Atypical respiratory symptoms due to hepatic hydatid cyst: A case report of emergency surgery

Abstract

Introduction

Cystic Echinococcosis (CE), caused by Echinococcus granulosus, primarily affects the liver and lungs, particularly in endemic regions. While commonly associated with gastrointestinal manifestations, CE can lead to severe complications that necessitate surgical intervention.

Case presentation

A 53-year-old female was referred due to a prolonged history of exertional dyspnea that recently worsened. Imaging studies indicated a large hydatid cyst in the right lobe of the liver and significant pleural effusion. Surgical management was conducted via thoracotomy, facilitating the excision of multiple cysts and drainage of the pleural fluid.

Discussion

This case illustrates the potential for respiratory symptoms to emerge from hydatid cyst infections, which often present with digestive issues. Effective diagnostic techniques are crucial for identifying the cysts and assessing their impact on surrounding structures. The surgical intervention not only relieved the patient's symptoms but also mitigated the risk of further complications associated with untreated cysts.

Conclusion

The findings underscore the importance of recognizing atypical presentations of hepatic hydatid cysts. Timely surgical intervention was essential in managing the patient's condition, highlighting the critical role of prompt diagnosis and treatment in preventing serious complications.

Highlights

• •This case report presents a patient with atypical respiratory symptoms due to hepatic hydatidcysts.
• •Surgical intervention via thoracotomy effectively relieved her condition.
• •Recognizing such unusual presentations is vital for timely treatment.

1. Introduction

Cystic Echinococcosis (CE) is an infection caused by a type of helminths called Echinococcus granulosus, which enters the body after eating food contaminated with its larvae, its move throws the GIT tract to the small intestine and penetrate it to reach any organ in the body and settle in it [1].

The liver, mainly the right lobe, is considered to be the most common organ of involvement followed by the lung, and multiple organ infection can occur. Quite often the liver and the lung are both involve [2].

CE is an endemic in the Mediterranean, China, Russia, Eastern Europe, and South America, with annual incidence ranges from <1 to 200 per 100,000 persons. it is believed that most infected individuals in United States are immigrants [3].

Although CE has slow growth rate, it may show serious symptoms, depending on the cysts size and location. Hepatic hydatid cysts compressing adjacent organs usually cause jaundice, abdominal pain, and nausea, and usually do not involve pulmonary symptoms [4,5].

The best way to treat hydatid cysts is surgery, depending on where the cyst is located. Synchronous liver and lung cysts require both laparotomy and thoracotomy, or can be treated by a single-stage approach via thoracotomy and phrenectomy. This method is safer and resulting in less complications compared with thoracotomy and laparotomy [6].

In this study, we present a patient suffering from pulmonary symptoms caused by a liver dome hydatid cyst, who underwent a single-stage approach via thoracotomy and phrenectomy. This case is considered one of the rarest in the medical literature due to the unique symptoms presented by the patient, as well as the surgical approach taken to achieve the patient's recovery. and we highlight the challenges encountered in managing this unique case as per the SCARE checklist [7].

2. Case presentation

A 53-year-old female patient from a rural area endemic to echinococcosis was referred to the hospital with complaints that began ten years ago, manifesting as exertional dyspnea. Over the past week, her condition worsened, presenting as persistent dyspnea and cough with white, frothy sputum and a bitter taste in her mouth, accompanied by fever, diaphoresis, and constipation. The patient has a history of liver cystectomy performed 30 and 20 years ago, as well as an appendectomy. Her family history includes hypertension and diabetes mellitus in her mother, and she herself has a history of hypertension. Upon examination, her vital signs showed a pulse of 77 beats per minute and blood pressure of 140/90 mmHg, with diminished breath sounds noted in the right lung. Hematological tests indicated leukocytosis. Imaging studies, including ultrasound and CT scans, revealed a heterogeneous liver with a large cyst in the right lobe, measuring approximately 10 cm in diameter, Fig. 1 alongside a significant pleural effusion in the right thoracic cavity.

Fig. 1.

CT image show a heterogeneous liver with a prominent, well-defined hydatid cyst in the right lobe, approximately 10 cm in diameter.

The patient was prepared for surgery under general anesthesia to excise the hydatid cysts. A right-sided thoracotomy was performed at the level of the fifth intercostal space, allowing access to the pleural cavity. A small cyst was identified at the base of the pleura on the dome of the right diaphragm, along with a quantity of bloody serous fluid in the pleural cavity. This fluid was drained, and a sample was sent for analysis. The right diaphragm was incised to access the hepatic cyst located on the upper posterior aspect of the liver. A significant number of cysts were excised, and a drain was placed in the hepatic cavity. The diaphragm was then sutured, and a chest drain (32 Fr) was inserted. Finally, the thoracic cavity was closed, and a sterile dressing was applied. (Fig. 2, Fig. 3.)

Fig. 2.

The image displays multiple hydatid cysts excised from the liver.

Fig. 3.

The surgical intervention image shows the right diaphragm incised, providing access to the upper posterior aspect of the liver where the hepatic cysts were accessed and a drain was placed in the hepatic cavity.

After the operation, the general condition and vital signs of the patient were stable. The following treatments were administered:

1 serum saline, 1 diabetic serum,1 mixed serum, Levofloxacin/500 mg (1 tablet, once daily), Paracetamol/1000 mg (1 tablet, three times daily), devomit ampoule/8 mg (1 ampoule, three times daily), Hydrocortisone vial/100 mg (1 vial, twice daily), Nebulizers (salbutamol/ambroxol), Thoracic exercises and physical therapy were recommended. The patient remained in the hospital for 10 days.

The chest drain was then removed, and the patient was discharged home, ten days later, the patient returned to the hospital, where the drain inside the liver cyst was removed.

3. Discussion

Abdominal hydatid cysts generally cause digestive symptoms such as jaundice, abdominal pain, and nausea. However, it is uncommon for them to present as respiratory symptoms like breathlessness and respiratory distress without clear pathological digestive changes. The most important complication of Echinococcus cysts is the rupture of the cyst, which carries a subsequent risk of anaphylactic shock and secondary hydatidosis in the peritoneal cavity [1].

The symptoms appear as if they are related to a chest problem. Nevertheless, pediatric infections often remain latent without clear symptoms due to the long incubation period of the parasite. The cysts are often discovered in adults when they visit the hospital due to presenting complaints. When the bronchial airways are affected by a pneumo-biliary fistula, the patient will experience bilioptysis. The common prolonged symptoms tend to be respiratory, including dyspnea [8].

In this case, the patient presented with several symptoms, including persistent dyspnea and a cough with white, frothy sputum, which are not typical symptoms of Abdominal hydatid cysts.

This case requires accurate diagnostic techniques to determine the cysts' location, biliary obstruction, and preoperative diagnosis. Best among them are radiological methods such as chest radiograph, abdominal ultrasound (USG), chest and abdominal CT scan, and, in rare cases, MRI [6].

The diagnosis in our case was established based on the patient's presenting symptoms, raising suspicion that the cysts were impacting the respiratory system. The cysts were situated on the dome of the liver, resulting in elevation of the diaphragm and subsequent irritation of the lung, which contributed to the observed respiratory symptoms.

The treatment manifests in surgical and alternative methods. Surgical techniques, for instance, laparoscopic and thoracoscopic excision, protect and prevent complications resulting from large incisions or opening the chest or abdomen, especially in patients with multiple cysts. As for non-surgical methods, the Port-in-cyst technique eliminates the risk of leakage and septic shock using an outer sheath and a wide-bore 10 mm suction cannula [9].

In our case, however, the treatment involved a thoracotomy due to the patient's respiratory complaints. This approach was necessary to address the significant pleural effusion and cystic formations that were impacting her respiratory function. Ultimately, the evaluation revealed that the lungs themselves were intact, which underscored the importance of surgical intervention to alleviate the symptoms and prevent further complications.

4. Conclusion

In conclusion, this case highlights the importance of recognizing atypical respiratory symptoms in patients with hepatic hydatid cysts, as they may indicate significant complications. Surgical intervention, specifically via thoracotomy, proved essential in addressing the patient's respiratory issues and preventing further complications while preserving lung integrity.

Informed consent

Unnecessary, information taken from the patient's file.

Consent for publication

All authors provide consent for publication.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Ethical approval

This case report does not require ethical approval as it involves a single patient case that is anonymized and does not include any identifiable personal information. The patient provided informed consent for the publication of this report.

Funding

There are no funding sources.

Author contribution

The work's conception and design: all authors.

paper writing, and article revision: all authors.

Final revision and approval: all authors.

Guarantor

Kadri Alhaj Moustafa.

Declaration of competing interest

The authors declare that they have no competing interests.