A 24-year-old man presented with left-sided tightening chest pain for three days and a few hours of productive coughing with blood-clotted sputum. The patient reported unintentional weight loss during the last month, intermittent night sweats but no fever or lethargy. His medical history was unremarkable, and he took no medicine. He had previously smoked for six months. The patient, a refugee from a rural Syria, had lived in Denmark for one year. He was exposed to sheep and dogs during his childhood. General physical examination revealed fever, a temperature of 39 C, a heart rate of 76 beats per minute, a respiratory rate of 22 breaths per minute, and a blood pressure of 130/70 mm Hg. Apart from this, the clinical examination was unremarkable. Blood samples revealed an elevated CRP of 197 mg/l, leukocytosis (15.4 x 109/L) with a strong component of granulocytosis, but no eosinophilia.
Chest X-ray revealed consolidation of the upper two thirds of the left lung (Fig. 1). Because of the medical history and possible exposure to tuberculosis, the patient was suspected to have pulmonary tuberculosis. Interferon-gamma release assay (IGRA) was taken and sputum was sent for microscopy; both were negative.
A computed tomography scan (CT scan) of the thorax showed a cavitary lesion with septae and air-fluid-level with filaments measuring approximately 8 x 11 x 13 cm, involving the left superior lobe. Folded membrane-like structures within the cavity suggested a hydatid cyst. The air filling indicated that the cyst communicated with the airways. The rest of the lung fields and mediastinum appeared without pathology. (Fig. 2). A CT scan of the abdomen revealed no abnormality. The patient was prescribed antihelminthic treatment with albendazole 400 mg, two times daily.
Blood samples tested with enzyme-linked immunosorbent assay (ELISA) for E. multilocularis and with indirect hemagglutination (IHA) for E. granulosus antibodies came out negative. Microscopy of sputum showed massive growth of Streptococcus pneumoniae, and it was concluded that the patient had a lung abscess. The patient was prescribed broad-spectrum antibiotics and albendazole was discontinued.
Few days later the patient developed acute chest pain; chest X-ray (Fig. 3) showed atelectasis of the lower part of the left lung with an air compartment above the abscess and a small mediastinal shift away from the pleural effusion. CT-scan showed a ruptured lung abscess or cyst and hydropneumothorax of the left lung. The patient was treated with therapeutic thoracentesis, approximately 600 mL yellow liquid was removed and sent for microscopy. Due to respiratory distress the patient was transferred to our intensive care unit (ICU). After 24 hours of care in the ICU, the now stable patient was transferred to the pulmonary ward.
A multidisciplinary team conference was held to discuss differential diagnoses, further investigations and management. The team concluded that further investigation with bronchoscopy was necessary. Microscopy and polymerase chain reaction (PCR) tests for E. granulosus bronchio-alveolar lavage (BAL) fluid were negative. However, tests for Aspergillus galactomannan antigen were positive. On suspicion of invasive aspergillosis the patient was prescribed antimycotic treatment with IV voriconazol 200 mg twice daily.
After presentation of the case to the department of thoracic surgery, lateral thoracotomy at IC5 was performed and the cyst was removed by lobectomy of the superior lobe of the left lung. Microscopic examination and polymerase chain reaction (PCR) for DNA showed the presence of E. granulosus. Thus, the diagnosis was changed accordingly, and the patient was prescribed albendazole 400 mg, twice daily for 6 months.
The patient came to regular follow-up in the outpatient clinic for infectious diseases for 12 months. The patient was asymptomatic during this period and no recurrence was observed.