Abstract
The management of a pulmonary echinococcal cyst consists mainly of medical treatment with a scolicidal agent such as albendazole and surgical extirpation. Rarely, a pulmonary cyst may rupture into a bronchus and be spontaneously expelled. This may result in seeding elsewhere in the bronchial tree, or even the alimentary tract, but occasionally, as in our case, may result in a cure.
Case report
A 15-year-old boy presented with insidious onset right upper chest pain and cough with streaky haemoptysis of three months’ duration. The pain worsened with bending forward and on coughing, and was relieved by lying on his right side. He had a weight loss of 3 kg. There was no history of fever, dyspnoea or chest wall trauma. He worked on a rural farm and was in close company of dogs.
A chest radiograph showed a homogeneous oval mass with ill-defined margins in the right upper lobe (RUL). Subsequently, contrast-enhanced thoraco-abdominal computed tomography revealed multiple cystic lesions with suggestions of membranes and surrounding ground glass opacities in the RUL. The lesion was in close communication with a bronchial branch, and an air crescent sign was seen within the lesion (Figure 1a and 1b). Multi-loculated cystic lesions were also seen in the liver. Hydatid serology, enzyme-linked immunosorbent assay for IgG, was positive (5.34; normal < 0.9). Sputum for acid-fast bacilli was negative. Oral albendazole treatment was commenced and the patient scheduled for right upper lobectomy. However, two days before the date of surgery, he developed an acute-onset fever, an intense cough and expectoration of purulent material mixed with blood and whitish membranes. A repeat chest radiograph showed total disappearance of the previously obvious opacity (Figure 1c). Albendazole treatment was continued for one whole month.
(a, b) Contrast-enhanced chest CT showing multiple cystic lesions with suggestions of membranes (arrow) and surrounding ground glass opacities, one of the segmental branches of RUL in close communication with the lesion with possible cytobronchial communication and air crescent sign within a lesion (arrow head). (c) Follow-up chest X-ray.
Discussion
Pulmonary hydatidosis is the second most common affected site (20–40%) of the disease. Simultaneous liver and lung involvement is seen in up to 25% of cases.1–3 Children and young adults are more commonly affected. Lung involvement may remain asymptomatic for years. Infection or bleeding into a cyst, or acute hypersensitivity reactions, may provoke symptoms. Rupture into a bronchus will result in an intense cough, often with expectoration of hydatid cyst contents. This may be life-threatening owing to anaphylactic shock or airway obstruction. 1
Spontaneous cure of echinococcosis may occur if there is complete expulsion of the fluid and membrane,4,5 although follow-up is necessary in case of unnoticed seeding of the bronchial or alimentary tree and, in our case, of simultaneous hepatic lesions.
Footnotes
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.