International Journal of Surgery Case Reports 95 (2022) 107138

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International Journal of Surgery Case Reports

journal homepage: www.elsevier.com/locate/ijscr

Case report

Pulmonary hydatid cyst mimicking lung tumor in a heavy smoker patient—

Uniportal VATS management
Rawand Abdulrahman Essa a, Sirwan Khalid Ahmed a, *, **, Mona Gamal Mohamed b
a
Department of Emergency, Rania Teaching Hospital, Rania, Sulaimani, Kurdistan-region, Iraq
b
Department of Adult nursing, RAK Medical and Health Sciences University, Ras Al Khaimah, United Arab Emirates

A R T I C L E I N F O A B S T R A C T

Keywords: Introduction and importance: Human infection with E. granulosus leads to the development of one or more hydatid
Alveolar echinococcosis cysts located most often in the liver and lungs. However, radiologically and clinically, analysis of atypical or
Hydatid disease complicated pulmonary hydatid cysts may resemble other types of malignancies.
Lung cancer
Case presentation: Here, we present a 65-year-old man presented with chest pain, loss of appetite, and weight loss
Uniportal VATS
for 6 months' duration. The patient was surgically treated for a pulmonary hydatid cyst that mimicked a lung
Pulmonary hydatidosis
tumor clinically and radiologically. The patient underwent surgery using a uniportal video-assisted thoracoscopic
surgery (UVATS) approach. The patient was put on an anti-helminthic drug (Albendazole table 400 mg twice
daily for 21 days and 14 days off). He will continue for 3 cycles on this schedule.
Discussion: The diagnosis of pulmonary hydatid cyst depends mainly on the imaging procedures supported by
appropriate serology and often histopathology. The treatment of choice for the pulmonary hydatid cyst is sur­
gical resection. The uniportal video-assisted thoracoscopic surgery (UVATS) method has been proven to be safe
and effective around globally. This includes a shorter surgery time, less pain, less chest tube drainage, and less
need for painkillers after the surgery.
Conclusion: In this report, we present a case of a radiologically and clinically pulmonary hydatid cyst mimicking a
lung tumor. In the differential diagnosis of a lung tumor, a pulmonary hydatid cyst should be considered
particularly in endemic regions.

1. Introduction (UVATS) approach. This study has been written in line with the SCARE
2020 criteria [12].
Hydatid disease is caused by Echinococcus granulosus (EG) and
Echinococcus multilocularis (EM) parasites. It is found all over the 2. Case report
world, but is most common in sheep and cattle-raising areas. While
humans can act as intermediate hosts by chance, hydatid cysts primarily A 65-year-old man presented with chest pain, loss of appetite, and
develop in the liver and lungs [1]. However, atypical or complicated weight loss for 6 months' duration. His body mass index (BMI) was 22.5
pulmonary hydatid cysts may resemble other types of malignancies kg/m2. He was a heavy smoker, with 40 cigarettes per day. The patient
radiologically and clinically [2–10]. There are reports claiming that had no chronic diseases or history of drug use. There were no significant
serologic tests that identify large cell lung cancer can give false-positive features in the patient's family history. Upon arrival, the patient's tem­
results, even though the serologic test for Echinococcus granulosus is perature was 38.3 ◦ C, blood pressure (BP) was 129/86 mmHg, respira­
positive [11]. The complicated echinococcal cysts and other lung tumors tory rate was 16/min, pulse rate was 95 bpm, and the patient's oxygen
look a lot alike, which makes it hard to diagnose and plan surgery [9]. saturation (SPO2) was 94% on room air. On December 20, 2021, a chest
Here, we present a case of a surgically treated pulmonary hydatid CT scan was performed and showed a tumor with a 3 cm lesion in the
cyst that mimicked a lung tumor both clinically and radiologically. The right lower lobe (RLL) (Figs. 1 & 2). Moreover, laboratory test results
patient underwent a uniportal video-assisted thoracoscopic surgery were within normal limits. In addition, the echinococcus serology test

* Corresponding author at: Department of Emergency, Rania Teaching Hospital, Rania 46012, Kurdistan region, Iraq.
** Corresponding author at: Department of Biotechnology, Institute of Science and Modern Technology, Rojava University, Qamishlo, Syria.
E-mail address: [email protected] (S.K. Ahmed).

https://doi.org/10.1016/j.ijscr.2022.107138
Received 20 March 2022; Received in revised form 25 April 2022; Accepted 29 April 2022
Available online 2 May 2022
2210-2612/© 2022 The Authors. Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
R.A. Essa et al. International Journal of Surgery Case Reports 95 (2022) 107138

Fig. 1. Axial view of the CT-scan shows a lesion in the right lower lobe.

Fig. 2. Coronal view shows a spider shape lesion in the right lower lobe.

was also negative. identifying the pericyst of the hydatid cyst, we placed several pads
On December 26, 2021, in the supine position, under general anes­ soaked with provide iodine around the cyst to prevent contamination at
thesia, a double lumen tube was inserted. Then the patient is positioned any risk of rupture. Then a 21-gauge needle is used to puncture the cyst
in the lateral decubitus, which is the standard position. Then the elbow wall and to aspirate the fluid contents carefully until the cyst collapses.
should be positioned at 90 degrees. A rolled sheet is placed below the The pericyst is opened about 2 cm and is caught with graspers. The cystic
axilla to increase the intercostal space. We use a thoracoscope with a 10 membrane is carefully removed, being careful not to contact the body.
mm diameter at 30o as a standard for adults. After the entrance of the We use gauze soaked in povidone iodine through the cavity. Ventilation
scope, we found a cystic-like lesion in the upper part of the right lower is done to check for air leaks from cyst-bronchial connections. The
lobe. In these conditions, the pleural space should be explored carefully bronchial openings are closed one by one using 3–0 Vicryl sutures, and
so as not to rupture the cyst or free pleural membranes. While capitonnage is done by plicating the cyst walls. The pleural cavity is

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R.A. Essa et al. International Journal of Surgery Case Reports 95 (2022) 107138

washed again with normal saline. The intercostal nerve block is done, Source of funding
and after good hemostasis, a chest tube is placed through the same
incision before closing the wound. This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
3. Follow up
Ethical approval
We have put the patient on anti-helminthic drugs (Albendazole table
400 mg twice daily for 21 days with 14 days off). He will continue for 3 Ethical approval has been given by the ethics committee of our
cycles on this schedule. Apart from the monthly repeat of the CXR, we faculty.
did both renal and liver function tests. His liver enzymes were moder­
ately elevated. We decided to decrease the dose; his enzymes decreased. Consent
The patient is being followed up on.
Written informed consent was obtained from the patients for publi­
4. Discussion cation of this case repot and accompanying images. A copy of the written
consent is available for review by the Editor-in-Chief of this journal on
Human infection with E. granulosus leads to the development of one request.
or more hydatid cysts located most often in the liver and lungs, and less
frequently in the bones, kidneys, spleen, muscles, and central nervous Registration of research studies
system. The asymptomatic incubation period of the disease can last
many years until hydatid cysts grow to an extent that triggers clinical Name of the registry: NA
signs. Approximately half of all patients that receive medical treatment Unique Identifying number or registration ID: NA.
for infections do so within a few years of their initial infection with the Hyperlink to your specific registration (must be publicly accessible
parasite [13]. and will be checked): NA.
Alveolar echinococcosis is characterized by an asymptomatic incu­
bation period of 5–15 years and the slow development of a primary Author agreement statement
tumor-like lesion that is usually located in the liver. Clinical signs
include weight loss, abdominal pain, general malaise, and signs of he­ We declare that this manuscript is original, has not been published
patic failure [14]. before and is not currently being considered for publication elsewhere.
Larval metastases may spread either to organs adjacent to the liver We confirm that the manuscript has been read and approved by all
(for example, the spleen) or distant locations (such as the lungs, or the named authors and that there are no other persons who satisfied the
brain) following dissemination of the parasite via the blood and criteria for authorship but are not listed. We confirm that the order of
lymphatic system. If left untreated, alveolar echinococcosis is progres­ authors listed in the manuscript has been approved by all of us. We
sive and fatal [15]. understand that the Corresponding Author is the sole contact for the
The larvae most often involve the liver (55–70%) followed by the Editorial process. He is responsible for communicating with the other
lungs (18–35%); the two organs can be affected simultaneously in about authors about progress, submissions of revisions and final approval of
5–13% of cases. However, any organ may be involved. Echinococcal proofs.
infestation of the pleura or chest wall has been reported to occur in
0.9–7.4% of patients with hydatid disease [16]. Guarantor
Diagnosis depends mainly on the imaging procedures supported by
appropriate serology and often histopathology. Therefore, CT is most Sirwan Khalid Ahmed ([email protected])
likely the best technique for elucidating the nature and location of the
cyst, as well as their precise relationships with surrounding organs, and Data availability statement
thus evaluating the cyst preoperatively. Cyst density may help distin­
guish parasitic from non-parasitic cysts [17]. All relevant data are within the manuscript.
The treatment of choice for the pulmonary hydatid cyst is surgical
resection. Although the percutaneous aspiration, injection of cysticidal Provenance and peer review
agent, and re-aspiration using radiographic guidance (PAIR) methods
are routinely used in cases of hydatid liver disease, the WHO currently Not commissioned, externally peer-reviewed.
recommends that PAIR should not be used in cases of pulmonary cysts.
In addition, the video-assisted thoracoscopic surgery (VATS) method has CRediT authorship contribution statement
been proven to be safe and effective around the world. This includes a
shorter surgery time, less pain, less chest tube drainage, and less need for Conception and design RAE and SKA acquisition of data RAE, SKA
painkillers after the surgery [18]. Surgery should be coupled with and MGM analysis and interpretation of data RAE, SKA and MGM,
albendazole (10–15 mg/kg/day) administration in two doses, from 4 drafting of the manuscript RAE, SKA and MGM. All authors critical
days before to at least 1 month after surgery. It has been found that anti- revision of the manuscript for important intellectual content and
helminthic therapy before surgery reduce the risk of recurrence by 3.5 approving final draft.
times [19].
Declaration of competing interest
5. Conclusion
There is no conflict to be declared.
In this report, we present a case of a radiologically and clinically
pulmonary hydatid cyst mimicking a lung tumor. The patient underwent Acknowledgments
minimally invasive surgery using a uniportal video-assisted thoraco­
scopic surgery (UVATS) approach. In the differential diagnosis of a lung 1. Special thanks for the pioneer of Uniportal VATS (Dr. Diego
tumor, a pulmonary hydatid cyst should be considered particularly in Gonzalez-Rivas) for teaching us this procedure and helping us in all the
endemic regions. consultations from far away.

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R.A. Essa et al. International Journal of Surgery Case Reports 95 (2022) 107138

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