Bas J Surg. Vol 4 No. 1 March 1998 p72-74.

Empyaema Thoracis Secondary to Intrapleural Rupture of Pulmonary Hydatid

Cyst: A Case Report.

BY

Prof. Abdulsalam Y Taha

Introduction:

Pleural hydatidosis is almost always secondary to pulmonary or hepatic hydatid

cysts. Primary hydatid disease of the pleura (i.e. originating from larvae

transported by blood and landing upon pleural surfaces) is denied to exist 1. The

extrusion of lung hydatid into the pleura is relatively a rare condition 1,

. The

reported incidence in the literature is 1 out of 189 cases and 2.41 of 246 cases 1.

Emergence of intact small cysts might be possible, but the larger cysts usually

rupture. This is followed by massive pneumothorax, as air enters freely via the

bronchial openings. Large amounts of fresh hydatid fluid pours over the pleural

surfaces and anaphylactic reaction may follow 1, 3-6

. Untreated bronchopleural

fistulae are unlikely to close and empyaema thoracis certainly ensues. Herein, we

report a case of empyaema secondary to intrapleural rupture of lung hydatid cyst.

The incidence, pathology, symptomatology and methods of management are

discussed.

Case 1:

A 17 years old unmarried Iraqi girl had been admitted to another hospital a

month earlier with sudden shortness of breath and left-sided chest pain. Chest

radiograph at that time revealed completely collapsed left lung and hydro

pneumothorax. She had been managed by insertion of apical and basal chest

tubes. Air leak persisted. Fever developed, with pus being continually drained via

the tubes. Antituberculous drugs were given without s response. She was then

transferred to the Department of Thoracic and Cardiovascular Surgery in Basrah

University Teaching Hospital. She looked toxic with mild shortness of breath. The

chest tubes drained thick pus with minimal air leak (Bronchopleural Fistula). The

chest film showed thickened parietal and visceral pleurae, gas-fluid level (

pyopneumothorax) and completely collapsed lung. The HB was 11.1 g/dl, the

leukocyte count= 13900 cell/cmm, ESR= 115 mm/hr, FBS= 90 mg/dl and blood

urea= 20 mg/dl. Culture and sensi=vity test of pus revealed a mixed growth of

Klebsiella and E Coli slightly sensitive to rifampicin. The patient was operated

upon via le? posterolateral 5th

space thoracotomy (single lumen endotracheal

tube general anaesthesia). Apart from the marked thickening of pleural surfaces

and foul smelling pus filling the pleural space, the surprising finding was the

laminated membrane of ruptured hydatid cyst floating in the empyaema cavity.

Multiple small bronchial fistulae were seen in the left upper lobe. The membrane

and pus were removed. Decortication was performed. The fistulae were closed by

0-silk sutures. The lung was healthy and expandable. The chest was closed with 2

drainage tubes. The postoperative course was uneventful apart from mild wound

infec=on managed conserva=vely. She was discharged home 3 weeks later in a

perfect health.

Figure 1. le?-sided pyopneumothorax. Figure 2. Postoperative CXR.

Discussion:

Rupture of pulmonary hydatid into the pleura is a distinct clinical entity which

requires a considerable clinical awareness to be recognized 1. It is relatively rare.

Bakir and Al-Omeri (1969) described 5 cases 5 while another case was reported by

Jesiot, Romanoff and Yaacob (1972) 6. The clinical picture is dominated by

pneumothorax and anaphylactic reaction. The pneumothorax can be of the

tension type; the collapsed lung throwing the edges of the opened pericyst cavity

into folds which act as a valve 1. The anaphylactic reaction results from absorption

of hydatd fluid via the pleura into the circulation. The combination of massive

pneumothorax and anaphylaxis may prove fatal 1,6

. The condition is almost always

misdiagnosed as tuberculosis, due to the prevalence of tuberculosis in many areas

of the world endemic to hydatid disease 1. In the acute phase, the management

consists of parenteral steroids (for anaphylaxis) and placement of chest tubes 1,3

.

Preoperative diagnosis is difficult; however, certain observations give hints.

Besides residence in an area endemic to hydatid disease, the drainage of crystal

clear fluid via the chest tube, the presence of pieces of laminated membrane (

plugging the tube sometimes), the persistent air leak ( which may necessitates

second or even a third tube) and features of anaphylaxis like urticaria and

bronchospasm, are helpful 1. The chest radiograph may show irregular gas-fluid

level due to the laminated membrane floating in the pleural space 1. Examination

of pleural fluid for scolices may be positive 1. Eosinophilia may be a valuable

pointer in the investigation of pleural effusions of doubtful origin if the source

was a rupture of a pulmonary hydatid 3. The definitive diagnosis and treatment is

by thoracotomy. Even if the patient recovers from the initial ill effects of the

pneumothorax, spontaneous closure of the bronchial openings is unlikely. Once

empyaema is added to the picture, expansion of the lung becomes even more

unlikely. Nothing short of thoracotomy can help these patients in the acute or

chronic phase. The time to do a thoracotomy is as soon as the patient has

recovered from the hazards of the pneumothorax and possible allergic

manifestations 1.

References:

1. Saidi F., Surgery of Hydatid Disease. W.B. Saunders Co. Ltd. London.

1976.

2. Rakower J and Milwidsky H. Hydatid Pleural Disease: Case Report.

American Review of Respiratory Diseases. 1964; 90: 623-631.

3. J Leigh Collis, D.B Clarke and R Abbey Smith. Human Pulmonary Hydatid

Disease in d, Abreu, s Practice of Cardiothoracic Surgery. Edited by

Edward Arnold. 1976; p.1544.

4. R.A. Clark. Pulmonary Hydatid Disease, in Essential Surgical Practice.

Edited by A. Cushieri, G.R. Giles and A.R. Moosa, Wright. London. 1988;

p 562.

5. Bakir F and Al-Omeri M A. Echinococcal Tension Pneumothorax. Thorax.

1969; 24: 547-556.

6. Jesioter M, Romanoff H and Yaacob B. Pneumothorax Following

Rupture of a Primary Pleural Hydatid Cyst. J of Thoracic and

Cardiovascular Surgery. 1972. 63: 594-598.

Correspondence to:

Prof. Abdulsalam Y Taha

Head of Department of Thoracic and Cardiovascular Surgery

College of Medicine

University of Sulaimani

Sulaimani

Region of Kurdistan

Iraq

Mobile: 00964 770 151 0420

E mail: salamyt_1963@hotmail.com