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Eur J Cardiothorac Surg 2002;21:1127-1128
© 2002 Elsevier Science NL

Letter to the Editor

A novel dissemination pathway of hydatid cyst

Turgut Isitmangil*, Alper Toker, Rauf Gorur, Saban Sebit

Department of Thoracic Surgery, Camlica Chest Diseases Hospital, Gülhane Military Medical Academy, Istanbul, Turkey

Received 13 November 2001; received in revised form 5 February 2002; accepted 18 February 2002.

* Corresponding author. GATA Lojmanlari C Blok D: 2, Haydarpasa, Kadikoy, 81327 Istanbul, Turkey. Tel.: +90-216-3496075; GSM: +90-532-6527765; fax: +90-216-3257257
e-mail: sitmangil{at}superonline.com
e-mail: tisitmangil{at}hotmail.com

Key Words: Extrapleural hydatid cyst • Hydatid cyst • Dissemination theory

We believe that a novel dissemination pathway can lead to new perspectives for the pathophysiology of hydatid cysts. So, we report this case in order to elucidate the dissemination pathway of a chest wall hydatid cyst, which is generally known to consist of 0.9–2% of all hydatid cysts [1].

Recently, a 20-year-old soldier with chest pain on the right side was admitted to our department. Chest X-ray showed multiple round shadows in his right hemithorax. Computerized tomographic evaluation of the chest confirmed a giant liver cyst with multiple pleural cystic lesions. He was intubated with double lumen endobronchial tube and standard posterolateral thoracotomy was performed. We did not observe any pleural adhesion, intrapleural cyst and pulmonary parenchymal cyst during the surgical operation. The multiple cysts were located just underneath the parietal pleura like a chain in the line of internal mammarian vessels and in a line ascending towards the apex throughout the paravertebral area. Diaphragm had two lobular enlargements with a large mass under them. We removed the small one of the two cysts on the diaphragm by enucleation. We performed cystotomy to the large cyst on the diaphragm and then reached to the large liver cyst. The large cyst in the liver was approximately 8-cm diameter showing dumbbell image. We cut the diaphragm and removed more than 340 daughter vesicles from the liver cyst. We performed capittonage to this large liver cavity and closed the diaphragm in a standard manner. We removed totally 12 extrapleural intrathoracic cysts between the parietal pleura and endothoracic fascia by enucleation without any rupture. We placed single pleural catheter and closed the thoracotomy incision. We removed chest tube on the second postoperative day. Ultrasonographic evaluation of the liver revealed no pathology on postoperative day 5. His postoperative chest X-ray was uneventful. He was discharged on postoperative day 8.

There is only one lymphatic pathway that was reported for hydatid cyst where embryos enter the lymphatic of the small intestine, proceed to the thoracic duct, to the internal jugular vein, to the right side of the heart, and to the lungs [2]. However, in this case there is a different pathway, which we believe is that the liver dome cyst as the largest one has been opened into the diaphragm and has caused two diaphragmatic cysts. The scoleces had probably been transported by diaphragmatic lymphatics. Drainage of lymphatics from the dome of liver and diaphragm was known to ascend anteriorly over the parasternal lymph nodes and posteriorly over the intercostal lymph nodes [3].

In our view, hydatid cyst dissemination via diaphragmatic, parasternal and intercostal lympatics is the first report till date. In this regard we suggest a universal name for the cysts located just underneath the parietal pleura as ‘extrapleural intrathoracic cysts’ depending upon the unusual pathway of the hydatid cysts.

Footnotes

This study was presented at the 5th Congress of Balkan Military Medical Committee, Ankara, Turkey, September 25–28, 2000.

References

  1. Jlidi R., Yaakoubi M.T., Ladeb M.F., Ben Ayeche M.L., Ghannouchi G., Moula T. Bone hydatosis. Ann Pathol 1992;12:98-101.[Medline]
  2. Aletras H., Symbas P.N. Hydatid disease of the lung. In: Shields T.W., LoCicero J., Ponn R.B., eds. General thoracic surgery, 5th ed Philadelphia, PA: Lippincott Williams and Wilkins, 2000:1113-1122.
  3. Kiss F., Szentágothai J. The lymphatic system. . Atlas of Human Anatomy. Oxford: Pergamon Press, 1964.




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