Pulmonary Hydatid Cysts

Professor IOAN CORDOS

 General Information I

• The term “Hydatid Cyst“ was first used

by Rudolphi (1771-1832) in 1808.
• Parasitic infestation by a tapeworm of
the genus Echinococcus
• The infection causes slowly enlarging
cystic masses.
General Information II
• 4 species of pathological interest
– Ech. Granulosus
– Ech. Multilocularis
– Ech. Vogeli
– Ech. Oligarthrus
• Rare thoracic localization:
– Chest wall
– Pleura
– Mediastinum
– Diaphragm
Echinococcus
Life Cycle
 Pericyst

Hydatid Cyst Structure

• inflammatory fibrous tissue belonging to the host
Hydatid Cyst Structure
Exocyst
• acellular laminated membrane

Germinal layer
• gives birth to daughter cysts

Hydatid fluid
• clear liquid usually, can be tubid in case of superinfection

Protoscolex
• juvenile, infective metacestode
 Patient Presentation
– Rash, fever, pulmonary congestion, bronchospasm.
• Intact cysts – no characteristics symptom
• Rupture of the cyst into bronchus
– Severe coughing
– Expectoration (salty sputum, fragments of the membrane)
• Rupture in the pleural cavity
– Non-productive cough, chest pain, dyspnea, malaise, anaphylactic
shock
 Imaging Studies
Radiography
• suggestive of benign disease

Computed Tomography
• best investigation for both for diagnosis and operative
planning

Ultrasonography
• in select cases or as limited resource
 Radiography

Uncomplicated
• round-oval opacity with well defined margins

Complicated
• Cavity with air-fluid level
• Pseudo-tumoral appearance
• Pleural effusion +/- pneumothorax

Lesions can be bilateral

Radiography
Radiography
Radiography
Radiography
Rupture of the pulmonary
hydatid cyst into the
pleural cavity

Pleural effusion -> empyema

Pneumothorax with total
collapse of left lung
 Computed Tomography

• Mass with well-defined borders

• Contents of liquidian density and hipodense relative to the
capsule
• Visualization of daughter cysts and germinal membrane
• Usually no lymphadenopathies

MRI does not offer additional information unless we suspect

diaphragm involvement
 Computed
Tomography
Diagnosis
• Leukocytosis, eosinophilia, hypogammaglobinemia
• ELISA and indirect hemagglutination
• Immunodiffusion and immunoelectrophoresis
• Intradermal skin test (Casoni test) – mainly historically
• Sputum tests – can identify hydatid material
• Bronchoscopy – only to rule out other diagnoses
Medical treatment
Indications
• inoperable liver or lung cysts
• cysts in 2 or more organs
• peritoneal cysts

Benzimidazoles
• Albendazole
• Mebendazole

Monitoring for adverse effects of agents every 2 weeks

• CBC count and
• Liver enzymes

Outcome
• 30% complete cure
• 30-50% decrease in the size of the cyst
• 20-40% had no changes
 Surgical therapy

• All pulmonary cysts should be removed if patient is fit for

surgery
• Surgical technique
– Wedge resection or anatomical resection
– Parenchyma sparring procedures
– Simple tube drainage
• It is optimal that the patient is undergoing medical
treatment pre- and post-operatively
 Lung resections

• When the cyst occupies more than 60%

of the affected anatomical division
– Lobectomy
– Pneumonectomy
• When the cysts are small and peripheric
– Wedge resection
Parenchyma sparring surgery
- Duban procedure
Optimal removal with intact hydatid membrane
Inactivation and removal of germinal layer
Residual cavity and Dor closure procedure
Long Term Monitoring
• Postoperative treatment with benzimidazoles

• ELISA or indirect hemagglutination tests at 3, 6, 12, and

24 months after surgery for recurrence detection

• CT scan at the same intervals as laboratory tests or if we

suspect recurrence.