Kumar N et al.

14

Ruptured Hydatid Cyst Diagnosed by Bronchoscopy in a Young Patient

with Hemoptysis
Pushpendra Kumar Verma*, Naresh Kumar**, Paras Kathuria**
Abstract
A 31- year old male patient of Nepalese origin presented with sudden onset of
hemoptysis and mild chest discomfort. The chest radiograph of the patient
showed a soft tissue density in the right lower zone and computerized
tomography of the chest showed a rounded opacity with fluid density within
the right lower lobe. Bronchoscopy showed gelatinous, white membrane- like
structures extruding from the posterior basal segment of the right lower lobe.
The membranes were sucked out partially and histologic examination showed
laminated membranes suggestive of hydatid cyst. Patient also went for
surgery and was treated with albendazole for 3 months. Hence, bronchoscopy
can be a valuable aid in the diagnosis of a ruptured hydatid cyst of the lung.

Keywords: Echinococcus granulosus, Hydatid cyst, lung, Hemoptysis,

Bronchoscopy.

Introduction in almost 60% of cases, 30% exhibit multiple

Hydatid disease is one of the most important
zoonotic diseases in the world. The disease is
caused in human by the larval stage of the
tapeworm Echinococcus granulosus. The adult
worm inhabits the intestinal tracts of the
definitive hosts such as dogs, cats or other
carnivores which release the eggs in their feces,
which are ingested by intermediate hosts
(generally herbivores). These eggs develop into
larvae within the viscera of the intermediate host.
Carnivores ingest these infected viscera
containing larvae and thus complete the cycle.1
Humans are the accidental hosts and contract the
disease through food/ water or by direct contact
with dogs. Once the eggs are ingested, they get
transformed into hexacanth embryos which pass
through the intestinal wall and get lodged into
the organ where they form cystic larval stage.
The liver is the most common site of cyst
formation, followed by the lung in 10– 30% of
cases and other sites (usually the spleen, kidney,
orbit, heart, brain and bone) in 10% of cases. 2
Among the patients with lung cysts, 20– 40%
patients also have accompanying liver cysts.
Pulmonary hydatid disease affects the right lung
*
National Institute of Tuberculosis and Respiratory Diseases, Mehrauli, New Delhi, India
**
Department of Medicine, Maulana Azad Medicine College & associated Lok Nayak Hospital, New Delhi, India
pulmonary cysts and 20% exhibit bilateral cysts.3
Pulmonary hydatid cysts usually remain
asymptomatic and are diagnosed incidentally
when they get complicated by rupture, infection
or abscess formation. Diagnosis of PHC is
usually clinico- radiological. Bronchoscopy
generally is not used in the diagnosis of
echinococcosis. However, it can prove to be
helpful in patients with atypical clinical and
radiological features.
Here, we present a young male patient with
hemoptysis, which on bronchoscopy was found
to be related to the rupture of a hydatid cyst of
the lung. This is a rare documentation of such a
presentation from a patient of Nepalese origin.
Case Report
A 31 year old male patient, a worker of Nepalese
origin from low socioeconomic status presented
with sudden onset of cough with hemoptysis and
mild right sided chest discomfort. There was no
accompanying fever, upper respiratory tract
infection or breathlessness. On detailed
questioning, patient revealed that he was treated

Correspondence to: Dr. Naresh Kumar, Department of Medicine, Maulana Azad Medicine College & associated Lok
Nayak Hospital, New Delhi, India. E- mail: drnareshmamc@gmail.com

J. Adv. Res. Med. 2014; 1(2): 14- 17.

15 Kumar N et al.

with a course of antibiotic for a right sided lung
lesion three years back. The patient denied any
history of similar illness in the past. Clinical
examination of the chest showed crackles in the
right axillary and mammary region. Rest of the
general physical and systemic examination was
unremarkable.
His hemogram, liver function tests, renal
function tests and other serum biochemical
parameters were within normal limits. Chest
radiograph of the patient (figure 1) showed a soft
issue density in right lower zone with well
defined lateral margin. Medial margin was
obscured by overlying rib shadow. There was no
evidence of cavitation or calcification. On
computerized tomographic scan of the chest
(figure 2), a rounded opacity with fluid density
within and well defined margins was seen in the
posterior basal segment of the right lower lobe.
Ultrasonography of the abdomen was normal. On
fiber- optic bronchoscopy, gelatinous, white
membrane- like structures were seen protruding
from the posterior basal segmental bronchus of
the right lower lobe. These white glistening
membranes (figure 3) were partially sucked out
and sent for histopathological examination,
which was consistent with the laminated layer
with germinal covering suggestive of hydatid
cyst. The hydatid serology was positive.

Figure 1.Chest Radiograph showing soft tissue density in the right lower zone.

Figure 2.Computerized tomographic scan of the chest: (2A) Lung window, & (2B) Mediastinal window showing
a rounded opacity with fluid density within
J. Adv. Res. Med. 2014; 1(2): 14- 17.
Kumar N et al.
Figure 3.Membranes aspirated on bronchoscopy
The patient’s hemoptysis resolved with
conservative medical management. The patient
was subsequently sent for surgery where excision
of the ruptured cyst was made. Postoperatively,
the patient was put on albendazole for twelve
weeks.
Discussion
Pulmonary hydatid cyst (PHC) disease is a
common clinical problem in the endemic area of
echinococcal infection. PHC are generally
asymptomatic. Symptoms develop in these
patients because of mechanical pressure, rupture
or leakage of the cyst, or superinfection.
Presenting symptoms can be non- specific such
as cough, chest pain or dyspnea. Hemoptysis as a
presenting symptom is common in adults,
although massive hemoptysis is rare. Occasional
rupture of cysts into the bronchus may result in
massive hemoptysis. Rupture of the hydatid cysts
can occur either spontaneously, after trauma,
and/ or following drug therapy for helminthes.
The rupture of echinococcal cysts is of three
types: Contained rupture, communicating rupture
and direct rupture. When only the parasitic
endocyst ruptures it is termed as contained
rupture. When cyst contents escape via bronchial
tree following the rupture, it is called
communicating rupture. Direct rupture occurs
when both the endocyst and the pericyst tear,
spilling cyst contents directly into the pleural
cavity.4 Communicating and direct forms have
more serious clinical implications than contained
rupture, but even contained rupture needs prompt
surgical attention to prevent it from developing
16
into one of the other forms.
The diagnosis of pulmonary hydatid cyst is
generally based on clinical and characteristic
radiological findings such as demonstration of
cyst wall with intervening septae, daughter cysts.
Sometimes calcification of cyst wall may be
demonstrable.5 Hydatid serology is positive in
50% cases of pulmonary hydatid cyst and has
only a supporting role in the diagnosis of PHC.
Although, bronchoscopy is generally
unnecessary in patients with hydatid lung disease,
it might be diagnostic in patients with atypical
clinical and radiologic appearances where
rupture and secondary infections had altered the
radiological features.6 Non- resolving pneumonia
has been diagnosed bronchoscopically to be a
result of the hydatid membrane induced
occlusion of the bronchial orifices. 7 In the series
of 14 patients with complicated hydatid cysts by
Deshmukh et al., white glistening membranes
were observed in 9 patients, whereas cytologic
evaluation was non- contributory.8 In our patient,
diagnosis of ruptured hydatid cyst was made
based on the bronchoscopic appearance and
subsequent histopathologic analysis of the
extracted membranes. A similar case has been
reported from the Kashmir valley of India.9 The
glistening membrane- like appearance on
extraction is characteristic of an echinococcal
cyst wall. Bronchoscopy also helps in collecting
the material for cytologic analysis for diagnosing
hydatid disease. The cystic contents and
pericystic elements may leak into the bronchial
tree, following cyst rupture. Although some of
the elements, like hooklets, fragments of scolex
J. Adv. Res. Med. 2014; 1(2): 14- 17.
17
and chitinous membrane have diagnostic
importance; their degenerated forms need special
techniques such as dark field microscopy or
special stains such as methenamine silver for
diagnosis.10 In case of ruptured hydatid
membrane, it can be partially or completely
extracted with fiber- optic bronchoscope.
Surgical options available for treatment of
pulmonary lung cyst are lobectomy, wedge
resection, intact endocystectomy, pericystectomy
and capitonnage.
We conclude that pulmonary hydatid cysts
although not an uncommon entity are generally
asymptomatic and are usually diagnosed by
clinico radiological correlation. But
complications such as cyst rupture or secondary
infection make bronchoscopy a valuable tool in
the diagnosis of such patients where clinical and
radiological features get altered.
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