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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 3  |  Issue : 2  |  Page : 137-140

Hydatid lung disease presented with multiple pulmonary nodules


Department of Respiratory, Critical Care and Sleep Medicine, Indraprastha Apollo Hospitals, New Delhi, India

Date of Web Publication29-Feb-2016

Correspondence Address:
Chand Trilok
B- 241, Sarita Vihar, New Delhi - 110 076
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2348-3334.177639

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  Abstract 

Hydatid disease is a parasitic infection caused by a tapeworm of the genus Echinococcus. Our case is a 36-year-old female patient from Afghanistan who presented with paroxysmal cough since 2 years and breathlessness with weight loss since 1 month. The patient underwent routine hematological investigations, chest X-ray, and bronchoscopy. After taking the sample, patient was asked to follow-up in the outpatient department but she came into the emergency department after 10 days with increased symptoms. The patient was given supportive treatment and on thorough investigations, she was diagnosed to have disseminated pulmonary hydatidosis with pleural effusion. She was successfully treated with intercostal chest tube drainage and albendazole.

Keywords: Albendazole, Echinococcus, hydatid disease, multiple pulmonary nodules, pleural effusion


How to cite this article:
Trilok C, Avdhesh B, Aanchal T. Hydatid lung disease presented with multiple pulmonary nodules. CHRISMED J Health Res 2016;3:137-40

How to cite this URL:
Trilok C, Avdhesh B, Aanchal T. Hydatid lung disease presented with multiple pulmonary nodules. CHRISMED J Health Res [serial online] 2016 [cited 2019 Oct 21];3:137-40. Available from: http://www.cjhr.org/text.asp?2016/3/2/137/177639


  Introduction Top


Hydatid disease was first described by Thebesius in the 17th century and Rudolphy (1808) first used the term hydatid cyst to describe echinococcosis in humans.[1] It is a chronic parasitic zoonotic infection of Echinococcus granulosus and endemic in the cattle and sheep-raising areas. The life cycle of echinococcosis is completed in definitive host and an intermediate host, humans are only accidental host.

Pulmonary symptoms are nonspecific, such as a cough, chest pain, and hemoptysis and are attributable due to compression of lung tissue by cysts and anaphylaxis due to a ruptured cyst.[2],[3] Diagnosis is based on clinico-radiological findings as well as serological diagnosis. The multiple pulmonary nodules as a radiological finding of hydatid disease are uncommon; our case was presented with nonspecific chest symptoms and multiple pulmonary nodules in high-resolution computed tomography (CT) of chest and she was diagnosed as hydatid disease. Patients with the hydatid lung disease can be managed medically and/or surgically, though the first treatment of choice is surgery.


  Case Report Top


A 36-year-old Afghani female presented to us with chief complaints of paroxysmal cough for 2 years, shortness of breath for 1 month, and 3 kg weight loss in last 1 month. There was no history of fever, chest pain, and hemoptysis.

On examination, she was found to be average built, conscious, oriented and alert, and vitals were stable. Her oxygen saturation was 98% on room air and chest auscultation was normal.

Her routine blood investigations found normal. Patient's chest X-ray (CXR) and CT-chest revealed bilateral nodular shadows [Figure 1] and [Figure 2]. Patient's bronchoscopy with bronchoalveolar lavage (BAL), transbronchial lung biopsy (TBLB), and transbronchial needle aspiration (TBNA) were performed, and she was asked to review after 5 days with reports.
Figure 1: Chest X-ray shows bilateral multiple round shadows

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Figure 2: High-resolution computed tomography chest shows bilateral multiple nodules and cavitation

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The patient presented to the emergency department after 10 days with right-sided chest pain and increased breathlessness with 3 episodes of hemoptysis. On examination, there was reduced breath sounds on the right side and few basal crepitations at the right base.

Her investigations revealed high total leucocyte counts-14,500/cmm and CXR showed right-sided pleural effusion with bilateral cysts and nodular shadows [Figure 3]. Patient's follow-up TBLB and TBNA reports were inconclusive, but the BAL culture report showed growth of Providencia and Pseudomonas. The patient was started on antibiotics, according to culture sensitivity report. Pleural fluid was sent for analysis, which revealed high eosinophil counts with structures morphologically resembling hooklets of E.granulosus in wet mount preparation. Patient's hydatid serology of blood also came positive for the anti-echinococcal antibody. The patient was started on albendazole 400 mg twice a day and right side pleural effusion was managed by intercostals tube drainage and streptokinase instillation in view of multiple septations. After 6 months of therapy, patient clinically improved and radiological resolution was also noted [Figure 4].
Figure 3: Chest X-ray shows right pleural effusion and nodular shadows

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Figure 4: Chest X-ray after treatment shows resolution of most of the shadows

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  Discussion Top


Hydatid disease is caused by metacestode stage of E. granulosus larvae. The E. granulosus is from Taeniidae family and there are four species of E. granulosus, namely E.granulosus, Echinococcus multilocularis, Echinococcus vogeli, and Echinococcus oligarthrus. There are two forms of echinococcosis defined.[4],[5] One is cystic echinococcosis or hydatidosis or hydatid disease which is caused by E.granulosus, and second is alveolar echinococcosis which is rare and potentially fatal, caused by E.multilocularis.

The humans are infected by ingestion of water or vegetables containing hexacanth egg of the dog tapeworm. The ingested ovum becomes larva in the intestine and they penetrate the intestinal wall, enter into the mesenteric circulation and reach to the liver and some parasites directly reach into the lungs. After 6–10 days of ingestion, larvae become mature hydatid cyst and sometimes daughter cysts also seen with primary cyst.[6] These cysts are filled with multiple protoscolices which can mature into an adult worm when ingested by the suitable host.

The most common cysts occur in liver, lung involve in 10–30% of cases, and other organs in 10% of cases.[4] Pulmonary hydatid disease affects the right lung in 60% of cases, 30% have multiple pulmonary cysts and 20% have bilateral cysts.[7]

The clinical presentation of hydatid disease is often nonspecific and many patients may be asymptomatic. The symptoms depend on the size and site of the lesion. Symptoms are usually attributable to the compression of underlying pulmonary tissue by the cyst and or to the presence of complications, such as rupture or infection. The cyst rupture or episodic leakage may produce fever, pruritis, urticaria, eosinophilia, or fatal anaphylaxis and rupture into the bronchial tree may produce a cough, chest pain, or hemoptysis. The hydatid infection can also give rise to immune complex-mediated diseases such as glomerulonephritis, nephrotic syndrome, and secondary amyloidosis.[8]

The initial diagnostic tool in pulmonary hydatid disease is the CXR. Typical CXR finding of uncomplicated pulmonary hydatid disease are single or multiple homogenous round mass with smooth boarders.[9],[10] There is some characteristic radiological sign of hydatid disease such as crescent or meniscus sign, cumbos sign with an “onion peel” appearance, water lily sign or camelotte sign, and “mass within a cavity” or Monods sign.[11],[12] The contrast-enhanced CT of chest may show a thin enhancing rim of cyst wall if unruptured and diagnosis may be confirmed by the presence of daughter or rupture of the main cyst.

Routine blood tests are usually nonspecific and only 15% patients show eosinophilia due to leakage of antigenic material.[7] Serological tests include enzyme-linked immunosorbent assay, latex agglutination and indirect hemagglutination test and an immunoblot assay using lentil-lectin purified glycol proteins, and it has >99% specificity and the test is highly sensitive.

The percutaneous aspiration of cyst can establish the diagnosis of hydatid disease by demonstrating the protoscolices, hooklets or cyst membranes, but it is too risky for routine diagnosis of lung cyst because spillage of content leads to life-threatening anaphylaxis. Specific diagnosis could be made histologically by demonstration of parasite in excised tissue.

Treatment of choice for hydatid disease is surgical excision or evacuation of the cyst.[13] Some scolicidal agents such as hypertonic saline, povidone iodine, formalin, cetrimide, ethanol, and hydrogen peroxide can be used intraoperatively. Medical therapy includes oral albendazole 10–15 mg/kg/day for 4 weeks in repeated cycles, separated by 2 weeks without treatment [14] and mebendazole 40–50 mg/kg/day, given 3 times a day after meals.

Our patient presented with nonspecific pulmonary symptoms and multiple pulmonary nodules in CT-chest, who later on developed right pleural effusion due to cyst rupture. The diagnosis was confirmed by serology and pleural fluid analysis. The patient was successfully managed by intercostals tube drainage and albendazole.


  Conclusion Top


Hydatid disease is a common expectation in endemic areas and in patients who presents with classical clinico-radiological features. However, patients who present with nonspecific pulmonary symptoms and radiological finding, diagnosis become difficult. Thus, any patient from endemic area presenting with nonspecific respiratory symptoms and multiple pulmonary nodules, hydatid disease should be considered as one of the differential diagnosis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Aletras H, Symbas PN. Hydatid disease of the lung. In: Shields TW, LoCicero J, Ponn RB, editors. General Thoracic Surgery. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2000. p. 1113-22.  Back to cited text no. 1
    
2.
Jerray M, Benzarti M, Garrouche A, Klabi N, Hayouni A. Hydatid disease of the lungs. Study of 386 cases. Am Rev Respir Dis 1992;146:185-9.  Back to cited text no. 2
    
3.
Solak H, Ceran S, Ozpinar C, Yeniterzi M, Yuksek T, Sunam GS, et al. Lung hydatid cyst rupture and its surgery. Indian J Med Sci 1994;48:155-7.  Back to cited text no. 3
[PUBMED]  Medknow Journal  
4.
Ammann RW, Eckert J. Cestodes. Echinococcus. Gastroenterol Clin North Am 1996;25:655-89.  Back to cited text no. 4
    
5.
King CH. Cestodes (Tapeworms). In: Mandell GL, Bennett JE, Dolin R, editors. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Disease. Philadelphia: Churchill Livingstone; 2000. p. 2956-70.  Back to cited text no. 5
    
6.
Ghaemi M, Soltani E. Bilateral pulmonary hydatidosis after traumatic rupture of lung hydatid cyst in a child: Report of a case. Internet J Surg 2009;20:1528-8242.  Back to cited text no. 6
    
7.
Morar R, Feldman C. Pulmonary echinococcosis. Eur Respir J 2003;21:1069-77.  Back to cited text no. 7
    
8.
Gelman R, Brook G, Green J, Ben-Itzhak O, Nakhoul F. Minimal change glomerulonephritis associated with hydatid disease. Clin Nephrol 2000;53:152-5.  Back to cited text no. 8
    
9.
Beggs I. The radiology of hydatid disease. AJR Am J Roentgenol 1985;145:639-48.  Back to cited text no. 9
[PUBMED]    
10.
Balikian JP, Mudarris FF. Hydatid disease of the lungs. A roentgenologic study of 50 cases. Am J Roentgenol Radium Ther Nucl Med 1974;122:692-707.  Back to cited text no. 10
[PUBMED]    
11.
Kuzucu A. Parasitic diseases of the respiratory tract. Curr Opin Pulm Med 2006;12:212-21.  Back to cited text no. 11
    
12.
Pedrosa I, Saíz A, Arrazola J, Ferreirós J, Pedrosa CS. Hydatid disease: Radiologic and pathologic features and complications. Radiographics 2000;20:795-817.  Back to cited text no. 12
    
13.
Shalabi RI, Ayed AK, Amin M. 15 Years in surgical management of pulmonary hydatidosis. Ann Thorac Cardiovasc Surg 2002;8:131-4.  Back to cited text no. 13
    
14.
Aggarwal P, Wali JP. Albendazole in the treatment of pulmonary echinococcosis. Thorax 1991;46:599-600.  Back to cited text no. 14
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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