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Year : 2003  |  Volume : 13  |  Issue : 2  |  Page : 203-205
Imaging of rupture cardiac hydatid cyst located on the interventricular septum with pulmonary embolism, a case report


Department of Radiology, Kalinga Hospital, Chandrasekharpur, Bhubanesware-751023, Orissa, India

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Keywords: Hydatid cyst, Pulmonary Embolism, Cardiac Mass

How to cite this article:
Mohapatra M, Sahoo P K, Pattnaik S C, Sahoo S, Pattnaik M R, Behera S. Imaging of rupture cardiac hydatid cyst located on the interventricular septum with pulmonary embolism, a case report. Indian J Radiol Imaging 2003;13:203-5

How to cite this URL:
Mohapatra M, Sahoo P K, Pattnaik S C, Sahoo S, Pattnaik M R, Behera S. Imaging of rupture cardiac hydatid cyst located on the interventricular septum with pulmonary embolism, a case report. Indian J Radiol Imaging [serial online] 2003 [cited 2019 Aug 22];13:203-5. Available from: http://www.ijri.org/text.asp?2003/13/2/203/28661

   Introduction Top


Hydatid disease is caused by the tapeworm Echinococcus granulosus and E multilocularis. The life cycle involves primary and the intermediate mammalian hosts. Dogs are the usual primary host and the intermediate host is usually a sheep or cow but sometimes human. In the intestine the eggs hatch and the embryo cross the intestinal mucosa, enters into blood vessel and lymphatic system. Liver and lungs together filters the majority (approximately 85 to 90%) of the embryo. Via systemic circulation approximately 10 to 15% may reach other organs including the cardiac chambers, interventricular septum and the pericardium (0.02-2%)[1],[2],[3]. Hydatid cysts locations in the pulmonary arteries are exceptional [4],[5]. Wherever the embryo settles, it forms a hydatid cyst. The cyst wall secreted by the embryo is consists of two layers, the outer ectocyst and the inner endocyst. The endocyst is the vital layer of the cyst responsible for formation of brood capsule, scolices, fluid inside the cyst and outer layer. A granular deposit found to settle at the bottom of fluid is called hydatid sand which is composed of brood capsules, free scolices and loose hook lets [7]. The present report describes a case of hydatid cyst localized on the interventricular septum, in bilateral pulmonary arteries and lungs. The CT, Ultrasonography and echocardiography helped to localize and characterize the lesion in different location and in some locations the imaging findings were characteristic of hydatid cyst, but presentation with hemoptysis is very rare [6]


   Case report Top


A 22 years female presented with cough and severe episodes of blood tinged sputum of one-month duration. In addition she has low grade pyrexia. She was treated with several antibiotics and antitubercular medications, till she was referred to our hospital. On clinical examination she was found to have tachycardia, hypotension, raised JVP with diminished breath sound in upper part of chest with scattered crepitations. There were no cardiomegaly or conduction disturbances but pulmonary component of second heart sound was exaggerated with a right ventricular gallop. Abdominal examination revealed no organomegaly. There was no neurological deficit. There was no history of swelling of both lower limbs.

Chest radiograph revealed multiple rounded homogenous well circumscribed nodular opacities of varying sizes in bilateral lung fields and the left cardiac outline is displaced downwards and medially [Figure - 1]. Non contrast and contrast enhanced CT scan of thorax shows a large hypodense well circumscribed mass lesion in left lung with enhancing wall [Figure - 2]a,b. Multiple similar lesions were seen on bilateral lung fields. A well marginated hypodense intraluminal lesion in right pulmonary artery with enhancement of its wall was seen on non contrast and contrast enhanced CT study [Figure - 2]a,b. Additionally intraluminal hypodense lesions with enhancement of its wall was seen in the interlobular branches of both right (not shown in the figure) as well as left pulmonary arteries [Figure - 3]. The CT sections at the level of cardia shows expanded interventricular septum with non enhancing hypodense lesion on it, which has got finger like projections into right ventricular lumen [Figure - 3]. Echocardiography appearance of the same lesion on the interventricular septum was multicystic cartwheel like with echogenic finger like projection from it into right ventricular lumen in addition to the expanded interventricular septum [Figure - 4]. Ultrasonographic appearance of the lung lesions were cystic thin walled masses with internal solid echogenic material in the dependant part suggestive of hydatid sand [Figure - 5]. No other cystic lesion detected in abdominal examination on ultrasonography. With these findings a provisional diagnosis of cardiac hydatid cyst with metastatic Echinococcosis in lungs and pulmonary artery was diagnosed. Serological finding was suggestive of echinococcosis. The serum Echinococcus IGG antibody titer was >800 (Titer >15 is positive , Speciality Ranbaxy Limited, Clinical reference Laboratories, Mumbai-93, India). She was planned for surgical removal of the cyst from the heart and pulmonary arteries, but on the night previous to surgery she suddenly developed tachycardia, hypotension and breathlessness suggestive of anaphylaxis and died.


   Discussion Top


Hydatid cyst localization inside the lumen of pulmonary arteries is very rare and is a consequence of embolism from primary cardiac location [3]. The other pathway for entry into pulmonary artery is from liver into inferior vena cava and from there via right cardiac chamber into pulmonary arteries [5]. In the present case the cysts were observed on the interventricular septum and membranes from this projecting into right ventricular cavity was seen, suggestive of rupture. Once the cyst gets entry into the lumen of pulmonary arteries it grows progressively to occlude the lumen (which is approximately 2-3cm per year). This process last long enough for adequate pulmonary perfusion to be established through the bronchial arteries and may initially be asymptomatic before presenting dyspnoea of long evolution. [6]. Symptoms may also be produced when the cysts compress a vital structure or rupture and produce anaphylaxis. In our case the first symptom was repeated hemoptysis and the chest radiograph was showing multiple well marginated nodular lesions of varying sizes, for which reason a hydatid disease was not initially suspected, rather she underwent CT study to rule out metastasis. Cysts on interventricular septum may produce conduction disturbances, which was also not present in our case. Noncomplicated cysts usually appear hypodense and well marginated on non contrast CT. Contrast study is essential to demonstrate the enhancement of the cyst wall and also to localize the cysts in interlobular pulmonary arterial branches. The lesion in pulmonary arteries and its branches are detected on cross sectional imaging like CT. A Differential diagnosis should be performed with intraluminal defects of pulmonary arteries, such as pulmonary thromboembolism and primary arterial tumor such as sarcoma [8],[9]. The cysts in pulmonary artery confuses with a thrombus. On contrast study the cyst wall enhances strongly and this does not normally so happen in case of thrombus. The cardiac lesion is difficult to characterize on CT study because firstly the membranes are not well delineated due to cardiac motion and secondly the cystic nature of the lesion is not confirmed on CT. The cardiac lesions are better evaluated on echocardiography. The lesion on interventricular septum with fingerlike projection from it into ventricular lumen should be differentiated from septal tumor with thrombus. In this case it represents ruptured hydatid cyst on the interventricular septum and the fingerlike projections represents membrane. The hypodense lesion on lungs detected on CT should be differentiated from any other cystic lesion. But the lesions that are peripheral and are accessible to ultrasound examination may show mobile echogenic material in the dependant part of the lesion, which suggest hydatid sand. Ultrasonography can also detect any other cystic lesion in abdominal viscera. This information helps proper surgical planning.


   Conclusion Top


In hemoptysis patients with multiple nodular opacities on chest radiograph, hydatid cyst should be considered in the differential diagnosis preferably in endemic areas. Because of the possibility of multiple locations of hydatid cysts, a combination of different imaging modalities are essential. Cardiac hydatid cysts with cysts in lungs and pulmonary artery and its branches are better evaluated by combination of different imaging modalities like chest radiograph, ultrasound, CT and echocardiography. The lesions in the pulmonary artery is better evaluated on cross sectional imaging like CT and the enhancing wall on contrast study is highly suggestive of cysts and not thrombus.

 
   References Top

1.BeggsI (1985). The radiology of hydatid disease. AJR 1, 639-648  Back to cited text no. 1    
2.Cantoni S, Frola C, Gatto R, Loria F, Terzi MI et al (1993). Hydatid cyst of interventricular septum of heart, MR findings. AJR 161: 753-754   Back to cited text no. 2    
3.Alper H, Yunten R, Sener NR (1995). Intramural hydatid cysts of pulmonary arteries: CT and MR findings. Eur J Radiology, 666-668  Back to cited text no. 3    
4.Von Sinner WN, te Strak L, Clark D, Sharif H (1991) MR finding in hydatid disease. AJR 157: 741-745  Back to cited text no. 4    
5.Ozturk C, Agildere AM, Cila A, Balkanci F (1992) Pulmonary arterial embolism secondary to hydatid cyst of liver. Can A soc Radiol J43 (5): 374-6   Back to cited text no. 5    
6.D Yague, M.P Lozano, C. Lampe, M.E Nunez, F Sanchez Bilateral hydatid cyst of pulmonary arteries: MR and CT findings. Eur Radiol 1998; 8(7): 1170-1172.  Back to cited text no. 6    
7.D Chattarjee, Echinococcus granulosus, Textbook of parasitology, 12th edition, Calcutta, India, Chatterjee Medical Publishers, April 1980: 121-127  Back to cited text no. 7    
8.Tardivon AA, Musset D, Maitre S et al (1993) Role of chronic pulmonary embolism: comparison with pulmonary angiography. J comput Assist Tomogr, 17: 345-351.  Back to cited text no. 8    
9.Bressler EL, Nelson JM (1992). Primary pulmonary artery sarcoma: diagnosis with CT, MR imaging, and transthoracic needle biopsy. AJR 159: 702-704  Back to cited text no. 9    

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Correspondence Address:
M Mohapatra
Department of Radiology, Kalinga Hospital, Chandrasekharpur, Bhubanesware-751023, Orissa
India
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Source of Support: None, Conflict of Interest: None


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    Figures

[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5]

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