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Chest X-ray in a hypertensive patient with stage 2 diastolic dysfunction/Evre 2 diyastolik disfonksiyonu bulunan hipertansif bir hastada akciger grafisi.

A 46-year-old woman presented with exertional dyspnea and leg swelling for 2 months. Her past medical history includes familial hyperlipidemia and uncontrolled hypertension for 6 years. She was evaluated for these complaints in another center. There was an opacity with regular contours at right lung middle lobe on her chest X-ray (Fig. 1). Electrocardiography revealed normal sinus rhythm with no abnormal changes. Transthoracic echocardiography showed left ventricular ejection fraction of 61%, left ventricular hypertrophy, mild mitral regurgitation, stage II left ventricular diastolic dysfunction and ratio of transmitral to septal myocardial flow velocities during early filling (septal E/e') equal to 10. Biochemical tests were within normal reference limits except brain natriuretic peptide (BNP) level of 215 pg/mL (N: 0-100 pg/mL). Therefore, thoracic computerized tomography (CT) was performed for differential diagnosis: There was a localized fluid collection in right major fissure with 20x22x32 mm diameters (Fig. 2), and reported as phantom tumor. Due to these findings, peroral diuretic treatment was initiated in that medical centre. After 2 weeks, control chest X-ray was performed (Fig. 3). So, the patient was admitted to our hospital with the same complaints. The physical examination was unremarkable. Her chest X-rays and thorax CT were evaluated again; no change in size of the mass was observed. Although its location is relevant for phantom tumor, there are no clinical symptoms and findings of heart failure. Fissural cyst hydatid was thought in differential diagnosis, but the test for ecchinococcus IHA was negative. Abdominal ultrasonography was performed and there was no cystic lesion in liver.

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What is your diagnosis?

1. Diastolic dysfunction

2. Tumor

3. Hydatid cyst

4. Local pleural liquid or empyema

doi: 10.5152/akd.2012.148

Right answer: 3. Hydatid cyst

Her chest X-rays and thorax CT were evaluated again. There was a cystic mass located at the right major fissure.

Albendazol treatment was initiated preoperatively. The patient was operated after 6 weeks of treatment. Cyst excision was performed with right thoracotomy and wedge resection. Per operative diagnosis was also cyst hydatid. There was no per operative complication occurred. The pathological specimen was showed lamellar cuticular membrane, active-chronic inflammation and fibrosis which were relevant for cyst hydatid diagnosis. The remaining hospital stay was uneventful and patient was discharged with albendazol treatment. Cyst hydatid, a clinical entity endemic in many sheep and cattle-raising areas, is still an important health problem in the world. Extra-pulmonary location of cysts in the thorax is rare. Cysts in pleural fissures were indeed attached by a thin pedicle to the visceral pleura (1, 2). Surgery to obtain a complete cure is the treatment of choice for most patients with intrathoracic but extra-pulmonary cysts; excision must be done without delay to avoid or relieve compression of surrounding vital structures (3). Distinguishing hydatid disease from other pathologies like phantom tumor may be extremely difficult, even with CT. Due to uncontrolled hypertension and diastolic dysfunction in our patient may cause to suspect from diastolic heart failure and cystic mass as phantom tumor. The clinical presentation of the patient, physical findings and imaging techniques like chest-X-ray, ultrasonography and CT may be helpful in correct diagnosis. In addition, surgical excision and pathological examination confirm the diagnosis in these patients.

References

(1.) McManus DPP Zhang W, Li J, Bartley PB. Echinococcosis. Lancet 2003; 362:1295-304. [CrossRef]

(2.) Eckert J, Deplazes P Biological, epidemiological, and clinical aspects of echinococcosis, a zoonosis of increasing concern. Clin Microbiol Rev 2004; 17:107-35. [CrossRef]

(3.) Miralles A, Bracamonte L, Pavie A, Bors V, Rabago G, Gandjbakhch I, et al. Cardiac echinococcosis. Surgical treatment and results. J Thorac Cardiovasc Surg 1994; 107:184-90.

Ugur Canpolat, Asena Gokcay Canpolat *, Necla Ozer

Departments of Cardiology and *Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara-Turkey

Address for Correspondence/Yazisma Adresi: Dr. Ugur Canpolat, Hacettepe Universitesi Tip Fakultesi, Kardiyoloji Anabilim Dali 06100, Sihhiye, Ankara-Tu'rk/ye Phone: +90 312 305 17 80 Fax: +90 312 305 41 37 E-mail: dru_canpolat@yahoo.com Available Online Date/Cevrimici Yayin Tarihi: 23.05.2012
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Title Annotation:Diagnostic Puzzle/Tanisal Bilmece
Author:Canpolat, Ugur; Canpolat, Asena Gokcay; Ozer, Necla
Publication:The Anatolian Journal of Cardiology (Anadolu Kardiyoloji Dergisi)
Date:Aug 1, 2012
Words:674
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