TENSION PNEUMOTHORAXA RARE PRESENTATION

OFPULMONARY HYDATID CYST

Prof. Abdulsalam Y TahaSchool of Medicine

University of SulaimaniIraq

https://sulaimaniu.academia.edu/AbdulsalamTaha

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INTRODUCTION

• Pleural hydatid disease is rare.• Tension pneumothorax and empyaema are also

rare.• A search through the net revealed less than 60

cases over 60 yrs all over the world.• Bakir F and Al-Omeri reported 5 cases of

Echinococcal Tension Pneumothorax in Iraq in 1969 for the first time.

• To the best of our knowledge, this is the 2nd report.

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INTRODUCTION

• HEREIN, TWO LADIES WITH PNEUMOTHORAX AND EMPYAEMA SECONDARY TO INTRAPLEURAL RUPTURE OF PHC ARE PRESENTED.

• THE AIM OF THIS REPORT IS TO EMPHASIZE THAT INTRAPLEURAL RUPTURE OF PHC SHOULD BE CONSIDERED IN ANY PATIENT WITH PNEUMOTHORAX IN AN ENDEMIC AREA.

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CASE 1

• A 17 YR OLD LADY FROM BASRAH• ADMITTED ONE MONTH EARLIER TO

ANOTHER HOSPITAL.• SUDDEN SOB.• COLLAPSED LUNG WITH

HYDROPNEUMOTHORAX• MANAGED BY APICAL AND BASAL CHEST

TUBES + ANTI-TB CHEMOTHERAPY.

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CHEST TUBES DRAINED THICK PUS.PERSISTENT AIR LEAK ( BPF).ENTRAPED LEFT LUNG.

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MANAGEMENT• L POSTEROLATERAL 5TH

SPACE THORACOTOMY• FINDINGS:• THICKENED PARIETAL &

VISCERAL PEELS.• FOUL SMELLING PUS.• COLLAPSED LUNG.• MULTIPLE BRONCHIAL

FISTULAE IN LUL• LAMINATED MEMBRANE

FLOATING IN PLEURAL SPACE.

POSTOPERATIVE RADIOGRAPH

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OPERATION

• DECORTICATION OF L LUNG.• REMOVAL OF PUS.• REMOVAL OF LAMINATED MEMBRANE.• CLOSURE OF BRONCHIAL FISTULAE.• UNEVENTFUL POSTOPERATIVE COURSE.

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CASE 2A LADY OF 35 FROM SAMARRA.SOB ONE MONTH EARLIER WHEN SHE WAS PREGNANTTRNSION PNEUMOTHORAXMANAGED BY CHEST TUBE.

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ON REFERRAL TO OUR UNIT:COLLAPSED LUNG.BPFANTI-TB DRUGS BEGAN IN SAMARRA

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CT SCANTHICKENED PARIETAL & VISCERAL PEELS.A CAVITY IN LLL

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PERSISTENT LUNG COLLAPSE DESPITE A SECOND APICAL CHEST TUBE.DECORTICATION WAS DECIDED

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DECORTICATIONLEFT THORACOTOMY:THICKENED PARIETAL AND VISCERAL PEELS.LAMINATED MEMBRANEMULTIPLE BRONCHIAL FISTULAE IN LLL

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INTRAPLEURAL RUPTURE OF

PHC

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FULLY EXPANDED DECORTICATED LUNG

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DISCUSSION

• PRIMARY PLEURAL HD IS DENIED TO EXIST.• IT IS ALMOST ALWAYS SECONDARY TO

PULMONARY OR HEPATIC HD.• PHCs MAY GROW INTO GIANT CYSTS…

ELASTICITY OF LUNG.• PHC MAY RUPTURE INTO BRONCHUS

( COMMON) OR• INTO PLEURA ( RARE).

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INCIDENCE

• A SEARCH THROUGH THE NET:• LESS THAN 60 CASES ALL OVER THE

WORLD SINCE 1950.• ONLY SPORADIC CASE REPORTS.• FROM COUNTRIES LIKE: TURKEY, IRAQ,

ITALY, INDIA, AUSTRALIA, SPAIN AND GREECE.

WADDLE DESCRIBED 6 CASES OF PNEUMOTHORAX IN 478 PATIENTS WITH PHD

AUSTRALIA 1950Waddle N. Pulmonary hydatid disease. A review of 478 cases

reported in the Louis Barnett Hydatid Registry of the Royal Australasian College of Surgeons. Aust. N.Z.J. Surg. 1950, 19,

273.

TOMALINO DESCRIBED 16 CASES OF PNEUMOTHORAX

SPAIN 1959Tomalino D. Pleural complications of hydatidosis, pleural hydatid accident, secondary pleural hydatidosis ( Study

of 47 personal observations). Thorax, 1952, 8, 73.

RAKOWER J AND MILWIDSKY H REPORTED ONE CASE

1964Rakower J and Milwidsky H. Hydatid Pleural Disease:

Case Report. American Review of Respiratory Diseases. 1964; 90: 623-631.

BAKIR F AND AL-OMERI MDESCRIBED 5 CASES OF ECHINOCOCCAL

TENSION PNEUMOTHORAX IN IRAQ

1969Bakir F and Al-Omeri M A. Echinococcal

Tension Pneumothorax. Thorax. 1969; 24

XANTHAKIS ET AL DESCRIBED 3 CASES OF HYDROPNEUMOTHORAX IN 88 GREEK

PATIENTS

1972Xanthakis D, Efthimidiadis M, Papadakis G, Primikirios N,

Chassapakis G, Roussaki A, Veranis N, Akrivakis A and Aligizakis C.J. Hydatid Disease of the Chest. Report of 91 patients

surgically treated. Thorax, 1972, 27, 517.

CONNELIAN ET AL DESCRIBED THE FIRST CASE OF ECHINOCOCCAL TENSION

PNEUMOTHORAX IN UK

1979

S.J. Connelian, A.W. Jowett and R.S.E. Wilson. Hydatid Disease

presenting as Tension Pneumothorax. Br. J. Dis. Chest

(1979) 37, 405.

JESIOTER ET AL REPORTED A CASE OF PNEUMOTHORAX FOLLOWING RUPTURE OF A

PRIMARY PLEURAL HYDATID CYST

1972Jesioter M, Romanoff H and Yaacob B. Pneumothorax Following

Rupture of a Primary Pleural Hydatid Cyst.J of Thoracic and Cardiovascular Surgery. 1972. 63: 594-598.

: 547-556.

ROLVERSORI R ET AL DESCRIBED ONE CASE IN ITALY

1989Rolverosi R, Daniele P, Serricchio E,

Zarrelli N, Grifa O, Accadia M. Hydropneumothorax caused by rupture of pulmonary hydatid cysts.

Description of a case. Radiol Med. 1989 Jun; 77 (6): 704-5.

AGRAWAL ET AL DESCRIBED ONE CASE IN INDIA

1993Agrawal RL, Jain SK, Gupta SC,

Agrawal DK, Ahmad KR, Nandi D. Hydropneumothorax secondary

to hydatid lung disease. Indian J Chest Dis Allied Sci. 1993 Apr-Jun; 35 (2): 93-6.

FAHRI ET AL DESCRIBED 16 CASES OF PLEURAL HYDATIDOSIS OUT OF 297 PTS WITH

INTRATHORACIC EXTRAPULMONARY HD

TURKEY 1997Fahri O~uzkaya, Yi~it Ak~ah, Cemal Kahraman, Naci Emiro~ullan,

Mehmet Bilgin and Atalay ~ahin. Unusually located Hydatid Cysts:

Intrathoracic but Extra pulmonary. Ann thorac Surg 1997; 64: 334-7.

Kürkçüoğlu IC ET AL DETECTED 5 CASES OF TENSION HYDROPNEUMOTHORAX

SECONDARY TO RUPTURE OF OF A HC OUT OF 185 CASES OF SPONTANEOUS

PNEUMOTHORAX TREATED IN THEIR CLINIC BETWEEN 1992 AND 1998 (2.7%)

TURKEY 2002

Kürkçüoğlu IC, Eroğlu A, Karaoğlanoğlu N, Polat P. Tension pneumothorax associated

with hydatid cyst rupture. J Thoracic Imaging 2002 January; 17 (1): 78-80.

ERDAL ET AL DESCRIBED A RARE CASE OF GIANT RUPTURED HC CAUSING TENSION PNEUMOTHORAX

IN A PATIENT WITH BLUNT THORACIC TRAUMA

Erdal Yekeler, Onur Celik, and Cevdet Becerik . A Giant Ruptured Hydatid Cyst Causing

Tension Pneumothorax and Hemothorax in a Patient with Blunt Thoracic Trauma: a Rare Case Encountered in the Emergency Clinic.

The Journal of Emergency Medicine . Vol XX, No. X. pp XXX, 2009.

TURKEY 2009

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PATHOGENESIS

• PHC USUALLY HAS A PERIPHERAL LOCATION.• THE ELASTICITY OF THE LUNG PERMITS A

HUGE SIZE.• INTRAPLEURAL RUPTURE RESULTS IN AIR,

FLUID AND MEMBRANE ENTRY INTO THE PLEURA.

• ABSORPTION OF FLUID RESULTS IN ANAPHYLAXIS.

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PATHOGENESIS

• TENSION PNEUMOTHORAX MAY RESULT FROM A CHECK VALVE MECHANISM..• COMBINATION OF MASSIVE

PNEUMOTHORAX AND ANAPHYLAXIS MAY PROVE FATAL.• UNTREATED.. BPF AND EMPYAEMA.

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MANAGEMENT

• Preoperative diagnosis is difficult.• In most of the reported cases, the diagnosis

was made at the time of thoracotomy.• In the acute phase: steroids for anaphylactic reaction and chest tube insertion for pneumothorax. Definite diagnosis and treatment:

thoracotomy.

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MANAGEMENT

• Almost always, it is misdiagnosed as PTB ( high prevalence of PTB in areas endemic to PHD).• However, certain observations

may give hints..

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WHICH OBSERVATIONS?

• Residence in an endemic area.• Drainage of crystal clear fluid via chest tubes.• Pieces of laminated membrane may plug the

tube.• Persistent air leak despite 2 or 3 chest tubes.• Features of anaphylaxis.• Exam of pleural fluid for scolices may be

positive.

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ALSO..

• Eosinophilia• Chest radiograph may show an irregular

gas-fluid level.• CT scan of chest: may show the cavity of

the cyst as well as the laminated membrane.

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CONCLUSIONS• Intrapleural rupture of PHC is rare.• Echinococcal tension pneumothorax may prove

fatal.• It should be considered in any patient with

pneumothorax in an area endemic to PHC.• Preoperative diagnosis is extremely difficult, though

certain observations may give hints.• Definite diagnosis and treatment is via

thoracotomy.• Thoracotomy should be done as soon as the patient

is stabilized and before development of empyaema.

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THANK YOU FOR YOUR ATTENTION