Berger, Christoph

Frey, Bernhard

Grimm, Felix

Kellenberger, Christian

Zingg, Walter

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ANSWER TO PHOTO QUIZ • CID 2003:37 (1 July) • 129A N S W E R T O P H O T O Q U I ZPhilip A. Mackowiak, Section EditorA 7-Year-Old Girl with Dyspnea and Rash(See pages 73–4 for Photo Quiz)Figure 1. A, Supine chest radiograph revealing a cavitary lesion within a consolidated right lower lobe, as well as a small pleural effusion. Thecurvilinear opacity seen within the cavity (A, arrow) appears to be floating on the upright view (B, arrow).Diagnosis: Cystic echinococcosis.On review of the supine chest radiograph (figure 1), a cur-vilinear opacity was noted within the cavitary lesion; this opac-ity appeared to be floating on the upright view. The findingsof a CT scan (figure 2) confirmed the presence of characteristicdetached and collapsed cyst membranes within the cavity [1].A small cyst was also present in the liver. Hydatid disease withrupture of a pulmonary cyst was diagnosed, and treatment withalbendazole (12 mg/kg q.d.) was initiated. The respiratorysymptoms resolved within the following 2 days, and the rashdisappeared. Thus, the bilateral consolidations seen on the CTscan might represent transient allergic alveolar-fluid exudationfollowing rupture. Marked blood eosinophilia (cell count, 2400eosinophils/mL) emerged after 7 days of hospitalization. Thegirl was discharged from the hospital 12 days after the ruptureof the cyst. At the follow-up, 3 months later, her condition wasgood, the pulmonary cavity had shrunk, but the hepatic cystremained unchanged. Specific IgG antibodies against Echino-coccus granulosus, absent from samples obtained from the pa-tient at admission to the hospital, were detected by immuno-fluorescence (1:5120), ELISA, and immunoblotting proceduresperformed on samples obtained at follow-up. The WBC countand differential count were normal. The treatment is plannedto continue for 6 months and will be followed by posttreatmentmonitoring for 2 years.Cystic echinococcosis, also known as cystic hydatid disease,is the most widespread and severe human cestode infection. Itis common in Mediterranean countries but is also becomingfrequent as an imported disease in other countries in Europeand in the United States [2]. Humans acquire E. granulosus130 • CID 2003:37 (1 July) • ANSWER TO PHOTO QUIZFigure 2. Contrast-enhanced chest CT scan confirming detached and collapsed cyst membranes (arrow) within a cavity characteristic of a rupturedhydatid cyst. Findings not previously seen on the radiographs include a second focal consolidation in the left lower lobe and a small right pneumothoraxfollowing pleurocentesis.following ingestion of its eggs, which are shed from the intestineof infected domestic and wild canids. The majority of cystsoccur in the liver and are asymptomatic, except when com-plicated by compression or rupture. In children, however, thelungs are the most common site of disease [3, 4]. Althoughechinococcosis is rarely the reason for acute dyspnea and rash,this child’s presentation is characteristic of the rupture of aformerly-unnoticed pulmonary cyst. Spillage of the contents ofthe cyst may cause allergic shock. The absence of detectableantibodies against E. granulosus during the acute clinical man-ifestation of the disease is not uncommon (˜50% of patientswith acute clinical manifestation of the disease have negativeblood-test results) [3, 4] and may indicate that the recognitionof the infection by the immune system evolves only after a cystruptures. Chest CT and abdominal sonography are valuabletools for confirming the diagnosis and monitoring the patientsduring and after treatment. In the absence of symptoms thatare caused by compression, surgical removal of the cyst shouldnot be considered as the first option for treatment; rather,administration of benzimidazole carbamates is the treatmentof choice [3, 5, 6]. Because an increasing number of the childrenwho present to emergency departments are immigrants, hydatiddisease must be considered among other potential causes ofsevere respiratory distress before starting specific diagnosticsand anti-infective treatment. Empiric treatment with alben-dazole needs to be initiated if hydatidosis is suspected on thebasis of clinical and radiological findings. Serological tests arecurrently unreliable.Walter Zingg,1 Christian Kellenberger,3 Bernhard Frey,2 Felix Grimm,4and Christoph Berger11Division of Infectious Diseases, 2Intensive Care Unit, and 3Departmentof Radiology, University Children’s Hospital, and 4Institute of Parasitology,University of Zu¨rich, SwitzerlandReferences1. Saksouk FA, Fahl MH, Rizk GK. Computed tomography of pulmonaryhydatid disease. J Comput Assist Tomogr 1986; 10:226–32.2. Donovan SM, Mickiewicz N, Meyer RD, Panosian CB. Imported echi-nococcosis in southern California. Am J Trop Med Hyg 1995; 53:668–71.3. Anadol D, Gocmen A, Kiper N, Ozcelik U. Hydatid disease in childhood:a retrospective analysis of 376 cases. Pediatr Pulmonol 1998; 26:190–6.4. Blanton R. Echinococcosis. In: Behrmann RE, Kliegman RM, Arvin AM,eds. Nelson textbook of pediatrics. 16th ed. Philadelphia: WB Saunders,1999:1079–81.5. Franchi C, Di Vico B, Teggi A. Long-term evaluation of patients withhydatidosis treated with benzimidazole carbamates. Clin Infect Dis1999; 29:304–9.6. Schantz PM. Editorial response: treatment of cystic echinococcosis: im-proving but still limited. Clin Infect Dis 1999; 29:310–1.Reprints or correspondence: Dr. Christoph Berger, Div. of Infectious Diseases, University Chil-dren’s Hospital, Steinwiesstr. 75, 8032 Zu¨rich, Switzerland (christoph.berger@kispi.unizh.ch).Clinical Infectious Diseases 2003; 37:129–30 2003 by the Infectious Diseases Society of America. All rights reserved.1058-4838/2003/3701-0017$15.00

A 7-Year-Old Girl with Dyspnea and Rash

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