Echinococcosis is an infection caused in human by complex parasites that causes cystic hydatid disease. These infections are prevalent in most areas where livestock is raised in association with dogs. These parasites are found in all continents. Slowly enlarging cysts generally remain asymptomatic until their size has expanded. Here we present a case of sudden death following cyst emboli to the large veins and right heart of a young adult female

Emam Hadi, Mohammad Ali

Najari, Fares

Soleimani, Leila

English

Mohammad Ali Emam Hadi

Fares Najari

Leila Soleimani

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Emergency. 2018; 6 (1): e20CASE REPORTSudden Death due to Hydatid Cyst Emboli; a Case ReportMohammad Ali Emam Hadi1, Fares Najari1∗, Leila Soleimani11. Department of Forensic Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.Received: January 2018; Accepted: March 2018; Published online: 19 March 2018Abstract: Echinococcosis is an infection caused in human by complex parasites that causes cystic hydatid disease. Theseinfections are prevalent in most areas where livestock is raised in association with dogs. These parasites arefound in all continents. Slowly enlarging cysts generally remain asymptomatic until their size has expanded.Here we present a case of sudden death following cyst emboli to the large veins and right heart of a young adultfemale.Keywords: Death, sudden; echinococcosis; embolism; case report© Copyright (2018) Shahid Beheshti University of Medical SciencesCite this article as: Emam Hadi M, Najari F, Soleimani L. Sudden Death due to Hydatid Cyst Emboli; a Case Report. Emergency. 2018; 6 (1):e20.1. IntroductionEchinococcosis is an infection caused in human by complexparasites that causes cystic hydatid disease. These infectionsare prevalent in most areas where livestock is raised in as-sociation with dogs. These parasites are found in all conti-nents. Slowly enlarging Echinococcal cysts generally remainasymptomatic until their expanding size or their occupationof space affects the spleen, lung, or brain (1-3). The liver andthe lungs are the most common sites of these cysts. Since anumber of years elapses before cysts enlarge sufficiency tocause symptoms, they may be discovered incidentally on aroutine x-ray or ultrasound study (4-6). Sudden death follow-ing embolization of cysts to the large veins is a rare compli-cation of this infectious disease. Previously, some cases havebeen reported in this regard (7-9). Here we report the autopsyfindings of the deceased unknown woman who was referredto legal medical center of Iran with history of dyspnea for 6hours followed by death without any further medical docu-mentation.2. Case presentation:The deceased was a young adult female, who was referred toKahrizak autopsy center, Tehran, Iran, by order of legal au-thority. With no significant medical history, the death was∗Corresponding Author: Fares Najari; Department of Forensic Medicineand Toxicology, Shohadaye Tajrish Hospital, Shahrdari Street, Tajrish Square,Tehran, Iran. Postal code: 1981964771 Tel: 00989123195140 Email:fares.hospital@yahoo.comreported by neighbors and EMS to the police center in sub-urb areas of Tehran. The victim was seen 1 hour before an-nouncing dead, while she was complaining about shortnessof breath and heaviness on the chest, but refusing to go to thedoctor because of attributing the symptoms to air pollutionand common cold. Neighbors called EMS with exacerbationof symptoms. The patient was announced dead upon arrivalof EMS. The deceased didn’t have any family members andidentification card (she was most probably an illegal immi-grant from east borders of Iran).The body was that of a 30 year old, well nourished, well devel-oped, female according to color of hair, skin, and teeth. Therewas no peripheral edema of the extremities. There was noarea of congestion, cyanosis, bruise and abrasion. There wasnormal hypostasis in the posterior parts of body and com-plete rigor mortis. Scalp, skull, spine, membrane, and brainwere normal. Trachea and larynx were normal. No fracture,pathology or hemorrhage were detected. The pleural cavitieshad no fluid or adhesion; however, dilated vein was noticedon the surface of left lung (figure 1). While cutting large arter-ies and large veins of the heart, multiple cysts (well defined,bubble shaped, round objects covered by shiny white mem-brane) 3 cm in diameter started to emerge rapidly and wereextracted from inferior Vena Cava vein and right chambers ofthe heart (figure 1).The heart was 300 grams in weight, appeared normal withoutany ruptured cyst in the chambers. Fibrosis, hyperemia, orany sign of infarction or hypertrophy weren’t detected. Valvesappeared intact. Coronary arteries were patent. There wasno abnormality in large vessels.This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0).Downloaded from: www.jemerg.comM. Emam Hadi et al. 2Figure 1: Anterior view of thoracic cavity (left upper) and Liver (right upper), cysts in right atrium and Inferior vena cava (left and right lower).Lungs weighed 300 grams. Pulmonary tissue was congested. There were also several cysts in the pulmonary artery, whichThis open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0).Downloaded from: www.jemerg.com3 Emergency. 2018; 6 (1): e20formed saddle emboli. Liver weight was 900 grams. The sur-face was course and adhesion bands to near structures madeit hard to remove the organ en bloc (figure 1). In several cutscongestion, nutmeg liver, and multiple cysts appeared. By re-moving the liver a lot of cysts came out of inferior vena cavaand occupied the abdomen cavity gall bladder, and spleen(Figure 1).Right kidney was not seen (previous surgery due to car acci-dent). Left contained 2 small simple cysts, which measured1 cm in diameter full of yellow clear fluid. In cortex cuts,medulla, and parenchyma appeared normal. Stomach andintestines contained ingested food and their mucous was in-tact.No ischemic change was seen in the cardiac tissue and brainwas reported to be normal. In the pulmonary tissue, mild tomoderate alveolar edema was seen. No evidence of hydatidcyst or remnants were observed in lungs neither microscopicnor macroscopic.Toxicological samples from vitreous, gastric content, urine,liver, and bile were obtained, analyzed, and reported nega-tive for Alcohol (by GC-MS on vitreous), narcotic and otherdrugs (by TLC on gastric content, urine, liver, and bile).Histopathology study of liver and lung cyst samples revealedthe cyst had a white thin fibrous membrane, which containeda clear fluid and some grain like particles laminated mem-brane of hydatid cyst with scolices and hooklets.BY Analyzing autopsy, histopathology, and toxicology andhistory data the commission of three board certified forensicspecialties decided to declare “cardiac arrest due to massiveemboli by multiple hydatid cysts” as cause of death.3. DiscussionAn embolus is an intravascular solid, liquid, or gaseous massthat is carried by the blood to a site distant from its pointof origin. The vast majority of emboli derive from a dis-lodged thrombus. Less common types of emboli include fatdroplets, bubbles of air or nitrogen, atherosclerotic debris,tumor fragments, bits of bone marrow, and amniotic fluid;emboli lodge in vessels resulting in partial or complete oc-clusion. Depending on the site of origin, emboli can lodgeanywhere in the vascular tree (10-12). The primary conse-quence of systemic embolization is necrosis of downstreamtissue while embolization in the pulmonary circulation leadsto hypoxia, hypotension, and right-sided heart failure. Theconsequence of embolization depends on the caliber of theoccluded vessel, the collateral supply, and the affected tis-sues vulnerability to anoxia.In this case, multiple hydatid cysts originated from liver andmoved through vena cava to the right side of the heart andpulmonary artery, which is compatible with definition of em-boli. We didn’t witness any hypoxic change in tissue of thebrain and heart; the reason may be the rapid onset of symp-toms, which lasted only 1 hour before occurrence of deathand compatible with the history. So the application of theterm “sudden death” seems to be accurate for our case.It seems that along with ischemic cardiac problems and poi-sonings, cases such as the discussed one should also be con-sidered in differential diagnosis of cause of death in youngpatients who face sudden death without any history of un-derlying illnesses. However, late diagnosis and weak clinicalsuspicion to rare cases such as this one might prevent the in-charge physician from saving the life of such patients.4. Appendix4.1. AcknowledgementsWe would like to express our special thanks to the forensiccenter of Tehran, Iran.4.2. Author’s contributionAll authors met the four criteria for authorship contributionbased on the recommendations of the international commit-tee of medical journal editors.4.3. Conflict of interestThe authors declared no potential conflict of interest with re-spect to the authorship and/or publication of this article.4.4. FundingNone.References1. Rahman ML, Badruzzaman M, Mokhlesuzzaman A,Kabir MM, Chowdhury MMG, Hossain MA. Hydatid CystOf Lung. KYAMC Journal. 2017;4(2):427-30.2. Gul Z, Liaqat F, Khattak MT, Ahmad W, Haq SZU. HY-DATID CYST OF BRAIN. Gomal Journal of Medical Sci-ences. 2014;12(3).3. Rasheed K, Zargar SA, Telwani AA. Hydatid cyst of spleen:a diagnostic challenge. North American journal of medi-cal sciences. 2013;5(1):10.4. Sahpaz A, Azem Irez HG, Sener MT, Kok AN. Non-thrombotic pulmonary embolism due to liver hy-datic cyst: a case report. Balkan medical journal.2017;34(3):275.5. Rao SB, Madi DR, Shetty AK. A cystic splenic massin a farmer. European journal of internal medicine.2017;46:e5-e6.6. Akcay MN, Akcay G, Balik AA, Boyuk A. Hydatid cysts ofthe adrenal gland: review of nine patients. World journalof surgery. 2004;28(1):97-9.This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0).Downloaded from: www.jemerg.comM. Emam Hadi et al. 47. Pakis I, Akyildiz EU, Karayel F, Turan AA, Senel B, OzbayM, et al. Sudden death due to an unrecognized cardiachydatid cyst: three medicolegal autopsy cases. Journal offorensic sciences. 2006;51(2):400-2.8. Malamou-Mitsi V, Pappa L, Vougiouklakis T, Peschos D,Kazakos N, Grekas G, et al. Sudden death due to an un-recognized cardiac hydatid cyst. Journal of Forensic Sci-ence. 2002;47(5):1-3.9. Chadly A, Krimi S, Mghirbi T. Cardiac hydatid cyst rup-ture as cause of death. The American journal of forensicmedicine and pathology. 2004;25(3):262-4.10. Nardi W, Buero A, Lozano S, Porto EA. Laparoscopic re-section of a bulky primary adrenal hydatid cyst. Journalof minimal access surgery. 2015;11(4):279.11. Unlu Y, Ceviz M, Karaoglanoglu N, Becit N, Kocak H. Ar-terial embolism caused by a ruptured hydatid cyst in theheart: report of a case. Surgery today. 2002;32(11):989-91.12. Odev K, Acikgozoglu S, GormÃijs N, Aribas O, Kiresi D,Solak H. Pulmonary embolism due to cardiac hydatiddisease: imaging findings of unusual complication of hy-datid cyst. European radiology. 2002;12(3):627-33.This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0).Downloaded from: www.jemerg.com

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