Intrapleural tenecteplase in complicated Hydatid Cyst: a case report

Introduction: Introduction: The complicated hydatid cyst of the lung is defined as any cyst ruptured in the bronchi tree or in the pleural cavity, infected, and rarely in the pericardial cavity. The aim of this study was to evaluate the problems of complicated pulmonary hydatid cyst, including presentation, diagnosis choice of surgical methods. and complication of delay in surgical treatment of pulmonary hydatid cysts. Methods: Between 2016 and 2021, 192 operations operated for pulmonary hydatid cysts, 42 of these patients were complicated hydatid cyst. Presentations were cough, chest pain and dyspnea.Diagnosis tools were CXR and CT-scan of chest. surgical approach was a posterolateral thoracotomy and anterolateral thoracotomyin all patients; a phrenotomy in eight patients and one-stage bilateral thoracotomy in six patients. Results: In 18 patients (67.5%), there were single hydatid cysts; whereas 4 patients (32.5%) had multiple cysts.12 patients had bilateral cyst and 8 had both lung and liver and others organs, 6 patients had preoperative hydatid cyst history. Iatrogenic rupture of an intact hydatid cyst occurred in 4 patients. Extrathoracic involvement was apparent in 6 patients (27%). Intrathoracic but extrapulmonary involvement was apparent in 4 patients (16%). Conclusion: Complicated hydatid cyst may present with different clinical and radiologically manifestations as a primary lung tumor , pleural effusion ,empyema hydropneumothorax. In patients with suspicious lung masses in endemic area or history of a hydatid cyst in patients a complicated pulmonary hydatid cyst may be in differential diagnosis.

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.

Aim: Echinococcosis is still an important health problem throughout the world, particularly in the Mediterranean area. In humans, the lungs are the second most commonly affected sites. The disease may affect children and its treatment may be challenging. In children, small hydatid cysts of the lungs respond favorably to the medical treatment. Surgery is the standard option for the treatment of large and complicated cysts. In current practice, thoracotomy and parenchyme-saving procedures such as cystostomy and capitonnage remain the standard surgical approach for pulmonary hydatid cysts in children. However, surgical experience with thoracoscopy is limited. The aim is to present the experience in thoracoscopic management of pulmonary hydatid cysts in children. Patients and Methods: Medical records of children who underwent thoracoscopic cystostomy of pulmonary hydatid cysts between 2008- 2016 were reviewed. Surgical treatment was recommended for patients who remained symptomatic on medical treatment and when the cyst size was larger than 6 cm in diameter. Parenchyme-saving surgery was preferred which included cystostomy, removal of germinative membrane and control of air leaks. Capitonnage was not preferred because of the risk of deterioration in lung capacity. Results: Fifteen patients underwent 16 thoracoscopy procedures for pulmonary hydatid cysts. One of the patients had bilateral complicated pulmonary hydatid cysts. There were conversions to mini-thoracotomy in 3 (20%) procedures because the air leaks could not be controlled safely. The procedure was completed thoracoscopically in 12 patients. In thoracoscopically completed cases, prolonged air leak (over a week) occurred in 3 (25%) patients and one of them underwent thoracotomy to control bronchopulmonary fistula. One of the patients underwent laparoscopic cystostomy and capitonnage for associated liver hydatid cyst. There were no recurrences during 60 months of mean follow-up time and no problem was observed during the follow-up period. Conclusion: Thoracoscopic management is recommended in children with uncomplicated hydatid cyst. In complicated hydatid cysts, however, thoracoscopic wedge resection is recommended. If there is difficulty in controlling bronchial openings, mini-thoracotomy could be considered.

Complicated hydatid cyst of the thorax is important to the clinical approaches and treatment methods in hydatid disease. The aim of this study was to evaluate the problems of complicated pulmonary hydatid cyst, including choice of surgical methods, diagnostic clues and to discuss the inherent risks of medical therapy and the delay of surgical treatment in pulmonary hydatid disease. Between 2002 and 2006, 40 operations were carried out in 37 patients whose diagnoses were complicated hydatid cyst. The surgical approach was a posterolateral thoracotomy in all patients; a phrenotomy in two patients and a thoracoabdominal approach in one patient and two-stage bilateral thoracotomy in four patients. The preferred surgical treatment procedure was cystotomy and modified capitonnage, which was carried out in 26 patients (70%). Other procedures included a cystotomy in five (14%) and decortication in six (16%) patients. Segmentectomy was carried out in 1 (3%), and wedge resection in four patients (11%). In 25 patients (67.5%), there were single hydatid cysts; whereas 12 patients (32.5%) had multiple cysts. Eleven patients had preoperative hydatid cyst history. Iatrogenic rupture of an intact hydatid cyst occurred in three patients. Extrathoracic involvement was apparent in 10 patients (27%). Intrathoracic but extrapulmonary involvement was apparent in six patients (16%). The morbidity ratio was 5%; there was prolonged air leak and atelectasis in one patient each. The mortality ratio was 3% (one patient). The average hospitalization duration for all patients was 5.7 days (range, 3-17 days). The mean follow up was 18.4 months with no recurrence. Complicated hydatid cyst may have different clinical manifestations and may present radiologically as a primary lung tumour. In patients with suspicious lung masses owing to endemic area, history of a hydatid cyst or contralateral or extrathoracic hydatid cyst involvement at the same time should indicate a complicated pulmonary hydatid cyst. Preoperative anthelmintic therapy must be avoided owing to the risk of perforation. Treatment of a complicated hydatid cyst differs from that of an intact hydatid cyst. Anatomic resection may be necessary owing to destroyed lung tissue secondary to suppuration from a hydatid cyst; however, parenchymal preserving surgery is preferable in an uncomplicated hydatid cyst. A modified capitonnage method is recommended for complicated hydatid cyst treatment as it has a low morbidity rate.

Complicated hydatid cysts of the lung: clinical and therapeutic issues

Evaluation of pulmonary hydatid cyst cases

The purpose of this study was to present the CT findings of complicated pulmonary hydatid cysts on the basis of the CT appearances. Preoperative CT examinations of 19 cases with hydatid cysts were evaluated retrospectively for the number and various features of the cysts and secondary changes in adjacent structures. The results were compared with surgical findings. While 7 patients had multiple pulmonary hydatid cysts, 12 patients had solitary cyst. The total number of the cysts was 29. Eleven of them were intact cysts. Two of the 18 complicated cysts were only ruptured, while the remaining 16 complicated cysts were ruptured and infected. The endocyst was separated from a pericyst in a local area in one ruptured cyst. Air-bubbles were seen within 14 infected cysts. Nine of the infected cysts had characteristic appearances of hydatid disease. The other 2 infected cysts showed soft tissue density. CT can provide the specific diagnosis of pulmonary hydatid cysts by demonstrating the number and features of the cysts, characteristic appearances of complicated cysts, and secondary changes in adjacent structures. Whether there are characteristic signs or not, the demonstration of air-bubbles within the cyst, together with ring enhancement, are strong indicators for infected hydatid cysts.

Background: Hydatid cyst still has worldwide distribution with many cases discovered yearly in endemic areas. It has a predilection to involve the liver and the lung. Capitonnage has been practiced long time to avoid postoperative complications mainly air leak in addition to empyema formation. It may be still controversy concerning the efficiency of capitonnage especially for complicated hydatid cyst which led us to evaluate. Aim of the study: To assess the efficacy of capitonnage surgery in minimizing the postoperative complications and hospital stay in complicated and non complicated pulmonary hydatid cysts. Patients and Methods: A prospective study has been done at the department of thoracic surgery in Al-Jumhory teaching hospital at right side of Mosul, Department of pediatric surgery in Al-Khansaa teaching hospital and in Al-Rabee private hospital at left side of Mosul / Iraq between February 2017 and December 2019. Totally 118 patients with hydatid cyst of lung, including all ages and on different types of complicated and non-complicated cysts were included for this study. Co-morbid diseases like acute myocardial ischemia and uncontrolled diabetes mellitus were excluded from our study. Patients were evaluated in responce to the gender, age, clinical presentation, cyst condition (size, site and where ruptured or not) and postoperative hospital stay. Enucleation of the HC and capitonnage were carried out for all patients. The patient followed for three months at monthly interval, then each year with the mean follow up of 22 months. Results: One hundred eighteen patients with median age of 32 years were operated using capitonnage method. In this study 49 (41.5%) of the patients found to have intact cyst and the remaining 69 (58.5%) had ruptured cyst. We recorded the early postoperative complications which include air leak in 10 cases, Atelectasis 8, pneumothorax 3, wound infection 3 and Hemoptysis in 2 cases. Conclusion: Capitonnage can decrease the incidence of air leak and shorten hospital stay in complicated and non-complicated lung hydatid cysts.

We describe a rare case of intact endobronchial hydatid cyst that posed a diagnostic challenge because of an unusual imaging manifestation (atelectasis) and unexpected bronchoscopic findings. Although the role of bronchoscopy in the management of pulmonary hydatid cyst is still controversial, 6 cases of complicated pulmonary hydatid cyst removed completely by suction through a fiberoptic bronchoscope have been reported so far. To the best of our knowledge, this is the first nonsurgically treated case of intact endobronchial hydatid cyst with an uneventful long-term follow-up.

The aim of this study was to assess the relationship between the pulmonary hydatid cyst size and the clinical presentation, surgical approach, and postoperative outcome. We review the problems encountered in treating large pulmonary hydatid cysts and highlight the risks associated with the rupture of the cyst and a delay of the surgical treatment. The medical records of 169 patients surgically treated for lung hydatid cysts were reviewed. Patients were divided into two groups based on cyst size: group 1 (n=128) with small (<10cm) cysts and group 2 (n=41) with giant (≥10cm) cysts. Data related to symptoms, preoperative complications, surgical procedures performed and postoperative morbidity were analyzed and compared. In both groups, the most common symptom was chest pain, followed by dyspnea and cough, respectively. There were no differences between the two groups with respect to cyst-associated parenchymal or pleural complications before surgery (p=0.80). In the large majority of cases, the surgical treatment was cystotomy, removal of the cystic membrane and capitonnage. Wedge resection was performed in nine patients in total (seven in group 1, two in group 2) and one patient in group 2 required a lobectomy. Decortication was required significantly more frequently in group 2 than in group 1 (p=0.001). Sixteen patients in group 1 and 10 patients in group 2 developed postoperative complications (p=0.19). There was no peri or postoperative mortality. There was no difference between the groups with respect to the duration of hospitalization (p=0.17). Two patients with complicated hydatid cysts in group 1 had recurrent lesions during follow-up, whereas there was no recurrence in group 2. All pulmonary hydatid cysts should be surgically treated as soon as possible after their diagnosis in order to avoid complications. Most of these lesions, regardless of size, can be surgically managed with procedures that preserve the maximal lung parenchyma and yield excellent outcomes.

Patient: Female, 32Final Diagnosis: Complicated hydatid cystSymptoms: Cough with expectoration and fever for the last 4 monthsMedication: Tab. AlbendazoleClinical Procedure: —Specialty: PulmonmologyObjective:Unusual clinical courseBackground:Hydatid cyst, or Echinococcosis, is an important helminthic zoonotic disease in humans that commonly affects the liver and lungs. Uncomplicated hydatid cysts, seen as round opaque lesions on chest radiography, are easily diagnosed, whereas complicated cysts (infected and or perforated) may change the radiographic appearance of the hydatid cyst, causing an incorrect diagnosis and delayed treatment. Although in radiology many signs have been described, the “air bubble” sign, seen in the mediastinal window of CECT as a single or multiple small rounded radiolucent areas with sharp margins within the periphery of a solid mass lesion, is being recognized as a sign with high sensitivity and specificity in the diagnosis of complicated hydatid cysts.Case Report:A 32-year-old female on anti-tubercular treatment for the past 3 months without any improvement was admitted to our hospital. CECT of the chest revealed a mass-like lesion with the “air bubble” sign. After 15 days the patient had a vigorous bout of coughing, leading to expectoration of pieces of whitish yellowish gelatinous membrane for the next 3 days. The ELISA result for Echinococcus was highly positive. On the basis of the “air bubble” sign, positive serology, and expectorated pieces of the membrane, the patient was diagnosed as having a complicated hydatid cyst.Conclusions:Due to the varied presentations of complicated hydatid cyst, the knowledge and awareness of various signs in radiology associated with the hydatid cyst, in particular the “air bubble” sign, is imperative in making a prompt and accurate diagnosis of a complicated hydatid cyst.

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

Even when radiological images are considered pathognomic for intracranial hydatid cysts, subtle image characteristics are evident depending upon the status/types of hydatid cysts. These imaging features, if finely scrutinized, may help to modify conventional surgical techniques of cyst excision. From January 2006 to December 2011, nine patients (male:female 7:2, age range 4-44 years, median 7 years) harbouring intracranial hydatid cysts were managed at our centre. In addition to CT scans, all patients underwent plain and contrast-enhanced MRI scans. Based on these radiological findings, the types of hydatid cysts were characterized into simple or complicated (infected) cysts. Complicated cysts were further differentiated into ruptured or intact subtypes based on imaging features. Surgical procedures including the Dowling water dissection technique, in addition to head rotation, were performed for removing these cysts intact. Children (n = 4) aged 6 years or less presented with increasing head size as the only complaint, while the rest of the patients (n = 5) had symptoms of raised intracranial pressure. MRI features of hypo-intensity on T1-weighted images, hyper-intensity on T2-weighted images, and non-contrast-enhancing cysts were noted for all simple cysts (n = 7), while iso- to mixed intensity on T1-weighted images and hyper-intensity on T2-weighted images with contrast-enhancing pericyst correctly diagnosed all complicated (infected) hydatid cysts (n = 2). One of these complicated cysts had spilled the infected contents outside the cyst wall, but within the confines of the cerebral parenchyma (pericyst). Such a case of contained spontaneously ruptured complicated hydatid cyst is described for the first time. At a median follow-up of 18 months, all patients remain free from cyst recurrence. Subtle changes in radiological features of CNS hydatid cysts should be appreciated so as to diagnose the type of cyst correctly. The surgical strategy should be tailored according to the type of cyst for favourable outcome.

Complicated pulmonary hydatid cyst disease can mimic tuberculosis, lung cancer, empyema and abscess. The diagnosis of complicated pulmonary hydatid cysts may not be easy. Bronchoscopy is not a routine procedure in hydatid cyst disease. However, it is inevitable when clinical and radiological appearance is atypical. A pulmonary hydatid cyst disease case with atypical clinical and radiological findings diagnosed by fiberoptic bronchoscopy was presented in this case report.

Objective. Biliary complications of hepatic hydatidosis are often difficult to detect and manage. The aim of this study was to present our experience on the effectiveness of endoscopic treatment modalities in cases of biliary complications of hepatic hydatid cysts. Material and methods. Over the past 10 years, 15 patients diagnosed with hepatic hydatidosis and manifesting symptoms and signs indicative of biliary involvement were examined by means of endoscopic retrograde cholangiopancreatography (ERCP) in our Gastroenterology Endoscopic Unit; 7 patients had already been operated on for hepatic hydatid cysts; one of them had a concomitant hydatid cyst in the lung. Diagnosis of the disease was based on a combination of ultrasonography (US), computed tomography (CT) and specific immunologic and/or microbiologic studies. Results. Biliary complications of hydatid cysts were detected by ERCP in 9 patients (60%). Eight (88.9%) patients displayed a communication between the hydatid cyst or its residual cavity and the biliary tree; 5 patients had daughter cysts or residual hydatid material within the biliary tree, 1 patient had a biliocutaneous fistula, 1 patient a postoperative biliary leakage and 1 patient had only an opacification of the hydatid cyst during ERCP. In one patient, ERCP showed stenoses of both of the main hepatic ducts due to their compression by the cyst. Jaundice (88.9%), fever (33.3%) and right upper quadrant abdominal pain (88.9%) were the most frequent manifestations. These complications were demonstrated by US and CT imaging in only 25% of the cases. Four patients underwent ERCP before surgery and 5 after surgery. Endoscopic management was successful in all patients, resulting in clearance of the biliary tree, closure of fistulas, stopping of biliary leakage and jaundice remission. No serious endoscopy-related complications were recorded, with the exception of a pulmonary hydatid cyst rupture during ERCP. Conclusions. This study suggests that endoscopic treatment modalities are helpful and safe methods in the treatment of biliary complications of hepatic hydatidosis before and after definitive surgical management of the hydatid cysts.