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Year : 2012  |  Volume : 55  |  Issue : 1  |  Page : 111-112
Unusual manifestations of pleuro-pulmonary hydatidosis


1 Department of Pathology (Cardiovascular and Thoracic Division), Seth G.S. Medical College and K. E. M. Hospital, Mumbai, India
2 Department of Radiology, Seth G.S. Medical College and K. E. M. Hospital, Mumbai, India

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Date of Web Publication11-Apr-2012
 

How to cite this article:
Vaideeswar P, Agnihotri MA, Hira P. Unusual manifestations of pleuro-pulmonary hydatidosis. Indian J Pathol Microbiol 2012;55:111-2

How to cite this URL:
Vaideeswar P, Agnihotri MA, Hira P. Unusual manifestations of pleuro-pulmonary hydatidosis. Indian J Pathol Microbiol [serial online] 2012 [cited 2019 Dec 7];55:111-2. Available from: http://www.ijpmonline.org/text.asp?2012/55/1/111/94878



   Case Reports Top


Case 1

A 20-year-old boy presented with left-sided chest pain, cough, and high grade fever since 15 days. Chest X-ray revealed massive left-sided effusion with shift to right. The patient was diagnosed empyema of tuberculous or bacterial etiology. He was treated symptomatically with intercostal drain; drain fluid was negative for acid fast bacilli. Subsequently, high resolution computed tomography (CT) showed cystic multi-septate lesion within the pleural space involving entire left hemithorax, causing complete lung collapse [Figure 1]a. Cystic lesions were not seen in the right lung or liver. The echinococcal indirect hemagglutination test was positive. The patient underwent left lung decortication. Multiple collapsible cysts [Figure 1]b, thick parietal pleura, and drained pus were sent for pathology examination. Microscopy showed typical laminated layered structure of hydatid cyst (HC) against the background of severe acute inflammation. A diagnosis of a purely intrapleural HC was made. Post-operatively, the patient was treated with albendazole for two months, and achieved complete clinical and radiological recovery.
Figure 1: (a) CT chest showing cystic lesions within the left pleural cavity with fluid collection (*). Note atelectasis of left lung (arrows); (b) Opalescent cysts delivered for the pleural cavity

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Case 2

A 19-year-old male had a nine-month history of low-grade fever off and on, persistent cough with mucopurulent expectoration, episodic hemoptysis, dyspnea on exertion, and chest pain. He was started on antituberculous therapy on the basis of heterogeneous opacity in left lung on chest X-ray. Following failure of clinical improvement, he was admitted in our hospital for re-evaluation. The computed tomography [Figure 2]a revealed 2 cm cavitatory lesion in superior segment of left lower lobe with features suggesting HC. Laboratory investigations, bronchoscopy, and pulmonary function tests were normal. Sputum for acid fast bacilli was negative. The indirect hemagglutination test for echinococcus antigen was positive. Left lower lobectomy was performed through a left thoracotomy with fifth rib resection. Grossly, left lower lobectomy specimen showed two HCs, 3 x 2 x 2 cm and 2.5 x 2 x 1.8 cm in the apical [Figure 2]b and posterobasal [Figure 2]c segments, respectively, accompanied by localized bronchiectasis and firm, hemorrhagic parenchyma. Surprisingly, both the cysts were present entirely within bronchi producing dilatation and transmural inflammation [Figure 3]. A diagnosis of endobronchial hydatidosis was made and the patient was discharged on appropriate anti-helminthic therapy.
Figure 2: (a) CT chest showing tubular bronchiectasis (arrow) in the superior segment of left lower lobe in relation to a nodule at the periphery; bisected left lower lobe showing hydatid cysts in the (b) apical segment and (c) posterobasal segment. Note presence of hemorrhagic consolidation with yellowish areas

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Figure 3: (a) Scanned whole mounted sections shows that both cysts are located entirely in the dilated bronchial lumens. Arrow shows the cartilaginous plates (Hematoxylin and eosin stain); Characteristic laminated membranes with inflammatory exudates present within the lumens of (b) the bronchus and (c) distal bronchiole. Note the presence of exuberant inflammatory response (Hematoxylin and eosin stain x 400)

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   Discussion Top


Hydatid cyst, known in times of Galen, is an anthropozoonosis produced in the intermediate hosts by the parasite Echinococcus granulosus. The lung is the second most organ involved (15% to 30% of hydatidosis) and results in asymptomatic or symptomatic pulmonary parenchymal disease. [1] In our review of 23 patients treated surgically for pulmonary hydatid cysts (PHC) in the last five years, 21 patients had intraparenchymal cysts; two of them had unusual locations, being purely intrapleural and endobronchial, respectively. In most instances, bronchopleural involvement is usually seen as features of complicated HC. Intrapleural cysts develop following the rupture of sub-pleural PHCs or by transdiaphragmatic spread from hepatic hydatidosis, and are seen in about 5% of patients. [2] It results in hydropneumothorax, pleural effusions, or even empyema or secondary cyst formation and patients present with dry cough, chest pain, dyspnea, malaise, and fever. [2] In the first reported case, the investigations did not reveal intraparenchymal pulmonary or hepatic cysts, thereby fulfilling the criteria of primary intrathoracic, extrapulmonary disease, which has an incidence of 1.5 to 7.4%. [3] Moreover, there was isolated intrapleural involvement and it was also noticed during operation that the visceral pleura of the collapsed left lung appeared intact, but focally covered by fibrinopurulent exudates. This location is even rarer (an incidence of 0.62% of thoracic echinococcosis) [3] and is often misdiagnosed due its rarity as multiloculated empyema (as in the first case) or even cystic pleural cancer. [4] Some patients, who manifest with vigorous cough, expectoration of a large amount of salty sputum or sudden and severe dyspnea, have a communicating rupture where the cyst breaks into an airway. [1] Such a bronchial fistulization is an example of complicated PHCs. Both the HCs in the second case were located entirely within the bronchial lumens, associated with transmural inflammation. There was no gross or histological evidence of previous intraparenchymal cyst. Such endobronchial locations are also exceedingly rare and can simulate endobronchial tumors. [5] This presentation, therefore, emphasizes the atypical manifestations of pleuropulmonary HCs, which is of importance to both clinicians and pathologists so that appropriate therapy (medical and/or surgical) can be instituted.

 
   References Top

1.Ramos G, Orduna A, Garcia-Yuste M. Hydatid cyst of the lung: Diagnosis and treatment. World J Surg 2001;25:46-57.  Back to cited text no. 1
    
2.Ozvaran MK, Ersoy Y, Uskul B, Unver E, Yalcin E, Baran R, et al. Pleural complications of pulmonary hydatid disease. Respirology 2004;9:115-9.  Back to cited text no. 2
[PUBMED]  [FULLTEXT]  
3.Gursoy S, Ucvet A, Tozum H, Erbaycu AE, Kul C, Basok O. Primary intrathoracic extrapulmonary hydatid cysts. Analysis of 14 patients with a rare clinical entity. Tex Heart J 2009;36:230-3.  Back to cited text no. 3
    
4.Singh J, Rana SS, Singh H, Sharma R, Sharma V. Multiple intrathoracic hydatids. Asian Cardiovasc Thorac Ann 2010;18:88-9.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Kilinc O, Doskaya M, Sakar A, Yorgancioglu A, Halilcolar H, Caner A, et al. Three atypical pulmonary hydatidosis lesions mimicking bronchial cancer from Turkey. New Microbiologica 2009;32:229-33  Back to cited text no. 5
    

Top
Correspondence Address:
Pradeep Vaideeswar
Department of Pathology (Cardiovascular and Thoracic Division), Seth G. S. Medical College and KEM Hospital, Parel, Mumbai - 400 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.94878

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  [Figure 1], [Figure 2], [Figure 3]



 

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