IJCA-18067; No of Pages 2 International Journal of Cardiology xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Unusual cause of chest pain in a 13 year-old young child: Left ventricular hydatid cyst Yunfei Ling 1, Yongjuan Qian 1, Wei Meng ⁎, Ke Lin Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Sichuan, People's Republic of China
a r t i c l e
i n f o
Article history: Received 12 April 2014 Accepted 13 April 2014 Available online xxxx Keywords: Echinococcosis Left ventricular hydatid cyst Chest pain
Hydatid cysts (echinococcosis) of the heart are rare and the prevalence of cardiac hydatosis is less of 2% of all human body infestations. The larvae reach the heart through the coronary circulation but the intestinal lymphatics, the thoracic duct, the superior and inferior vena cavae, hemorrhoidal veins and the pulmonary veins may also be additional pathways [1,2]. Predominantly registered locations are the left ventricle (75%), followed by the right ventricle (18%) and the interventricular septum (7%) [3]. The following report is of a young girl who presented with repeated chest pain and abdominal pain and who was finally diagnosed to have massive left ventricular and left hepatic hydatid cyst by echocardiography and magnetic resonance imaging that has successfully been surgically removed. A 13-year old girl was admitted to our department for exploration of repeated chest pain and abdominal pain during the past 1 year. The clinical examination revealed no weight loss and no fever. The heart rate was 76 beats/min and the blood pressure was 100/65 mm Hg, cardiac and chest auscultation was uncharacteristic but abdominal examination presented hepatomegaly especially in the left lobe and no sign of acute abdomen. Neurological examination revealed no abnormalities and electrocardiogram was completely uncharacteristic. Transthoracic echocardiography was performed, revealing a massive cystic mass (3.7 ∗ 3.8 cm) developing inside the left ventricle, and mildly compressing the outflow tract evocating hydatid cyst, but no relevant valve disease (Fig. 1A). And complementary cardiac magnetic resonance imaging (Fig. 1C–D) subsequently carried out corroborated the echocar-
⁎ Corresponding author. 1 These authors contributed equally to this work.
diographic findings, highlighting, the presence inside the left ventricular cavity, of a large 3.7 ∗ 3.8 cm cystic structure partially developing towards the outflow tract. The abdominal ultrasonic revealed hepatomegaly, with a large well-defined hypoechoic mass lesion (12 ∗ 11 cm) separated by a thick septa in the left lobe of the liver (Fig. 2A) and abdominal CT scan confirmed the diagnosis of liver hydatid disease (Fig. 2B) and left ventricular mass (Fig. 1B). Cardiac surgery was performed under total cardiopulmonary bypass; preoperative exploration found a 3.7 ∗ 3.8 cm mass corresponding to the cyst; sterilization of the cyst contents was performed using hypertonic saline solution and then cystic material was evacuated through a syringe aspiration. The cyst wall was opened, and the residual cavity was washed and then excised. Histopathological examination confirmed the diagnosis of the cardiac hydatid cyst [4]. Sterilization of the cyst contents was performed using hypertonic saline solution and then cystic material was drained through needle aspiration. The cyst wall was opened, and daughter cysts were removed. The residual cavity was washed and then excised. Histopathological examination confirmed the diagnosis of the cardiac hydatid cyst. And then the patient was transferred to the general surgery department for the further treatment. And the follow-up was good. Hydatid disease is zoonosis that is caused by Echinococcus granulosus. The parasites reside mostly in the liver and sometimes in the lung. It transforms into a cyst and may stay latent for many years, cardiac manifestations of hydatid cysts are rare and occur in about 0.2 to 3% of all cases of human hydatidosis [6]. Hydatid cysts located in the cardiac four chambers and interventricular septum, sometimes associated with multiple intracranial hydatid cysts were reported in the literature. But to our knowledge the patients with liver hydatid disease and associated with left ventricular endocardial echinococcosis in the children are not reported. The diagnosis of the hydatid cyst in the liver or the ventricular depends on the combination of the three modalities: the first is clinical suspicion: especially, in echinococcosis endemic regions particularly, when an already known history of previous hydatid cyst disease is present, the second is imaging characteristics of the hydatid cysts and both magnetic resonance imaging [5] and echocardiography are sensitive and useful diagnostic procedures in cardiac echinococcosis and the last is specific serologies, and in particular, the indirect hemagglutination test which is highly sensitive and specific for hydatid diseases [3,7]. Cysts located in the subepicardial region may compress coronary arteries causing chest pain and intracavitary growth may interfere with heart valve function causing stenosis or incompetence. Sometimes
http://dx.doi.org/10.1016/j.ijcard.2014.04.166 0167-5273/© 2014 Elsevier Ireland. Ltd
Please cite this article as: Ling Y, et al, Unusual cause of chest pain in a 13 year-old young child: Left ventricular hydatid cyst, Int J Cardiol (2014), http://dx.doi.org/10.1016/j.ijcard.2014.04.166
e2
Y. Ling et al. / International Journal of Cardiology xxx (2014) xxx–xxx
Fig. 1. Preoperative transthoracic echocardiogram revealing a cyst-like structure in the left ventricle (A), and the CT scan also revealing the mass (B). Magnetic resonance imaging transaxial transverse (C) and short axis (D) views revealing a massive 3.7 ∗ 3.8 cm cystic mass developing inside the left ventricle.
Involvement of the interventricular septum may interfere with the conduction system leading to rhythm disturbances. They may rupture into pericardial cavity causing pericarditis, tamponade, anaphylaxis and death [8]. Due to the fatal consequences of the above serious complications, surgical excision is the treatment of choice, even in asymptomatic patients [5]. In conclusion, although cardiac hydatid diseases are rare pathology, they should keep in mind, especially, in endemic zones when presenting with cardiac or paracardiac masses, and make sure that the other organs are free from the hydatid diseases especially in the liver and lung. References [1] Niarchos C, Kounis GN, Frangides CR, et al. Large hydatic cyst of the left ventricle associated with syncopal attacks [J]. Int J Cardiol 2007;118(1):e24–6. [2] Kammoun S, Frikha I, Fourati K, et al. Hydatid cyst of the heart located in the interventricular septum [J]. Can J Cardiol 2000;16(7):921–4. [3] Rekik S, Krichene S, Sahnoun M, et al. Unusual cause of syncope in a 17 year-old young woman: left ventricular hydatid cyst [j]. Int J Cardiol 2009;136(1):e21–3. [4] Beheshtirouy S, Kakaei F, Oliaei-Motlagh M, et al. Syncope in a patient with a large left ventricular hydatid cyst: an unusual presentation [J]. Int J Cardiol 2014;172(3): e385–6. [5] Kelle S, Köhler U, Thouet T, et al. Cardiac involvement of Echinococcus granulosus evaluated by multi-contrast CMR imaging [J]. Int J Cardiol 2009;131(2):e59–60. [6] Zobel C, Kuhn-Regnier F, Krüger K, et al. Echinococcus cyst located in the interventricular septum [J]. Clin Res Cardiol 2006;95(11):600–4. [7] Miralles A, Bracamonte L, Pavie A, et al. Cardiac echinococcosis. J Thorac Cardiovasc Surg [J]. J Thorac Cardiovasc Surg 1994;107(1):184–90. [8] Kardaras F, Kardara D, Tselikos D, et al. Fifteen year surveillance of echinococcal heart disease from a referral hospital in Greece [J]. Eur Heart J 1996;17(8):1265–70.
Fig. 2. Preoperative transthoracic echocardiogram revealing a well-defined hypoechoic mass lesion (12 ∗ 11 cm) separated by a thick septa in the left lobe of the liver (A). And the CT scan confirmed the diagnosis (B).
Please cite this article as: Ling Y, et al, Unusual cause of chest pain in a 13 year-old young child: Left ventricular hydatid cyst, Int J Cardiol (2014), http://dx.doi.org/10.1016/j.ijcard.2014.04.166
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Unusual cause of chest pain in a 13 year-old young child: Left ventricular hydatid cyst Yunfei Ling 1, Yongjuan Qian 1, Wei Meng ⁎, Ke Lin Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Sichuan, People's Republic of China
a r t i c l e
i n f o
Article history: Received 12 April 2014 Accepted 13 April 2014 Available online xxxx Keywords: Echinococcosis Left ventricular hydatid cyst Chest pain
Hydatid cysts (echinococcosis) of the heart are rare and the prevalence of cardiac hydatosis is less of 2% of all human body infestations. The larvae reach the heart through the coronary circulation but the intestinal lymphatics, the thoracic duct, the superior and inferior vena cavae, hemorrhoidal veins and the pulmonary veins may also be additional pathways [1,2]. Predominantly registered locations are the left ventricle (75%), followed by the right ventricle (18%) and the interventricular septum (7%) [3]. The following report is of a young girl who presented with repeated chest pain and abdominal pain and who was finally diagnosed to have massive left ventricular and left hepatic hydatid cyst by echocardiography and magnetic resonance imaging that has successfully been surgically removed. A 13-year old girl was admitted to our department for exploration of repeated chest pain and abdominal pain during the past 1 year. The clinical examination revealed no weight loss and no fever. The heart rate was 76 beats/min and the blood pressure was 100/65 mm Hg, cardiac and chest auscultation was uncharacteristic but abdominal examination presented hepatomegaly especially in the left lobe and no sign of acute abdomen. Neurological examination revealed no abnormalities and electrocardiogram was completely uncharacteristic. Transthoracic echocardiography was performed, revealing a massive cystic mass (3.7 ∗ 3.8 cm) developing inside the left ventricle, and mildly compressing the outflow tract evocating hydatid cyst, but no relevant valve disease (Fig. 1A). And complementary cardiac magnetic resonance imaging (Fig. 1C–D) subsequently carried out corroborated the echocar-
⁎ Corresponding author. 1 These authors contributed equally to this work.
diographic findings, highlighting, the presence inside the left ventricular cavity, of a large 3.7 ∗ 3.8 cm cystic structure partially developing towards the outflow tract. The abdominal ultrasonic revealed hepatomegaly, with a large well-defined hypoechoic mass lesion (12 ∗ 11 cm) separated by a thick septa in the left lobe of the liver (Fig. 2A) and abdominal CT scan confirmed the diagnosis of liver hydatid disease (Fig. 2B) and left ventricular mass (Fig. 1B). Cardiac surgery was performed under total cardiopulmonary bypass; preoperative exploration found a 3.7 ∗ 3.8 cm mass corresponding to the cyst; sterilization of the cyst contents was performed using hypertonic saline solution and then cystic material was evacuated through a syringe aspiration. The cyst wall was opened, and the residual cavity was washed and then excised. Histopathological examination confirmed the diagnosis of the cardiac hydatid cyst [4]. Sterilization of the cyst contents was performed using hypertonic saline solution and then cystic material was drained through needle aspiration. The cyst wall was opened, and daughter cysts were removed. The residual cavity was washed and then excised. Histopathological examination confirmed the diagnosis of the cardiac hydatid cyst. And then the patient was transferred to the general surgery department for the further treatment. And the follow-up was good. Hydatid disease is zoonosis that is caused by Echinococcus granulosus. The parasites reside mostly in the liver and sometimes in the lung. It transforms into a cyst and may stay latent for many years, cardiac manifestations of hydatid cysts are rare and occur in about 0.2 to 3% of all cases of human hydatidosis [6]. Hydatid cysts located in the cardiac four chambers and interventricular septum, sometimes associated with multiple intracranial hydatid cysts were reported in the literature. But to our knowledge the patients with liver hydatid disease and associated with left ventricular endocardial echinococcosis in the children are not reported. The diagnosis of the hydatid cyst in the liver or the ventricular depends on the combination of the three modalities: the first is clinical suspicion: especially, in echinococcosis endemic regions particularly, when an already known history of previous hydatid cyst disease is present, the second is imaging characteristics of the hydatid cysts and both magnetic resonance imaging [5] and echocardiography are sensitive and useful diagnostic procedures in cardiac echinococcosis and the last is specific serologies, and in particular, the indirect hemagglutination test which is highly sensitive and specific for hydatid diseases [3,7]. Cysts located in the subepicardial region may compress coronary arteries causing chest pain and intracavitary growth may interfere with heart valve function causing stenosis or incompetence. Sometimes
http://dx.doi.org/10.1016/j.ijcard.2014.04.166 0167-5273/© 2014 Elsevier Ireland. Ltd
Please cite this article as: Ling Y, et al, Unusual cause of chest pain in a 13 year-old young child: Left ventricular hydatid cyst, Int J Cardiol (2014), http://dx.doi.org/10.1016/j.ijcard.2014.04.166
e2
Y. Ling et al. / International Journal of Cardiology xxx (2014) xxx–xxx
Fig. 1. Preoperative transthoracic echocardiogram revealing a cyst-like structure in the left ventricle (A), and the CT scan also revealing the mass (B). Magnetic resonance imaging transaxial transverse (C) and short axis (D) views revealing a massive 3.7 ∗ 3.8 cm cystic mass developing inside the left ventricle.
Involvement of the interventricular septum may interfere with the conduction system leading to rhythm disturbances. They may rupture into pericardial cavity causing pericarditis, tamponade, anaphylaxis and death [8]. Due to the fatal consequences of the above serious complications, surgical excision is the treatment of choice, even in asymptomatic patients [5]. In conclusion, although cardiac hydatid diseases are rare pathology, they should keep in mind, especially, in endemic zones when presenting with cardiac or paracardiac masses, and make sure that the other organs are free from the hydatid diseases especially in the liver and lung. References [1] Niarchos C, Kounis GN, Frangides CR, et al. Large hydatic cyst of the left ventricle associated with syncopal attacks [J]. Int J Cardiol 2007;118(1):e24–6. [2] Kammoun S, Frikha I, Fourati K, et al. Hydatid cyst of the heart located in the interventricular septum [J]. Can J Cardiol 2000;16(7):921–4. [3] Rekik S, Krichene S, Sahnoun M, et al. Unusual cause of syncope in a 17 year-old young woman: left ventricular hydatid cyst [j]. Int J Cardiol 2009;136(1):e21–3. [4] Beheshtirouy S, Kakaei F, Oliaei-Motlagh M, et al. Syncope in a patient with a large left ventricular hydatid cyst: an unusual presentation [J]. Int J Cardiol 2014;172(3): e385–6. [5] Kelle S, Köhler U, Thouet T, et al. Cardiac involvement of Echinococcus granulosus evaluated by multi-contrast CMR imaging [J]. Int J Cardiol 2009;131(2):e59–60. [6] Zobel C, Kuhn-Regnier F, Krüger K, et al. Echinococcus cyst located in the interventricular septum [J]. Clin Res Cardiol 2006;95(11):600–4. [7] Miralles A, Bracamonte L, Pavie A, et al. Cardiac echinococcosis. J Thorac Cardiovasc Surg [J]. J Thorac Cardiovasc Surg 1994;107(1):184–90. [8] Kardaras F, Kardara D, Tselikos D, et al. Fifteen year surveillance of echinococcal heart disease from a referral hospital in Greece [J]. Eur Heart J 1996;17(8):1265–70.
Fig. 2. Preoperative transthoracic echocardiogram revealing a well-defined hypoechoic mass lesion (12 ∗ 11 cm) separated by a thick septa in the left lobe of the liver (A). And the CT scan confirmed the diagnosis (B).
Please cite this article as: Ling Y, et al, Unusual cause of chest pain in a 13 year-old young child: Left ventricular hydatid cyst, Int J Cardiol (2014), http://dx.doi.org/10.1016/j.ijcard.2014.04.166
