Giant pulmonary and hepatic hydatid cysts in a child

Case history

An eight-year-old boy from a rural region of Western Romania was admitted to hospital with suspicion of pulmonary tuberculosis. The information obtained from his parents revealed a modification of the child's general condition from the previous two weeks – he presented with fatigue, a productive cough and dyspnoea. After admission, his general condition worsened and he became afebrile, presenting with a loss of appetite and coughing fits with abundant expectoration. The physical examination revealed: chest asymmetry with bulging of the left hemithorax; normal lung sounds in the right hemithorax and superior third of the left hemithorax; sub-dullness at the percussion of the medium third of the left hemithorax; vesicular murmur present in the superior third; reduced murmur in the medium third and abolished in the inferior third of the left hemithorax; dyspnoea (thoracic breathing) with polypnea (40–42 breaths/min); a supple abdomen, painful in the right hypochondrium both spontaneously and at palpation; and liver palpable and painful 4 cm under the ribcage.

The chest X-rays (front and left lateral views: Figure 1A and B) showed a bulging left hemithorax with enlarged intercostal spaces, the trachea and heart displaced to the right, intense homogenous opacity of the entire left hemithorax and faded costodiaphragmatic sinus. The abdominal ultrasound examination indicated a cystic and partially calcified image in the liver. On admission, the laboratory tests indicated increased erythrocyte sedimentation rate (ESR) (100 mm/1 h) and positive immunoglobulin (IgG) antibodies against Echinococcus granulosus (index of 1.37). A diagnosis of giant pulmonary hydatid cyst and hepatic hydatid cyst was established.

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Figure 1

Chest X-rays of (A) front view (before surgery), (B) lateral view (before surgery), (C) front view (after surgery) and (D) lateral view (after surgery)

Shortly after admission, the patient's general condition worsened and physicians noticed a generalized maculopapular eruption (allergic skin reaction), polypnea with a respiratory frequency of 42 breaths/min, tachycardia at 104 beats/min, cyanosis of the lips (accompanied by oedema of the upper lip) and limbs and absence of the vesicular murmur in the inferior half of the left hemithorax.

Therapy included of hydrocortisone hemisuccinate (3 × 15 mL/day intravenous in 1000 mL glucose 5% infusion for 7 days) and albendazole (1 vial of 0.4 g/10 mL per day, orally, for 7 days). After the administration of the treatment the urticaria totally regressed and the patient continued to have productive coughing fits with mucous expectorations, as well as dyspnoea with thoracic breathing.

The surgical intervention that removed the pulmonary cyst consisted of a cystectomy. The postsurgical therapy again included hydrocortisone hemisuccinate and albendazole in the same dosage.

The chest X-rays (front and left lateral views: Figure 1C and D) performed after the surgical intervention revealed a cavitary image (with a well-defined wall and hidroaeric level) localized in the inferior two-thirds of the left hemithorax (inferior lobe), with a drainage tube posted in the bottom of the posterior costodiaphragmatic recess.

The post-surgical evolution was favourable and the patient became afebrile, with an ameliorated appetite and a good general condition. He was discharged from the hospital with recommendations for follow-up therapy with albendazole and future surgical removal of the hepatic hydatid cyst.

Discussion

In contrast to adults, where the liver is the prevailing location for hydatid cysts, in children the lung is the main site for the development of the parasite's larval forms. ¹ It has also been shown that the combination of hepatic and pulmonary hydatid cysts occurs more frequently in children than in adults (16% versus 4%). ²

Conclusion

This is a case of a patient suffering from one of the most important parasitic zoonoses in Romania ^3,4 and is illustrative of how this kind of disease can affect the young and the negative consequences of this illness on children's health and development as a result of prolonged hospitalizations, surgical interventions and chemotherapy.

Authors' declarations: The authors declare that they have no conflicts of interest and that there were no funding sources. The guarantor for this paper is Raul Neghina MD, PhD. All the authors were involved in the development of the manuscript and approved the final version.