Pulmonary Hydatid Cyst with Complicating Aspergillus Infection Presenting as a Refractory Lung Abscess

Abstract

BackgroundHydatid disease is rare in the United States. Rarely the hydatid cyst can become infected with mycotic organisms, such as Aspergillus. We describe a young male who presents with clinical features of suppurative lung abscess whose workup diagnosed hydatid cyst complicated by Aspergillus co-infection.Case presentationA 27-year-old Peruvian male was hospitalized because of fever, chills, and productive cough of three months’ duration. Clinical features were consistent with a suppurative lung abscess. Significant findings included leukocytosis with eosinophilia and a chest x-ray showing a large lingular lobe thick-walled cavity with a wavy irregular fluid level. The patient ultimately underwent surgical resection of the lingular lobe. Examination of the surgical specimen revealed the cavity to be a hydatid cyst. Histologic examination of the cyst wall showed intense inflammation and several septate hyphae of Aspergillus species. The patient recovered fully and has remained in good health.ConclusionA thick-walled cavity and a wavy meniscus constitute unusual features for an ordinary pyogenic lung abscess and suggests other possibilities. Endogenous cases of hydatid disease are uncommon in the United States, with the majority of cases occurring in immigrants. There are few published case reports describing incidental findings of Aspergillus in a hydatid cyst. The rare occurrence of such a condition can lead to a delay in diagnosis and treatment.

Pulmonary hydatid disease with aspergillosis - an unusual association in an immunocompetent host

“…a cyst may rupture into a bronchus, pleura or a vessel, causing hemoptysis. The patient may expectorate cyst contents, have recurrent episodes of hemoptysis, productive cough, fever or even anaphylactic shock due to aspiration of cyst contents in such cases (1,2,7,9,18). in our case, similar presenting features were seen in the form of fever and non-resolving pneumonia for eight months, dyspnoea since 15 days and recurrent episodes of hemoptysis since 5 days.…”

“…aspergillus may have a propensity to colonise cysts close to the hilum as obliteration of the cavity does not occur in these cases (10). The large size of the hydatid cyst may predispose to secondary infection, which may even result in the formation of an abscess, causing purulent sputum (6,18). However, in many instances, fungal colonization has been observed even in the absence of the above mentioned predisposing conditions (15).…”

“…in such cases, oral antifungal treatment is also required. in unresectable, recurrent or inoperable echinococcosis, oral anti-helminthic therapy is warranted (13,18). as our patient was immunocompetent, there was no dissemination of aspergillus and the postoperative stay was uneventful.…”

“…Serological tests for Echinococcus include Casoni's intradermal test, hemagglutination tests, flocculation tests, precipitin reaction, complement fixation test. indirect fluorescent antibody test and immune- electrophoresis have also been used (18). However, there was no eosinophilia in peripheral blood examination in our patient.…”

Ruptured pulmonary hydatid disease mimicking a lung mass: diagnosed by flexible video bronchoscopy

“…The diagnosis was made by fungal culture of bronchial washings and by the galactomannan test in the serum which was also positive. Mahmood et al 26 also reported a hydatid cyst complicated by an Aspergillus infection and the patient finally underwent surgical resection of the hydatid cyst. Coexistence of pulmonary hydatid cyst and pulmonary tuberculosis is also seen in some cases 27.…”