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Facing the Unexpected: Chest Wall Swelling 7 Years After A Stab Injury
The Journal of Emergency Medicine, Vol. -, No. -, pp. 1–3, 2015 Copyright Ó 2015 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2015.06.023
Visual Diagnosis in Emergency Medicine
FACING THE UNEXPECTED: CHEST WALL SWELLING 7 YEARS AFTER A STAB INJURY Eleftherios Spartalis, MD, Demetrios Moris, MD, Antonios Athanasiou, MD, Dimitrios Dimitroulis, MD, and Periklis Tomos, MD Second Department of Propedeutic Surgery, University of Athens Medical School, ‘‘Laikon’’ General Hospital, Athens, Greece Corresponding Address: Demetrios Moris, MD, Second Department of Propedeutic Surgery, University of Athens Medical School, Anastasiou Gennadiou 56, 11474, Athens, Greece
site of a 7-year-old superficial stab wound that had been left to heal by secondary intention. The physical examination revealed a healed scar. The area of swelling was approximately 11 cm 8 cm, nontender, globular in shape, and firm in consistency. A computed tomography (CT) scan revealed a hypodense lesion located above the right pectoralis major muscle (Figure 1B). The liver, lungs, spleen, and brain were entirely normal at a detailed workup by CT scan. Total excision of a thick-walled, multilocular cyst with grapelike daughter cysts was performed (Figure 2). Histologic examination of the specimen and positive serology for Echinococcus granulosus was confirmatory for the diagnosis of subcutaneous echinococcosis. The patient’s postoperative course was uneventful. Albendazole was administered postoperatively for 6 months. No recurrence was observed during the follow-up period.
INTRODUCTION Hydatid cyst is a parasitic infection that is endemic mostly in countries along the Mediterranean Sea coast (1,2). Humans are partially involved in the natural cycle of the cyst via oral ingestion of the cystic form of the parasite (1,3). The cyst is ingested in the duodenum and can spread to any organ via the arterial, venous, or lymphatic systems (1,3). The most common localization is the liver (55-60% of cases), followed by the lungs (25-30% of cases); localization to other organs occurs in approximately 5% of cases (4,5). We present a unique case of thoracic wall/extrapulmonary hydatid cyst 7 years after a stab injury. CASE REPORT A 57-year-old man was admitted to our hospital with swelling on the right chest wall of 4 months’ duration (Figure 1A). The patient noticed swelling at the same
DISCUSSION Hydatid disease or echinococcosis is a zoonosis caused by tapeworms of the genus Echinococcus. The most commonly encountered cystic disease (CE) is caused by E granulosus and is highly endemic in Mediterranean countries (e.g., Spain, France, Greece, etc.), the Middle East (Israel), South America (i.e., Argentina
Reprints are not available from the authors. Key Clinical Message: A solitary subcutaneous hydatid cyst must always be considered in the differential diagnosis of a silent growing mass in soft tissue.
RECEIVED: 3 June 2015; ACCEPTED: 11 June 2015 1
2
E. Spartalis et al.
Figure 1. (A) Chest wall swelling. (B) A computed tomography scan revealed a hypodense lesion located above the right pectoralis major.
and Chile), and certain areas of Asia (i.e., China and India) (1,6). With the observed population shifts because of migration and ease of travel in the modern era, echinococcosis has the potential of becoming a worldwide disease, creating a need for increased information and alert among physicians. It is estimated that 1.2 million people are affected and 3.6 million disability-adjusted life years are lost globally (7). Patient history and clinical examination are nonspecific and may provide only indications toward the diagnosis. Serology tests are not the criterion standard because of their low sensitivity, their inconclusiveness to identify active and inactive cysts, and their prolonged ‘‘false’’ positivity even after a cyst is surgically removed. In clinical practice, 2 serologic tests with enzyme-linked immunosorbent assay and indirect hemagglutination are commonly used (8). Serology has mainly supportive role in confirming the diagnosis and following-up the patient. Imaging has been fundamental for diagnosis, with ultrasonography playing an important role in the categorization of cysts (9). CT scans are extremely helpful in the
planning of surgery because they provide more accurate information about cyst location and the depth; it also clearly shows the presence of daughter cysts (10). Hydatid cysts can be encountered in all tissues and organs, but occurrence in the chest wall, ribs, and sternum is extremely rare; intrathoracic extrapulmonary hydatid cysts occur in 7.4% of cases (4,5,11,12). Surgery remains the first choice for treatment in hydatid cyst disease in that surgery can remove the parasite radically. However, in osseous localization, treatment with albendazole for 6 months can help in sterilizing the cyst and reduce the recurrence rate (5,12). CONCLUSION Hydatid disease with osseous localization is uncommon and can be confused with tumor. Patient history and clinical examination are nonspecific and may provide only indications towards the diagnosis. Serology tests are hampered by their low sensitivity, and therefore clinical suspicion and alertness should be present, especially in patients from endemic regions. Surgery remains the first choice for treatment in hydatid cyst disease in that surgery can remove the parasite radically. In osseous localizations, pre- and postoperative courses of albendazole can help sterilize the cyst and reduce the recurrence rate. REFERENCES
Figure 2. A multilocular cyst with grapelike daughter cysts.
1. Amir-Jahed AK, Fardin R, Farzad A, Bakshandeh K. Clinical echinococcosis. Ann Surg 1975;182:541–6. 2. Dziri C. Hydatid disease—continuing serious public health problem: introduction. World J Surg 2001;25:1–3. 3. Langer JC, Rose DB, Keystone JS, Taylor BR, Langer B. Diagnosis and management of hydatid disease of the liver. A 15-year North American experience. Ann Surg 1984;199:412–7. 4. Oguzkaya F, Akcali Y, Kahraman C, Emirogullari N, Bilgin M, Sahin A. Unusually located hydatid cysts: intrathoracic but extrapulmonary. Ann Thorac Surg 1997;64:334–7. 5. Jlidi R, Yaakoubi MT, Ladeb MF, Ben Ayeche ML, Ghannouchi G, Moula T. Bone hydatidosis. 12 cases. Ann Pathol 1992;12:98–101.
Chest Swelling after Stabbing 6. Safioleas MC, Misiakos EP, Kouvaraki M, Stamatakos MK, Manti CP, Felekouras ES. Hydatid disease of the liver: a continuing surgical problem. Arch Surg 2006;141:1101–8. 7. Craig PS, Budke CM, Schantz PM, et al. Human echinococcosis: a neglected disease? Trop Med Health 2007;35: 283–92. 8. Rinaldi F, Brunetti E, Neumayr A, Maestri M, Goblirsch S, Tamarozzi F. Cystic echinococcosis of the liver: a primer for hepatologists. World J Hepatol 2014;6:293–305.
3 9. Gharbi HA, Hassine W, Brauner MW, Dupuch K. Ultrasound examination of the hydatic liver. Radiology 1981;139:459–63. 10. Sayek I, Onat D. Diagnosis and treatment of uncomplicated hydatid cyst of the liver. World J Surg 2001;25:21–7. 11. Ozpolat B, Ozeren M, Soyal T, Yucel E. Unusually located intrathoracic extrapulmonary mediastinal hydatid cyst manifesting as Pancoast syndrome. J Thorac Cardiovasc Surg 2005;129:688–9. 12. Alloubi I, Chadmi T, Ezerrouki A. Pseudotumoral hydatid cyst of chest wall. Gen Thorac Cardiovasc Surg 2012;60:593–4.
http://dx.doi.org/10.1016/j.jemermed.2015.06.023
Visual Diagnosis in Emergency Medicine
FACING THE UNEXPECTED: CHEST WALL SWELLING 7 YEARS AFTER A STAB INJURY Eleftherios Spartalis, MD, Demetrios Moris, MD, Antonios Athanasiou, MD, Dimitrios Dimitroulis, MD, and Periklis Tomos, MD Second Department of Propedeutic Surgery, University of Athens Medical School, ‘‘Laikon’’ General Hospital, Athens, Greece Corresponding Address: Demetrios Moris, MD, Second Department of Propedeutic Surgery, University of Athens Medical School, Anastasiou Gennadiou 56, 11474, Athens, Greece
site of a 7-year-old superficial stab wound that had been left to heal by secondary intention. The physical examination revealed a healed scar. The area of swelling was approximately 11 cm 8 cm, nontender, globular in shape, and firm in consistency. A computed tomography (CT) scan revealed a hypodense lesion located above the right pectoralis major muscle (Figure 1B). The liver, lungs, spleen, and brain were entirely normal at a detailed workup by CT scan. Total excision of a thick-walled, multilocular cyst with grapelike daughter cysts was performed (Figure 2). Histologic examination of the specimen and positive serology for Echinococcus granulosus was confirmatory for the diagnosis of subcutaneous echinococcosis. The patient’s postoperative course was uneventful. Albendazole was administered postoperatively for 6 months. No recurrence was observed during the follow-up period.
INTRODUCTION Hydatid cyst is a parasitic infection that is endemic mostly in countries along the Mediterranean Sea coast (1,2). Humans are partially involved in the natural cycle of the cyst via oral ingestion of the cystic form of the parasite (1,3). The cyst is ingested in the duodenum and can spread to any organ via the arterial, venous, or lymphatic systems (1,3). The most common localization is the liver (55-60% of cases), followed by the lungs (25-30% of cases); localization to other organs occurs in approximately 5% of cases (4,5). We present a unique case of thoracic wall/extrapulmonary hydatid cyst 7 years after a stab injury. CASE REPORT A 57-year-old man was admitted to our hospital with swelling on the right chest wall of 4 months’ duration (Figure 1A). The patient noticed swelling at the same
DISCUSSION Hydatid disease or echinococcosis is a zoonosis caused by tapeworms of the genus Echinococcus. The most commonly encountered cystic disease (CE) is caused by E granulosus and is highly endemic in Mediterranean countries (e.g., Spain, France, Greece, etc.), the Middle East (Israel), South America (i.e., Argentina
Reprints are not available from the authors. Key Clinical Message: A solitary subcutaneous hydatid cyst must always be considered in the differential diagnosis of a silent growing mass in soft tissue.
RECEIVED: 3 June 2015; ACCEPTED: 11 June 2015 1
2
E. Spartalis et al.
Figure 1. (A) Chest wall swelling. (B) A computed tomography scan revealed a hypodense lesion located above the right pectoralis major.
and Chile), and certain areas of Asia (i.e., China and India) (1,6). With the observed population shifts because of migration and ease of travel in the modern era, echinococcosis has the potential of becoming a worldwide disease, creating a need for increased information and alert among physicians. It is estimated that 1.2 million people are affected and 3.6 million disability-adjusted life years are lost globally (7). Patient history and clinical examination are nonspecific and may provide only indications toward the diagnosis. Serology tests are not the criterion standard because of their low sensitivity, their inconclusiveness to identify active and inactive cysts, and their prolonged ‘‘false’’ positivity even after a cyst is surgically removed. In clinical practice, 2 serologic tests with enzyme-linked immunosorbent assay and indirect hemagglutination are commonly used (8). Serology has mainly supportive role in confirming the diagnosis and following-up the patient. Imaging has been fundamental for diagnosis, with ultrasonography playing an important role in the categorization of cysts (9). CT scans are extremely helpful in the
planning of surgery because they provide more accurate information about cyst location and the depth; it also clearly shows the presence of daughter cysts (10). Hydatid cysts can be encountered in all tissues and organs, but occurrence in the chest wall, ribs, and sternum is extremely rare; intrathoracic extrapulmonary hydatid cysts occur in 7.4% of cases (4,5,11,12). Surgery remains the first choice for treatment in hydatid cyst disease in that surgery can remove the parasite radically. However, in osseous localization, treatment with albendazole for 6 months can help in sterilizing the cyst and reduce the recurrence rate (5,12). CONCLUSION Hydatid disease with osseous localization is uncommon and can be confused with tumor. Patient history and clinical examination are nonspecific and may provide only indications towards the diagnosis. Serology tests are hampered by their low sensitivity, and therefore clinical suspicion and alertness should be present, especially in patients from endemic regions. Surgery remains the first choice for treatment in hydatid cyst disease in that surgery can remove the parasite radically. In osseous localizations, pre- and postoperative courses of albendazole can help sterilize the cyst and reduce the recurrence rate. REFERENCES
Figure 2. A multilocular cyst with grapelike daughter cysts.
1. Amir-Jahed AK, Fardin R, Farzad A, Bakshandeh K. Clinical echinococcosis. Ann Surg 1975;182:541–6. 2. Dziri C. Hydatid disease—continuing serious public health problem: introduction. World J Surg 2001;25:1–3. 3. Langer JC, Rose DB, Keystone JS, Taylor BR, Langer B. Diagnosis and management of hydatid disease of the liver. A 15-year North American experience. Ann Surg 1984;199:412–7. 4. Oguzkaya F, Akcali Y, Kahraman C, Emirogullari N, Bilgin M, Sahin A. Unusually located hydatid cysts: intrathoracic but extrapulmonary. Ann Thorac Surg 1997;64:334–7. 5. Jlidi R, Yaakoubi MT, Ladeb MF, Ben Ayeche ML, Ghannouchi G, Moula T. Bone hydatidosis. 12 cases. Ann Pathol 1992;12:98–101.
Chest Swelling after Stabbing 6. Safioleas MC, Misiakos EP, Kouvaraki M, Stamatakos MK, Manti CP, Felekouras ES. Hydatid disease of the liver: a continuing surgical problem. Arch Surg 2006;141:1101–8. 7. Craig PS, Budke CM, Schantz PM, et al. Human echinococcosis: a neglected disease? Trop Med Health 2007;35: 283–92. 8. Rinaldi F, Brunetti E, Neumayr A, Maestri M, Goblirsch S, Tamarozzi F. Cystic echinococcosis of the liver: a primer for hepatologists. World J Hepatol 2014;6:293–305.
3 9. Gharbi HA, Hassine W, Brauner MW, Dupuch K. Ultrasound examination of the hydatic liver. Radiology 1981;139:459–63. 10. Sayek I, Onat D. Diagnosis and treatment of uncomplicated hydatid cyst of the liver. World J Surg 2001;25:21–7. 11. Ozpolat B, Ozeren M, Soyal T, Yucel E. Unusually located intrathoracic extrapulmonary mediastinal hydatid cyst manifesting as Pancoast syndrome. J Thorac Cardiovasc Surg 2005;129:688–9. 12. Alloubi I, Chadmi T, Ezerrouki A. Pseudotumoral hydatid cyst of chest wall. Gen Thorac Cardiovasc Surg 2012;60:593–4.