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Department of Radiology
Seth G.S. Medical College and K.E.M. Hospital, Mumbai , India
Case of the Month
Case of the Month
Transdiaphragmatic rupture of a hepatic hydatid cyst with extensive thoracic, chest wall, and pulmonary Involvement
Transdiaphragmatic rupture of a hepatic hydatid cyst with extensive thoracic, chest wall, and pulmonary Involvement
Contributed by Nikhil Janardhan Vyawhare
Contributed by Nikhil Janardhan Vyawhare
Introduction :
Introduction :
Hydatid disease remains endemic in many regions of the world, with the liver (60–70%) and lungs (20–25%) being the most frequent sites of involvement [1,2]. Rupture of a hepatic hydatid cyst into the thoracic cavity through the diaphragm is an uncommon but recognized complication, typically associated with chronic pressure erosion, infection, or cyst enlargement. Thoracic extension may manifest as pleural disease, pulmonary hydatidosis, or chest wall daughter cysts. Plain radiographs might raise a suspicion, but cross-sectional imaging plays a central role in identifying the origin of the cyst, the rupture pattern, and extent of dissemination.
Hydatid disease remains endemic in many regions of the world, with the liver (60–70%) and lungs (20–25%) being the most frequent sites of involvement [1,2]. Rupture of a hepatic hydatid cyst into the thoracic cavity through the diaphragm is an uncommon but recognized complication, typically associated with chronic pressure erosion, infection, or cyst enlargement. Thoracic extension may manifest as pleural disease, pulmonary hydatidosis, or chest wall daughter cysts. Plain radiographs might raise a suspicion, but cross-sectional imaging plays a central role in identifying the origin of the cyst, the rupture pattern, and extent of dissemination.
Case presentation:
Case presentation:
A 65-year-old man came with progressive dyspnoea on exertion, intermittent fever, and chronic cough for six months. He had a history of pulmonary tuberculosis three years prior and was a chronic smoker. No recent trauma or surgery was reported. Physical examination revealed decreased breath sounds over the right hemithorax and mild chest wall tenderness. Laboratory values were unremarkable.
A 65-year-old man came with progressive dyspnoea on exertion, intermittent fever, and chronic cough for six months. He had a history of pulmonary tuberculosis three years prior and was a chronic smoker. No recent trauma or surgery was reported. Physical examination revealed decreased breath sounds over the right hemithorax and mild chest wall tenderness. Laboratory values were unremarkable.
A chest radiograph followed by contrast-enhanced CT scan of the thorax and upper abdomen were performed.
A chest radiograph followed by contrast-enhanced CT scan of the thorax and upper abdomen were performed.
Radiological Findings-
Radiological Findings-
Frontal chest Radiograph (Figure 1) shows a large, well-defined soft tissue opacity occupying the right mid and lower lung zones measuring approximately 10 x 6 cm. It obscures the right hemidiaphragm and the right costophrenic angle. Multiple rounded soft-tissue opacities are seen along the right lateral chest wall. A cystic lucency is noted in the right apical zone.
Frontal chest Radiograph (Figure 1) shows a large, well-defined soft tissue opacity occupying the right mid and lower lung zones measuring approximately 10 x 6 cm. It obscures the right hemidiaphragm and the right costophrenic angle. Multiple rounded soft-tissue opacities are seen along the right lateral chest wall. A cystic lucency is noted in the right apical zone.
Figure 1 Frontal chest radiograph- A large soft tissue opacity occupies the right mid and lower zones along the parietal pleura and obscures the right costophrenic angle and the right hemidiaphragm. Multiple rounded soft-tissue opacities are seen over the right lateral chest wall. A cystic lucency with an air–fluid level is noted in the right apical region.
Images from the contrast-enhanced CT scan of the thorax and upper abdomen are shown in figures 2-6.
Images from the contrast-enhanced CT scan of the thorax and upper abdomen are shown in figures 2-6.
Fig 2
Fig 3
Fig 4
Figure 2: Contrast enhanced CT scan of the upper abdomen. A peripherally calcified, well-defined hypodense cystic lesion is noted in segment VII of the liver.
Figure 3 - Contrast enhanced CT scan of the chest - The hepatic cystic lesion shows superior extension through the right hemidiaphragm, maintaining continuity with a large well-defined collection along the right chest wall.
Figure 4 - Multiple, well-defined, fluid-attenuation cystic lesions are seen along the right lateral chest wall between the 2nd and 6th ribs, with the dominant cyst at the right 4th costochondral junction.
Fig 5
Fig 6
Figure 5 – Sagittal images show a rent in the right hemidiaphragm with superior extension of the ruptured hepatic hydatid cyst.
Figure 6- A thick walled cavitary lesion with dependent soft tissue is noted in the right apical zone- a likely post infective lesion.
Radiological diagnosis:
Radiological diagnosis:
A thick walled cavitary lesion with dependent soft tissue is noted in the right apical zone- likely post infective.
A thick walled cavitary lesion with dependent soft tissue is noted in the right apical zone- likely post infective.
Management:
Management:
Oral Albendazole was started, and the patient was discharged to follow up in the chest medicine department. Sonography guided tap of the thoracic collection was attempted; this was unsuccessful due to the thick nature of the content. A surgical plan under the cardiovascular and thoracic surgery department will be explored after a four-month course of Albendazole.
Oral Albendazole was started, and the patient was discharged to follow up in the chest medicine department. Sonography guided tap of the thoracic collection was attempted; this was unsuccessful due to the thick nature of the content. A surgical plan under the cardiovascular and thoracic surgery department will be explored after a four-month course of Albendazole.
Discussion:
Discussion:
Rupture of hydatid cysts can manifest as contained rupture, communicating rupture, or direct rupture into adjacent structures [1]. In this case, a direct transdiaphragmatic rupture from segment VII of the liver resulted in chest-wall daughter cysts, a diaphragmatic cyst, and a secondary pulmonary hydatid cyst—an uncommon but recognized pattern; similar to presentations with transdiaphragmatic migration, chest-wall implantation and secondary pulmonary disease are described in surgical series and case reports. [2–4]
Rupture of hydatid cysts can manifest as contained rupture, communicating rupture, or direct rupture into adjacent structures [1]. In this case, a direct transdiaphragmatic rupture from segment VII of the liver resulted in chest-wall daughter cysts, a diaphragmatic cyst, and a secondary pulmonary hydatid cyst—an uncommon but recognized pattern; similar to presentations with transdiaphragmatic migration, chest-wall implantation and secondary pulmonary disease are described in surgical series and case reports. [2–4]
Such patterns occur due to progressive cyst expansion, erosion of the diaphragm, and dissemination of parasitic elements into the thorax [1]. Chest wall involvement is rare and may pose a risk of formation of a chronic fistula or rib erosion. Pulmonary hydatid cysts may rupture into the bronchi, allowing entry of air and producing imaging signs such as the “Cumbo sign” and the “water-lily sign” [5,6]. Additional CT signs of rupture include floating membranes, air–fluid levels, and the presence of daughter cysts in ectopic subdiaphragmatic or thoracic locations. Case series emphasize that pleural contamination, empyema, or chest-wall collections can complicate presentation and management. [3,4]
Such patterns occur due to progressive cyst expansion, erosion of the diaphragm, and dissemination of parasitic elements into the thorax [1]. Chest wall involvement is rare and may pose a risk of formation of a chronic fistula or rib erosion. Pulmonary hydatid cysts may rupture into the bronchi, allowing entry of air and producing imaging signs such as the “Cumbo sign” and the “water-lily sign” [5,6]. Additional CT signs of rupture include floating membranes, air–fluid levels, and the presence of daughter cysts in ectopic subdiaphragmatic or thoracic locations. Case series emphasize that pleural contamination, empyema, or chest-wall collections can complicate presentation and management. [3,4]
CT imaging is the modality of choice for defining cyst morphology, identifying rupture patterns, and establishing continuity between abdominal and thoracic components [1,7]. MRI further aids in characterizing diaphragmatic invasion and can delineate daughter cysts or membranous detachment with superior soft-tissue contrast. Multiplanar reconstructions are particularly valuable in demonstrating transdiaphragmatic tracts, pleural seeding, and chest-wall extension, which have important implications for surgical planning [7,8].
CT imaging is the modality of choice for defining cyst morphology, identifying rupture patterns, and establishing continuity between abdominal and thoracic components [1,7]. MRI further aids in characterizing diaphragmatic invasion and can delineate daughter cysts or membranous detachment with superior soft-tissue contrast. Multiplanar reconstructions are particularly valuable in demonstrating transdiaphragmatic tracts, pleural seeding, and chest-wall extension, which have important implications for surgical planning [7,8].
Thoracic involvement—including chest-wall or pulmonary seeding have been reported to correlate with chronicity of the hepatic lesion and may occasionally mimic neoplastic, infectious, or congenital cystic processes on imaging - thus emphasizing the need for careful differential diagnosis [7,8]. Radiologists must be familiar with these mimics, as misinterpretation can delay diagnosis or lead to inappropriate intervention, such as percutaneous aspiration techniques which are contraindicated in ruptured or thoracic-communicating cysts [9].
Thoracic involvement—including chest-wall or pulmonary seeding have been reported to correlate with chronicity of the hepatic lesion and may occasionally mimic neoplastic, infectious, or congenital cystic processes on imaging - thus emphasizing the need for careful differential diagnosis [7,8]. Radiologists must be familiar with these mimics, as misinterpretation can delay diagnosis or lead to inappropriate intervention, such as percutaneous aspiration techniques which are contraindicated in ruptured or thoracic-communicating cysts [9].
Management typically involves a combination of surgical removal and antiparasitic therapy (albendazole), as recommended in global health guidelines [10]. Accurate preoperative radiologic mapping is essential to avoid intraoperative spillage and to ensure complete treatment of thoracic extensions. Several surgical reports highlight the need for combined thoracoabdominal approaches when diaphragmatic or chest-wall components are present. [2–4]
Management typically involves a combination of surgical removal and antiparasitic therapy (albendazole), as recommended in global health guidelines [10]. Accurate preoperative radiologic mapping is essential to avoid intraoperative spillage and to ensure complete treatment of thoracic extensions. Several surgical reports highlight the need for combined thoracoabdominal approaches when diaphragmatic or chest-wall components are present. [2–4]
This case highlights the need for radiologists to recognize the imaging features of advanced hydatid disease, particularly in patients with chronic pulmonary symptoms where findings may be misleading [5]. Awareness of rare manifestations such as chest-wall and pleural involvement can improve diagnostic accuracy and guide appropriate multidisciplinary management.
This case highlights the need for radiologists to recognize the imaging features of advanced hydatid disease, particularly in patients with chronic pulmonary symptoms where findings may be misleading [5]. Awareness of rare manifestations such as chest-wall and pleural involvement can improve diagnostic accuracy and guide appropriate multidisciplinary management.
References:
References:
1. Pedrosa I, Saíz A, Arrazola J, Ferreirós J, Pedrosa CS. Hydatid disease: radiologic and pathologic features and complications. Radiographics. 2000;20(3):795-817. doi:10.1148/radiographics.20.3.g00mc06795
1. Pedrosa I, Saíz A, Arrazola J, Ferreirós J, Pedrosa CS. Hydatid disease: radiologic and pathologic features and complications. Radiographics. 2000;20(3):795-817. doi:10.1148/radiographics.20.3.g00mc06795
2. Topçu S, Kurul IC, Tastepe I, et al. Intrathoracic rupture of a hydatid cyst of the liver: clinical and diagnostic considerations. Ann Thorac Surg. 2000;69(3):875-879. doi:10.1016/S0003-4975(99)01324-0
2. Topçu S, Kurul IC, Tastepe I, et al. Intrathoracic rupture of a hydatid cyst of the liver: clinical and diagnostic considerations. Ann Thorac Surg. 2000;69(3):875-879. doi:10.1016/S0003-4975(99)01324-0
3. Bedioui H, Daghfous A, Ayadi S, et al. Thoracic rupture of hepatic hydatid cysts: imaging findings and management. World J Surg. 2006;30(3):372-378. doi:10.1007/s00268-005-0159-4
3. Bedioui H, Daghfous A, Ayadi S, et al. Thoracic rupture of hepatic hydatid cysts: imaging findings and management. World J Surg. 2006;30(3):372-378. doi:10.1007/s00268-005-0159-4
4. Kabiri EH, El Maslout A, Benosman A. Thoracic rupture of hepatic hydatid cysts: a study of 15 cases. Ann Thorac Surg. 2001;72(6):1883-1886. doi:10.1016/S0003-4975(01)03231-X
4. Kabiri EH, El Maslout A, Benosman A. Thoracic rupture of hepatic hydatid cysts: a study of 15 cases. Ann Thorac Surg. 2001;72(6):1883-1886. doi:10.1016/S0003-4975(01)03231-X
5. Morar R, Feldman C. Pulmonary echinococcosis. Eur Respir J. 2003;21(6):1069-1077. doi:10.1183/09031936.03.00020603
5. Morar R, Feldman C. Pulmonary echinococcosis. Eur Respir J. 2003;21(6):1069-1077. doi:10.1183/09031936.03.00020603
6. Yilmaz A, Tuncer LY, Damadoglu E, et al. Clinical features, diagnosis and treatment of pulmonary hydatid cysts. Respiration. 2004;71(5):559-566. doi:10.1159/000079640
6. Yilmaz A, Tuncer LY, Damadoglu E, et al. Clinical features, diagnosis and treatment of pulmonary hydatid cysts. Respiration. 2004;71(5):559-566. doi:10.1159/000079640
7. Polat P, Kantarci M, Alper F, Suma S, Koruyucu MB, Okur A. Hydatid disease from head to toe: imaging findings. Radiographics. 2003;23(2):475-494. doi:10.1148/rg.232025704
7. Polat P, Kantarci M, Alper F, Suma S, Koruyucu MB, Okur A. Hydatid disease from head to toe: imaging findings. Radiographics. 2003;23(2):475-494. doi:10.1148/rg.232025704
8. Von Sinner WN. New diagnostic signs in hydatid disease: radiography, US, CT and MRI correlated to pathology. Eur J Radiol. 1991;12(2):150-159. doi:10.1016/0720-048X(91)90007-N
8. Von Sinner WN. New diagnostic signs in hydatid disease: radiography, US, CT and MRI correlated to pathology. Eur J Radiol. 1991;12(2):150-159. doi:10.1016/0720-048X(91)90007-N
9. Akhan O, Ozmen MN, Dincer A, Sayek I, Gocmen A. Percutaneous treatment of liver hydatid cysts: long-term results. AJR Am J Roentgenol. 1996;167(1):91-97. doi:10.2214/ajr.167.1.8659350
9. Akhan O, Ozmen MN, Dincer A, Sayek I, Gocmen A. Percutaneous treatment of liver hydatid cysts: long-term results. AJR Am J Roentgenol. 1996;167(1):91-97. doi:10.2214/ajr.167.1.8659350
10. Brunetti E, Kern P, Vuitton DA; Writing Panel for the WHO-IWGE. Expert consensus for the diagnosis and treatment of cystic and alveolar echinococcosis. Acta Trop. 2010;114(1):1-16. doi:10.1016/j.actatropica.2009.11.001
10. Brunetti E, Kern P, Vuitton DA; Writing Panel for the WHO-IWGE. Expert consensus for the diagnosis and treatment of cystic and alveolar echinococcosis. Acta Trop. 2010;114(1):1-16. doi:10.1016/j.actatropica.2009.11.001
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