Akciğer kist hidatik ve tüberkülozunun birlikte gözlendiği bir hasta: olgu sunumu

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Introduction
The most common causes of pulmonary hydatid
cysts and tuberculosis are echinococcus granulosis
and mycobacterium tuberculosis, respectively (1,2).
Pulmonary hydatid cyst with tuberculosis is very rare
(1). Pulmonary hydatid cyst has an important differential diagnosis from other diseases in areas where
echinococcosis is endemic, such as Asia, North Africa
and the Middle East (1-3). While searching this coexistence, we found that only a few cases have been
reported. In this article, we report a patient with pulmonary hydatid cysts with coexisting tuberculosis,
and review the literature.
Case Report
A 21-year-old male was admitted to our department
with a history of pulmonary hydatid cysts. In the last
year before admission, he had been diagnosed by a
transthoracic fine needle biopsy (TTFNB) and treated
with a 6-month course of albendezol (800 mg/day).
After this treatment, the course of the patient did not
regress clinically and radiologically. The patient presented with cough, fever and hemoptysis. The sputum microscopy and cultures for acid-fast bacilli were
negative 4 times. ELISA test was positive. The chest
radiograph revealed bilateral pulmonary multinodular lesions. For further investigation of the lesions,
computed tomography (CT) of the chest was ordered,
which showed bilateral pulmonary multinodular lesions (Figure 1).
This kind of lesions is unexpected for pulmonary
hydatid cysts. So we thought that he was misdiagnosed or he had another disease. Then, TTFNB was
performed. Histopathological diagnosis was not
achieved. The fiberoptic bronchoscopic examination
was normal. Hydatid cyst indirect hemaglutination
titration was 220 (normal range: 1/100). Open lung
biopsy was performed, and histopathological exami-
* Department of Thoracic Surgery, Gulhane Military Medical Faculty
** Department of Pathology, Gulhane Military Medical Faculty
*** Department of Chest Diseases, Gulhane Military Medical Faculty
Reprint request: Dr. Orhan Yücel, Department of Thoracic Surgery, Gulhane
Military Medical Faculty, Ankara, Turkey
E-mail: orhanycl@gmail.com
Date submitted: March 07, 2008 • Date accepted: May 27, 2008Volume 51 • Issue 2 Pulmonary hydatid cyst and tuberculosis • 129
nation revealed pulmonary hydatid cysts and pulmonary tuberculosis (Figure 2).
Postoperative course was uneventful and he was
discharged with anti-tuberculosis treatment. Anti-tuberculosis treatment including isoniasid, rifampicin,
pyrazinamide and ethambutol was given. Albendazole
was not added because he received hydatid cyst therapy. The patient showed clinical improvement after 6
months of anti-tuberculosis treatment, and was well
after a 12-month follow-up.
Discussion
The pulmonary parenchyma may be affected by
a great number of parasites and infectious diseases
(1,4). The most common parasitary disease, known as
hydatidosis, has been acknowledged as a clinical entity since ancient times (4). Hydatidosis remains as a
significant health problem in endemic areas (2,3). In
addition, the more significant pulmonary parenchymal infectious disease is tuberculosis (5). Pulmonary
hydatid cyst and tuberculosis have an important differential diagnosis from other diseases as they increase
the risk of morbidity and mortality (3,6,7). Delays in
the diagnosis of tuberculosis and hydatidosis may
result in increased morbidity and mortality (3,7,8).
Patients without respiratory symptoms are misdiagnosed more frequently than those with symptoms.
Hino et al. have aimed to describe tuberculosis-related
mortality in Brazil. This study has shown that deaths
are related to late diagnosis (7). In our case, the reasons of delay in diagnosis were unexpected finding
of chest radiography and thoracic computed tomography, atypical presentations and negative acid-fast
smears culture results. Improved clinical acumen and
development of rapid diagnostic tests are desirable to
control pulmonary tuberculosis.
Diagnosis of pulmonary hydatidosis is usually
based on chest radiography, ultrasonography and
computed tomography scan, and immune diagnosis
may help in suspicious cases (2,4). Diagnosis of an
intact hydatid cyst is usually based on a suspicion resulting from an unexpected finding on routine chest
radiographs (2,3). Radiographically the hydatid cyst
appears as a homogeneous spherical opacity with
definite edges (2). The radiologic picture depends
mainly on the size and location of the cyst (2,3).
A small cyst may appear as a small “vesicle” and is
difficult to recognize until it grows large enough to
present a clear image on the chest radiograph (6). The
presence of hydatid disease should be considered in a
patient who presents with a well-explained spherical
density of the lung, particularly in a patient who has
been living in an endemic area (2,6). On the contrary,
pulmonary tuberculosis produces a broad spectrum
of radiographical appearance (7,9). In our case, the
chest radiograph and computed tomography showed
bilateral pulmonary multinodular lesions. This kind
of lesions is unexpected for pulmonary hydatid cysts.
Moreover, after a 6-month albendazol treatment, the
patient did not show a clinical and radiological regression. So we thought that he was misdiagnosed or
he had another disease.
Pulmonary hydatid cyst has no characteristic symptoms (2). The clinical manifestations depend on the
site and size of the lesions, whether the cyst is intact
or ruptured (2,10). For example small and peripherally located lesions are usually asymptomatic, but large
central lesions may manifest with symptoms (3,6).
Moreover, the clinical manifestations of pulmonary
Figure 1. Computed tomography showed bilateral pulmonary
multinodular lesions
Figure 2. Histopathological examination revealed a. granulamatous
inflammation, and b. germinal membrane (Low magnification-H&E
staining)130 • June 2009 • Gulhane Med J Yücel et al.
tuberculosis are highly varied and unspecific, and can
be superimposed on that of any other bacterial infection that affects the same organs (5,9). Our case presented with cough, fever and hemoptysis. This type
of symptoms is not diagnostic for pulmonary tuberculosis and hydatid cyst.
The laboratory diagnosis of hydatidosis and tuberculosis is complementary to the clinical and radiological methods (1-3). For example, serological tests
can be used for diagnosis of pulmonary hydatidosis.
These serological tests are Casoni’s intradermal test,
Weinberg complement fixation test and the indirect hemagglutination test. But these tests have limited value for the exact diagnosis of hydatid disease
(2,3). In our case, serological tests assisted to correct
diagnosis.
The sputum microscopy and cultures for acid-fast
bacilli, ELISA test, TTFNB were performed. Open lung
biopsy was performed because histopathological diagnosis was not achieved. Histopathological examination showed pulmonary hydatid cysts and tuberculosis. The clinical manifestations of thoracic tuberculosis are highly varied and unspecific, and can be
superimposed on that of any other bacterial infection
that affects the same organs.
The treatment of pulmonary hydatid cyst is essentially surgical (11,12). Numerous researchers prefer
lung-sparing operations such as enucleation of the
cyst or pericystectomy with closing of the bronchial
openings with or without capitonnage of the pericystic space as a first choice of treatment (2,6,11).
Surgery is essential in most cases, but it must be conservative (2,4). It was advised to use medical treatment postoperatively for complicated hydatidosis
and for the treatment of patients with inoperable
cysts (2,8). Complicated hydatidosis, disseminated
hydatidosis disease, is difficult for surgical treatment
(2). In our experience, medical treatment is useful
when operation is contraindicated or if there is a risk
of dissemination at operation. In our case, albendazol
treatment had been given 6 months before the operation. Then, anti-tuberculosis treatment was given in
the postoperative course. The patient demonstrated
clinical improvement after 8 months of anti-tuberculosis treatment.
Hydatid disease, as well as tuberculosis, is still
prevalent in Turkey (11,13). Our case presents that a
patient may have pulmonary hydatid cysts with coexisting tuberculosis. Hydatid cyst with pulmonary
tuberculosis increases the risk of morbidity and mortality (14). This case emphasizes the importance of
suspicion in concomitant disease in endemic areas
for echinococcosis and tuberculosis.