Bilateral ruptured pulmonary hydatid cysts


Pulmonary hydatid disease remains a significant health problem in endemic areas including Saudi Arabia. Different surgical tactics and approaches are still a subject of discussion. Here, we present a case of bilateral pulmonary hydatid cysts with spontaneous rupture that underwent successful one-stage bilateral enucleation and capitonnage.

Keywords: Echinococcus granulosus , pulmonary cyst, pulmonary hydatid disease

How to cite this article:
Regal M, Al-Jehani Y, Bousbait H. Bilateral ruptured pulmonary hydatid cysts. Ann Trop Med Public Health 2012;5:259-61


How to cite this URL:
Regal M, Al-Jehani Y, Bousbait H. Bilateral ruptured pulmonary hydatid cysts. Ann Trop Med Public Health [serial online] 2012 [cited 2020 Aug 5];5:259-61. Available from:



Hydatid disease, an infestation commonly caused by Echinococcus granulosus. In humans, who serve as an accidental intermediate host, infection is acquired by ingesting food or soil contaminated with eggs excreted from the canine, the definitive host. In primary echinococcosis, larval cysts may develop in every organ. The lung is the second most commonly affected organ after the liver. [1] Cysts are surrounded by the periparasitic host tissue (endocyst). Inside the laminated layer, or hyaline membrane, the cyst is covered by a multipotential germinal layer, giving rise to the protoscolices. The central cavities of cysts of E. granulosus are filled with clear fluid and protoscolices. All hydatid cysts carry the risk of rupture, which is the most common complication. Pulmonary hydatid cysts usually remain asymptomatic until the time of rupture when the patient presents with productive sputum, hemoptysis, and fever. Surgery remains the treatment of choice for hydatid cysts of the lung with the aim of using the most conservative surgical method possible. In Saudi Arabia, hydatid disease is not uncommon, with the highest prevalence of the disease reported in the southwestern region of the country. [2] A reported peak frequency of hydatid disease in Saudi Arabia was in the age group of 20-39 years, with higher frequency among males. [3] Surgical treatment constitutes 0.3% of the operative general surgical load and 5% of all major surgical procedure. [2],[4]

Case Report

A 22-year-old non-smoker female who was previously healthy developed high fever for 2 days followed by one episode of severe cough with hemoptysis of about 100 ml. She had no history of Shortness of Breath (SOB), night sweat, or weight loss. After one week, she went to a hospital where she was diagnosed with pneumonia and treated accordingly; however, no improvement was seen. Further evaluation by chest Computed Tomography (CT) showed three cavitary lesions; for treatment she was referred to us as a case of pulmonary cystic disease. On examination, the patient’s vital signs were stable. On the right chest, there was bronchial breathing with expiratory rhonchi on the lower posterior zone and coarse crepitations on the middle zone. On the left chest, reduced air entry with expiratory rhonchi was detected on the lower posterior zone along with dullness on percussion. Laboratory works were unremarkable, except for echinococcal serology, which was positive (1:4096). Sputum was negative for Acid-Fast Bacilli (AFB) and scolices. Chest X-ray [Figure 1] showed bilateral round homogenous lesion. Pre- and post-contrast axial CT of the chest [Figure 2] revealed three cavitary lesions; one in the right middle lobe measuring about 6.8 × 5.2 cm and another in the left upper lobe of about 3.4 × 2.4 cm in size. Walls of these two cavities were thick, irregular, and showed some post-contrast enhancement; the cavities contained soft tissue component with air shadow, which did not show post-contrast enhancement, and infiltrative changes around the cavities; all these features indicate ruptured cysts. The third cavity was in the left lower lobe of size about 8.5 × 6.1 cm with intact thin wall without any calcifications with significant enhancement. Right-sided mild pleural effusion was seen, but no significant lymph node enlargement. The patient underwent bilateral enucleation of the hydatid cysts with capitonnage as one-stage thoracotomies. The surgeries were conducted with Double-lumen endotracheal tube. Left posterior-lateral thoracotomy was done in the 5 th Intercostal Space (ICS), with identification of an intact hydatid cyst in the left lower lung lobe measuring 8.0 × 8.0 × 7.0 cm. The peri-cystic tissue was opened and enucleation of the cyst was performed. The thoracic cavity was irrigated with hypertonic saline (14%) and cleaned with hydrogen peroxide closed thereafter. The feeding bronchus in the floor of the cavity was closed as well. Capitonnage was performed. Another cyst was found in the left upper lobe and treated in a similar fashion. On the right side, lateral thoracotomy in the 5 th ICS was performed. Extensive adhesions were found and released between the right upper lobe, right middle lobe, and chest wall. The disturbed cyst, measuring approximately 10.0 × 10.0 × 10.0 cm, was found in the lower part of the right middle lobe with no fluid in it and extending to the fissure and the posterior aspect of the right middle lobe. The cyst was removed with its membranes and peri-cystic tissue as well. The thoracic cavity was washed with hypertonic saline and cleaned with hydrogen peroxide, followed by closure of the feeding bronchus in the floor of the cavity. Capitonnage was also performed. On the second day post-operatively, fibro-optic bronchoscopy was performed, which showed right and left main bronchus filled with viscid bloody secretions. Suction and lavage with NaHCO 3 were performed. Chest tubes were removed at the 4 th and 5 th days after the expansion of both lungs, and the patient was discharged on the 20 th day. Albendazole 400 mg PO Q8h was the therapy until the patient was discharged. The final pathology results were consistent with pulmonary hydatid disease.

Figure 1: Chest X-ray showing bilateral round homogenous lesions

Click here to view

Figure 2: CT scan showing cavitary lesions; one in the right middle lobe and another in the left upper lobe. Walls of these two cavities were thick, irregular, and showed some post-contrast enhancement. The cavities contained soft tissue component with air shadow, and these features indicate ruptured cysts

Click here to view



Hydatid disease is endemic in some parts of the world and still an important public health problem, especially in the rural areas. Middle Eastern countries, including Saudi Arabia, have reported high prevalence of hydatid disease attributed to the presence of sheep and dogs living in close contact with humans, especially among the Bedouins. [2] Most patients with hydatid disease have single organ involvement with solitary cyst. Only 10-15% of the patients have simultaneous involvement of two or more organs. Liver is involved in 75% of the cases, the lung in 15%, and other anatomical locations in 10%. [1] Studies conducted in Saudi Arabia have shown a relatively high frequency of pulmonary hydatid disease, presumably because of airborne spread, with the lungs acting as the first filter instead of the liver. [2],[5] Multiple cysts are found in the lung in 20-30% of the patients. The size of such cysts can reach up to 20 cm due to a relatively higher elasticity of the lung tissue as compared with other tissues. [6],[7] Most pulmonary cysts are located in the lower lobes, more often posteriorly than anteriorly. About 50% of the cysts are localized in the right lung, 40% in the left lung, and 10% bilaterally. [8] Patients with uncomplicated hydatid cyst in the lung are usually asymptomatic and diagnosed incidentally or the patient may present with cough dyspnea and chest pain. Cyst rupture might be observed spontaneously or as a result of trauma causing symptoms including cough, chest pain, hemoptysis, fever, anaphylaxis, and even expectoration of the cyst material if ruptured into bronchus. Rupture of the cyst into the pleural cavity can cause effusion, empyema, simple or life-threatening tension pneumothorax. [9] Super-infection of the cysts such as by Haemophilus influenzae can also happen. [10] Diagnosis of pulmonary hydatid cysts depends mainly on the imaging procedures together with the serology testing. On chest X-ray, the simple cyst (intact, closed) typically appears as homogenous opacity, round with definitive edges, situated in the pulmonary field. [11] CT is often the best technique to elucidate the nature of the cyst, evaluate the cyst preoperatively, and detect additional cysts that cannot be seen on chest X-ray. [12] Surgical treatment is mandatory in any ruptured or large cyst. Intraoperatively, cyst management can either be radical, which includes segmentectomy, lobectomy, and pneumonectomy or a more conservative approach such a cystectomy and intact cyst enucleation or removal after needle aspiration. Overall, the lung-conserving surgical approach is the treatment of choice for most patients with pulmonary hydatid cyst. In the case of bilateral involvement, one-stage surgery is superior to a classic two-stage operation as it decreases the morbidity, hospital stay, and cost. [13] Video-assisted thoracic surgery is suggested for selected patients. In our case, we performed bilateral thoracotomies in single-stage procedure because there were bilateral ruptured cyst and a third cyst, which was about to rupture. Several scolicidal agents can be used to sterilize the thoracic cavity, such as 10% hypertonic saline, which we used, and 0.5% formalin or iodine diluted to 50% with normal saline. Medical treatment using albendazole or mebendazole has been used as primary drug therapy and as an adjunct to surgery to diminish recurrence and potential spread. [14] In conclusion, pulmonary hydatid disease should always be considered in the differential diagnosis of cystic pulmonary lesions for a prompt diagnosis, especially in endemic areas like Saudi Arabia. Surgery should be the first line of management for resectable cases. CT examination should be done to elucidate cystic nature of the lung lesion and for accurate localization in the preoperative period. Public health measures should be adopted to eradicate infected animals and dogs in order to break the cycle of transmission.



1. Beggs I. The radiology of hydatid disease. AJR Am J Roentgenol 1985;145:639-48.
2. Malaika SS, Attayeb A, Sulaimani S, Reddy JJ. Human echinococcosis in Saudi Arabia. Saudi Med J 1981;2:77-84.
3. Alam AA. Epidemiology of hydatid disease in Riyadh: A hospital-based study. Ann Saudi Med 1999;19:450-2.
4. Kidess EA, Akiel AS, Ba’aqeel HS, Malaika SS. Echinococcosis: An obstetric and gynecological view. Ann Saudi Med 1988;8:202-7.
5. Kattan YB. Intrabiliary rupture of hydatid cyst of the liver. Ann R Coll Surg Engl 1977;59:108-14.
6. Ozhan MH. Pulmonary hydatidosis: State of the art. Int Arch Hydatidosis 2001;34:11-2.
7. Symbas PN, Aletras H. Hydatid disease of the lung. In: Shields TW, editor. General thoracic surgery. Philadelphia: Williams and Wilkins; 1994. p. 1021-31.
8. Gottstein B, Reichen J. Hydatid lung disease. Clin Chest Med 2002;23:397-408.
9. Kurkcuoglu IC, Eroglu A, Karaoglanoglu N, Polat P. Tension pneumothorax associated with hydatid cyst rupture. J Thorac Imag 2002;17:78-80.
10. Lamy AL, Cameron BH, Le Blanc JG, Culham JA, Blair GK, Taylor GP. Giant hydatid lung cysts in the Canadian northwest: Outcome of conservative treatment in three children. J Pediatr Surg 1993;28:1140-3.
11. Aytac A, Yurdakul Y, Ikizler C, Olga R, Saylam A. Pulmonary hydatid disease: Report of 100 patients. Ann Thorac Surg 1997;23:145-51.
12. Godwin JD. Pleural disease. In: Putman CE, Ravin CE, editors. Textbook of diagnostic imaging. 2 nd ed. Philadelphia: Saunders; 1994. p. 450.
13. Petrov DB, Terzinacheva PP, Djambazov VI, Plochev MP, Goranov EP, Minchev TR, et al. Surgical treatment of bilateral hydatid disease of the lung. Eur J Cardiothorac Surg 2001;19:918-23.
14. Mawhorter S, Temeck B, Chang R, Pass H, Nash T. Nonsurgical therapy for pulmonary hydatid cyst disease. Chest 1997;112:1432-6.

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1755-6783.98633


[Figure 1], [Figure 2]

Paul Mies has now been involved with test reports and comparing products for a decade. He is a highly sought-after specialist in these areas as well as in general health and nutrition advice. With this expertise and the team behind, they test, compare and report on all sought-after products on the Internet around the topics of health, slimming, beauty and more. The results are ultimately summarized and disclosed to readers.


Please enter your comment!
Please enter your name here