GOEMINNE, H

Gosselin, Robert

Praet, Marleen

ROMBAUT, B

Tournoy, Kurt

Van Meerbeeck, Jan

Vermassen, Frank

English

Ghent University Academic Bibliography

Fax +41 61 306 12 34E-Mail karger@karger.chwww.karger.com The Eye Catcher  Respiration  DOI: 10.1159/000088692  The Sound of the Parasite Diagnosing Mediastinal Cysts with Endoscopic Ultrasound Techniques Kurt G. Tournoy    Bart Rombaut    Hannelore Goeminne    Marleen Praet    Frank Vermassen    Robert Gosselin    Jan P. Van Meerbeeck   Department of Respiratory Diseases, Endoscopy Unit, Ghent University Hospital,  Ghent , Belgium hepatic or cerebral involvement. Because the patient had a thora-cotomy before, and thus anticipating difﬁ cult surgery, we treated him with albendazole. This resulted in a radiographic reduction in the size of the cyst after 2 and 4 months, and a stabilization after 6 months whereafter the patient was referred for resection. The intact cyst was sent for pathological examination ( ﬁ g. 1 C). It was ﬁ lled with a clear ﬂ uid and its inner wall was covered with a white folded membrane. Microscopy showed that the outer part of the cyst wall or pericyst ( ﬁ g. 1 D) consisted of a dense eosinophilic inﬁ ltrate cov-ering an acellular ﬁ brinous exudate. This pericyst represents the inﬂ ammatory reaction of the host. The inner part of the cyst wall ( ﬁ g. 1 E) consisted of an exocyst (parasite-derived laminated mem-brane) and an endocyst (germinal layer), the latter barely detect-able. The cyst lumen contained numerous scolices.  This is the ﬁ rst time a  mediastinal echinococcosis was diag-nosed by EUS, an elegant tool to investigate endothoracic cystic structures  [3] which are hypoechogenic lesions that can be de-formed by the ultrasound probe. The distal reinforcement of the ultrasound signal beyond the cyst is the hallmark of its ﬂ uid content. In this case, the laminated hyperechogenic cyst wall and the pres-ence of daughter cysts were the pathognomonic characteristics, not observed on the CT scan. Echinococcosis is caused by tapeworm infections  (Echinococcus granulosis) and results in cyst formation mainly in the liver (70% of the cases) but also in the thorax, bone, spleen and brain. For the liver, there are a few cases indicating the high diagnostic value of abdominal ultrasonography  [4] . Because of the risk of infection and parasite spreading, puncture of medias-tinal cystic structures is not recommended  [3, 5] . Patients with mediastinal cystic masses are often referred for surgery  [6] . How-ever, in case of parasitic disease, this includes the danger of para-sitic spread in the thorax. Our ﬁ ndings with EUS prompted us to treat the patient ﬁ rst with albendazole in order to facilitate the sur-gical procedure.  The management of patients with intrathoracic cystic structures is a challenge to pulmonologists. In adults, these symptomless struc-tures are often discovered coincidentally on radiographs. However, an exact diagnosis is needed in view of the differential diagnoses including malignant mediastinal tumours. The main tool for imag-ing these structures is the CT scan, although MRI is sometimes advocated. However, these techniques do not always provide the clinician with an unequivocal diagnosis. Hence, patients are often referred to a surgeon for resection.  Oesophageal endoscopic ultrasound (EUS) with a curved linear ultrasound probe is a fairly new diagnostic technique in pulmonary medicine for the investigation of the middle and posterior medias-tinum. This outpatient technique allows ‘real time’ ﬁ ne needle as-pirations and is increasingly used for the diagnosis and staging of lung cancer. It signiﬁ cantly decreases  the number of mediastinos-copies and is thus cost effective  [1, 2] . We show that EUS is a valu-able technique for the investigation of mediastinal cystic structures, inﬂ uencing clinical decisions.  A 38-year-old Turk presented with mild thoracic pain. Three years ago, he underwent surgery for a mediastinal cyst. The diag-nosis of echinococcosis was made on the resected specimen and positive serum antigens. On physical examination, no abnormal-ities were detected. A laboratory analysis including liver function tests and C reactive protein was normal. A contrast CT scan showed a mediastinal mass compatible with a para-atrial cyst ( ﬁ g. 1 A) that could be approached closely with a curved linear oe-sophageal ultrasound probe. EUS showed a 50-mm  cystic lesion reaching from the subcarinal to the retrocardial region ( ﬁ g. 1 B). The cyst could be deformed with the ultrasound probe and a distal re-inforcement of the echo-signal was observed. The cyst wall was hyper echogenic, irregular and showed the presence of different membranes. A heterogeneous content with membranes and daugh-ter cysts (arrows in  ﬁ g. 1 B) were pathognomonic for echinococcosis. Fine needle aspiration was not performed. The CT scan excluded  Published online: September 30, 2005  Kurt G. Tournoy, MD, PhDDepartment of Respiratory Diseases – Endoscopy UnitGhent University Hospital, Building 7K12 IDe Pintelaan 185, BE–9000 Ghent (Belgium)Tel. +32 9 2402611, Fax +32 9 2402341, E-Mail kurt.tournoy@UGent.be  © 2005 S. Karger AG, Basel0025–7931/05/0000–0000$22.00/0  Accessible online at:www.karger.com/res  Tournoy/Rombaut/Goeminne/Praet/Vermassen/Gosselin/Van Meerbeeck Respiration 474 2 Fig. 1. A CT scan of the chest showing the sharply marginated spherical paramediastinal mass, compatible with a right-sided para-atrial cystic lesion. The diameter measured 55 mm. The wall was thin, regular and took up the contrast (80 Hounsﬁ eld units) while the centre of the cystic structure had a density of only 8 Hounsﬁ eld units, compatible with a liquid content. B Oesopha-geal endoscopic ultrasound with a curved linear probe shows de-tails of this cystic structure that are pathognomonic for medias-tinal echinococcosis. The arrows indicate the multiple daughter cysts. The cyst wall is multilayered while the retrocystic reinforce-ment of the ultrasound signal is clearly visible. The asterisk (*) indicates the position of the left atrium. C Resection specimen.  References  1 Kramer H, van Putten JW, Post WJ, van Dullemen HM, Bongaerts AH, Pruim J, Suur-meijer AJ, Klinkenberg TJ, Groen H, Groen HJ: Oesophageal endoscopic ultrasound with ﬁ ne needle aspiration improves and simpliﬁ es the staging of lung cancer. Thorax 2004;  59:  596–601.  2 Larsen SS, Krasnik M, Vilmann P, Jacobsen GK, Pedersen JH, Faurschou P, Folke K: En-doscopic ultrasound-guided biopsy of medias-tinal lesions has a major impact on patient management. Thorax 2002;  57:  98–103.  3 Wildi SM, Hoda RS, Fickling W, Schmulewitz N, Varadarajulu S, Roberts SS, Ferguson B, Hoffman BJ, Hawes RH, Wallace MB: Diag-nosis of benign cysts of the mediastinum: the role and risks of EUS and FNA. Gastrointest Endosc 2003;  58:  362–368.  4 Gerwe L, Haas A: Echinococcal liver cyst. J Diagn Med Sonogr 2003;  19:  369–371.  5 Annema JT, Veselic M, Versteegh MI, Rabe KF: Mediastinitis caused by EUS-FNA of a broncho-genic cyst. Endoscopy 2003;  35:  791–793.  6 Eroglu A, Kurkcuoglu C, Karaoglanoglu N, Tekinbas C, Kaynar H, Onbas O: Primary hy-datid cysts of the mediastinum. Eur J Cardio-thorac Surg 2002;  22:  599–601.  A well-circumscribed, intact cystic lesion measuring 76 mm in diameter was resected. Upon opening of the cyst, a clear ﬂ uid was evacuated. The inner wall of the cyst was covered by a smooth, irregular, folded, whitish membrane which easily loosened from the wall. The global thickness of the wall measured 7 mm. D His-topathology of the pericyst. The outer wall of the cyst represents the host’s reaction and consists of a dense eosinophilic inﬁ ltrate (U), covering a pink, acellular  ﬁ brinous exudate (U U). HE. !400. E Histopathology of the parasite-derived exocyst and endocyst. A laminated membrane (j) is lined by a barely detectable germinal layer and on this picture, 14 intraluminar scolices (h) are shown. HE. !640. 

The sound of the parasite. diagnosing mediastinal cysts with endoscopic ultrasound techniques

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The sound of the parasite. diagnosing mediastinal cysts with endoscopic ultrasound techniques

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