AD is a 26 year old female, born and raised in urban Huancayo, capital of the Junin region of the Peruvian Highlands, having a history of intimate contact with dogs that had exposure to meat products from the local market and were witnessed to be consuming animal entrails.
AD began experiencing recurring episodes of spontaneously remitting thoracic spine pain which was 8 or 9 out of 10 in severity, lasting intermittently for 1.5 hours. Routine X-ray demonstrated an RML lesion and a follow-up CAT showed a 4.5 cm x 3.7 cm lobulated mass of low attenuation, pleural-based at the right lateral lung field; referral to outpatient clinic for CAT-guided percutaneous aspiration needle biopsy of the RML lesion previously seen on Chest X-ray (CXR) (see Fig. 1). 20 mL of clear fluid was aspirated and sent for study. Post-procedure, a minimal pleural effusion was noted in the right lung field and there was no evidence of pneumothorax.
AD presented to the ER 5 hours after CT-guided needle aspiration biopsy was performed. AD complained of a 30 minute history of drowsiness, weakness, near syncope, and pleuritic pain at the biopsy site. AD took 2 tablets of Advil, without relief. She experienced an occipito-frontal headache with dizziness and subsequently fell. AD denied having any constitutional symptoms as well as any past history of pneumonia or lung infection and had no chest imaging done prior to her current illness. AD acknowledged an unintentional weight loss of 5 pounds over the past 3 months along with a decreased appetite. AD's PPD and HIV status was negative as of February 2007. On physical exam, temperature was 98.8, pulse was 76, respiration was 18, orthostatic blood pressure was 90/51 increased to 106/51, and pulse ox on room air was 97%. AD was alert, awake and in mildly painful distress. Her skin was warm and dry. On chest exam, breath sounds were decreased over the right base, with dullness to percussion, egophony at the right base and no evidence of wheezes, rales, or rhonchi. Tenderness to palpation was present over biopsy site with no evidence of hematoma. Cardiovascular exam revealed no evidence of irregularity, tachycardia, or gallop. A grade III/VI systolic ejection murmur was present, best heard at the pulmonic area. AD's labs revealed leukocytosis of 11.5. Post-biopsy chest x-ray revealed an ill-defined RML opacity with a small amount of fluid in the minor fissure. Repeat chest CT post-biopsy revealed a 3.5 cm x 3.2 cm septated, air-filled juxta-pleural RML lesion previously filled with fluid. Fluid density suggested the substance was unlikely to be blood. A new small, right non-loculated pleural effusion was noted compared to the previous CT, with no evidence of pneumothorax.
Given the patient's epidemiological characteristics, the clinical setting was felt to be consistent with echinococcal granulosis with a solitary pulmonary lesion, which secondary to needle drainage had now ruptured into the pleural space with resultant signs and symptoms of pleuritis and effusion. Pulmonary and Infectious Disease specialists were consulted; cardiothoracic evaluation was also sought for definitive removal of the tissue in question and long-term albendazole treatment was started as a supportive measure to prevent secondary lesions. Liver function tests, which were obtained to detect liver involvement, were within normal limits and she was ruled out for Tuberculosis with negative PPD and pleural fluid stains. During the course of her hospitalization, she remained afebrile with no aberrations of vital signs to suggest an anaphylactic reaction. She continued to experience pain at the biopsy site that was non-radiating, pleuritic in nature and improved over time with no associated dyspnea. She continued to complain of weakness but denied further episodes of syncope or lightheadedness. Three days after admission, she underwent a right mini-thoracotomy and resection of the RML cyst. 2 chest tubes were also placed for drainage of the pleural effusion. During the procedure she developed cardiovascular collapse most likely from anaphylaxis caused by the cystic fluid. She was treated with IV fluids and methylprednisolone; hypotension subsequently reversed. CXR performed after the procedure revealed a mild right lung atelectasis and effusion and small apical pneumothorax, which were followed to resolution (see Fig. 2, Fig. 5). Both chest tubes were removed by postoperative day (POD) #5. Aside from weakness and slight pain around the chest tube sites, she denied any chest pain, palpitation, dyspnea, fever, nausea or vomiting. With improved pain and respiration and response to appropriate medical treatment, she was discharged on POD #8. She was placed on Albendazole 400 mg twice daily, instructed to continue with incentive spirometry and ambulation. She was instructed to follow-up in the Medicine, Pulmonary and Infectious Disease outpatient clinics (see Fig. 3, Fig. 4, Fig. 6).
Repeat serologic markers became positive for Echinococcus as she continued on Albendazole for an additional 3 months. Follow up CAT scan of chest (see Fig. 5) and Abdominal Ultrasound showed resolution of pleural effusion and no new masses.