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Giant hydatid cysts of the left lung: case report.

INTRODUCTION: Echinococcosis is one of the most important zoonotic diseases in the world. [123] It is endemic in sheep raising countries, notably Australia, New Zealand, South America, and MiddleEast. [1,2,3] It is caused by larval stages of various cestode (tape worm) species of the genus Echinococcus. [1,2] The dog is the optimum definitive host, and man is the intermediate host. [1,2] The lungs are the second most common site (15%) for hydatid cysts after the liver (75%). [4,5] Large hydatid cysts measuring 10cm or more is a special clinical entity called giant hydatid cyst. [4] Anaphylaxis is a life threatening complication of ruptured hydatid cyst. [1,2,3]

CASE HISTORY: We present a case of ruptured hydatid cyst of left lung with-out anaphylactic reaction in a 50-year-old lady, she presented in March 2010 with complaints of chest pain and palpitation of six days duration. CT scan of chest showed two well-defined oval cystic lesions in posterior basal segment of left lower lobe and suggested the possibilities of Bronchogenic cyst or Hydatid cyst. She was discharged with a clinical diagnosis of bronchogenic cyst. Three years later she was re-admitted with complaints of breathlessness, wheezing and cough with expectoration and reevaluation CT scan of chest showed classical sign of ruptured hydatid cyst (water lily sign) and increase in size of other cyst. Sputum culture and sensitivity showed isolated species of enterococcus. Echinococcus -IgG antibodies was positive (0.38 OD units). X-ray chest [Figure 1] and USG abdomen showed left sided pleural effusion. There was no evidence of endobronchial lesion on Fiber optic bronchoscopy and she underwent left lower lobectomy.

HISTOPATHOLOGICAL EXAMINATION:

GROSS: Specimen of left lower lobe of the lung weighing 400 grams. Two cysts were identified in the lung parenchyma. The larger one, which was intact measuring 16.5cm in diameter and the other ruptured cyst, was measuring 7cm in diameter. Both the cysts were lined by glistening pearly white membrane of thickness 0.2cm. 200ml of cyst fluid drained from the intact cyst and centrifuged for hydatid sand. [Figure 2]

MICROSCOPIC EXAMINATION: Sections from the both cysts showed outer laminated hyaline membrane the ecto cyst and inner granular germinal layer the endocyst, focally attached to the endocyst are brood capsules containing scolices within. [Figure 3] Cyst fluid drained for hydatid sand shows innumerable scolices with invaginated suckers and hooklets of Echinococcosis granulosus. [Figure 4] Interstitium was widened due to perivascular and peribronchial chronic inflammatory cell infiltrate.

FINAL DIAGNOSIS:

* Ruptured hydatid cyst of left lower lobe of the lung.

* Hydatid sand- numerous scolices with suckers and hooklets.

* Lung- interstitial pneumonia.

DISCUSSION: Pulmonary hydatid cysts most commonly appear in the lower lobe of the right lung (50%) and are usually solitary. [1,2,4,5] 40% in the left lung and 10% bilaterally. [4,5] Multiple cysts are found in the lung in 20-30% of patients. [4,5] The size of the cyst can reach up to 20cm due to a relatively higher elasticity of the lung tissue as compared with other tissues. [4,5] Anaphylaxis is a life threatening complication of hydatid cyst rupture and needs to be promptly diagnosed. [1,2,3] Computed tomography is the most sensitive means of diagnosing cyst rupture [1,2] and emergency surgery remains the only effective therapy for a ruptured hydatid cyst. [1,2,5,6] The present case was associated with Giant viable hydatid cyst and ruptured hydatid cyst without anaphylactic reaction. Following left lower lobectomy, patient improved well and she is under follow up. Albendazole is indicated for six months to reduce the risk of distant recurrence. [4,5,6,7]

CONCLUSION: This case is unusual due to its presentation as multiple unilateral giant viable hydatid cysts. Anaphylaxis is a common complication of ruptured hydatid cyst. Our case is unique and we would like to highlight that lower lobe cyst had ruptured without the life threatening complication of anaphylactic shock.

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DOI: 10.14260/jemds/2014/4105

REFERENCES:

[1.] Basavana GH, Siddesh G, Jayaraj BS, Krishnan MG. Ruptured Hydatid Cyst of Lung: Case Report. J Assoc Physicians India 2007 Feb; 55: 141- 5.

[2.] Shameem M, Akthar J, Bhargava R, Ahmed Z, Khan AN, and Baneen U. Ruptured Pulmonary Hydatid Cyst with Anaphylactic Shock and Pneumothorax. Respir Care 2011 June; 56 (6): 863-5.

[3.] Zapatero CD and Laterre FP. Ruptured hydatid cyst in a patient with shock. HepatobiliaryPancreat Dis Int 2009 December; 8 (6): 638-9.

[4.] Ghallab HN and Alsabahi AA. Giant viable hydatid cyst of the lung: a case report. J of medical case reports 2008; 2: 359.

[5.] Regal M, Jehani YA and Bousbait H. Bilateral ruptured pulmonary hydatid cysts: case report. Ann Trop Med Public Health 2012; 5 (3): 259-61.

[6.] Farahmand M and Yadollahi M. Echinococcosis-an Occupational Disease: case report 2010 April; 1 (2): 88-91.

[7.] Dakak M, Genc O, Gurkuk S, Gozubuyuk A and Balanli K. Surgical treatment for pulmonary hydatidosis: a review of 422 cases. J R CollEdinb 2002; 47(5): 689-92.

Nada Chettian Kandy (1), Muktha R. Pai (2), Reba Philipose T (3), Zulfikar Ahmed (4)

PARTICULARS OF CONTRIBUTORS:

(1.) Post Graduate Student, Department of Pathology, A. J. Institute of Medical Sciences, Mangalore, Karnataka.

(2.) Professor, Department of Pathology, A. J. Institute of Medical Sciences, Mangalore, Karnataka.

(3.) Professor, Department of Pathology, A. J. Institute of Medical Sciences, Mangalore, Karnataka.

(4.) Associate Professor, Department of Pathology, A. J. Institute of Medical Sciences, Mangalore, Karnataka.

NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Nada Chettian Kandy, Post Graduate Student, Department of Pathology, A. J. I. M. S, Kuntikana, Mangalore, Karnataka. E-mail: cknada@gmail.com

Date of Submission: 02/12/2014.

Date of Peer Review: 08/12/2014.

Date of Acceptance: 19/12/2014.

Date of Publishing: 29/12/2014.
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Article Details
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Title Annotation:CASE REPORT
Author:Kandy, Nada Chettian; Pai, Muktha R.; Reba, Philipose T.; Ahmed, Zulfikar
Publication:Journal of Evolution of Medical and Dental Sciences
Article Type:Clinical report
Date:Dec 29, 2014
Words:970
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