Atypical presentation of hydatid cyst with anchovy sauce liver aspirate

Background: Hydatid disease is a zoonotic parasitic infestation caused by cysts containing the larva stages of tapeworm of the genus Echinococcus. Cystic echinococcosis (CE) and alveolar echinococcosis are the two most important forms in humans. CE accounts for 95% of human infection and is usually a clear fluid cystic disease with the liver being the most frequently affected organ. Other organs that could be affected include the lungs, muscles, bone, spleen, heart, and brain. Case Presentation: We report a case of a 53-year-old man who presented with 5-week history of cough, 2-week history of abdominal pain, and 1-day history of difficulty with breathing. Examination revealed a middle-aged man in respiratory distress with tender hepatomegaly and features of bilateral pleural effusion. An abdominal ultrasound scan revealed cysts in both lobes of the liver. He also had elevated liver enzymes as well as eosinophilia. The patient could not afford to do a serological test for hydatid cyst. The patient had percutaneous liver aspiration which revealed an anchovy paste aspirate. We initially entertained the possibility of an amoebic liver abscess for which he had antibiotics for one month without any improvement. We eventually considered hydatid cyst as our diagnosis, and he made a remarkable improvement after the commencement of a therapeutic trial of albendazole. Informed consent was obtained from the patient for this case report. Conclusion: Hydatid cysts should be strongly considered as part of the differential diagnosis when in contact with any patient with cystic liver disease irrespective of the color or appearance of the liver aspirate.