Ideal Surgery Time in COVID-19 Process: A Case Report of Pulmonary Hydatid Cyst in Covid Patient

A cross sectional study compared the clinical features of the pulmonary and hepatic hydatid cysts in children and adults and evaluated IHAT and ELISA techniques in diagnosis. The results showed that the patients ages were 5-14 years (10.6 ± 3.7) in children and 16-75 years (32.2 ± 14) in adults, patients 34 (75.5%) had liver cysts, 25 (55.5%) had pulmonary cysts and 7 (15.5%) had both liver and lung cysts. In hepatic hydatidosis, 7/34 (20.5%) cases were asymptomatic while others showed variable clinical manifestations. The commonest symptom was localized right hypochondrial pain in 13 (38.2%) and the least one was jaundice in 4 (11.7%). The commonest sign was abdominal masses on the right hypochondrium in 88.2% and the least one was ascites in 5.8%.The commonest symptom of pulmonary hydatidosis was chest pain in 8 (34.7%) followed by cough and hemoptysis pn 4 (17.3%) and the least one was cough and fever (8.6%). Pulmonary hydatid cysts in children were significantly higher in males (17.3%) than females (4.3%), but without significance in adults (26% in male vs. 21.7% in females). Sex difference in hydatid cyst frequencies between adults and children was significant (P < 0.05). Mixed hepatic and pulmonary cysts were less in children than in adults (14.3% vs. 85.7%), with huge pulmonary cysts of 20 cm were more common in children (37.7%) than in adults (17.7%). The high sensitivity (95.5%) of ELISA-IgG recommended this test showed a dependable sero-diagnosing one.

THE LUNG is the second commonest site in man, where the intermediate larval-cysticercal stage of Echinococcus granulosus develops. It is not unusual to find more than one cyst in the lung in man. However, the successful removal of more than two cysts from the lung is exceptionally rare. The incidence of hydatids occurring in lungs varies in different countries (Spencer, 1962), viz: Greece 30% (Toole et al., 1953) Australia 25% France 9% (Barrett) New Zealand 40% A survey of hydatid disease in the Waikato Hospital Board area from 1942 to 1959 (New Zealand) by Ellis Dick (1962-63) showed that 124 cases were treated and the distribution among them was as follows: liver-55 lung-49 lung and liver combined-10 However, the incidence of multiple pulmonary hydatid cysts was rarely mentioned. d'Abreu & Lambert Rogers (1938) reported the first case of two cysts, one on each side of the lung. Borrie (1962-63), in his report of fifty cases of thoracic hydatid disease, mentions that only seven cases of multiple cysts were seen. The maximum number of cysts was only two, in the seven cases seen. Barrett (1960) reports that the largest number of primary hydatid cysts in the lung was three. One of the three was a simple cyst and the remaining two were ruptured in the bronchial tree and the patient died. Thomas (1965) reports seeing three cysts in the lungs. Deve (Barrett, 1960) analysed thirty-one cases of multiple metastatic hydatid cysts in the lungs and found that the primary cyst was in the heart (twenty cases), liver (eight cases) and iliac bones (three cases). Thus the successful removal of three cysts or more from the lung is very exceptional. The following is a report of three cases of pulmonary hydatid cysts, successfully operated upon, where the number of cysts removed was more than two in each case. Case 1 Mr S., a 40-year-old male, had, at the time of admission, two cysts in the right lung (upper and lower lobe one each), four cysts in the left lung (both lobes involved) and two cysts in the liver. The two cysts on the right side were unequal in size. However, all the cysts on the left side and one on the right (upper lobe) appeared to be almost equal in size, signifying that they were all of almost the same age (Fig. 1). It was decided to do the right thoracotomy first in order to release the right lung, the lessaffected side (10 September 1963). Both cysts were removed and ruptured during removal. The patient went into anaphylactic shock but soon recovered. The second operation (29 October 1963), a laparotomy by a Rutherford Morrison incision on the right side, consisted of marsupialization of a large cyst in the liver. The second cyst, a smaller one, 1 X I1 in., was just attached to the free margin of the liver and was therefore excised with a portion of the liver. Haemostasis was achieved

A rare combination of cardiac and pulmonary cyst and review of the literature.

Sir, A 33-year-old female presented with right-sided pleuritic chest pain and expectoration of mucopurulent, foul-smelling, and salty sputum for one year. There was a history of close contact with a pet dog for last two years. General survey and systemic examination revealed no abnormality. Absolute eosinophil count was 800/cmm. Sputum microscopy for acid fast bacilli was negative. A homogenous opacity in right lower lobe was seen in chest radiogram [Figure 1]. Contrast enhanced computed tomography (CECT) scan of thorax showed two rounded, heterogenous opacities (1 × 1 cm and 1.5 × 2 cm, respectively) with presence of air pockets within the lesions—the "air – bubble sign" [Figure 2]. Ultrasonography (USG) of thorax revealed loculated collection of fluid with echogenic organization inside. USG-guided aspiration of the lesion revealed viscid material. Cytology of the smear showed fragmented membranous structures with lamination along with aggregates of degenerated inflammatory cells in a background of proteinaceous fluid [Figure 3]. Fiberoptic bronchoscopy did not reveal any endobronchial lesion. USG of whole abdomen did not reveal cyst in intra-abdominal organs. Serum anti-echinococcal IgG level was 26.41 U/ml (normal value: <8 U/ml, ELISA method). A diagnosis of infected hydatid cyst in right lung was made and albendazole tablet, 400 mg twice daily, was started. The patient was referred to the department of cardiothoracic surgery for further management and follow up.Figure 1: Chart X-ray—PA and right lateral view showing homogenous opacity in right lower lobe with sparing of right costophrenic angleFigure 2: CECT thorax showing "Air – bubble" signFigure 3: FNAC showing fragmented membranous structures with laminationEchinococcosis, a zoonosis caused by Echinococcus granulosus is endemic in India, mostly involving liver and lungs. Most pulmonary cysts are asymptomatic and become clinically evident as a result of complications like cyst rupture and secondary infection. Pulmonary cysts are characteristically solitary and involve single lobe, mainly the lower lobe, and more common on the right.[1] Structurally, the cysts consist of pericyst, exocyst, and endocyst from outside inwards. Echinococcal cysts carry high risk of rupture with subsequent seeding to the other viscera[2] and secondary infection. The rupture may lead to anaphylactic reaction.[2] Most common respiratory symptoms of ruptured hydatid cyst are cough with fetid expectoration.[2] CECT scan of thorax is the diagnostic modality of choice for pulmonary hydatid cyst. Most of intact pulmonary cysts present as solid lesions of fluid density on CECT thorax. But ruptured cysts almost always present with a variety of radiological appearances due to different combinations of collapsed membrane, air, and fluid, making its diagnosis difficult. Sometimes, secondary bacterial infection supervenes on the ruptured cyst with subsequent increase in attenuation numbers in CECT thorax.[3] Because of solid density of the cyst, the differentiation from a pulmonary neoplasm is usually impossible. Serological test like anti-echinococcal IgG is helpful in most patients for final diagnosis, but measurable immunological response may not develop in few patients. Pulmonary hydatid cyst may rupture through pericyst only or through pericyst, exocyst, and endocyst with expulsion intracystic contents within airways. A number of radiological signs of ruptured cysts are described which include crescent sign, water lily sign, daughter cyst, double arch sign, ring within a ring sign, serpent or snake sign, and spin or whirl sign.[4] When there is dissection of air between the pericyst and parasitic membrane, due to erosion of a bronchiole by an expanding cyst, "airbubble" sign is seen. The "air bubble" sign which is a relatively newly recognized radiological sign is reported to be very sensitive and specific (85.7% sensitivity and 96.6% specificity) in establishing diagnosis of ruptured, infected hydatid cyst.[5] Air bubble sign is best seen in mediastinal window as single or multiple small, rounded radiolucent areas with sharp margins within the periphery of a solid mass lesion.

The purpose of the present study was to compare the clinical features and the surgical approaches of the pulmonary hydatid cysts in children and adults. One hundred and thirty-four patients, operated on for pulmonary hydatid cysts over the last 10 years were retrospectively evaluated in two groups: 39 children who were younger than 18 years old (29%) and 95 adults (71%). The patients in each group were analysed according to their clinical, radiological and surgical findings. The frequency of pulmonary hydatid cysts in children was significantly higher in boys (74%) than in girls (26%). However, there was no sex tendency in adults (52% in male vs 48% in women). The sex difference in hydatid cyst frequencies between adults and children was significant (P < 0.05). Among preoperative pleural complications, pneumothorax (15.5%) in children and empyema (11%) in adults were more frequent. The frequency of concomitant hepatic cysts was less in children than in adults (33%vs 79%). Huge pulmonary cysts (=10 cm) were more common in children (31%) than in adults (22%). Cystotomy with capitonnage was the most frequently preferred method in both groups. Postoperative complications developed in six children (16%) and 19 adults (19%), and were more frequent in patients with huge cysts (27%vs 16%). No recurrence was observed in both groups. Isolated pulmonary cysts are more common in children than adults. The cysts also tend to be bigger in children than adults. The frequency of concomitant hepatic cysts is less in children. Because of higher lung expansion ability and improvement capacity in children, resection should be avoided and lung saving surgical procedures should be performed. In spite of differences observed in the clinical features it does not change the treatment of pulmonary hydatid cysts in children.

Complicated hydatid cysts of the lung: clinical and therapeutic issues

The combination of pulmonary and hepatic hydatid cysts is frequently encountered, and poses a challenge in terms of surgical accessibility. The surgical treatment of the two locations by the same incision (thoracotomy with phrenotomy) has been proposed, but always from the right side. However, applying this technique to the left side seems to be more difficult and unusual. We herein describe a new left-sided technique that was used to treat two patients with pulmonary and hepatic hydatid cysts. The first patient was 14-year-old; he had bilateral pulmonary hydatid cysts and one type I cyst of the left lobe of the liver. The second patient was a 10-year-old female who had a hydatid cyst of the upper left lobe with one type III cyst of hepatic segments 2 and 3. Both patients were operated on via a left lateral thoracotomy through the sixth intercostal space. They underwent cystectomy for the left pulmonary hydatid cysts, followed by padding, and then the hepatic cyst was treated by Lagrot's method via a radial phrenotomy. The postoperative course was uneventful in both cases, with postoperative hospital stays of 3 and 5 days, respectively. This combined treatment of pulmonary and hepatic hydatid cysts by the left-sided thoracic approach is feasible and provides a good outcome. It should be indicated under the same conditions of accessibility and feasibility applied for the right thoracic side.

Hydatid cyst disease is caused by the metacestod form of Echinococcosis granulosus from cestods. Pulmonary hydatid cyst is the second most frequent form of the disease after the liver involvement and may open into the bronchial or pleural space by perforation and may cause complications. The aim of the study was to evaluate the clinical features and the frequency of the complicated pulmonary hydatid cyst disease. Fifteen hydatid cyst patients were evaluated according to socio-demographical, clinical and radiological findings between 2009 and 2011 retrospectively. Hydatid cyst diseases were diagnosed histopathologically after chest surgery. Diagnostic difficulties and clinical features were analysed in four complicated pulmonary hydatid cyst cases. Pneumothorax, pleural effusion, lung abscess, and hemoptysis were observed in four complicated cases. The complicated cases were diagnosed after surgery. Eleven of lung cysts were intact, radiological and histopathological features were typical for images of hydatid cyst disease and reported as compatible with the clinical diagnosis. A synchronized liver and pulmonary hydatid cyst was evaluated as a morbidity factor. Hydatid cyst should be considered in the differential diagnosis of uncertain chest pathologies, especially in rural areas where the disease is endemic.

The two-stage approach for treating combined pulmonary and hepatic hydatid cyst: A case report.

Concomitant pulmonary and liver hydatid cysts occur in 4% 25% of patients with echinococcosis. To evaluate the safety of a single-stage operation, experience with this procedure between 1992 and 2005 was reviewed. Of 152 patients who underwent surgery for pulmonary hydatid cyst, 30 had an additional hepatic cyst that was located on the upper dome of the liver in all cases. Pulmonary cysts were excised first via a posterolateral thoracotomy. After phrenotomy, the hepatic hydatid cyst was evacuated without capitonnage, and a Folly catheter was left in the cavity. Postoperative complications in the 30 patients with cysts in both locations included empyema in 2, bronchopleural fistula in 1, excessive biliary discharge in 3 and hemorrhage in 1. Hepatic hydatid cysts recurred in 2 patients. There was no hospital death. A single-stage posterolateral thoracotomy for extraction of pulmonary and liver hydatid cyst is an effective and safe surgical technique with few complications.

Air Travel and Pneumothorax

Single-stage transthoracic approach for right lung and liver hydatid disease

Single approach to pulmonary and liver hydatid cysts

Objective: Hydatid cysts can occur in any place such as the liver, lung, spleen, kidney, brain, and soft tissue. Pulmonary hydatid cysts are more prone to rupture than liver hydatid cysts. In this study, we aimed to present the demographic characteristics, clinical symptoms, radiological findings, surgical findings, type of surgery performed, and postoperative complications of patients with pulmonary hydatid cysts.Materials and method: The files of 94 patients who were operated on for pulmonary hydatid cysts in our clinic between January 2011 and October 2021 were retrospectively analyzed. The patients were divided into two groups: ruptured pulmonary hydatid cysts and non-ruptured pulmonary hydatid cysts.Results: A total of 120 pulmonary hydatid cysts were detected in 94 patients who were operated on for pulmonary hydatid cysts. Cyst rupture was detected in 63 (52.5%) patients. Rupture was found significantly higher in cysts with a diameter of <10 cm (p=0.005). Complaints of fever and hemoptysis were found significantly higher in the ruptured group. Pneumothorax was detected in six patients after the operation with an average of two months, one of which was the patient who underwent video-assisted thoracoscopy (VATS).Conclusion: Pulmonary hydatid cyst should be kept in mind in children presenting with lower respiratory tract symptoms in regions where echinococcosis is endemic. Parenchyma-sparing methods should be the first choice in the management of pulmonary hydatid cysts. Patients who develop early postoperative complications should also be followed closely for late impediments.

Pulmonary hydatid cyst mimicking lung tumor in a heavy smoker patient- Uniportal VATS management.