University of Alabama at Birmingham

Gorgas Case 2001-01

Universidad Peruana Cayetano Heredia
The Gorgas Courses in Clinical Tropical Medicine are given at the Tropical Medicine Institute at Cayetano Heredia University in Lima, Peru. In 2001 we disseminated each week by e-mail an interesting case seen by the course participants that week. Each case included a brief history and an attached digital image pertinent to the case. The diagnosis and a brief discussion were posted at the same time on this website. These are the 11 cases that were presented in that format.

These cases are now available for online CME credit. Please visit UAB CME Online for more information.

Image A for Case 2001-01
image overlay
History: 27 year old male presents with 10 day history of fever, cough, mild hemoptysis and production of very white sputum which tastes salty. 10 years ago had surgery for acute right upper quadrant pain of sudden onset and was told that a cyst had been removed from his liver.

Epidemiology: Grew up on farm in Lake Titicaca region, and has lived in Lima the past 5 years. Non-smoker, no history of or exposure to TB. No EtOH abuse.

Physical Examination: Temp 38 degrees C, decreased air entry and rales R base. No hepatosplenomegaly.

Labs/X-ray: Hct 40, WBC 10,500 with normal differential. Normal alkaline phosphatase, bilirubin, and transaminases are at upper limit of normal. Urine normal with normal renal function. Chest x-ray is shown [Image A].
Diagnosis: Echinococcus granulosus. Complicated multivesicular echinococcal cyst of the lung with erosion through the diaphragm into the abdominal cavity. No intrahepatic cysts found at surgery.
Images BC for Case 2001-01
image overlay

Discussion: Pre-operative CT scan and the echinococcal (commonly called hydatid) cyst removed at surgery are shown [Images B, C]. The hydatid cyst was exposed through a thoracic incision, injected with hypertonic saline and right lower lobectomy performed. Erosion of the cyst into hilar vessels was noted by the surgeon. Daughter cysts contiguous with the main cyst extended into the abdomen through a hole in the diaphragm.

Hydatid disease secondary to Echinococcus granulosus is caused by the larval form of this dog tapeworm. Humans ingest the tapeworm eggs in contaminated environments and become accidental intermediate hosts. Larval cysts usually in the liver and/or lung expand slowly over years becoming symptomatic as they impinge by virtue of their size on important structures.

In this case, there are 2 possible courses of events. The patient had a ruptured hepatic cyst 10 years ago causing an acute abdomen and seeded his abdominal cavity with larval cestodes. He does remember receiving drug therapy at that time, probably with albendazole. An expanding intra-abdominal cyst over years eroded through the diaphragm and into the lung. Alternatively, the present cyst was a primary pulmonary cyst that eroded into the abdomen. The patient was told that the chest x-ray 10 years ago had something (no more info than this) in his lung. The highly experienced surgeon commented that he has not before seen a case like this with erosion of a pulmonary cyst through the diaphragm.

The present clinical presentation of hemoptysis and salty expectorated sputum is seen in this case is seen when a cyst erodes into a blood vessel or bronchus and ruptures with release of intracystic fluid.