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Case Report

Massive hemorrhagic pleural effusion in Hydatidosis

1Student, University of Texas , 2Assistant Professor, Dept. of Forensic Medicine, Malla Reddy Institute of Medical Sciences, 3,4 Assistant pro- fessor, 5 Professor and HOD, 6-13 Postgraduates Department of pulmonary and critical care medicine, Kamineni institute of medical sciences, Sreepuram, Narketpally, Nalgonda, TS, India.

ABSTRACT

We present an unusual case of massive hemorrhagic effusion due to hydatidosis, which was masquerading as malignant pleural effusion with bloody effusion and rapid refilling. Computerized tomography has shown the hydatid cyst in lung parenchyma (circular opacity) which has ruptured in to the pleural cavity. After a day, glistening membranes of the daughter hydatid cyst appeared with in the ICD bag which on histopathological examination confirmed as hydatid cyst. It is unusual and rare to present as hemorrhagic pleural effusion.

Introduction

Hydatidosis or hydatid disease is a zoonotic parasitic disease1 which is caused by the parasite called Echinococcus granulosus. This disease is known since ancient times of Hippocrates.2 This disease is prevalent all over the world and endemic in parts of Turkey, South America, Russia, Australia, Tunisia and Mediterranean countries.3 It is not uncommon in Indian subcontinent also.4 It usually involves liver (60%) and secondly lung5(30%) but extrathoracic6 and intrapleural (8.75%) is rare7, more so presenting as hemorrhagic effusion. It also involves other organs like heart, kidney, bone and brain.8It’s a huge economic burden with morbidity and mortality, particularly Echinococcus multilocularis.

Case Report
Fig 1.Axial plain Ct of chest showing hydatid cyst which has ruptured into pleural cavity with pleural effusion.
Fig 2.ICD bag showing a glistening membranous cyst i.e., hydatid cyst
Fig 3.Section studies shows hydatid cysts with internal germinal layer with laminated membrane and externally is fibrous capsule with dense inflammatory infiltrate predominantly lymphocytes, histiocytes and lymphoid aggregates with dilated and congested vessels with adjacent lung tissue.

A 38year old female was admitted in the department of pulmonology with 15 days duration of cough, chest pain and 10days duration of shortness of breath. On examination patient was dyspneic, pale with no cyanosis or jaundice with pulse rate of 100 beats /min which was regular, BP 110/70 mmHg, RR 24/min, abdomino- thoracic. Respiratory system examination showed signs of right sided massive pleural effusion. Examination of other systems was normal. X ray chest was done and ultrasound chest confirmed presence of pleural effusion. Other routine investigations was not significant with Hb-12.8gm/dl, RBC-4.3million/cu.mm, blood urea and serum creatinine was 30mg/dl and 1.2 respectively. Diagnostic aspiration was done which revealed hemorrhagic effusion. Therapeutic aspiration was done using ultrasound guidance. Pleural fluid was negative for AFB and malignant cells. Rapid refilling occurred for which ICD tube was inserted. Computerized tomography showed a circular opacity in the lung which ruptured into the pleural cavity. After a day, glistening membranes of the cysts appeared in the ICD bag which was sent for histopathological examination shows fibro collagenous tissue and skeletal muscle bundle with mild chronic inflammatory infiltrates, features of hydatid cyst wall exhibiting membranous loose and edematous wall lined by germinal lining cells. No evidence of granulomatous/giant cells/ malignant foci.

Hydatid disease is caused by the parasite called Echinococcus granulosus. There are 4 species (i) E. granulosus (ii)E. multilocularis (iii) E. oligarthus (iv) E. vogeli. E. granulosus is the most common. This disease is said to have a prevalence of one in 20million9 and is a huge economic burden of US$763,980,979.10This parasite spreads from the dog and wolf. (primary host) by fecal contamination of food, water by grazing cattle (intermediate host) and man is the accidental and dead end of the parasite.11 The egg enters into the intestine and develops into hexacanth tapeworm and then enters the portal vein to enter the liver (60%) and also the lungs(20-30%) and rest of the organs(10%). It enters into the heart, kidney, bone, brain, muscle8 etc., The mode of spread to the lungs is by the (i) transthoracic (ii) trans diaphragmatic pores (iii) through inferior venacava (iv) posterior sinusoids.

Hydatid disease of the lung is seen in 10% of the cases. It is usually associated with liver hydatid. Hydatid disease of the extra pulmonary site is very rare particularly primary hydatid disease. Soner gursoy reported2 8.75% and Refikulku reported 8 cases of pleural hydatid out of 133 cases.15

Secondary pleural hydatid can occur as a complication of rupture of hydatid cyst into the pleura. In our case, patient presented with massive hemorrhagic pleural effusion and was mistaken for malignant pleural effusion clinically because of rapid refilling but computerized tomography of the chest revealed the underlying cyst which has ruptured into the pleural cavity and after one day, hydatid daughter cysts was collected in the ICD bag which was confirmed histopathologically. Casoni’s test was not done in this case and no other confirmative test was performed. Patient was put on 15mg/kg of albendazole and referred to cardiothoracic surgeon because a combined medical and surgical treatment is more effective.

Conclusions

Hydatid disease can present as massive hemorrhagic pleural effusion, in all such cases hydatid disease should be included as a differential diagnosis.

  1. Extra thoracic and intrapleural hydatid disease (primary) is rare and usually secondary to rupture of lung hydatid.
  2. Computerized tomography is useful in the diagnosis of hydatid cyst.
  3. One must be diligent in introducing ICD in such cases which can rupture the hydatid cyst leading to anaphylaxis and spill over the daughter cysts.
  4. Prevention is more effective than treatment.
  5. Combined medical and surgical treatment is rewarding.
Acknowledgements

The authors are grateful to Dr. T. Seshagiri Rao, Professor, Dept. of Pathology and KIMS, Narketpally for their support in conducting this study.

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