Australas Radio1 1991; 35: 199-202
Transdiaphragmatic Rupture of Calcified Hepatic Hydatid Cyst VINCENT H.S. LOW, M.B.B.S, D.R.A.C.R Registrar Radiology Department Royal Perth Hospital, Wellington Street, Perth WA 6000 Australia.
FIGURE I - Chest x-ray: Focal deformity of the dome of the right hemidiaphragm.
FIGURE 2 - Right posterior oblique view of the hepatic area: Rounded heavily calcified inhahepatic lesion.
ABSTRACT A case of calcified hepatic hydatid disease with the
unusual complication o f transphrenic migration and pulmonary abscess shown by plain x-rays, ultrasonography and computed tomography is presented and the literature reviewed briefly.
Hydatid infection in man most commonly involves the liver. Recognised sequelae of the hydatid cysts include calcification, secondary bacterial infection, communication with the biliary tree and rupture into the peritoneal cavity (Lewall and McCorkell 1986). However, rupture of a hepatic hydatid cyst through the diaphragm into the pulmonary parenchyma is unusual with computed tomography (CT) appearance rarely reported (Grande et a/ 1990, Porta et a/ 198 1 ).
Key words: Liver, echinococcosis Lung. abscess Ultrasound Computed tomography Address for correspondence: Vincent H.S. Low Radiology Department McMaster University Medical Centre I200 Main Street West Hamilton Ontario L8N 325 Canada Aurtralarian Radin1oR.y. \i,l 3.5. No 2. May. 1991
CASE REPORT A 27 year old man presented to his general practitioner with mild right costal margin pain. Chest x-ray demonstrated lobulation of the right hemidiaphragm (Figure 1). A right posterior oblique view of the upper
Submitted for pUhllCdli0n on 17th OctdRr. 1990 Accepted for publication on: 15th Januaq. 1 9 9 1
I99
VJNCENT H.S. LOW abdomen revealed a round calcified lehion in the liver (Figure 2 ) . Abdominal ultrasound confirmed the intrahepatic calcified lesion (Figure 3A) along with a 6 cni mixed echotexture lesion in the diaphragmatic aspect of the ri2ht lobe of the liver (Figure 3B). The patient did not return for follow-up.
Three weeks later, he presented to the hospital with a week of increasingly severe right sided chest pain, feeling more unwell and with one day of haemoptysis. Chest x-ray now showed consolidation of the right lower lobe (Figure 4). Further views of the right upper quadrant revealed the calcified hepatic lesion had altered in configuration suggesting cephalad rupture (Figure 5).
FIGURE 3A - Ultrasound scan of liver: Heavily c&-rfied lesion wihin the right lohe.
FIGURE 3B - Ultrasound scan of liver: 6 x 4 cm mixed echogenecity lesion on the diaphragmatic surface of the right hepatic lobe.
FIGURE 4 -Chest x-ray: Right lower lobe considation.
FIGURE 5 - Plain film: The calcified hepatic mas\ has ruptured in a oephalad direction.
200
AiN/-olu,/u/,R u d ~ o / o y \ \(>I , -3.5, N o . -7. Mr/J. 1991
RUPTURE O F CALCIFIED HEPATIC HYDATID CYST
A chest drain was inserted and a small volume of turbid, yellow-brown fluid with fragments of material obtained. Histological examination c o n f i i e d the presence of hooklets and laminated membrane consistent with hydatid disease. However, scolices were absent suggesting that the cyst was no longer active. Culture of the fluid grew Streptococcus milleri, Group B Streptococcus and Klebsiella pneumonia. CT was performed two weeks after admission to hospital. A large abscess cavity with a thick wall and overlying pleural reaction (Figure 6A) was seen in the right lower lobe of the lung. In the liver, the calcified mass was easily
Whether bacterial infection occurs as a cause or affect of cyst rupture remains controversial (Lewall and McCorkell 1986). Sonographically, infected cysts have a mixed echogenecity or contain echogenic debris (Jain et al 1989, Lewall and McCorkell 1985). On CT, infection is suggested by poor definition of the cyst margins, or presence of water-air or liquid-liquid interphases (Choliz et a1 1982). Transhepatic rupture is a rare complication of hepatic hydatid disease. This may go on to pleural dissemination or penetration into the pulmonary parenchyma producing
FIGURE 6A - CT scan: Thorax: Thick walled abscess with cavitation and established pleural reaction.
LlGLJRE 6B - C T scan: Liver: Heavily calcified remnant of the hepatic hydatid lesion. Part of the track resultant from i!s rupture is seen anteriorly (mows).
seen (Figure 6B). A track was seen extending cephalad from it through the diaphragm to the pulmonary abscess. Management comprised initially antibiotics (oral mebendazole, intravenous cefotaxime and intravenous metronidazole) and surgery the day after the C T scan. Immediately prior to thoraco-laparotomy, bile was noticed coming up the right bronchial tree indicating a biliary connection. Operation involved resection of the abscess in the right lower pulmonary lobe, debridement and irrigation with 0.5% Cetrimide of the hydatid cavity in the liver and repair of the intervening defect in the diaphragm.
pneumonitis, pulmonary abscess or bronchial fistula (Grande et a1 1990). Recognition of hydatid disease underlying a hepatic or pulmonary abscess is important to allow administration of the appropriate antihelminthic drugs. At surgery precautions must be taken to avoid spill of the hydatid material with the resultant risks of dissemination and anaphylactic reaction (Lewall & McCorkell 1986, Novick e f a1 1987, Qian 1988). Heavy calcification of a hydatid cyst had been considered to imply inactive disease (Jain et a1 1989, Lewall & McCorkell 1985). However, viable scolices have been reported from such lesions (Beggs 1983). This case illustrates that such a calcified cyst may be complicated by rupture and bacterial infection and cannot be disregarded as a totally inactive, benign lesion.
DISCUSSION The various pathognomonic as well as non specific features of hepatic and pulmonary hydatid disease by plain radiographs, ultrasonography (US) and computed tomography (CT) have been well described. Plain radiographs of the hepatic area yield diagnostic information in 35% of patients. Cyst calcification is visible in a quarter of cases. Where there is involvement of the adjacent hemidiaphragm, elevation or deformation occurs (Kalovidouris et a1 1986, Lewall & McCorkell 1986, Ramos Gonzalez et a1 1979, Saksouk et a1 1986).
ACKNOWLEDGEMENTS
I am very grateful to Barbara Taylor and Helen Garside for their assistance in the preparation of this manuscript.
Hydatid cyst rupture has been classified into contained (within the host-derived pericyst), communicating (with biliary or bronchial tree) and direct (into peritoneal or pleural cavities) types. The latter two types have very serious implications with mortality rates up to 50%. The cause of cyst rupture remains unknown with possible contributing factors including degeneration of the parasitic membranes due to chemical or host defence mechanisms or ageing and trauma (Lewall & McCorkell 1986). Australasian Radiology IJd. 35.No. 2. M a y 199I
20 1
VINCENT H.S. LOW REFERENCES Beggs I. The radiological appearances of hydatid disease of the liver. Clin Radiol 1983; 34 : 555-563. Choliz JD, Olavem FJL, Casas TF and Zubieta SO. Computed tomography in hepatic echinococcosis. Amer J Roentgenol 1982; 139 :699-702. Grande D,Ruiz JC, Elizagray E. Grande J. Barcena V and Equidazu J. Hepatic echinococcosis complicaled with transphrenic migration and bronchial fistula: CT demonstration. Gastrointest Radiol 1990; 15 : 115-118.
Jain AK, Gupta PD and Saha MM. Sonographic appearance of hepatic hydatid disease. Australas Radiol 1989: 33 :373-375. Kalovidouris A, Pissioitis C, Pontifex G, Gouliamos A, Pentea S and Papavassiliou C . CT demonstration of multivesciular hydatid cysts. J Comput Assist Tom0 1986 10 :428431. Lewall DB and McCorkell SJ. Hepatic echinococcal cysts: sonogmphic appearance and classification. Radiology 1985; 155 :773-775.
202
Jxwall DB and Mc Corkell SJ. Rupture of echinococcal cysts: diagnosis, classification and clinical implications. Amer J Roentgenol 1986; 146 : 391-394.
Novick RJ, Tchervenkov CI and Wilson JA. Surgery for thoracic hydatid disease: A North American experience. Ann Thorac Surgery 19%;' 43 : 68 1-686.
Porta E, Borgstrom MS, Giampaglia F, Carrillo F and Angelillo M. Conmbution of CT and ultrasound to the preoperative diagnosis of bilobronchial fistula caused by echinococcosis of the liver. CT 1981: 5 : 349-350.
Qian Z. Thoracic hydatid cysts: A report of 842 cases treated over a thirty year period. Ann Thorac Surg 1988; 46 : 342-346. Ramos Gonzalez L, Marcos J, Illanas M, Hernandez-Mora M, Pena F, Picouto JP, Cienfuegos JA and Alvarez JLR. Radiologic aspects of hepatic echinococcosis. Radiology 1979; 130 : 21-27. Saksouk FA, Fahl MH and Rizk GK. Computed tomography of pulmonary hydatid disease. J Comp Assist Tom0 1986; 10 : 226-232.
Australasian Radiology. %I. 35. No. 2. May, 1991
Transdiaphragmatic Rupture of Calcified Hepatic Hydatid Cyst VINCENT H.S. LOW, M.B.B.S, D.R.A.C.R Registrar Radiology Department Royal Perth Hospital, Wellington Street, Perth WA 6000 Australia.
FIGURE I - Chest x-ray: Focal deformity of the dome of the right hemidiaphragm.
FIGURE 2 - Right posterior oblique view of the hepatic area: Rounded heavily calcified inhahepatic lesion.
ABSTRACT A case of calcified hepatic hydatid disease with the
unusual complication o f transphrenic migration and pulmonary abscess shown by plain x-rays, ultrasonography and computed tomography is presented and the literature reviewed briefly.
Hydatid infection in man most commonly involves the liver. Recognised sequelae of the hydatid cysts include calcification, secondary bacterial infection, communication with the biliary tree and rupture into the peritoneal cavity (Lewall and McCorkell 1986). However, rupture of a hepatic hydatid cyst through the diaphragm into the pulmonary parenchyma is unusual with computed tomography (CT) appearance rarely reported (Grande et a/ 1990, Porta et a/ 198 1 ).
Key words: Liver, echinococcosis Lung. abscess Ultrasound Computed tomography Address for correspondence: Vincent H.S. Low Radiology Department McMaster University Medical Centre I200 Main Street West Hamilton Ontario L8N 325 Canada Aurtralarian Radin1oR.y. \i,l 3.5. No 2. May. 1991
CASE REPORT A 27 year old man presented to his general practitioner with mild right costal margin pain. Chest x-ray demonstrated lobulation of the right hemidiaphragm (Figure 1). A right posterior oblique view of the upper
Submitted for pUhllCdli0n on 17th OctdRr. 1990 Accepted for publication on: 15th Januaq. 1 9 9 1
I99
VJNCENT H.S. LOW abdomen revealed a round calcified lehion in the liver (Figure 2 ) . Abdominal ultrasound confirmed the intrahepatic calcified lesion (Figure 3A) along with a 6 cni mixed echotexture lesion in the diaphragmatic aspect of the ri2ht lobe of the liver (Figure 3B). The patient did not return for follow-up.
Three weeks later, he presented to the hospital with a week of increasingly severe right sided chest pain, feeling more unwell and with one day of haemoptysis. Chest x-ray now showed consolidation of the right lower lobe (Figure 4). Further views of the right upper quadrant revealed the calcified hepatic lesion had altered in configuration suggesting cephalad rupture (Figure 5).
FIGURE 3A - Ultrasound scan of liver: Heavily c&-rfied lesion wihin the right lohe.
FIGURE 3B - Ultrasound scan of liver: 6 x 4 cm mixed echogenecity lesion on the diaphragmatic surface of the right hepatic lobe.
FIGURE 4 -Chest x-ray: Right lower lobe considation.
FIGURE 5 - Plain film: The calcified hepatic mas\ has ruptured in a oephalad direction.
200
AiN/-olu,/u/,R u d ~ o / o y \ \(>I , -3.5, N o . -7. Mr/J. 1991
RUPTURE O F CALCIFIED HEPATIC HYDATID CYST
A chest drain was inserted and a small volume of turbid, yellow-brown fluid with fragments of material obtained. Histological examination c o n f i i e d the presence of hooklets and laminated membrane consistent with hydatid disease. However, scolices were absent suggesting that the cyst was no longer active. Culture of the fluid grew Streptococcus milleri, Group B Streptococcus and Klebsiella pneumonia. CT was performed two weeks after admission to hospital. A large abscess cavity with a thick wall and overlying pleural reaction (Figure 6A) was seen in the right lower lobe of the lung. In the liver, the calcified mass was easily
Whether bacterial infection occurs as a cause or affect of cyst rupture remains controversial (Lewall and McCorkell 1986). Sonographically, infected cysts have a mixed echogenecity or contain echogenic debris (Jain et al 1989, Lewall and McCorkell 1985). On CT, infection is suggested by poor definition of the cyst margins, or presence of water-air or liquid-liquid interphases (Choliz et a1 1982). Transhepatic rupture is a rare complication of hepatic hydatid disease. This may go on to pleural dissemination or penetration into the pulmonary parenchyma producing
FIGURE 6A - CT scan: Thorax: Thick walled abscess with cavitation and established pleural reaction.
LlGLJRE 6B - C T scan: Liver: Heavily calcified remnant of the hepatic hydatid lesion. Part of the track resultant from i!s rupture is seen anteriorly (mows).
seen (Figure 6B). A track was seen extending cephalad from it through the diaphragm to the pulmonary abscess. Management comprised initially antibiotics (oral mebendazole, intravenous cefotaxime and intravenous metronidazole) and surgery the day after the C T scan. Immediately prior to thoraco-laparotomy, bile was noticed coming up the right bronchial tree indicating a biliary connection. Operation involved resection of the abscess in the right lower pulmonary lobe, debridement and irrigation with 0.5% Cetrimide of the hydatid cavity in the liver and repair of the intervening defect in the diaphragm.
pneumonitis, pulmonary abscess or bronchial fistula (Grande et a1 1990). Recognition of hydatid disease underlying a hepatic or pulmonary abscess is important to allow administration of the appropriate antihelminthic drugs. At surgery precautions must be taken to avoid spill of the hydatid material with the resultant risks of dissemination and anaphylactic reaction (Lewall & McCorkell 1986, Novick e f a1 1987, Qian 1988). Heavy calcification of a hydatid cyst had been considered to imply inactive disease (Jain et a1 1989, Lewall & McCorkell 1985). However, viable scolices have been reported from such lesions (Beggs 1983). This case illustrates that such a calcified cyst may be complicated by rupture and bacterial infection and cannot be disregarded as a totally inactive, benign lesion.
DISCUSSION The various pathognomonic as well as non specific features of hepatic and pulmonary hydatid disease by plain radiographs, ultrasonography (US) and computed tomography (CT) have been well described. Plain radiographs of the hepatic area yield diagnostic information in 35% of patients. Cyst calcification is visible in a quarter of cases. Where there is involvement of the adjacent hemidiaphragm, elevation or deformation occurs (Kalovidouris et a1 1986, Lewall & McCorkell 1986, Ramos Gonzalez et a1 1979, Saksouk et a1 1986).
ACKNOWLEDGEMENTS
I am very grateful to Barbara Taylor and Helen Garside for their assistance in the preparation of this manuscript.
Hydatid cyst rupture has been classified into contained (within the host-derived pericyst), communicating (with biliary or bronchial tree) and direct (into peritoneal or pleural cavities) types. The latter two types have very serious implications with mortality rates up to 50%. The cause of cyst rupture remains unknown with possible contributing factors including degeneration of the parasitic membranes due to chemical or host defence mechanisms or ageing and trauma (Lewall & McCorkell 1986). Australasian Radiology IJd. 35.No. 2. M a y 199I
20 1
VINCENT H.S. LOW REFERENCES Beggs I. The radiological appearances of hydatid disease of the liver. Clin Radiol 1983; 34 : 555-563. Choliz JD, Olavem FJL, Casas TF and Zubieta SO. Computed tomography in hepatic echinococcosis. Amer J Roentgenol 1982; 139 :699-702. Grande D,Ruiz JC, Elizagray E. Grande J. Barcena V and Equidazu J. Hepatic echinococcosis complicaled with transphrenic migration and bronchial fistula: CT demonstration. Gastrointest Radiol 1990; 15 : 115-118.
Jain AK, Gupta PD and Saha MM. Sonographic appearance of hepatic hydatid disease. Australas Radiol 1989: 33 :373-375. Kalovidouris A, Pissioitis C, Pontifex G, Gouliamos A, Pentea S and Papavassiliou C . CT demonstration of multivesciular hydatid cysts. J Comput Assist Tom0 1986 10 :428431. Lewall DB and McCorkell SJ. Hepatic echinococcal cysts: sonogmphic appearance and classification. Radiology 1985; 155 :773-775.
202
Jxwall DB and Mc Corkell SJ. Rupture of echinococcal cysts: diagnosis, classification and clinical implications. Amer J Roentgenol 1986; 146 : 391-394.
Novick RJ, Tchervenkov CI and Wilson JA. Surgery for thoracic hydatid disease: A North American experience. Ann Thorac Surgery 19%;' 43 : 68 1-686.
Porta E, Borgstrom MS, Giampaglia F, Carrillo F and Angelillo M. Conmbution of CT and ultrasound to the preoperative diagnosis of bilobronchial fistula caused by echinococcosis of the liver. CT 1981: 5 : 349-350.
Qian Z. Thoracic hydatid cysts: A report of 842 cases treated over a thirty year period. Ann Thorac Surg 1988; 46 : 342-346. Ramos Gonzalez L, Marcos J, Illanas M, Hernandez-Mora M, Pena F, Picouto JP, Cienfuegos JA and Alvarez JLR. Radiologic aspects of hepatic echinococcosis. Radiology 1979; 130 : 21-27. Saksouk FA, Fahl MH and Rizk GK. Computed tomography of pulmonary hydatid disease. J Comp Assist Tom0 1986; 10 : 226-232.
Australasian Radiology. %I. 35. No. 2. May, 1991
