Hydatid disease is a parasitic infestation by a tapeworm of the genus Echinococcus. We present the case of 34-year-old female who complained of chest pain and had a past history of hydatid cyst resection four times in last 15 years. She was found to have extrapleural hyatid cysts of chest that were removed via thoracotomy. The patient fully recovered and experienced an uneventful follow-up

Fatimi, Saulat H.

Gowani, Saqib Ali

Khan, Asmatullah

Khowaja, Ameer Ali

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eCommons@AKUSection of Cardiology Department of MedicineOctober 2008Extrapleural hydatid disease of chest: a case ofrecurrent hydatid diseaseAmeer Ali KhowajaAga Khan UniversitySaqib Ali GowaniAga Khan UniversityAsmatullah KhanAga Khan UniversitySaulat H. FatimiAga Khan UniversityFollow this and additional works at: http://ecommons.aku.edu/pakistan_fhs_mc_med_cardiolPart of the Cardiology CommonsRecommended CitationKhowaja, A., Gowani, S., Khan, A., Fatimi, S. (2008). Extrapleural hydatid disease of chest: a case of recurrent hydatid disease. Journalof the Pakistan Medical Association, 58(10), 569-71.Available at: http://ecommons.aku.edu/pakistan_fhs_mc_med_cardiol/21symptomatic patients.7-9 Biopsy is recommended evenwhen the imaging presentation seems typical ofelastofibroma. The pathologic findings are diagnostic. Notreatment is necessary in the asymptomatic patient.5,9 Therehave been no reported cases of malignant transformation.9Briccolli et al3 at the last clinical evaluation of the operatedpatients observed that excised lesions had no evidence oflocal recurrence or joint disability, whereas a recurrence rateof 7% in another study has been related to incompletesurgery.2 On the other hand Muramatsu et al.10 reported thatpostoperative haematoma formation was an importantcomplication of surgical treatment. Naylor et al7 stated thatincreased awareness of the characteristic appearance andlocation of these benign, often asymptomatic lesions willincrease radiologic diagnosis, decrease the need for biopsy,and decrease surgical removal of elastofibromas aspresumed malignancies. References1. Kayaselcuk F, Demirhan B, Kayaselcuk U, Ozerdem OR,Tuncer I. Vimentin,smooth muscle actin, desmin, S-100 protein, p53, and estrogen receptorexpression in elastofibroma and nodular fasciitis. Ann Diagn Pathos2002;6:94 -9.2. Kransdorf MJ, Meis JM, Montgomery E. Elastofibroma: MR and CTappearance with radiologic-pathologic correlation. AJR Am J Roentgenol1992;159:575-9.3. Briccoli A, Casadei R, Di Renzo M, Favale L, Bacchini P, Bertoni F.Elastofibroma dorsi. Surg Today 2000; 30:147-52.4. Kara M, Dikmen E, Kara SA, Atasoy P. Bilateral elastofibroma dorsi:proper positioning for an accurate diagnosis. Eur J Cardiothorac Surg2002;22:839-41.5. Guha AR, Raja RC, Devadoss VG. Elastofibroma dorsi--a case report andreview of literature. Int J Clin Pract 2004 ;58:218-20.6. Maldjian C, Adam RJ, Maldjian JA, Rudelli R, Bonakdarpour A.Elastofibroma of the neck. Skeletal Radiol 2000; 29:109-11.7. Naylor MF, Nascimento AG, Sherrick AD, McLeod RA. Elastofibromadorsi: radiologic findings in 12 patients. AJR Am J Roentgenol 1996;167:683-7.8. Zembsch A, Schick S, Trattnig S, Walter J, Amann G, Ritschl P.Elastofibroma dorsi. Study of two cases and magnetic resonance imagingfindings. Clin Orthop Relat Res 1999; 364:213-9.9. Valls R, Melloni P, Darnell A, Sanchez-Flo R. Elastofibroma dorsi: a chestwall pseudotumor. Computed tomography and magnetic resonance imagingdiagnosis. Acta Orthop Belg 1996; 62:103-6.10. Muramatsu K, Ihara K, Hashimoto T, Seto S, Taguchi T. Elastofibromadorsi: diagnosis and treatment. J Shoulder Elbow Surg 2007; 16:591-5. AbstractHydatid disease is a parasitic infestation by atapeworm of the genus Echinococcus. We present thecase of 34 year old female who complained of chest painand had a past history of hydatid cyst resection four timesin last 15 years. She was found to have extrapleuralhyatid cysts of chest that were removed via thoracotomy.The patient fully recovered and experienced anuneventful follow-up. IntroductionHydatid disease is a worldwide zoonosis producedby the larval stage of the Echinococcus tapeworm. Of the4 known species of Echinococcus, 3 are of medicalimportance in humans. These are Echinococcusgranulosus, causing cystic echinococcosis (CE);Echinococcus multilocularis, causing alveolarechinococcosis (AE); and Echinococcus vogeli. Egranulosus is the most common of the three. Emultilocularis is rare but is the most virulent, and Evogeli is the rarest. The two main types of hydatiddisease are caused by E granulosus and E multilocularis.The former is commonly seen in the great grazingregions of the world — particularly the Mediterraneanregion, Africa, South America, the Middle East,Australia, and New Zealand — and is the most frequentlyencountered type of hydatid disease in humans.Theoretically, echinococcosis can involve any organ. Theliver is the most common organ involved, followed bythe lungs. These 2 organs account for 90% of cases ofechinococcosis.1 Clinical presentation is often non-specific and may be asymptomatic. Approximately, 60%have right hypochondrial pain and 15% becomejaundiced. Other features include skin rashes, pruritusand allergic reactions. Diagnosis can be made by Complete Blood Count(CBC) which will detect eosinophilia in 30% of patients,plain abdominal x-ray which may show calcification incyst wall while the cyst can also be imaged with569 J Pak Med AssocCase ReportExtrapleural Hydatid Disease of Chest: A Caseof Recurrent Hydatid DiseaseAmeer Ali Khowaja1, Saqib Ali Gowani2, Asmatullah Khan2, Saulat Hasnain Fatimi3Department of Biological and Biomedical Sciences1, Medical Students2, Cardiothoracic Section, Department of Surgery3, Aga Khan University, Karachi.ultrasound or CT. It can be confirmed by indirecthaemagglutinin assay. Aspiration should not beperformed if hydatid disease is suspected as it isassociated with risk of dissemination of infection oranaphylaxis.2,3Management in the form of pharmacologicaltreatment is not curative but it is used as an adjunct tosurgery to kill spilled scolices. The drugs of choice arealbendazole, mebendazole and praziquantel. If surgery isrequired a laparotomy is performed to exclude othercysts.Operative mortality is less than 2%.Complications include subphrenic abscess and prolongedcyst drainage.Case ReportA 34 years old female presented with chest pain,cough and low grade fever. At the time of presentationshe also had abdominal pain that had history of severalyears. She had history of resection of hydatid cysts fromthe abdomen 4 times in last 15 years. After resection ofhydatid cyst for the fourth time she developed respiratorysymptoms that turned out to be hydatid cysts in thoraxand was referred to our center for further management.On examination she was vitally stable. CT abdomen wasdone that revealed widespread disease involving liver,kidney, spleen and pelvic structure. Therefore diagnosisof Hydatid disease was made and decision ofthoracotomy and removal of hydatid cyst was taken.Patient was placed in left lateral decubitusposition and right posterolateral thoracotomy via 5thintercoastal space was performed. Extrapleural hydatidcysts were located in costophrenic angle, posterior todiaphragm. More than 800 cysts were removed. Cystscovered with thick exocysts were partially removed. Restof the space was washed with hypertonic saline. Lungand pleura were normal. Extrapleural catheter was placedfor pain control. Chest was closed in layers. Specimen ofhydatid cysts were sent for culture and sensitivity.Culture and Sensitivity revealed nomicroorganism, there were moderate pus cells seen.Significant numbers of β-hemolytic streptococcus groupG were appreciated and treated accordingly post-operatively. Post-operative chest X-ray revealed rightpleural effusion along with right chest basal atelectaticchanges. Some subcutaneous emphysema was notedalong the right lateral chest wall. Left lung was clear.Follow-up chest X-ray showed resolution of atelectaticchanges on right side.Marcaine was used as post-operative analgesia.Patient was sent to physiotherapy services forstrengthening chest muscles. Post-perative course wasuneventful.DiscussionThe diagnosis of hydatid disease in endemic areasis not very difficult to suspect. But the atypical sitesinvolved by the disease may at times place hydatiddisease down in the differentials as evidenced by caseseries published by Abu-eshy et al4. Though lung issecond most common site involved5 but extra-pulmonaryhydatid disease is very rare that have been only scarcelyreported in the literature6. Since the diagnosis ofabdominal hydatid disease had already been establishedin our patient, it was actually clinical features of chestthat made the case worth presenting. Chest radiographyis considered to be most valuable first line of imagingstudy as reported by Dogan et al.7 Since our patient washaving recurrent abdominal  hydatid disease therefore weopted for CT scan as imaging modality to determine theextent of abdominal and/or chest disease. FurthermoreCT scan also helps to define the anatomy of disease.Since thoracotomy offers adequate simultaneous accessto both the chest and hepatic lesions with acceptablemorbidity and mortality, capitonnage provides noadvantage in operations for pulmonary hydatid cysts asreported by Turna et al.8 Therefore we performedstandard thoracotomy in our patient. To the best of ourknowledge there is no case of hydatid disease incostophrenic angle posterior to diaphragm reported yet.Though operative morbidity and mortality in hydatiddisease is 0-13% and 0-5% respectively9 and moreclinical emphasis is on medical management of diseasewith Albendazole10. But surgical approach combinedwith chemotherapy in recurrent hydatid diseaseespecially involving more than one organ system hasbeen the cornerstone of management though othereffective protocols of management combiningchemotherapy, percutaneous drainage and surgery needto be design. We presented the case of extrapulmonaryhydatid disease in an unusual location and withrecurrence that was indeed a medical and surgicalchallenge to manage.ConclusionHydatid Disease is prevalent in many parts of theworld. Though highly variable in presentation it typicallyinvolves the liver but can involve virtually any organsystem. Both chemotherapy and surgical options areavailable for management of hydatid cysts disease.Albendazole is active against Echinococcus. InvasiveVol. 58, No. 10, October 2008 570options include percutaneous drainage along withscolicidal agents or more invasive but safer method is thesurgical resection of cysts to avoid the rupture andconsequent anaphylaxis.References1. Mustapha B., Ben Hamadi F, Bouziani A, Ghyoula M, Hassine E, BenCheikh M, Ben Hassine K: Extra-pulmonary thoracic hydatid cyst(Pneumology and radiology services of the Military Hospital of Tunis).Med Trop (Mars). 1992; 52:399-405.2. Ayles H N, Corbett E L, Taylor I et al. A combined medical and surgicalapproach to hydatid disease:  12 years experience at the Hospital forTropical Diseases, London. Ann R Coll Surg Eng 2002;  84:  100-1053. Sayek I, Onat D.  Diagnosis and treatment of uncomplicated hydatidcyst of the liver. World J Surg 2001; 25:  21-27.4. Abu-Eshy SA. Some rare presentations of hydatid cyst (Echinococcusgranulosus): J.R.         Coll.  Surg. Edinb., 1998; 43: 347-525. Dahniya MH., Hanna RM., Ashebu S., Muhtaseb SA., El-Beltagi A., etal The imaging     appearances of hydatid disease at some unusual sites.Br J Radiol 2001; 24: 283-896. Eroglu A., Kurkcuoglu C., Karaoglanoglu N., Tekinba C.,Kaynar H., etal Primary hydatid cysts of the mediastinum. Eur J Cardiothorac SurgOctober 2002; 22: 599-6017. Dogan R., Yuksel M., Cetin G., Suzer K., Alp M. Surgical treatment ofhydatid cysts of the lung: Report on 1055 patients. Thorax 1989; 44:192-998. Turna A., Yilmaz MA., Haciibrahimoglu G., Kutlu CA., et al Surgicaltreatment of pulmonary hydatid cysts: is capitonnage necessary? Ann.Thorac. Surg., 2002; 74: 191-95.9. Qian Z. Thoracic hyatid cysts: a report of 842 cases treated over athirty-year period. Ann Thorac Surg 1988; 46:342-46.10. Teggi A, Lastilla MG, De Rosa F. Therapy of human hydatid diseasewith mebendazole and albendazole. Antimicrob Agents Chemother1993; 37:1679-84.AbstractA case of fallopian tube fimbrial cyst torsion withhaemorrhage is presented, occurring in a 37 year old femalewho had tubal ligation 6 years back. She presented inemergency with acute abdomen. Initial assessment ofovarian cyst haemorrhage or torsion was made. Ultrasoundshowed cystic structures in left adnexa and complex cyst inright adnexa with suspicion of torsion. Laparoscopy wasperformed and bilateral fimbrial cysts in fallopian tubeswere identified with torsion on right side, and a left ovarianhaemorrhagic cyst, which was subsequently confirmed onhistopathology. Although fallopian tube torsion of fimbrialcyst is rare, it should be considered in patients who hadhistory of bilateral tubal ligation. Again it should also beconsidered in the differential diagnosis of acute abdomen infemales.IntroductionIsolated twisting of fallopian tubes is an uncommonevent1. The frequency is 1/1,500,000 women2. Rightfallopian tube is most commonly affected. The condition isfrequently misdiagnosed with acute appendicitis or ovariantorsion. The torsion of fallopian tube and para-ovarian cystis usually seen in reproductive age group. The age range isfrom 21-40 years3. It is also rare in pregnancy, with only onecase in 120,000 pregnancies being reported over a period of10 years4. The exact cause of fallopian tube torsion isunknown; however several etiologies have been postulated.The signs and symptoms and physical findings mimiccommon diseases as mentioned above, therefore thediagnosis is never established before an invasive procedurelike laparoscopy. Accurate and immediate diagnosis canlead to early intervention, avoid complications and mayeven save the organ.Case ReportA 37 year old female presented in emergencydepartment complaining of diffuse abdominal pain for 3days, with maximum intensity in right iliac fossa. Pain wassudden in onset, initially mild to moderate whichprogressively became severe. It was associated with nausea,but no vomiting, bowel or urinary symptoms. Patient did notcomplain of any history of vaginal bleeding. Patient's obstetric and gynaecological historyincluded four live births and one miscarriage. Lastdelivery resulted in a lower segment caesarian section sixyears back during which patient had bilateral tuballigation. Patient also suffered from menorrhagia andanaemia and was treated with blood transfusions andintravenous iron injections. Ultrasound examination foran episode of pelvic inflammatory disease 2 years backshowed tubular structure in right adnexa about 5.1 x 2.3cm consistent with hydrosalpinx. It was treatedconservatively. Repeat ultrasound six months back wasnormal.During this admission, vitals were within normal571 J Pak Med AssocCase ReportTorsion of Fallopian Tube, Fimbrial CystImrana Masroor, Nadir Khan,Radiology Department, Aga Khan University Hospital, Karachi.

Extrapleural hydatid disease of chest: a case of recurrent hydatid disease

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Extrapleural hydatid disease of chest: a case of recurrent hydatid disease

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