Aspergilloma in a Pulmonary Hydatid

doi:10.4236/wjcs.2013.33020

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World Journal of Cardiovascular Surgery, 2013, 3, 108-110

http://dx.doi.org/10.4236/wjcs.2013.33020 Published Online July 2013 (http://www.scirp.org/journal/wjcs)

Aspergilloma in a Pulmonary Hydatid*

Nikhil Tiwari#, Ramesh Kaushik, Gaurav Kumar, Gautam Ganguly, Shabaz Hasnain

Department of Cardiothoracic Surgery, Military Hospital (CTC), Pune, India

Email: #[email protected]

Received May 6, 2013; revised June 13, 2013; accepted June 22, 2013

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Aspergilloma infection in the lung can occur in preexisting cavities and is usually seen after tuberculosis, pulmonary

infarction and bronch estasis. Occassionally aspergilloma has b een reported within a hydatid cyst. We describe a patient

with aspergilloma formed within cyst hydatid. The primary symptom in this patient was recurrent hemoptysis. In this

42-year-old male, the diagnosis was established by HRCT chest. Treatment consisted of postero-lateral thoracotomy

with a bilobectomy of lower and middle lobe. Aspergilloma is an unusual complication of hydatid cyst and results fro m

the deterioration of local defence against opportunistic infection s .

Keywords: Tuberculous Cavity; Lung Hydatid Cyst; Aspergilloma

1. Introduction

Pulmonary aspergilloma generally complicates an exist-

ing cavity that was due to tuberculosis; however, it can

develop in any kind of pulmonary cavity. Regnard et al.

reported growth of aspergilloma in a post-tuberculosis

cavity in 69% in their series [1] and rarely in hydatid cyst

cavities [2]. A review of literature shows isolated case

reports with aspergilloma invading residual cavities left

after cystectomy in lung hydatid [3,4]. Julio C. Vasquez

et al. in their article recommend anatomic lung resection

for such cases. A positive diagnosis relies on direct iden-

tification of Aspergillus species or serodiagnosis. A se-

rodiagnosis is almost always positive in chronic infec-

tions and is detected by immunoelectrophoresis or a sin-

gle precipitation with catalase activity. The rarity of as-

pergilloma within hydatid cyst probably occurs due to

the different elective site for the two diseases. The de-

velopment of aspergilloma on cyst residual cavities can

occur in the early post-operative period and alternatively

after many years. The coexistence of hydatid cyst and

aspergillosis is extremely rare [5,6] and such an associa-

tion has been reported in both immunocompromised and

immunocompetent patients.

2. Case Report

44 yrs old male presented to us with a history of recur-

rent bouts of cough with haemoptysis. He gave a history

of a diffuse right sided chest pain. He was a nonsmoker,

had undergone a six month course of ATT two years

back for pulmonary Koch. His clinical examination was

not contributory. A chest roentgenogram (Figure 1) re-

vealed a cavity in th e right mid zone (RMZ) with promi-

nent vascular markings. A high resolution CT (Figure 2)

revealed a soft tissue mass in superior segment of the

right lower lobe with a thin crescentric lucency which

changes with patient’s position suggestive of aspergil-

loma with adjacent lung consolidation. Bilateral pleural

thickening was also noted. A fibreoptic bronchoscopy re-

vealed a normal tracheobronchial tree. Fungal stains &

culture, Gram stains, pyogenic culture, AFB & MTB

cultre & a Polymerase chest reaction (PCR) of bron-

Figure 1. CXR: Cavity within the RMZ & RLZ consolida-

tion.

*Conflict of interest: Authors have no conflict of interest.

#Corresponding author.

N. TIWARI ET AL. 109

choscopic alveolar lavage from the superior segment of

RLL were negative for AFB and fungus. His spirometery

was normal. He was planned for (Rt) lower lobectomy or

a bilobectomy. While awaiting surgery he had a major

bout of haemoptysis necessitating bronchial artery em-

bolization and was taken up for surgery 48 hrs later. A

left posterolateral thoracotomy was done through the 5th

ICS. Intraoperatively extensive adhesions were noted be-

tween the chest wall and the lungs. The fissures between

upper & lower lobes were fused & RML was collapsed.

A 5 × 5 × 5 cm lesion was noted in RLL abutting the

upper lobe and densely adherent to it hence a bilobec-

tomy (RLL & RML) was done.

Grossly the cut surface showed an apical 3.5 × 3 × 2

cm cyst with a fibrous wall containing a delicate white

membrane (Figure 3). Microscopy revealed a fibrous

pericyst containing a dominated chitinous membranous

material. Septate narrow angle branching filaments and

fungal spores were seen on the outer wall as well as sur-

rounding lung showed focal edema, congestion, mixed

inflammatory infiltrate, necrosis & dilated bronchioles.

No invasion of fungal hyphae into lung parenchyma was

Figure 2. CT scan: Soft tissue mass sup segment RLL.

Figure 3. A fibrous pericyst containing a dominated chiti-

nous membranous.

noted.

Final HPE report was—Hydatid cyst (Rt) lung lower

lobe with Aspergillus colonization. Post operatively he

continued to have a prolonged drainage (150 ml) in the

intercostal drains lasting for three weeks which then sud-

denly subsided. Patient was administerd Tab Albenda-

zole 400 mg BD as pulse therapy. He has had an un-

eventful recovery with good expansion of the remaining

lung.

3. Discussion

Aspergilloma is a common form of pulmonary fungal

infection and has a tendency to occur in tubercular cavi-

ties, on rare occasions it may occur in hydatid cavities

[5-7]. The most common sites of aspergilloma and hy-

datid cyst are respectively the upper lobe and the lower

lobe of the lung. Such association has been reported in

both immunocompromised and immunocompetent pa-

tients [8]. The single most important pointer for asper-

gilloma is its mobility in different positions. The differ-

ential diagnosis of Aspergillus colonies entrapped in a

hydatid cyst is tuberculosis, malignancy, an intact hy-

datid cyst, or a necrotizing pulmonary abscess [8].

Surgery is the mainstay of treatment of this opportun-

istic pulmonary mycosis. Recommended surgical treat-

ment for aspergilloma in patients with adequate pulmo-

nary function is lung resection [9]. Anatomic lung resec-

tion is advised in pulmonary aspergilloma as there is un-

certainity in how much lung parenchyma should be re-

moved to safely resect the lesion. Hemoptysis is a known

presentation in pulmonary hydatid cyst and also pulmo-

nary aspergillosis, which was the presenting symptom in

our patient [10]. Hepatic cysts are noted in 20% of such

cases however our case did not have any hepatic cysts

[11]. In conclusion we present a rare case and suggest

that an association between aspergilloma with hydatid

must be kept in mind when dealing with pulmonary as-

pergillosis.

4. Literature Review

There are very few isolated case reports describing coex-

istence of aspergilloma in a hydatid cavity. Sameh

M’saad et al. [12] describe two such cases who initially

presented with recurrent hemoptysis. They were treated

with a postero-lateral thracotomy with wedge resection

of aspergilloma in the left upper lobe because of massive

hemoptysis. In both cases, patients progressed favourably

without antifungal therapy. They describe aspergilloma

as an unusual complication of hydatid cyst resulting from

the deterioration of local defence against opportunistic

infections. Prognosis appears to be better than aspergil-

loma within tuberculous cavities. Buzdar, M.S. et al.

describe invasive aspergillosis in a ruptured hydatid cyst

N. TIWARI ET AL.

110

[2] in a patient earlier treated for pulmonary Koch’s and

who had fever and recurrent hemoptysis and was man-

aged successfully with a wedge resection.

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