Introduction:Cardiac Hydatidosis is a rare and ominous complication of hydatid disease. Cardiac echinococcosis may be asymptomatic for several years but could be discovered after the development of lethal complications.
Case Presentation:A 31-year-old-male referred with possible diagnosis of acute pericarditis. Abdominal and pelvic spiral CT scan showed focal and heterogeneous increased thickness of lateral left ventricular (LV) wall with protrusion into LV and bulging into pericardial space without central enhancement. His condition deteriorated suddenly due to cardiac tamponade with round cystic lesions suspected to hydatid cyst. Cardiac magnetic resonance imaging showed some round particles within effusion suggestive of possible scolex around the LV. There was round, and inhomogeneous cystic mass originated from sub-epicardial layer of mid-lateral LV that protruded into pericardial space. Diagnosis of hydatic cyst was confirmed by surgical specimen.
Conclusions:We suggest that patients with pericarditis should be probed with echocardiography for the presence of hydatid cysts.
Cardiac Hydatidosis is a rare and ominous complication of hydatid disease (1). Cardiac echinococcosis may be asymptomatic for several years but could be discovered after the development of lethal complications (2). With this, we report a rare case of ruptured hydatid cyst resulted in the pericardial effusion and cardiac tamponade.
2. Case Presentation
A 31 years-old-male referred with a chief complaint of pleuritic chest pain with a possible diagnosis of acute pericarditis. electrocardiography (ECG) showed new T inversion in V5-V6 that was absent in the available ECG from last year. The initial trans-thoracic echocardiography (TTE) showed no pericardial effusion. The chest pain was diminished using non- steroid anti-inflammatory drugs. After four days of hospitalization, he suffered from repetitive chest pain episodes that were resistant to nitrate and analgesic treatment. One fever episode about 40OC was also noticed. ECG at this time showed low voltage in all leads (Figure 1).
Laboratory data showed leukocytosis, normal erythrocyte sedimentation rate (ESR) level, elevated pro-calcitonin level and liver enzymes. Abdominal and pelvic spiral CT scan showed no hepatic mass, but showed focal and heterogeneous increased thickness of lateral LV wall with protrusion into LV and bulging into pericardial space without central enhancement after contrast injection. His condition deteriorated suddenly, and TTE showed moderate size pericardial effusion resulted in cardiac tamponade with a round cystic lesion suspected to hydatid cyst (Figure 2).
Cardiac MRI showed extensive and severe circumferential pericardial effusion with CMR evidence of cardiac tamponade. Some round and small particles within effusion suggestive of possible scolex around LV were also detected. There was round, and inhomogeneous cystic mass lesion (length: 31 mm, width: 17 mm) originated from a sub-epicardial layer of mid-lateral LV that protruded into the pericardial space. Along with a small suspicious defect in its outer rim (6mm) that could suggest rupture point into the pericardial space (Figure 3). He received antibiotic treatment and underwent a prompt surgical operation. Surgical exploration confirmed the presence of daughter cysts (Figure 4).
Median sternotomy and partial pericardiectomy were performed. In lateral wall of LV, there was a cystic mass (3*3cm) that was filled by injected hypertonic saline. Then, the cyst wall was opened and scolexes were removed. After irrigation of cyst space, the internal spacen of pericardium was irrigated using hypertonic saline and finally it was repaired following deaine insertion.
Prior history of infection with echinococcosis can help physicians in rapid diagnosis of its complications in symptomatic cases, but unfortunately, patients are unaware of their infection in some instances. Thus, being familiar with the broad spectrum manifestation of this disease is essential for better patient management. Cardiac hydatidosis is a rare complication of this disease, and cardiac events depend on the location, number and size of hydatid cysts and their induced complications (3). Pericarditis, pericardial effusion and tamponade could occur in this setting due to the presence of pericardial effusion due to cyst rupture into the pericardial cavity (4). Hydatid cysts reach the heart through coronary arteries. Their most common implantation sites are interventricular septum and left ventricular free wall with less involvement of pericardial space and paracardiac sites (5-7). Fazlinezhad et al. reported the apicolateral and apical left ventricular segments as the implantation site of the cyst (8). This site was in the mid-lateral wall in our case.
In conclusion, we suggest that patients with pericarditis should be probed with echocardiography for the presence of hydatid cysts to prevent further development of tamponade and clinical deterioration.
Hosseinian A, Mohammadzadeh A, Shahmohammadi G, Hasanpour M, Maleki N, Doustkami H, et al. Rupture of a giant cardiac hydatid cyst in the left ventricular free wall: successful surgical management of a rare entity. Am J Cardiovasc Dis. 2013;3(2):103-6. [PubMed: 23785588]. [PubMed Central: PMC3683408].
Oraha AY, Faqe DA, Kadoura M, Kakamad FH, Yaldo FF, Aziz SQ. Cardiac Hydatid cysts; presentation and management. A case series. Ann Med Surg (Lond). 2018;30:18-21. doi: 10.1016/j.amsu.2018.04.001. [PubMed: 29946454]. [PubMed Central: PMC6016321].
Kosecik M, Karaoglanoglu M, Yamak B. Pericardial hydatid cyst presenting with cardiac tamponade. Can J Cardiol. 2006;22(2):145-7. doi: 10.1016/s0828-282x(06)70254-9. [PubMed: 16485050]. [PubMed Central: PMC2538998].
Tuncer E, Tas SG, Mataraci I, Tuncer A, Donmez AA, Aksut M, et al. Surgical treatment of cardiac hydatid disease in 13 patients. Tex Heart Inst J. 2010;37(2):189-93. [PubMed: 20401292]. [PubMed Central: PMC2851433].
Tejada JG, Saavedra J, Molina L, Forteza A, Gomez C. Hydatid disease of the interventricular septum causing pericardial effusion. Ann Thorac Surg. 2001;71(6):2034-5. discussion 2035-6. doi: 10.1016/s0003-4975(00)02269-4. [PubMed: 11426797].
Fazlinezhad A, Moohebati M, Azari A, Bigdeloo L. Acute pericardial tamponade due to ruptured multiloculated myocardial hydatid cyst. Eur J Echocardiogr. 2009;10(3):459-61. doi: 10.1093/ejechocard/jen249. [PubMed: 18818301].