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

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) All 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.
Although the first case had a similar clinical picture
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JOURNAL OF THE ROYAL MEDICAL SERVICES
Vol. 15 No. 2 August 2008