Water Lily and Snake Signs

A 55-year-old Kashmiri woman who presented with right upper quadrant pain was referred to our center with a diagnosis of complex cystic space occupying lesion in segment VII of liver on ultrasonography elsewhere. She denied fever, jaundice, weight loss, gastrointestinal bleeds, or alcohol and drug abuse and did not suffer from chronic comorbid conditions. Clinical examination was positive for mild pallor and firm non-tender hepatomegaly. Laboratory tests revealed normocytic normochromic anemia with hemoglobin 9.4 g/dL and normal liver and renal function tests. Tumor markers such as alpha-fetoprotein, carcinoembryonic antigen, and CA 19-9 were within normal limits. Serology for hydatid disease (immunoglobulin G) was positive. Ultrasonography at our institute revealed a complex cystic lesion in the liver with floating membranes (water lily sign; Figure 1). Magnetic resonance imaging revealed a well-defined 7.5cm T1 hypointense and T2 hyperintense cystic lesion containing undulating collapsed membranes (snake sign) consistent with Gharbi Class II cyst (Figure 2). She was offered surgical resection but chose chemotherapy with albendazole and is currently on follow-up without symptoms.