The Twinkling Trap: Mistaking Hydatid Cysts for Vascular Soft Tissue Masses

Hydatid disease is a parasitic infection that can mimic various pathologies on imaging, leading to diagnostic challenges. We present a case of a 37-year-old woman with chronic abdominal pain whose hepatic lesions were initially misinterpreted as vascular soft tissue masses due to the presence of twinkling artifacts on color Doppler ultrasound. Subsequent imaging with CT and contrast-enhanced MRI revealed characteristic features of hydatid cysts, including peripheral calcifications, internal membranes, and a T2 hypointense rim. Notably, the twinkling artifact was present even in lesions without calcification, likely due to rough internal surfaces, and was probe- and machine-dependent. This artifact, while useful in detecting small calcifications, may be misleading when mistaken for vascular flow, potentially leading to hazardous interventions like biopsy. This case underscores the importance of integrating multimodal imaging and using spectral Doppler to distinguish artifacts from true vascular signals, especially in endemic areas where hydatidosis should be a key differential.