A 30-year-old female farmer and nonsmoker with chief complaints of hemoptysis from time to time for 3 years with increased amount and frequency for the last 30 days was admitted to Manmohan Cardiothoracic Vascular and Transplant Center, Kathmandu, Nepal. At the time of admission, she complained of cough with associated hemoptysis and chest pain.
She was in her usual state of health 3 years back when she developed coughing up blood with a frequency of 1-2 episodes a month. With these symptoms, 7 months later, she visited a nearby medical center where she was diagnosed and treated for pneumonia. The symptoms persisted with occasional episodes of coughing up blood for which no medical intervention was sought. Around a year back from now, she noticed the presence of whitish pieces mixed with blood for 2 episodes while coughing up, which was associated with a sour/bitter taste in her mouth. With the persistence of her symptoms of coughing up blood, a few months later she visited a tuberculosis center near her village where a CT scan demonstrated lesion on her lungs, and she was diagnosed of having a hydatid cyst in her lungs. From there, she was referred to our center for further management.
She denied a history of fever, shortness of breath, night sweats, significant weight loss, contact with TB, history of travel, family history of malignancy, the use of immunosuppressive drugs, and similar illnesses in family members. There was no history of pre-existing pulmonary diseases, extrapulmonary symptoms, and known previous medical problems in the patient. Tracing her history, her home was near a jungle, and including hers, nearly all homes had domesticated dogs. She gave a history of prolonged exposure to domesticated dogs. She was a nonsmoker, nonalcoholic, and consumed a mixed diet.
In our center, her vital signs showed normality with a blood pressure of 118/70 mm Hg, a pulse rate of 80 beats/minute, a respiratory rate of 18 breaths/minute, an oxygen saturation of 97% in room air, and an axial body temperature of 98 degrees Fahrenheit. Routine laboratory examination showed no abnormality with hemoglobin of 12 g/dl and there was no eosinophilia on peripheral blood examination. Total and differential leukocyte counts were within normal limits. Serum electrolytes, liver function tests, renal function tests, and other systemic examinations were unremarkable. Sputum smears were negative for acid-fast bacilli. She was nonreactive for Hepatitis B and HIV antigens. Physical findings were confined to the chest with decreased breath sound on the right hemithorax. The laboratory parameters of our patient at the time of admission are tabulated in Table 1.
Her chest CT upon presentation showed well-defined nonenhancing cystic lesion in the anterior basal segment of the right lower lobe adjacent to a major fissure. Multiple air foci were seen within it. There was a segmental bronchus seen within the cyst with the possibility of communication with the cyst. It was causing segmental collapse with the upward pull of the right hemidiaphragm. No obvious pleural or chest wall communication was seen (Figures 1 (d) and (e)). There was no associated liver lesion on abdominal ultrasonography.
The surgery was performed via the right posterolateral thoracotomy from the 5th intercostal space. Intraoperatively, the cyst was approximately of size 7.5 * 5.5 cm in the superior segment of the right lower lobe. Four bronchial communications were identified. A cystectomy was done, and at least 4 cystobronchiole communications were noted which were individually closed with nonabsorbable sutures, and then capitonnage was also performed. The excised cyst was sent for histopathological examination. What was exceptional was the presence of a laminated membrane of the ectocyst along with fungal elements (Aspergillus) in the form of septate hyphae with acute angle branching in hematoxylin and eosin stain (H&E) (Figures 1 (a) and (b)). To further confirm this finding, Periodic acid-Schiff (PAS) staining was done which also showed acute angle branching with thin septa (Figure 1 (c)). This led us to the final diagnosis of coinfection by Echinococcus and Aspergillus. She has been on oral albendazole since the first postoperative day at a dose of 10-15 mg/kg/day in divided doses. Her stay after surgery was uneventful and she was discharged on 3 postoperative days. She had been on routine follow-up.