Purpose or Case Report: Hydatid cysts caused by larval infection with the tapeworm Echinococcus granulosus commonly affect the liver and lungs, although other organ systems may also be involved. Patients may be asymptomatic for years, presenting only when there is cystic rupture. We present the case of a 12-year-old male with no known prior medical history whose family immigrated from Afghanistan to the United States three years earlier. The patient arrived as a transfer to the emergency department (ED) with acute abdominal pain following blunt trauma. While playing soccer, he collided with another player, who landed on his abdomen. Upon arrival to the ED, he was febrile, tachycardic, and endorsed diffuse abdominal tenderness to palpation. He had no recent fevers, cough, congestion, nausea, vomiting, night sweats, or weight loss. He denied recent travel. Initial labs revealed mild leukocytosis with eosinophilia. Liver function tests and lipase were within normal limits. A contrast-enhanced abdominal-pelvic CT revealed a large, complex cystic structure centered in the right hepatic lobe, containing a peripheral membrane-like structure with evidence of internal hemorrhagic components extending into the peritoneum. Further interrogation with ultrasound confirmed the free-floating internal membrane, known as the “water lily” sign, which is highly specific for hydatid cysts. Using the World Health Organization classification, this was categorized as a CE 3A cyst. A follow-up MRI for drainage localization confirmed hemoperitoneum arising from the ruptured hydatid cyst, as well as peritoneal inflammation. We observed the expected MR features of a hydatid cyst with high T2 signal and low T2 internal debris, as well as overall low T1 mixed signal intensity. Ultrasound-guided percutaneous aspiration and alcohol ablation of the hepatic hydatid cyst was performed using catheter drainage. Fluid analysis demonstrated hooklets and protoscolices confirming the presence of Echinococcus spp. Morbidity and mortality related to echinococcosis is usually due to mass effect from enlarging cysts, which may result in organ disruption, or cyst rupture, potentially leading to anaphylaxis. This case highlights the incidental nature of hydatid cysts, which, although relatively easy to treat, often go undiagnosed until discovered by chance.
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