Cystic lung lesion Dr. Moshe Rotschild Dr. Moshe Rotschild Pediatric Pulmonology Unit Meyer Children’s Hospital
Case presentation Case presentation • 15 y old, F, Arab Muslim • No significant past history, mild dev. delay • May 2011,hospitalized due to cough, fever, chest pain and chest X‐ray and chest X ray findings findings • PE:Temp‐ 37.7C, RR‐ 27, Sat ‐98%, Rt. Lung sound • Lab: CRP ‐16,WBC‐ L b CRP 16 WBC 10000 ;68% neutrophils 10000 68% t hil • Chest X‐ray (from out‐ patient clinic)
M 2011 May 2011
Case presentation cont’ p • • • •
Working diagnosis :Pleuropneumonia Tx: IV ampicillin Clinical and radiological improvement g p Ambulatory Repeat CXR 06/ 2011:improvement
01/2012 : intermittent cough i t itt t h PE‐N CXR No change (over 6 mon CXR‐ N h ( 6 i filt t ) infiltrate) CT – D/d
Healthy 15 Yr old & CT findings Healthy 15 Yr old & CT findings • • • • • • •
CCAM? Foreign body aspiration? Foreign body aspiration? Pneumatocele? Bronchogenic cyst? Sequestration? Sequestration? Bronchial atresia? Other?
Bronchoscopy Bronchoscopy • FOB: normal anatomy, y, no foreign body, g y, no secretions , BAL culture negative 6 days later cough fever chills cough,fever, chills • 6 days later …… • Admitted :Temp ‐40C, RR‐50 , Sat‐97,breath sounds RLL toxic appearance RLL, toxic appearance • LAB: WBC16,700; 78 neutophils, CRP‐291 • What happens ??? bactermia ? Secondary infection? p g . • IV antibiotics‐ Amp; Augmentin
6 days after FOB
What happens ??? What happens ??? • IV antibiotics‐ Amp; Augmentin . Ciproxin + clindamycin • Toxic , still febrile ,no improvement • FOB? CT?
Pulmonary abscess ?Other ? Pulmonary abscess ?Other ? • • • • •
Serology for echinococal cyst‐ strongly positive Conservative therapy? Conservative therapy? Mebendazole ? Surgery ? (drain? open thoracotomy? VATS?) Starts Mebendazole :fortunately Starts Mebendazole :fortunately – the patient the patient coughed vigorously multiple,membranous gelatinous debris & dramatically improvement l ti d b i &d ti ll i t
Aviv 2007 Aviv 2007
Scheduled for operation Follow up CXR+ CT Scheduled for operation Follow‐up CXR+ CT
Wh t’ What’s now ? ?
E. granulosus‐Hydatid disease • Definitive hosts are dogs or other canines • Intermediate hosts Intermediate hosts – sheep, goats, camels, sheep, goats, camels, horses, humans • Australia, New Zealand, Argentina, Chile, A li N Z l d A i Chil Ireland, Scotland, middle Europe, Kenya, middle east
Echinococcus granulosus (hydatid) Geographic Distribution
Lif C l Life Cycle •
(1) Adult tapeworms in bowels of definitive host
•
(2) Eggs passed in feces, ingested by intermediate host
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(3) Onchosphere penetrates intestinal wall, carried via blood vessels to lodge in organs
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(4) Hydatid cysts develop
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(5) Protoscolices (larvae) ingested (5) Protoscolices (larvae) ingested by definitive host
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(6) Attach to small intestine of definitive host and grow to adult worm.
Infected Dogs Infected Dogs Small intestine of a dog infected with Echinococcus infected with Echinococcus granulosus Adult tapeworms are small (2 mm) but they can be very numerous
F. Rochette, 1999, Dog Parasites and Their Control, Janssen Animal Health, B.V.B.A.
Adult Adult Tapeworm Tapeworm Body is separated into 3 sections into 3 sections Scolex with Scolex with nonretractable rostellum armed with rostellum armed with double crown of 28‐50 hooks
Echinococcus granulosus (hydatid) M h l Morphology
E. granulosus hydatid cyst
‐100µm Laminated layer‐ Several mm
Adventitial layer, mm‐cm ‐20µm
Cyst stage in Humans Cyst stage in Humans
The cyst consists of a thick outer The cyst consists of a thick outer layer (*), several thinner internal layers, and many protoscolices. Th The protoscolices are often called li f ll d "hydatid sand."
A single protoscolex. A single protoscolex “Hooks” can be seen that will form the hooks associated with the adult worm's rostellum d l ' ll
http://www.biosci.ohio‐state.edu/~parasite/echinococcus.html
Hydatid disease • • • •
75% hepatic involvement 25% pulmonary 25% pulmonary Other organs – brain, bone, heart, kidney symptoms due to mass effect, rupture, y , p y secondary infection, anaphylaxis
Pulmonary Echinococcal Diease Pulmonary Echinococcal • • • • •
60% ‐RT lung 50‐60% 50 60% ‐ Lower lobes Lower lobes Lungs a more common site in children 30% have multiple cysts in the lungs 20% of pts &lung involvement have liver 20% of pts &lung involvement have liver involvement
Typical findings Typical findings
Laboratory Data Laboratory Data • • • • • • •
LLess than 15% have peripheral eosinophilia th 15% h i h l i hili (only if leakage of antigenic material) I Immunodiagnostic testing for serum antibodies di ti t ti f tib di 50% positive for pulmonary > 90% for hepatic False positive if have another parasitic infection False positive if have another parasitic infection False negative if intact cyst Percutaneous aspiration: Not often use in aspiration: Not often use in pulmonary echinococcus Aspiration is used with hepatic cysts for diagnosis Aspiration is used with hepatic cysts for diagnosis and treatment. Fluid contains hooklets, protoscolices, etc.
Management 2 Management 2 • Ch Chemotherapy: Used for poor surgical candidate, un‐ th U df i l did t resectable lesion, multiple cysts, after cyst rupture, or after intra‐operative after intra operative spillage spillage • Chemotherapy ‐Prior to surgery to reduce tension/rupture • Albendazole 50‐60mg/kg/day TID for 3‐12 months • Disappearance in 30%, size in 30‐50%, no change 20% • 25% relapse rate • More relapses with multiple cysts, children and elderly adults
Prevention • A Avoiding close contacts with dogs idi l t t ith d • Careful washing of hands • Prohibition of home slaughter of sheep and to prevent dogs from eating the infected viscera • Treating infected dogs with Praziquantal • Eliminating stray dogs Eliminating stray dogs • Vaccination: Appears to be 95% effective in animal studies, not used on humans currently t di t d h tl
Discussion • Echinoccocal cyst should be suspected in any persistent lung lesion – classical echin cyst not common in children • Especially in non Jewish from Galilee villages (Tamra and Yarca) and Negev areas • Serological tests and blood eosinophillia can help in d ag os s diagnosis • Casoni skin test – helps when srongly positive otherwise high false negative/positive high false negative/positive
01/2012 : intermittent cough i t itt t h PE‐N CXR No change (over 6 mon CXR‐ N h ( 6 i filt t ) infiltrate) CT
Bronchoscopy : the bad and the good guy??? Bronchoscopy : the bad and the good guy??? Toxic illness . But … Toxic illness But Secondary infection by FOB aid us in diagnosis Therapy via bronchial echinococal debris expectoration Therapy via bronchial echinococal debris expectoration