H. El-Khushman, A. Sharara, J. Momani, A. Al-Suleihat, M. Al ...

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proved that it was a laminated membrane of a hydatid cyst wall. A thoracotomy with excision of the cyst was carried out few days later and the diagnosis was confirmed surgically and histopathologically. He had an uneventful recovery and was discharged asymptomatically. A follow up Chest CT scan 3 months later showed no sign of recurrence. Fig. 1. Hydatid cyst Fig. 2. Hydatid cyst Abdominal ultrasound was normal. He underwent a diagnostic fiberoptic bronchoscopy (FOB), which showed a whitish membrane floating from the orifice of lateral segment of the right lower lobe (Fig. 3). Fig. 3. Hydatid cyst It was very typical of a ruptured hydatid cyst membrane. A small biopsy from this membrane Second Case: Mrs. H.A was a 39-year-old female patient who lives in Jordan valley. She presented with progressive shortness of breath over the last few months. A chest X-ray showed very large welldemarcated opacity occupying more than two thirds of the right lung field suggestive of a cystic lesion. A chest CT scanning further outlined these findings. Her laboratory tests were normal and serological tests for Echinococcus Granulosus were negative. A diagnostic FOB showed a whitish shiny lesion bulging from the orifice of right upper lobe apical segment that was very suggestive of a hydatid cyst membrane. Biopsy was not taken because the membrane had an intact appearance in order not to create its rapture. She underwent surgical resection of the cyst, which proved the bronchoscopic findings, and she had an uneventful recovery course. Third Case: Mrs. Z.R. was a 46-year-old female who lives in the eastern part of Amman. She presented with gradually progressive shortness of breath and recurrent attacks of dry coughs. A chest X-ray and a CT scan showed bilateral rounded cystic lesions; one in the right upper lobe of around six centimeters in diameter and the other was about seven centimeters in diameter occupying the left lower lobe. Her laboratory tests were normal apart from mild eosinophilia. Immune serological tests for Echinococcus Granulosus were negative. A diagnostic FOB showed a whitish lesion bulging through the orifice of the posterior segment of right upper lobe bronchus, which was very suggestive of a pulmonary hydatid disease. This was excised surgically and further elective surgery for the other side of her chest wall was planned. Fourth Case: Miss A.G. was a 26-year-old female who presented with a similar picture to the first patient JOURNAL OF THE ROYAL MEDICAL SERVICES Vol. 15 No. 2 August 2008 57
except that her heamoptysis was of a larger degree. Her chest CT showed a relatively dense rounded lesion in the right lower lobe posterior segment with mild pleural effusion. She was managed as a case of chest infection with para-pneumonic effusion but showed only a partial clinical response over the next few days. A diagnostic FOB showed a hyperemic right lower lobe basal segments with mild bleeding coming from the posterior segment of right lower lobe and an ill defined membrane at the same site. Echinococcus Granulosus serological tests were positive. Surgical resection of a hydatid cyst proved the diagnosis and she had an uneventful recovery apart from mild residual pleural thickening at the right costophrenic angle. Discussion Echinococcal disease is caused by infection with the metacestode stage of the tapeworm Echinococcus, which belongs to the family Taeniidae. The initial phase of primary infection is always asymptomatic and may remain so for many years. Subsequent clinical features of Echinococcus Granulosus infection depend upon the site of the cysts and their size. Small and/or calcified cysts may remain asymptomatic indefinitely, but symptoms due to mass effect within organs, obstruction of blood or lymphatic flow, or complications such as rupture or secondary bacterial infections can result. (1,2) While approximately 50 percent of detected cases occur in asymptomatic patients, many more cases remain undiagnosed or are found incidentally at autopsy. (3) The first and fourth case represent the clinical presentation of a ruptured hydatid cyst which usually if not thought of properly will be misdiagnosed as a lung tumor or sequelae of chronic infection. The average age at presentation is 36 years. Cysts typically increase in diameter at a rate of one to five centimeters per year. Hydatid cysts may be found in almost any site of the body, either from primary inoculation or via secondary spread. The liver is affected in approximately two-thirds of patients, the lungs in approximately 25 percent. Eighty-five to 90 percent of patients with Echinococcus Granulosus infection have single-organ involvement, and more than 70 percent have only one cyst. (4) Lung involvement with Echinococcus Granulosus can lead to a variety of symptoms, including chronic cough (sometimes with accompanying heamoptysis or evacuation of cyst material), chest pain, pleuritis or dyspnea. (1) If cysts rupture into the pleural space, a pleural effusion may develop. (2,5,6) Lung abscesses can also occur. Our second and third cases presented with only progressive dyspnea and dry cough paroxysms, which are not unusual for un-ruptured pulmonary hydatid disease. Endobroncheal hydatid cyst is a very rare clinical entity in which a hydatid membrane can be seen endobroncheally via a fiberoptic bronchoscope. There is little information in the medical literature about the diagnosis of hydatid disease by FOB evaluation. (7-9) Jerray et al. (7) reported 21 out of 105 cases of hydatid cyst with membrane detected by FOB. Henry et al. (8) reported the cases of two patients who underwent surgical resection after observation of intrabronchial cystic membrane. In a study by Saygi et al .(9) a whitish-yellow gelatinous membrane was detected in 12 cases out of 24 patients with surgically proven pulmonary hydatid disease. There are no large-scale studies outlining the real incidence and the endemic areas of hydatid disease in Jordan. Yaghan et al. (10) reported on 65 patients from the northern part of the country over 10 years period. Ammari et al. (11) reported 14 surgically proven pulmonary hydatid cysts at a northern hospital as well. The majority of cases seen in our practice have been reported from the Jordan Valley area. Approximately 60 percent of pulmonary hydatid disease affects the right lung and 50 to 60 percent involve the lower lobes. Multiple cysts are common and approximately 20 percent of patients with lung cysts also have liver cysts. (12,13) <strong>Al</strong>l our cases had their cysts on the right lung; the third case had a second cyst on the left side as well. Serologic tests may help to confirm a suspected case of echinococcosis. Immune responses in hydatid infection are often quantitatively small and frequently not sufficiently intense to be detected by routine serologic techniques. The serology also has some utility in the follow up of patients after surgical or pharmacological treatment; however, since antibody levels remain detectable for many years even in patients who have been cured, serological tests can give only limited support to clinical findings. In our study only one case (Miss A.G.) with the ruptured cyst showed a positive IHA and ELISA tests for Echinococcus Granulosus. <strong>Al</strong>though the first case had a similar clinical picture 58 JOURNAL OF THE ROYAL MEDICAL SERVICES Vol. 15 No. 2 August 2008
Page 1: ENDOBRONCHEAL HYDATID CYST: ANALYSI

H. El-Khushman, A. Sharara, J. Momani, A. Al-Suleihat, M. Al ...

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