9×109/L (reference range 4.0-11.0), eosinophil count of 2.1×109/L (0.04-0.4), and a C reactive protein of 26 mg/L (0-5). His bilirubin was 105 µmol/L (<21 µmol/L), with alkaline phosphatase 220 U/L (30-130) and aspartate aminotransferase 101 U/L (0-32). He had no relevant medical history.

Despite treatment with broad spectrum antibiotics, he developed biliary sepsis with tachycardia and hypotension. He underwent various tests including imaging of his abdomen (fig 1).

Fig 1 Transverse magnetic resonance imaging scan taken through the upper abdomen


  • 1 What does the magnetic resonance imaging scan show and what is the probable diagnosis?

  • 2 How would you confirm the diagnosis?

  • 3 How is it acquired?

  • 4 What treatment options are available?


1 What does the magnetic resonance imaging scan show and what is the probable diagnosis?

Short answer

The scan shows large complex cystic lesions with multiple septations suggestive of daughter cysts. The most likely diagnosis is hydatid disease secondary to Echinococcus granulosus (fig 2).

Fig 2 Transverse magnetic resonance imaging scan showing two large cystic lesions (black arrowheads) in the liver with daughter cysts that are characteristic of hydatid cysts. The black arrow indicates the stomach and the white arrow indicates the liver

Long answer

Hydatid cysts are secondary to a parasitic infection caused by the cestode E granulosus.1 Molecular studies have identified 10 distinct genetic types (G1-G10), with the sheep strain (G1) being commonly associated with human infections.2 3 The …

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