IJTCVS Goyal et al 412010; 26: 41–42 Chest wall hydatid

Large chest wall hydatid cyst - An unusual presentation

Vikas Goyal, MS, Kumar Asnani, MD, Sanjeev Devgarha, MCh, Chandra Prakash Srivastava, MChDepartment of CTVS, SMS Medical College, Jaipur, India

Abstract

A large chest wall hydatid cyst extending into the thoracic cavity and causing atelectasis of part of rightlung is reported. Presenting symptoms were chest pain and swelling chest wall. Computed tomographic Scanled to diagnosis of chest wall hydatid cyst extending into the thorax. On thoracotomy, cyst was found tooriginate from chest wall with extension into the thoracic cavity without infiltration of lung parenchyma andwith collapse of underlying lobe of the lung. Multiple cysts were enucleated along with resection of part ofrib. Post-operative recovery was uneventful. (Ind J Thorac Cardiovasc Surg 2010; 26: 41-42)

Key words : Thoracotomy, Hydatid cyst, Chest wall

Introduction

Hydatid cyst is a parasitic disease known from thetime of hippocrates. Liver and lung are the mostcommon sites. Extrapulmonary location of the diseasein the thorax is very rare1. Hydatid disease is caused byechinococcus granulosus and is known asechinococcosis or hydatidoses. Rudolphi2 (1808) firstused the term hydatid cyst for the description ofechinococcosis in humans. It is frequently encounteredin the sheep and cattle-raising regions of the world andhas been observed in Australia, New-Zealand, SouthAfrica, South America and Mediterranean Countries ofEurope, Asia and Africa2.

Case report

A 30-year-old female patient presented to us withcomplaints of chest pain and swelling on the right sideof chest. Chest x-ray and Computed Tomography (CT)Scan showed large intrathoracic cyst (Fig. 1) withoutair fluid level arising from the chest wall (Fig. 2) andproducing swelling which was visible externally.Operative intervention was done in left lateral decubitusposition as the cyst was postero-laterally placed.

Postero-lateral thoracotomy was done through 6thintercostal space just below the level of swelling. Onthoracotomy cyst was found to originate from themusculature of the chest wall and was adherent to thelung but not invading it. Rest of the thoracic cavity wasnormal with no daughter cysts. Pericyst was incisedafter placing hypertonic saline soaked sponges to isolatethe cyst and multiple cysts (50-60 in number) of varyingsizes (1 to 25 cms) were enucleated from the cavity. Therewere no bronchial openings in the cyst furtherconfirming that cyst arised from the chest wall. Cystwall was excised along with part of rib and related

Address for correspondence:Dr. Vikas GoyalDepartment of C.T.V.S., S.M.S. Medical CollegeJaipur, IndiaEmail: vigoyal77@yahoo.comPh. : 09915872343Fax: +00 91 141 2377329© IJTCVS 097091342610310/31 CR

Received - 07/03/09; Review Completed - 21/12/09; Accepted - 23/12/09.

Case report

Fig. 1. CT Scan Chest showing large multiloculated cyst in righthemithorax.

42 Goyal et al IJTCVSChest wall hydatid 2010; 26: 41–42

intercostal muscles. Primary closure of the chest wasdone without use of muscle flap or prosthetic material.Post-operative recovery was uneventful with completeexpansion of the collapsed lobe.

Discussion

Hydatid cysts of lung and liver are common inendemic areas but extra pulmonary hydatid cyst of chestwall are rare. Ribs, sternum, or soft tissues of the thoracicwall may become a locus3. Only a few cases are reportedin literature.

Radiodiagnostic techniques, dermal test,complementary fixation test and indirect hem-agglutination test can be used for diagnostic purposes.The most reliable of these techniques is theradiodiagnostic test4,5. It is possible to establish asatisfactory and reliable diagnosis when conventionalroentgenogram is supported with CT Scan,ultrasonography or echocardiography. Fluoroscopysometimes show characteristic water - lilly sign inpulmonary hydatid cyst. Air-fluid level andmultiloculation are usually seen on chest X-ray or CT

Fig. 2. CT Scan Chest showing multiloculated cyst arising fromChest Wall.

Scan. In this case, there was no air-fluid level in the cystpointing to extrapulmonary origin of the cyst. Moreover,this patient didn't have history of cough andexpectoration which are common in cases of pulmonaryhydatid.

Other rare sites of intrathoracic and extrapulmonarysites of hydatid cyst origin reported in literatureare - mediastinum6, pericardium7 and diaphragm8.Comparison between operative and non-operativeprocedures in the treatment of hydatid cysts have beenmade. However, surgical treatment gives good resultsespecially in large cysts like this which can lead tocompression or infiltration of surrounding structures.

Conclusion

Large hydatid cysts should be removed surgically toprevent complications. Results of operative interventionare excellent with minimal morbidity and negligiblemortality.

References

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4. Ozcelik C, Inci I, Toprak M, Eren N, Ozgen G, Yasar T. Surgicaltreatment of pulmonary hydatidosis in children : experience in92 patients. J Pediatr Surg 1994; 29: 392–95.

5. Ayuso LA, Peralta GT, Lazaro RB, Stein AJ, Sanchez JA, AymerichDF. Surgical treatment of pulmonary hydatidosis. J ThoracCardiovasc Surg 1981; 82: 569–75.

6. Zidi A, Zannad-Hantous S, Mestiri I, et al. Hydatid cyst of themediastinum: 14 case reports. J Radiol 2006; 87: 1869-74.

7. Gurlek A, Dagalp Z, Ozyurda U. A case of multiple pericardialhydatid cysts. Int J Cardiol 1992; 36: 366–68.

8. Cattelani L, D'Ippolito R, Facciolongo N, Soliani P. Localizationof hydatid cysts in the left hemidiaphragm. Discription of a case.Acta Biomed Ateneo Parmense 1988; 59: 41–47.