Pleural Complications Research Articles

Editorial Comment

This retrospective multi-institutional study aimed to determine whether an intercostal approach to the superior calyx resulted in different outcomes compared with a subcostal approach. Interestingly, of the entire cohort of 581 patients who were treated using a percutaneous technique, only 37% were approached via an upper pole access. Of the 142 patients approached via a superior pole access for which follow-up data were available, 72% underwent an intercostal approach, while 38% had a subcostal upper pole access. The intercostal approach resulted in a statistically significant overall improved stone-free rate for staghorn calculi and “large-burden” superior pole calculi compared with the subcostal approach. Major pulmonary complications between the intercostal vs subcostal approach were surprisingly low with only 1 pneumothorax in the subcostal cohort and 1 hemothorax in the intercostal group for an overall pulmonary complication rate of 1.4%. The authors' experience is significantly better than the 7%-15% pneumothorax or hydrothorax rate reported by others when accessing a superior pole calyx. 1 Shaban A. Kodera A. El Ghoneimy M.N. et al. Safety and efficacy of supracostal access in percutaneous renal surgery. J Endourol. 2008; 22: 29-34 Crossref PubMed Scopus (36) Google Scholar , 2 Lojanapiwat B. Prasopsuk S. Upper-pole access for percutaneous nephrolithotomy: comparison of supracostal and infracostal approaches. J Endourol. 2006; 20: 491-494 Crossref PubMed Scopus (95) Google Scholar Intuitively, the higher the intercostal space used for access, the higher the risk for pulmonary and/or pleural injury. The authors did not elucidate which intercostal space (supra 12th rib vs supra 11th rib vs supra 10th rib) was typically used for access. Their lower reported rates of pulmonary complications may be due to a more inferior intercostal space being used. Regardless, one may conclude that in circumstances when a superior pole access is considered preferable, an intercostal approach can provide good access with more than acceptable stone-free rates and acceptable complication rates. I agree with the authors that preoperative CT imaging with reconstructions may assist in proper tract positioning when superior pole access is entertained and reduce the risk of pulmonary, liver, and splenic injury. ReplyUrologyVol. 74Issue 4PreviewThe reviewer's comments address a most pertinent issue. Of our 103 intercostal access routes, 4 were supra 12th rib, 30 supra 11th rib, and 69 supra 10th rib. The only pulmonary complication occurred in 1 of the 4 supra 12th rib accesses, while 2 AV fistulae arose in the supra 11th rib accesses for staghorn calculi, and only 1 arteriocalyceal fistula occurred in the supra 10th rib access. The probability of a pulmonary or pleural complication seems to increase with a higher point of access and likely also in the presence of obesity, which tends to affect the angle of access trajectory. Full-Text PDF Risks, Advantages, and Complications of Intercostal vs Subcostal Approach for Percutaneous NephrolithotripsyUrologyVol. 74Issue 4PreviewTo establish the efficacy of nephrolithotripsy via intercostal access route vs subcostal access route with respect to attained stone-free status, operating time, and complications. Full-Text PDF

What imaging should we perform for the diagnosis and management of pulmonary infections?

Keywords Pneumonia.Empyema.Radiography.Ultrasonography.Computedtomography.Image-guidedpercutaneousinterventionDefinition and pathophysiologyPneumonia is an infection of the lower respiratory tract,involving the lung parenchyma. Whereas most pulmonaryinfections in children are viral and of the upper respiratorytract, bacterial pneumonias have a higher morbidity and aremore frequent indications for imaging. It appears that thelung response to an infective antigen is more age-specificthan antigen (i.e. bacteria vs. viral) dependent [1, 2].The complications of pneumonia include parapneumonic(pleural) effusion, empyema, or abscess. Progression of apleural effusion to empyema is through three stages:exudative, fibrinopurulent and organization. These compli-cations may arise when there is an unbalance between thevirulence of the offending organism and the defensemechanisms of the host, which may be compromised byanatomic factors that impede clearance of secretions(congenital malformations such as pulmonary sequestrationand systemic disease such as cystic fibrosis) and/or immunedeficiency conditions.EpidemiologyWorldwide, there are over 150 million cases of pneumoniaannually in children less than 5 years of age [3]. In theUnited States, 20 million hospitalizations occur annually inchildren, but this count includes viral etiologies [3]. In thedeveloped nations, 5–10% of children under the age of5 years will develop pneumonia annually [4]. The incidenceof pneumonia in children is 34 to 40 per 1,000 [5].Complicated pneumonia such as necrotizing pneumoniaand abscess formation increased in incidence over the yearsbetween 1990 and 2005 [6, 7]. Parapneumonic effusionscomplicate pneumonia in 36–56% of cases, resulting in anincidence of 0.4–0.6 per 1,000 [8]. Empyema complicatesan estimated 0.6% of all childhood pneumonias, resulting inan incidence of 3.3 per 100,000 [9]. There has been arecent emergence of community-acquired MethicillinResistant Staphylococcus Aureus (MRSA) pneumonias inchildren, originally thought to be mainly hospital-acquired[10] (Fig. 1).Cost to societyIn the adult population in Europe, the cost to societyresulting from uncomplicated pneumonia (1.1 millioncases annually) is estimated at 8 billion dollars [11].Childhood pneumonias are a frequent cause of doctor visits,antibiotics prescription, loss of work days for parents, andreduction of quality of life [12]. Regarding treatment ofpneumonia with pleural complications, gross total cost isapproximately equal between thoracentesis, pleural drainplacement, or video-assisted thorascopic surgery (VATS),but hospital length of stay is substantially shorter withVATS [8].

Accelerated Pulmonary Nodulosis and Sterile Pleural Effusion in a Patient With Psoriatic Arthropathy During Methotrexate Therapy

Pulmonary nodulosis and sterile pleural exudates are well-known extra-articular manifestations in rheumatoid arthritis patients with a positive rheumatoid factor. In some patients, treatment with methotrexate has been postulated as the trigger of these complications. We report a patient with psoriatic arthropathy, negative RF, negative anticyclic citrulinated peptide antibodies but positive antibodies to cardiolipin who developed massive sterile pleural empyema and multiple cavitary pulmonary nodules during methotrexate treatment. We suggest that awareness of methotrexate-induced lung and pleural complications should be extended to other than rheumatoid arthritis diseases, not necessarily accompanied by rheumatoid factor or anticyclic citrulinated peptide antibodies.

Percutaneous Nephrolithotomy: A Single Center Experience of 610 Cases

Purpose: We performed this study to evaluate the outcomes and complications of percutaneous nephrolithotomy (PCNL) at a single institute with a large series. Materials and Methods: We reviewed the medical records of 610 patients who underwent PCNL between March 1995 and June 2008 for staghorn calculi in 139 (22.8%), partial staghorn calculi in 104 (17.0%), renal pelvis stone in 222 (36.4%), proximal ureter calculi in 60 (9.8%), and calculi within a caliceal diverticulum in 85 (13.9%) patients. Stone-free status was defined as no visible residual calcification or remnant calcification smaller than 4 mm in diameter (clinically insignificant residual fragment) on a plain KUB (X-ray examination of the kidney, ureter, and bladder) image. Characteristics of the stones, operation time, stone-free rate, and complications were evaluated. Results: Initial stone burden was 665.9±600.6 mm. Average operation time was 103.2±58.6 minutes. The mean hospital stay was 7.9 days. The stonefree rate was 84.9%, and ancillary procedures were required in 66 patients (10.8%), including 34 (5.6%) second-look PCNL and 26 (4.3%) ureteroscopic procedures. In the univariate analysis for prediction of stone-free rate, hydronephrosis, stone type, stone composition, and stone burden were significant prognostic factors. In the multivariate analysis, initial stone burden was the only independent factor affecting the stone-free rate. Complications were found in 95 patients (16.1%), 5 (0.8%) of whom needed embolization due to bleeding and 23 (3.8%) of whom showed pleural complications. Conclusions: PCNL is an effective method for the treatment of staghorn, large calyceal, and some upper ureteral stones with acceptable complication rates. (Korean J Urol 2009;50:669-674) 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏

The risk of postoperative pulmonary or pleural complications after aortic valve replacement is low in elderly patients: an observational study

What factors predict postoperative pulmonary and pleural complications following aortic valve replacement? Retrospective study. One thousand consecutive patients who underwent aortic valve replacement with a pericardial valve between 1986 and 2006. Of these, 610 underwent also coronary artery surgery. Thirty putative predictors were investigated. Postoperative pulmonary complications (defined as respiratory failure, pneumonia, atelectasis) and postoperative pleural complications (defined as pleural effusion, pneumothorax, haemothorax, empyema) within 30 days of surgery were identified. 58 (6%) patients developed pulmonary complications and 45 (5%) developed pleural complications. None of the pleural and only 3 of the pulmonary complications were fatal if they occurred alone. Postoperative heart failure (OR 4.7, 95% CI 1.8 to 11.9), previous pacemaker implant (OR 4.4, 95% CI 1.8 to 11.2) and chronic obstructive pulmonary disease (OR 1.7, 95% CI 1.0 to 3.1) independently predicted postoperative pulmonary complications. Postoperative bleeding (OR 7.4, 95% CI 1.8 to 29.9), carotid artery disease (OR 2.8, 95% CI 1.4 to 5.5), previous coronary artery surgery (OR 2.7, 95% CI 1.1 to 6.4), chronic obstructive pulmonary disease (OR 1.9, 95% CI 1.0 to 3.8) and cardiac conduction defect (OR 1.9, 95% CI 1.0 to 3.7) independently predicted postoperative pleural complications. Postoperative pulmonary and pleural complications were rare. A history of cardiac and/or pulmonary problems are risk factors for pulmonary complications after aortic valve replacement. Further study is needed to reveal if preventive physiotherapeutic intervention in these patients is effective.

Safety and Efficacy of Supracostal Access in Percutaneous Renal Surgery

During percutaneous renal surgery, subcostal access is preferred because it carries no risk of injury to either the lungs or pleura. However, in some situations, a supracostal approach may provide more direct access and achieve a more satisfactory result than the subcostal approach. In this prospective study, we evaluated the safety and efficacy of supracostal approaches in percutaneous renal surgery. Between 2004 and 2006, 30 patients underwent percutaneous renal surgery with a supracostal approach either as the sole or as a secondary access. The indications were staghorn stones, upper caliceal stones, upper ureteral stones, secondary ureteropelvic junction obstruction, disturbed lower caliceal anatomy, and high-lying kidneys. The puncture was above the eleventh rib in six procedures and above the twelfth rib in 24 procedures. All patients were examined for equal air entry on both sides of the chest, and all had chest radiography performed immediately after surgery to exclude pneumothorax or hydrothorax. Bleeding was assessed with evaluation of preoperative and postoperative hemoglobin, levels and vital signs; urine was also examined for gross hematuria. A routine nephrostogram was obtained for all patients. Supracostal was the sole access in 63.3% of patients and a secondary access in 36.7% of patients. Intraoperatively, bleeding occurred in one patient. Hydrothorax in another patient necessitated insertion of an intercostal chest drain. A renopleural fistula developed in another patient 2 days postoperatively that necessitated placement of a chest drain and Double J stent. Access in both patients with pleural complications had been above the eleventh rib. The mean drop in hemoglobin level was 0.79 +/- 0.72 g/dL. Our overall stone-free rate was 88.9%. Supracostal access above the twelfth rib is relatively safe; however, access above the eleventh rib should be limited to necessity because a higher incidence of pleural complications can be expected. A chest radiograph should be obtained immediately postoperatively for early detection of hydrothorax or pneumothorax.

Spontaneous bacterial empyema in liver cirrhosis: An underdiagnosed pleural complication

Spontaneous bacterial empyema, defined as spontaneous infection of the pleural fluid, represents a distinct complication of hepatic hydrothorax with a different pathogenesis, clinical course and treatment strategy from those of empyema secondary to pneumonia. Nearly 40% of episodes of spontaneous empyema are not associated with spontaneous bacterial peritonitis (SBP) or even ascites. The condition portends a poor prognosis, and is frequently under-diagnosed. This article reviews the pathogenesis, diagnosis and management of spontaneous bacterial empyema.

Symptomatic mediastinal myelolipoma with associated hemorrhagic pleural effusion

We report the case of an 85 year old female patient who presented a mediastinal myelolipoma associated with hemorrhagic pleural effusion and anemia. Pathologic examination identified zones of acute and old intratumoral hemorrhage. The occurrence of a potential severe pleural complication has not been reported for this tumor, regarded as indolent. Such observation has practical relevance since it contrasts with the suggestion that these tumors may be followed without surgery.

The treatment of non-union of the clavicle with the AO mini external fixator

Osteosynthesis of non-union of fractures of the clavicle were achieved using bone graft and the AO mini external fixator. The technique was used in nine patients, and no neurovascular or pleural complications occurred. The average time before the patient was considered for this method was 11 months. The external fixator was removed at an average of eight weeks, with solid union in all cases. The outcome was excellent and all patients returned to pre-injury level of normal activity. This method provides safe and relatively simple treatment for this difficult non-union.

Pleural Complications in End-Stage Renal Disease

Pleural Complications in End-Stage Renal Disease

MANAGEMENT PREFERENCES FOR PLEURAL INTERVENTION PRIOR TO LUNG TRANSPLANTATION IN LYMPHANGIOLEIOMYOMATOSIS

PURPOSE: Lymphangioleiomyomatosis (LAM) is a progressive pulmonary disease which may ultimately require lung transplantation. Many patients develop pneumothorax (70%) or chylothorax (30%) requiring pleural interventions which can complicate lung transplantation and affect candidacy. Management strategies for pleural complications of LAM remain controversial.

P6: Decortication after lung transplantation

Purpose: Pleural complications are common after lung transplantation and may compromise allograft function. Lung entrapment resulting from loculated pleural effusion, empyema or fibrothorax is often amenable to surgical decortication. However, obliterated tissue planes and fragility of the transplanted lung make decortication more technically challenging and less predictable in this group. We examined our experience with decortication in lung transplant recipients to characterize pleural pathology, determine the extent of lung re-expansion, and analyze patient outcome. Methods: We identified 490 patients in our prospective database that underwent lung transplantation at the Cleveland Clinic between February, 1990 and January, 2006. Results: Decortication was performed 20 times in 19 patients (3.9%), a median of 86 days after lung transplant (range 12 to 964days). Suspected empyema was the most common indication for operation (11), followed by loculated effusion (6), hemothorax (2) and fibrothorax (1). Complete re-expansion of the transplanted lung was achieved after 16 of the 20 decortications (80%). The median length of stay was 17.5days (range 3-102) and the operative mortality was 25%. Conclusions: Empyema is the most common indication for decortication after lung transplant followed by loculated pleural effusion and hemothorax. While decortication leads to complete expansion of the majority of transplanted lungs, the length of stay is long and mortality high. Clinical implications Decortication should be used selectively after lung transplantation, weighing the risks of lung entrapment and pleural space infection against considerable operative mortality.

Un épanchement pleural liquidien compliquant une chambre à cathéter implantable

Totally implanted venous devices (TIVD) are an essential tool for repeated intravenous treatments such as chemotherapy for cancer and antibiotics for cystic fibrosis. A woman of 76 years was treated for bronchiectasis, colonised by Pseudomonas aeruginosa, with courses of intravenous antibiotics. On account of poor peripheral veins a TIVD was implanted. The implantation and subsequent antibiotic injections were uncomplicated. Three years later a further course of antibiotics was prescribed. As no reflux of blood was obtained on puncturing the device the position of the catheter was checked radiologically. The patient complained of right shoulder pain following each infusion. The chest x-ray showed a pleural effusion. The sudden onset of the effusion, the absence of signs of infection and the patient's good clinical condition suggested pleural extravasation of the antibiotic infusion from the TIVD. Pleural aspiration yielded 1400 mls of watery fluid. Injection of contrast into the TIVD confirmed intra-pleural extravasation. When using a TIVD it is important to bear in mind the possibility of late pleural complications.

Massive empyema caused by Mycoplasma pneumoniaein an adult: A case report

BackgroundMycoplasma pneumoniae is responsible for more than 20% of community acquired pneumonia cases, and capable of causing upper respiratory illness as well. Complications of M.pneumoniae infections include CNS involvement but other as pericarditis were also reported. The lack of feasible culture methods and under appreciation of the pathogens ability to cause invasive disease leads to reduced number of diagnosed M.pneumoniae related complications. In contrast to many other respiratory pathogens causing pneumonia, M. pneumoniae related severe pleural complications were almost never reported.Case presentationWe report a previously healthy 57 years old woman presented with indolent massive right pleural effusion, leukocytosis and elevated ESR. Extensive microbiological evaluation didn't reveal any pathogen in the pus even before antibiotic treatment was started. Surprisingly, M.pneumoniae DNA was detected in the pus from the empyema using PCR designed to detect M.pneumoniae. A serological assay (Serodia-Myco II) using convalescent serum was indeterminate with a titer of 1:80. The patient responded well to a treatment that included right thoracotomy with pleural decortication and a combination of antibiotics and anti-inflammatory medications.ConclusionM.pneumoniae related empyema was never reported before in adult patients and was reported in only a few pediatric patients. In our patient there was no evidence to any common pathogens even before initiating antibiotic treatment. The only pathogen detected was M.pneumoniae. In this patient, serology was not helpful in establishing the diagnosis of M.pneumoniae related diseases, as was suggested before for older patients. We suggest that M.pneumoniae related empyema is probably under-diagnosed complication due to insensitivity of serology in older patients and under use of other diagnosis methods.

O papel da cirurgia torácica vídeo-assistida - CTVA - no tratamento da pneumonite necrosante na criança

OBJETIVO: Avaliar o papel da cirurgia torácica vídeo-assistida (CTVA) no tratamento das complicações pleurais da pneumonite necrosante (PN) na criança, em sua fase aguda. MÉTODO: Avaliação prospectiva de sete pacientes com idades entre quatro e sete anos, portadores de empiema pleural com PN, com diagnóstico confirmado por tomografia computadorizada de tórax (TC) e cirurgia. Realizou-se a descorticação pulmonar com esvaziamento do pleuris, desbridamento e ressecção do tecido pulmonar comprometido, e drenagem torácica, através de videotoracoscopia com três portais. Foram avaliados no pós-operatório a curva térmica, o leucograma, o tempo de drenagem torácica e a permanência hospitalar. RESULTADOS: Houve re-expansão pulmonar completa em todos os pacientes tratados pela CTVA, com rápida melhora do estado geral, queda de temperatura e da leucocitose na primeira semana pós-tratamento. O período de drenagem pós-CTVA variou de sete a 17 dias, e a permanência hospitalar póscirúrgica foi menor quando comparada com dados da literatura em que o tratamento utilizado foi a drenagem torácica com antibioticoterapia ou a cirurgia a céu aberto. CONCLUSÕES: A utilização da CTVA como coadjuvante no tratamento da PN acompanhada de complicações pleurais, tem papel importante na aceleração da recuperação clínica do paciente, proporcionando a reexpansão mais rápida do pulmão colapsado, com melhoria das condições respiratórias.

Delayed diagnosis of pleural complications in ventriculoperitoneal shunt—Case reports of three patients

Summary Symptomatic pleural effusion following ventriculoperitoneal (VP) shunt insertion is very rare. We report our experience with three patients with VP shunt and massive pleural effusion. The three were seen multiple times in the emergency room before diagnoses were reached. Awareness of this possible complication may prevent futile surgical interventions or redundant treatments.

Videothoracoscopy versus intrapleural streptokinase for management of post traumatic retained haemothorax: a retrospective study of 65 cases

Post traumatic retained haemothorax (PRH) may cause pulmonary restrictions or septic pleural complications. Currently, minimally invasive procedures such as videothoracoscopy or intrapleural fibrinolysis have replaced open surgery in an effort to avoid these complications. We have reviewed retrospectively our use of videothoracoscopy versus intrapleural streptokinase for the management of PRH over the last 10 years. There were 56 males and nine females in the study. Thirty-one cases had been managed by intrapleural streptokinase (group I), and videothoracoscopy was performed on 34 cases (group II). Therapeutic results for both groups were determined by chest radiographs. In the population from which we drew our study group, retained haemothoraces occurred in 10.9% of 596 cases with traumatic haemothorax. In group I, 22 patients had radiological improvement; the others underwent thoracotomy. In this group, mean hospitalisation time was 14.5(+/-4.2) days, and three cases were complicated by empyema. In group II, all patients except four had complete radiological improvement; two of them required a decortication. In this group, mean hospital stay was 9.8(+/-3.7) days. There were no deaths in either group. The differences between group I and group II for length of hospital stay and number of thoracotomies was statistically significant. Videothoracoscopy is therefore a more effective procedure than intrapleural streptokinase for the management of PRH.

Video-assisted thoracoscopic management of recurrent primary spontaneous pneumothorax after prior talc pleurodesis: a feasible, safe and efficient treatment option

To assess the role of video-assisted thoracoscopic surgery (VATS) in the management of a recurrent primary spontaneous pneumothorax after a prior talc pleurodesis. From 1996 to 2002, we retrospectively reviewed all patients who were treated for a recurrent primary spontaneous pneumothorax after a previous talc pleurodesis. Data on the talc procedure and the recurrent pneumothorax, delay between both, and operative features were studied. Conversion rate to a thoracotomy and postoperative complications as well as long-term outcome were reported. We collected 39 patients (28 male) with a median age of 25 years (15-41 years). The initial procedure consisted of thoracoscopic talc poudrage in all cases. The median delay between the talc procedure and the recurrence was 23 months [10 days-13 years]. Size of recurrence involved 10-80% of the hemithorax. The VATS procedure was successfully achieved in 27 patients (69%) while 12 required conversion to a thoracotomy. The main cause for conversion was the presence of dense pleural adhesion at the mediastinal part of the pleural cavity. Postoperative morbidity was limited to pleural complications in the VATS group (n=6, 22%). Median follow-up was 26 months [10-38 months]. One patient treated by VATS developed a partial recurrent pneumothorax at 12 months with a favorable outcome without further surgery. Feasibility, safety and efficacy of VATS for management of recurrent primary spontaneous pneumothorax following thoracoscopic talc poudrage are strongly suggested.

Correlation between levels of tumour necrosis factor-α and levels of pH, glucose, and lactate dehydrogenase in parapneumonic effusions

Objectives. This study was undertaken to investigate the correlation, which has not been previously investigated, between levels of tumour necrosis factor-α (TNF) and levels of pH, glucose, and lactate dehydrogenase (LDH) in pleural fluid of patients with uncomplicated parapneumonic effusion (UCPPE), and patients with complicated parapneumonic effusion (CPPE). Methods. Using a commercially-available high sensitivity ELISA kit, levels of TNF were measured in pleural fluid of patients with UCPPE ( n=23), and CPPE ( n=15), and were compared with levels of pH, glucose, and LDH in these two groups. Results. The mean±SD values of pleural fluid TNF, pH, glucose, and LDH in the UCPPE group were 11.05±7.65 pg/ml, 7.41±0.08, 125±48 mg/dl, and 306±182 IU/l, respectively. In the CPPE group the values were 56.07±28.5 pg/ml, 6.82±0.25, 42±36 mg/dl, and 2096±1916 IU/l, respectively. The only significant correlation, which was negative, was found between levels of TNF and pH in the CPPE group ( r=−0.62, P=0.01). Levels of pleural fluid TNF and LDH were significantly higher, and levels of glucose were significantly lower in the CPPE group than in the UCPPE group ( P<0.0001). Conclusions. This study demonstrates, for the first time that TNF levels correlate inversely with levels of pH in pleural fluid of patients with CPPE but not of patients with UCPPE. This correlation may, in part, explain the pathophysiology of the pleural complications which occur in the presence of CPPE.

Pleural complications of pulmonary hydatid disease.

The aim of this study was to determine the incidence and diagnostic features of pleural manifestations of pulmonary hydatid disease. Patients with pleural pathology in association with surgery for pulmonary hydatid disease over an 8-year period were evaluated. Twenty-nine (6%) of 474 patients with histologically confirmed pulmonary hydatid disease had pleural abnormalities. The diagnosis was determined preoperatively in 22 patients and was based on radiographic, clinical, and/or serology findings. Bronchoscopic specimens were diagnostic in two of seven patients who had bronchoscopy. Five patients were not diagnosed until surgery. Radiographic abnormalities consisted of pleural thickening and/or free fluid without intrapleural rupture of the cysts in 21 patients. Eight patients had a hydropneumothorax. Sixteen patients had an exudative, uncomplicated effusion. The remaining patients had empyemas. All patients had resection of the pulmonary cysts, and 20 also underwent a pleurectomy. The mean length of hospital stay was 23 +/- 14 days. There was no hospital mortality. Pleural lesions associated with pulmonary hydatid disease are rare and have a variable radiographic appearance. In regions in which echinococcal disease is endemic, a high level of clinical suspicion is necessary for diagnosis and appropriate management of this condition.