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Multiple lung metastases?

Published:December 14, 2016DOI:https://doi.org/10.1016/j.ejim.2016.12.006
      A Tunisian migrant with no past medical history, recently arrived in France, was referred for weight loss and multiple lung nodules on chest X-ray, suggesting lung metastases (Fig. 1a ). The patient had worked in Sardigna as a shepherd during the previous 6 years. He had never smoked. Physical examination was normal. Routine blood examination showed eosinophilia of 1.7 G/L. A CT scan of thorax and abdomen is shown in Fig. 1b and c.
      Fig. 1
      Fig. 1Chest X-ray showing multiple lung nodules of both lungs (a). CT scan displaying well-defined nodules (b) and a typical hepatic hydatic cyst with peripheral calcifications (c).

      1. What is the diagnosis?

      1.1 Diagnosis

      Cystic echinococcosis with multiple lung lesions.

      1.2 Discussion

      The chest CT scan displayed multiple well-defined nodules with soft tissue density of both lungs (Fig. 1b) and a hepatic cyst with septations and peripheral calcifications in segments VII–VIII, 7 × 8 cm in diameter (Fig. 1c). Echinococcosis serology and western blot were consistent with Echinococcus granulosus or E. multilocularis infection. Other investigations were negative and weight loss was related to his social difficulties. Diagnosis of cystic echinococcosis was established. The patient received albendazole since he declined other treatments. Two months later he presented with hemoptysis, expectoration of cyst membranes and fluid related to fistulization of one cyst. Treatment with albendazole was pursued.
      Cystic echinococcosis or cystic hydatidosis is a zoonotic infection endemic in sheep-raising areas including Mediterranean and Middle East countries, but also New Zealand and Argentina [
      • Sarkar M.
      • Pathania R.
      • Jhobta A.
      • Thakur B.R.
      • Chopra R.
      Cystic pulmonary hydatidosis.
      ]. It is due to ingestion of E. granulosis eggs releasing embryos which penetrate the intestinal wall and develop cysts mainly in liver and in lungs resulting in this latter case mainly from transdiaphragmatic route or hematogenous spread [
      • Sarkar M.
      • Pathania R.
      • Jhobta A.
      • Thakur B.R.
      • Chopra R.
      Cystic pulmonary hydatidosis.
      ]. Pulmonary cysts are asymptomatic for many years before pain, vomiting or coughing occur and rupture of cyst fluid can induce allergic reactions or even deaths. Lung lesions are described as solitary or multiple cystic lesion, from 1 to 20 cm in size, unilateral or bilateral, predominantly in the lower lobes, and can mimic lung metastases as observed in the present case [
      • Polat P1.
      • Kantarci M.
      • Alper F.
      • Suma S.
      • Koruyucu M.B.
      • Okur A.
      Hydatid disease from head to toe.
      ]. Albendazole is effective on cysts. Surgery, the only curative measure, and percutaneous aspiration injection could be considered in limited symptomatic or active lesions [
      • Sarkar M.
      • Pathania R.
      • Jhobta A.
      • Thakur B.R.
      • Chopra R.
      Cystic pulmonary hydatidosis.
      ,
      • Kuzucu A.
      • Ulutas H.
      • Reha Celik M.
      • Yekeler E.
      Hydatid cysts of the lung: lesion size in relation to clinical presentation and therapeutic approach.
      ]. Prevention is mandatory in endemic areas relying on good hygiene, actions on dogs, and control measures in the cattle slaughtering.

      References

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