Pulmonary hydatid cyst presenting as massive unilateral pleural effusion

Subrata Chakrabarti; Arabinda Patra; Priyankar Biswas; Kajari Mandal

doi:10.4103/2320-8775.146847

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CASE REPORT

Year : 2015 | Volume : 3 | Issue : 1 | Page : 20-22

Pulmonary hydatid cyst presenting as massive unilateral pleural effusion

Subrata Chakrabarti¹, Arabinda Patra¹, Priyankar Biswas¹, Kajari Mandal²
¹ Department of General Medicine, IPGMER, Kolkata, West Bengal, India
² Department of Pathology, IPGMER, Kolkata, West Bengal, India

Date of Web Publication

12-Dec-2014

Correspondence Address:
Subrata Chakrabarti
Department of General Medicine, Doctor Hostel, IPGMER, AJC Bose Road, Kolkata 700 020, West Bengal
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/2320-8775.146847

Abstract

Pulmonary parenchymal hydatid cysts are uncommon entities even in endemic areas. Extra-parenchymal intra-pleural hydatid cysts are even rarer. We report a case of a 42-year-old male who developed massive unilateral pleural effusion following rupture of intra-pleural hydatid cyst. The objective of this case report is to highlight upon this not so common cause of pleural effusion and assess the attendant complications and possible modes of management.

Keywords: Hydatid cyst, intra-pleural, pleural effusion

How to cite this article:
Chakrabarti S, Patra A, Biswas P, Mandal K. Pulmonary hydatid cyst presenting as massive unilateral pleural effusion . J Assoc Chest Physicians 2015;3:20-2

How to cite this URL:
Chakrabarti S, Patra A, Biswas P, Mandal K. Pulmonary hydatid cyst presenting as massive unilateral pleural effusion . J Assoc Chest Physicians [serial online] 2015 [cited 2022 Dec 4];3:20-2. Available from: https://www.jacpjournal.org/text.asp?2015/3/1/20/146847

Introduction

Hydatid disease is a zoonotic disease most commonly caused by larval stages of Echinococcus granulosus. Humans act as an accidental intermediate host. Infection is acquired by ingesting food or soil contaminated with eggs excreted from the canines, that is, the definitive host. Larval cysts may develop in almost every organ in primary Echinococcosis. The lung is the second most commonly affected organ after the liver. Pulmonary hydatid cysts usually remain asymptomatic until the time of rupture when the patient presents with productive sputum, hemoptysis, and fever. Or they may come to notice due to pleural effusion. Surgery or percutaneous aspiration remains the treatment of choice for hydatid cysts of the lung. ^[1],[2]

Case report

A 42-year-old nonsmoker, nonalcoholic Hindu male, farmer by occupation developed left sided chest pain and heaviness for last 4 months and low-grade intermittent fever for last 2 months. He also had occasional nonproductive cough during this period and had recently developed severe dyspnea. He had no history of antitubercular drug intake or any chronic respiratory diseases or diabetes mellitus or hypertension. General physical examination was within the normal limits. Respiratory system examination revealed diminished movement of the left side of the chest with shifting of trachea and heart to right side chest but no local swelling or tenderness. Percussion note was dull over left hemi-thorax. On auscultation, almost absent vesicular breath sounds side and diminished vocal resonance, with occasional coarse crackles were noted on the left chest.

Complete blood counts showed normal counts and hemoglobin; renal and liver function tests, serum electrolytes were also within normal limits. Sputum for acid-fast bacilli, pyogenic, and fungus samples were negative. Chest X-ray revealed complete homogenous opacity involving right sided chest with contralateral shifting of upper and lower mediastinum suggestive of massive pleural effusion [Figure 1]. Pleural fluid study showed muco-purulent whitish fluid with exudative nature and slight eosinophilic prominence. Therapeutic removal of fluid was done considering the significant dyspnea after which a repeat chest X-ray showed a large cystic lesion at basal part of the right lung [Figure 2]. A contrast-enhanced computed tomography (CT) of the chest revealed a cystic structure (10 cm × 10 cm) in the lower part of the right lung with thick, smooth wall and regular contrast enhancement of the walls with cystic attenuation but without any calcifications or significant lymph node enlargement [Figure 3]. The cyst was pleural based and showed secondary collapse of surrounding lung parenchyma.

Figure 1: (Initial chest X-ray on admission) Homogenous right sided opacity (massive pleural effusion) with mediastinal shift

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Figure 2: (Chest X-ray after pleural fluid drainage) Cystic structure in right lung base

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Figure 3: Thick, smooth walled contrast-enhanced pleural based cystic structure on contrast enhanced computed tomography thorax suggestive of pleural based hydatid cyst

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Echinococcal serology (antibody titer) by Eznyme-linked Immunosorbent Assay was positive in strong titers (1:4096). The patient underwent enucleation of the hydatid cysts with capitonnage as one-stage posterolateral thoracotomy. The cyst cavity was irrigated with hypertonic saline (14%) and cleaned with hydrogen peroxide and closed thereafter. Pleural biopsy samples sent for histopathology were supportive of echinococcal etiology. The patient was treated with albendazole 400 mg twice daily for 4 weeks followed by monthly follow-ups over 1 year. He was discharged in stable condition on 22 ^nd day of admission and follow-up at 3 months revealed complete resolution of symptoms. Follow-up with CT and X-ray showed regression and almost complete disappearance of the pleural cyst and serial hydatid antibody titers showed a progressive decline from 1/4096 to 1/32 (negative) after 1 year.

Discussion

Hydatid disease is still endemic in some parts of the world and is common, especially in the rural areas, attributed to the presence of sheep and dogs living in close contact with humans. Liver is involved in 75% of the cases, the lung in 15%, and other anatomical locations in 10%. ^[1] Most pulmonary cysts are located in the lower lobes (posterior > anterior). The distribution of the cysts is as follows: 50% of the cysts are localized in the right lung, 40% in the left lung, and 10% bilaterally. ^[2] They develop outside the visceral pleura, but inside the parietal pleura. Patients with uncomplicated hydatid cyst (including unruptured ones) in the lung are usually asymptomatic and diagnosed incidentally. Symptoms may be caused either by the enlarging size of cyst or more commonly if complications arise, by its rupture. Rupture may occur into the pericardium or mediastinum, the lung and bronchial tree, the pleural cavity, or the peritoneal cavity. ^[3] Cyst rupture may occur spontaneously or as a result of trauma. The patient then develops symptoms such as cough, chest pain, hemoptysis, fever, anaphylaxis, and expectoration of the cyst material (if ruptured into bronchus). Rupture of the cyst into the pleural cavity can cause effusion, empyema, and pneumothorax. The index patient presented with cough, dyspnea, and chest pain due to pleural effusion. Super-infection of the cysts can also happen (most commonly by Haemophilus influenzae). ^[4]

Diagnosis depends mainly on the imaging procedures supported by appropriate serology and often histopathology. CT is probably the best technique to elucidate the nature and location of the cyst, finding their relation with surrounding organs and thus evaluate the cyst preoperatively, and also to detect additional cysts, which are not seen on chest X-ray. Cyst density may serve to differentiate parasitic from nonparasitic cysts. ^[5] On the basis of density and clinical symptoms, hydatid cysts of the lungs can be classified as simple cysts, complicated cysts, and ruptured cysts (including cysto-bronchial communication). Inverse crescent sign, signet ring sign are commonly recognized as features of pulmonary hydatid cysts on CT. Pathognomonic features in ruptured or complicated hydatid cysts on CT include detached or collapsed endocyst membrane, collapsed daughter cyst membranes, and intact daughter cysts. ^[6] Though hydatid cysts of the liver commonly undergo calcification, it is rare for pulmonary or mediastinal hydatid cysts to develop calcification. Magnetic resonance imaging is probably better than CT scanning in the evaluation of postsurgical residual lesions and recurrences. ^[7],[8]

Percutaneous aspiration of a suspected hydatid cyst is generally not recommended because of the risk of an allergic reaction including systemic anaphylaxis, and because of the danger of the spread of the disease by spillage of the cyst's contents. However, Karawi et al. postulated that an anaphylactic reaction reaction occurs only if there is a direct contact between the fluid from the ruptured cyst and the circulation or if the patient is allergic to hydatid fluid. ^[9] Pleural fluid study may show eosinophilic predominance, and so hydatid disease should be included in the differential diagnosis of eosinophilic pleural effusions in endemic regions. ^[10]

Surgical treatment is mandatory in any ruptured or large cyst. The effective treatment of hydatid cysts in the lung is complete excision of the cysts with maximum preservation of the lung parenchyma. Additional medical treatment with albendazole should be carried out for high-risk group patients namely patients with ruptured cysts. ^[11] The role of antihelmintics is not clearly established, but there is evidence that they are capable of sterilizing cysts and curing some of them, though they are not always effective. But in the case of cyst rupture, the antihelmintic albendazole must be used in conjunction with surgical measures; doses of 10 mg/kg daily for 3-4 weeks may be necessary. There seems to be a strong case for their use in cyst rupture, perisurgically and where surgery is thought to be too risky. ^[12],[13]

Various approaches, including right and left thoracotomy, sternotomy, are known for mediastinal hydatidosis, depending on the location of the cyst in the thorax. Postero-lateral approach is commonly used as in this case. One-stage surgery is superior to classic two-stage approach as it decreases the morbidity, hospital stay and costs. ^[14] Intra-operatively, cyst management can either be radical, which includes segmentectomy, lobectomy, and pneumonectomy or a more conservative approach such a cystectomy and intact cyst enucleation or removal after needle aspiration. Although the gold standard is the radical removal of the germinative membrane and pericyst through the appropriate thoracic incision, a simple cystectomy will suffice in most instances with comparable results. ^[15],[16]

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