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Sharply Demarcated Thoracic Mass in an Asymptomatic Boy
I ROENTGENOGRAM OF THE MONTH Sharply Demarcated Thoracic Mass in an Asymptomatic Boy Yizhar Floman, M.D., Uri Freund, M.D., and Henry Romanoff. M.D., F.C.C.P. 0
This 16-year-old boy, born in Jerusalem, was referred for a routine chest film after it was Department of Thoracic and Vascular Surgery, Hadassah University Hospital, Jerusalem, Israel. Reprint requests: Dr. Floman, HadmJsah Medical Organization, PO Box 499, Jerusalem, Israel 0
FIGURE
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CHEST, VOL. 64, NO. 2, AUGUST, 1973
found that his seven-year-old brother had bilateral pulmonary disease. He was asymptomatic, and physical examination was negative. Routine laboratory examinations were normal. Liver scan with 198 Au was normal.
FIGURE
2
241
242 ·Diagnosis: Primary Pleural Hydatid Cyst The anteroposterior chest film showed a large mass in the right hemithorax. It was well delineated laterally while its medial border merged with the mediastinal shadow (Fig 1 ) . On lateral view, the mass was seen in the posterior chest (Fig 2). Its edges did not taper. A hydatid cyst located in the posterior mediastinum rather than in the lung was suspected. The Weinberg agglutination test was negative. The Casoni intradermal test was positive. At operation, the right pleural cavity was entered. No adhesions were found between the lung and the chest wall. The cyst was immediately apparent, lying between the right upper and lower lobes posteriorly. It measured 5 x 8 x 12 em. Aspiration revealed 200 ml of crystal clear fluid. The pericyst was then widely opened and the germinative layer extracted intact. Unroofing of the cyst was performed. Small patches of pericyst membrane were left over both lobes. The pleural cavity was drained, and the chest closed in the usual fashion. It was obvious that the cyst had originated from the parietal pleura, about 1 em below the azygos vein, and had developed in the upper half of the major fissure. There was no bronchial communication with the cyst cavity. The patient was discharged on the tenth postoperative day. The brother had proved pulmonary echinococcosis. Primary pleural echinococcosis is rare; its incidence in the disease is estimated as 1 percent. 1 Apezteguia 1 observed ll cases in a 15-year period,
FLOMAN, FREUND, ROMANOFF
among 1049 patients with thoracic hydatidosis. He suggested that the embryo is carried in the blood~ stream via the intercostal arteries which explains the posterior location of the cyst. Among the ll patients, six had a univesicular cyst. Another pleural Echinococcus cyst has been recently reported. 2 The calcified cyst was found at thoracotomy in the seventh intercostal space. Rakower and Milwidsky, 3 from this hospital, reported 19 cases of pleural echinococcosis, among which one was thought to be of primary origin. Scremini and Rosa 4 reported a case of tension pneumothorax in a three-year-old, which had resulted from perforation of an intact cyst into the lung. The cyst was found between the lower lobe and the diaphragm. One of us ( HR) recently published a case of subpleural cyst in the right thorax which perforated into the posterior basal segment of the lower lobe, producing a wide bronchopleural fistula. 5 REFERENCES
1 Apezteguia JLM: Hidatidosis interpleuroparietal. Torax 19:192-201, H170 2 Freigero L: Archivo radiologico: Quiste hidatico interpleuroparietal. Torax 19:216, 1970 3 Rakower J, Milwidsky H: Hydatic pleural disease. Am Rev Resp Dis 90:623-631, 1964 4 Scremini AP, Rosa F: Equinococosis pleural heterotopica. Torax 19:211-212, 1970 5 Jesiotr M, Romanoff H: Pneumothorax following rupture of a primary pleural hydatic cyst: a case report. J. Tho rae Cardiovasc Surg 63:594-598, 1972
CHEST, VOL. 64, NO. 2, AUGUST, 1973
This 16-year-old boy, born in Jerusalem, was referred for a routine chest film after it was Department of Thoracic and Vascular Surgery, Hadassah University Hospital, Jerusalem, Israel. Reprint requests: Dr. Floman, HadmJsah Medical Organization, PO Box 499, Jerusalem, Israel 0
FIGURE
1
CHEST, VOL. 64, NO. 2, AUGUST, 1973
found that his seven-year-old brother had bilateral pulmonary disease. He was asymptomatic, and physical examination was negative. Routine laboratory examinations were normal. Liver scan with 198 Au was normal.
FIGURE
2
241
242 ·Diagnosis: Primary Pleural Hydatid Cyst The anteroposterior chest film showed a large mass in the right hemithorax. It was well delineated laterally while its medial border merged with the mediastinal shadow (Fig 1 ) . On lateral view, the mass was seen in the posterior chest (Fig 2). Its edges did not taper. A hydatid cyst located in the posterior mediastinum rather than in the lung was suspected. The Weinberg agglutination test was negative. The Casoni intradermal test was positive. At operation, the right pleural cavity was entered. No adhesions were found between the lung and the chest wall. The cyst was immediately apparent, lying between the right upper and lower lobes posteriorly. It measured 5 x 8 x 12 em. Aspiration revealed 200 ml of crystal clear fluid. The pericyst was then widely opened and the germinative layer extracted intact. Unroofing of the cyst was performed. Small patches of pericyst membrane were left over both lobes. The pleural cavity was drained, and the chest closed in the usual fashion. It was obvious that the cyst had originated from the parietal pleura, about 1 em below the azygos vein, and had developed in the upper half of the major fissure. There was no bronchial communication with the cyst cavity. The patient was discharged on the tenth postoperative day. The brother had proved pulmonary echinococcosis. Primary pleural echinococcosis is rare; its incidence in the disease is estimated as 1 percent. 1 Apezteguia 1 observed ll cases in a 15-year period,
FLOMAN, FREUND, ROMANOFF
among 1049 patients with thoracic hydatidosis. He suggested that the embryo is carried in the blood~ stream via the intercostal arteries which explains the posterior location of the cyst. Among the ll patients, six had a univesicular cyst. Another pleural Echinococcus cyst has been recently reported. 2 The calcified cyst was found at thoracotomy in the seventh intercostal space. Rakower and Milwidsky, 3 from this hospital, reported 19 cases of pleural echinococcosis, among which one was thought to be of primary origin. Scremini and Rosa 4 reported a case of tension pneumothorax in a three-year-old, which had resulted from perforation of an intact cyst into the lung. The cyst was found between the lower lobe and the diaphragm. One of us ( HR) recently published a case of subpleural cyst in the right thorax which perforated into the posterior basal segment of the lower lobe, producing a wide bronchopleural fistula. 5 REFERENCES
1 Apezteguia JLM: Hidatidosis interpleuroparietal. Torax 19:192-201, H170 2 Freigero L: Archivo radiologico: Quiste hidatico interpleuroparietal. Torax 19:216, 1970 3 Rakower J, Milwidsky H: Hydatic pleural disease. Am Rev Resp Dis 90:623-631, 1964 4 Scremini AP, Rosa F: Equinococosis pleural heterotopica. Torax 19:211-212, 1970 5 Jesiotr M, Romanoff H: Pneumothorax following rupture of a primary pleural hydatic cyst: a case report. J. Tho rae Cardiovasc Surg 63:594-598, 1972
CHEST, VOL. 64, NO. 2, AUGUST, 1973