Grand round presentation

Presenter; Komanya Francisca B.

Mmed 2-IM
 Demographic data
• Name ; A.K
• Age; 43 yrs.
• Sex; Male
• Residence; Kondoa
• Occupation; Peasant.
• Mode of admission; Self Referral at DRRH
• Date of admission; 19/09/2020
• Date of discharge: 25/09/2020
 Chief complaints
• Cough 3/12

• Fever 2/12
 History of present illness
Cough
• Gradual onset, and persistent
• Was non productive, however one day before
admission he had 2 episodes productive cough
with streaks of blood
• Associated with
– Dull chest pain more marked on the left side, non
radiating, not positional related, not aggravated by
breathing, no h/o of trauma.
 History of present illness cont.
– Difficult in breathing initially was marked on heavy
activities and recently he was barely able to walk
50 meter without resting
• No h/o Dib on lying flat, air hunger at night,
heat beat awareness, lower limb swelling,
• No h/o smoking cigarette, or working in
mines/industries
• No h/o asthma in the family, recurrent runny
nose/sneezing or feeling of liquid running
down the back of the nose
 History of present illness cont.
• He denied h/o heart burn
• No h/o using medication like (ACEi)
 HPI cont…
Fever
• Low grade fever, intermittent, marked during
the day
• Associated with unintentional weight loss,
fatigue,
• No h/o excessive night sweat
• No h/o headache, convulsions,confusion or
loss of conciousness.
 Review of other systems
• ENT-No hx of easy bruising or bleeding per ENT.
• CVS-No hx of awareness of hearbeats,difficult in
breathing on lying flat,waking up at night due to
air hunger.
• GIT-No hx of abd pain, distension, passing of
hard or loose stool
• GUT-No hx of painfully micturation,no hx of
increase in frequency of urination or penile
discharge
 Past medical history
• This is the first admission.
• Had history of being treated for TB 3 times.
– 1st On 2016, Diagnosed by CXR at Kondoa District
Hospital, completed 6/12 treatment
– 2nd On 2018, diagnosed by CXR at DRRH,
completed 6/12 treatment.
– 3rd at Makole Health Centre by CXR on 2020, he is
on anti-TB medication for 3/12.
• No hx of surgeries ,blood transfussion or drug
allergy.
 Family social history
• Married(monogamy),has 8 children.
• Peasant and also keeps domestic animals
(dog,cat,goats and cows)
• Has Ordinary level education.
• No history of diabetic, hypertension or
Asthma in his family.
 Summary one
• 43yrs old male presenting with history of dry cough,
progressive dyspnea and chest pain for 3/12,and
recently had 2 episodes of hemoptysis also has
intermittent low grade fever, weight loss and general
body malaise 2/12.

• He is a peasant and he keeps domestic animals .

• Non alcoholic , never smoked or worked in
industrial/mines

• Has previous been treated for PTB 2 times and currently

diagnosed with TB-Pleural on anti-TB for 3/12.
 General examination
• Alert, afebrile, not pale, not dyspneic, not
jaundiced, not cyanosed, no LLE
VITALS;
• BP = 110/80mmHg,
• PR = 90 bpm,
• RR = 20 c/min
• SPO2 = 94% on RA
• T=37⁰C
 Systemic examination
Respiratory system
• RR=18 breaths/min
• No chest wall deformity, no marks on the chest.
• Trachea central located
• Reduced chest wall expansion on the left side.
• No areas of tenderness, no palpable lymph nodes.
• Reduced tactile vocal fremitus.
• Stony dullness percussion note on the left hemi
thorax.
• Absent breath sounds on the left hemi thorax.
 Systemic examination cont.
CNS
• Fully conscious, oriented to TPP, normal speech,
intact short and long-term memory.
• No signs of meningeal irritation.
• All cranial nerves were intact.
• Motor system-Has reduced muscle bulkiness on
both limbs, has normal tone and power of 5/5 on
both limbs with normal reflexes.
• Coordination, sensation and gait were normal.
 Systemic examination cont.
P/A
• Not distended
• No scars/marks
• Moves with respiration
• No visible peristalsis
• No distended veins
• Non tender
• No palpable mass, liver span 12cm
• Tympanic percussion note.
• Normal bowel sounds heard.
 Systemic examination cont.
CVS
• PR 88bpm,regular,good volume ,non
collapsing, synchronous with other peripheral
pulses.
• No precordial bulge or hyperactivity
• AB - 5th ICS MCL
• S1 & S2 heard normally
 Second summary
• 43yrs old male presenting with history of dry cough,
progressive dyspnea and chest pain for 3/12 and recently
had 2 episodes of hemoptysis ,also has intermittent low
grade fever, weight loss and general body malaise 2/12.
• He is a peasant and he keeps domestic animals .
• Non alcoholic , never smoked or worked in
industrial/mines.
• Has previous been treated for PTB 2 times and currently
diagnosed with TB-Pleural on anti-TB for 3/12.
• Has stable vitals, with reduced left side chest wall
expansion as well as tactile vocal fremitus, stony dull
percussion note and absent breathing sounds on left hemi
Provisional diagnoses ?
 Provisional diagnoses
• Drug resistant Turbeculosis of pleural
• DDx-Lung carcinoma
-Metastatic pleural effusion
-Lung abscess
- Pulmonary hydatid cyst
-Lymphoma
-Lung abscess
Investigations

CHEST XRAY

• Homogenous
opacification on the left
hemi thorax with
mediastinum shifting
towards the right side.
 Investigations cont.
• Sputum for Acid fast bacilli and Gene X-pert
was Negative.
• PITC –Non reactive
• Serum Carcinoembryonic antigen- was
0.5ng/mL(normal is less than 3ng/mL)
Variables Reference range Results

WBCs (3 - 11) x 10^3µL 5

Neutrophils (27 - 72) % 70
Hb (8 - 17 ) g/dl 11
Hct (26 - 50) % 29.6
MCV (86 - 110) fL 87
MCH (26 - 38) pg 32
MCHC (31 - 37) g/dl 33.1
RDW (11 - 16 )% 21.3
PLTc (150-340) x 10^3µL 200
CT scan of the chest

Large cystic lesion

occupying the whole left
hemi thorax, displacing
the mediastinum to the
contralateral side, has
thick rind double
membrane with
peripheral calcification.
Investigations cont.
 Final diagnoses
• Left Pulmonary hydatid cyst.
 Treatment
1. T.Albendazole 400mg BID 28 days, repeated
after 14 days without treatment to a total of 3
treatment cycles.
Echinococcosis
 Introduction
• Echinococcosis, or Hydatid disease, is a zoonotic disease
most commonly caused by larval stages of Echinococcus
granulosus an infection caused by tapeworms of the
Cestode parasites ,Family Taeniidae, Genus Echinococcus.
• Five species of Echinococcus have been identified,
Echinococcus granulosus
Echinococcus multiocularis
Echinococcus vogeli
Echinococcus oligarthrus
Echinococcus shiguicus
• E. granulosus sensu lato -General term for all species and
strains
 Introduction cont.

• Infection is acquired by hand to mouth transfer after

handling dogs or contaminated objects, ingestion of
food, water or soil contaminated with eggs excreted
from the canines(definitive host).

• Larval cysts may develop in almost every organ in

primary Echinococcosis.

• The lung is the second most commonly affected organ

(15%)after the liver(75%) and other anatomical
locations (10%).
 Epidemiology

• The World Health Organization (WHO)

estimates the incidence of human infection to
exceed 50 cases per 100,000 person-years in
echinococcosis-endemic areas.
• The prevalence is as high as 5–10% in parts of
Argentina, China, Central Asia, and East Africa.
• The average postoperative death rate of cystic
Echinococcosis is 2.2%, and 6.5% of cases
relapse after intervention, as stated by the
WHO.
Life cycle
 Pathogenesis
• The echinococcal cyst is a unilocular fluid-filled cyst lined by
an inner germinal layer of cells and surrounded by an
acellular laminated membrane.
• Small vesicles called brood capsules bud from the inner
germinal layer of cells and produce protoscoliosis.
• Protoscoliosis accumulate inside the cyst as “hydatid sand”
and can produce adult tapeworms or daughter cysts.
• Disease occurs from cyst disruption. Cysts can also become
superinfected with bacterial pathogens by hematogenous
spread or via the biliary and bronchial tree.
• Infected cysts can cause abscesses in the organs they
invade.
 Clinical Presentation
Incubation period
• Month to years
• 20 to 30 years documented for cysts that grow
slowly and are not in a critical location.
Clinical signs
• Depend on size, number and location of
metacestodes,symptoms due to mass effect
within organs, complications i.e. rupture or
secondary bacterial infections.
 Clinical presentation cont.
• The most common symptoms of pulmonary
cystic echinococcosis (CE) described in the
literature include
– Cough (53 to 62 %)
– Chest pain (49 to 91 %)
– Dyspnea (10 to 70 %)
– Hemoptysis (12 to 21 %)
 Clinical presentation cont.
Hepatic hydatid cyst
• Hepatomegaly with -/+ RUQ pain
• Nausea and vomiting
• Cyst rupture in biliary tree can cause biliary colic,
obstructive jaundice, cholangitis or pancreatitis.
• Mass effects on bile ducts, portal and hepatic
veins or inferior venacava results in cholestasis,
portal HTN,venous obstruction/Budd-Chiari
syndrome.
 Diagnosis
• Imaging is the technique of choice supported by
appropriate serology and often histopathology.
Imaging
• Ultrasonography –Has sensitivity of 90-95%.
• CT scan has sensitivity of 95-100% can elucidate
the nature and location of the cyst to precise their
relation with surrounding organs and thus evaluate
the cyst preoperatively.
 Diagnosis cont.
Serology
• IgG ELISA was the most sensitive 94 % and
specific 99 % for the majority of cyst locations in
patients with E. granulosus infection .
• Hydatid antigen dot immunoassays, are used for
field testing and population screening, has
sensitivity of 88 to 96 % and a specificity of 90 to
98 %
• Immunoblot and gel diffusion assays has
approximately 90% with a specificity of 97 - 100
 Diagnosis cont.
Cytology
• Cyst aspiration or biopsy - reserved when other
diagnostic methods are inconclusive because of the
potential for anaphylaxis and secondary spread of the
infection .
 Active cysts have clear, watery fluid containing
scolices and elevated pressure.
 Inactive cysts have cloudy fluid without detectable
scolices and do not have elevated pressure . In lung
cysts, protoscolices or degenerated hooklets may be
demonstrable in sputum or bronchial washings.
• Polymerase chain reaction — are limited to research
settings but may play a diagnostic role in the future .
 Treatment
• The treatment of choice in the pulmonary
hydatid cyst is surgical resection.
• Percutaneous aspiration, injection of cysticidal
agent, and re-aspiration using radiographic
guidance (PAIR) method is being routinely
used in cases of hydatid liver disease.
• WHO currently recommends that PAIR should
not be used in case of pulmonary cysts.
 Treatment cont.
• Surgery should be coupled with Albendazole
(10-15 mg/kg/day) administration in two
doses from 4 days before to at least 1 month
after surgery.
• Anthelminthic therapy before surgery has
shown to reduce the risk of recurrence by 3.5
times.
• Pharmacotherapy with anthelminthic .
Copyrights apply
 SURGERY
• Is the treatment of choice for management of
complicated cysts (eg, rupture cyst, cysts with biliary
fistulae, cysts compressing vital structures, cysts with
secondary infection or hemorrhage
• Other indications for surgery include cyst diameter
>10 cm, superficial cyst at risk of rupture due to
trauma, and extrahepatic disease (lung, bone, brain,
kidney, or other site)
• It is also appropriate in settings where percutaneous
treatment is not available.
 SURGERY
• Surgical approaches for management of lung
cysts include
– Lobectomy
– Wedge resection
– Pericystectomy
– Intact endocystectomy, and
– Capitonnage
• Study was conducted from 1957 to 1985, including 842 patients
diagnosed as having thoracic hydatid cyst
• 79% of the procedures were endocystectomie.
• Intact endocystectomy without preliminary aspiration was the
approach of choice
• 106 patients underwent endocystectomies were
followed ,Ruptures occurred during cyst manipulation in 35
patients (33%). Recurrence after operation was seen in 2 patients
(1.9%). There were no deaths.
• In comparison, 136 patients who underwent aspiration
endocystectomy and the recurrence rate was 3.7% (5 patients)
Ann Thorac Surg. 1988;46(3):342
• 18 patients received no Albendazole treatment (controls), 18
received Albendazole (10 mg/kg daily) for 1 month (group A),
and 19 received the drug for about 3 months (group B).

• Treatment in B was significantly associated with total cyst

membrane disintegration 68% showed by echographic changes,
and only 1 of 20 cysts during treatment was judged viable (p =
0.00006)
Lancet 1993; 342: 1269-72
• The relative efficacy of mebendazole (MEB) and albendazole (ALB) was
tested by treating 51 patients with single, multiple and multi-organ hydatid
cysts; 28 patients were treated with MEB, 50-70 mg kg- 1 body weight daily
for six to 24 months, and 23 with ALB, 10 mg kg- 1 body weight daily in four
courses of 30 days

• Treatment with MEB was successful in eight cases (28·6%), partially

successful in eight (28·6%) and unsuccessful in 12 (42·8%). Treatment with
ALB was successful in 10 cases (43·5%), partially successful in 10 (43·5%)
and unsuccessful in three (13%). Annals of tropical medicine and parasitology,
 Prevention
• Wash fruits and raw vegetables before eating.
• Wash hands before eating or smoking, after
handling dogs and after contact with items
that are likely to be soiled with dog faeces.
• Discourage dogs from licking people’s faces,
and do not kiss dogs.
• Do not allow dogs to defecate near vegetable
gardens or children’s play areas
 Prevention cont.
Reduce the amount of disease in dogs
• Ensure dogs are kept away from areas where animals are
slaughtered and are not allowed to scavenge on carcasses.
• Prevent dogs from eating uncooked offal.
• Dispose of infected offal by deep burial or burning to prevent it
from being consumed by dogs or other canines.
• Reduce dog populations on farms to the occupational need for
them.
• Seek advice from your veterinarian about effective treatment
to prevent infection in working, pet or visiting dogs. This is
particularly important for dogs in rural areas or those that may
have contact with wildlife or feral animals
 Refferences
• Diagnosis and Treatment of Pulmonary Hydatid Disease,Meral
Ekim and Hasan Ekim, Journal of Liver and Clinical Research,2017.
• Echinococcosis,WHO, 2021.
• Giant isolated hydatid lung cyst: two case reports, Jay et al,
Journal of Medical case repots,2020.
• Medical treatment of cystic echinococcosis:Systematic review and
meta-analysis, Velasco-Tirado et al. BMC Infectious Diseases
(2018).
• Primary Pleural Hydatidosis—A Rare Occurrence:A Case Report
and Literature Review, Cornel et al,Medicina,2020
• Radiological manifestations of thoracic hydatid cysts: pulmonary
and extrapulmonary findings, Durhan et al. Insights into
Imaging ,2020.
• Up to date