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 Table of Contents  
INTERESTING CASE REPORT
Year : 2020  |  Volume : 4  |  Issue : 2  |  Page : 196-199

Cardiac Hydatid Cyst


Heartline Cardiac Care Centre, Allahabad, Uttar Pradesh, India

Date of Submission16-May-2019
Date of Acceptance16-Jun-2019
Date of Web Publication19-Aug-2020

Correspondence Address:
Dr. Ishita Banerji
Heartline Cardiac Care Centre, 14/18 Elgin Road, Civil Lines, Allahabad - 211 001, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiae.jiae_24_19

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  Abstract 

A 52-year-old female presented with features suggestive of acute coronary syndrome. A transthoracic echocardiogram done to assess the cardiac function and regional wall motion abnormality revealed a large cardiac cystic lesion instead, in the apical part of the interventricular septum, suggestive of a hydatid cyst. Cystic hydatid disease results from infection with the larval or adult form of the Echinococcus granulosus tapeworm. Cardiac hydatid cyst is a rare condition seen in 0.5%–2% of patients with hydatid disease, and the location of a hydatid cyst in the interventricular septum is exceptional. Cardiac hydatid cysts can rupture and cause cardiac tamponade, fatal arrhythmias, or systemic infection. The atypical location of a large hydatid cyst in the apical interventricular septum encroaching into the right ventricular cavity filling almost half of it, was an interesting finding, found worth reporting. Also, further investigations that unraveled two more hydatid cysts in the liver, made the case more interesting to report.

Keywords: Echocardiography, hydatid cyst, interventricular septum


How to cite this article:
Banerji I. Cardiac Hydatid Cyst. J Indian Acad Echocardiogr Cardiovasc Imaging 2020;4:196-9

How to cite this URL:
Banerji I. Cardiac Hydatid Cyst. J Indian Acad Echocardiogr Cardiovasc Imaging [serial online] 2020 [cited 2020 Sep 29];4:196-9. Available from: http://www.jiaecho.org/text.asp?2020/4/2/196/292622


  Introduction Top


Cystic echinococcosis (hydatid disease), a human and animal endoparasitic infestation by Echinococcus granulosus tapeworm, is endemic in various livestock-raising countries including India (highly prevalent in Kashmir, Andhra Pradesh, Tamil Nadu, and Central India [Eastern Uttar Pradesh]).[1]Echinococcus disease in humans is caused by the larval development of Echinococcus granulosus, a cestode tapeworm. The parasite in its eugenic stage lives in the intestines of carnivorous animals, the definitive hosts (dog, wolf, etc.), whereas human beings, the incidental hosts, harbor the slug stage by accidental ingestion of ova in food and water contaminated with dog feces. The liver is the organ most frequently involved in Echinococcus disease, followed by the lung. Cardiac involvement is seen only in 0.5%–2% of cases.[2],[3],[4] Cardiac involvement is very rare, but it occurs when the parasite penetrates both hepatic and lung filters to gain access to coronary circulation, with left ventricle as the most commonly reported site. The coronary circulation is the main pathway by which the parasitic larvae reach the heart.[5] Because of a rich coronary blood supply, the left ventricle is the site of cardiac hydatid cysts in 55%–60% of cases. Less frequently involved are the right ventricle (10%–15% of cases), pericardium (7%), pulmonary artery (6%–7%), left atrium (6%–8%), right atrium (3%–4%), and interventricular septum (4%).[4],[5],[6],[7] Although cough is typically the chief clinical symptom of hydatid disease, cardiac hydatid cysts are usually asymptomatic, especially in their early stages, and only 10% of patients have clinical symptoms.[2],[5] Clinical manifestations that result from cardiac hydatid cyst are dependent on the specific location of the cyst within the heart and the resulting interference with the function of the surrounding cardiac structures.


  Clinical Presentation Top


A middle aged woman, a known case of hypothyroidism, presented with a complaint of chest pain radiating to back for 2 days before admission associated with sweating, nausea, and vomiting. Clinical examination revealed a pulse rate of 119/min, blood pressure 100/60 mmHg, temperature 100°F, respiratory rate 16/min, and SpO296% in room air with bilateral normal vesicular breath sounds and normal heart sounds. Electrocardiography (ECG) revealed T-wave inversion in the chest leads V1 through V6, with raised cardiac enzymes with progressive increase in titer suggestive of acute coronary syndrome. Preliminary blood examination revealed normal blood counts with leukocytosis and raised erythrocyte sedimentation rate (35 mm) whereas liver function tests and renal function tests were within normal limits. However, hemoglobin was reduced at 9.2 gm%. The chest X-ray was otherwise unremarkable with normal cardiothoracic ratio, except the upturned apex suggestive of right ventricular (RV) forming the cardiac apex [Figure 1].
Figure 1: Chest X-ray

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A routine echocardiogram revealed a large avascular cystic mass in the apical portion of the interventricular septum protruding into the right ventricle filling half the RV cavity, thereby significantly reducing the RV volume. The apical four-chamber view revealed a well-encapsulated, large cystic mass apparently in the apical musculature protruding well into the RV [Figure 2] and [Figure 3]. Color Doppler revealed a laminar biventricular inflow and outflow, though the cystic mass remained avascular with free-flowing strands within the fluid of the cyst [Figure 4]. The cystic lesion measured 40 mm × 42 mm in cross section [Figure 5].
Figure 2: Hydatid cyst in apical four-chamber view

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Figure 3: Encapsulated cystic mass in the right ventricular apex

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Figure 4: Avascular cystic mass

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Figure 5: Large 40 mm × 42 mm cystic mass embedded in apical musculature

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With the suspicion of hydatid cyst, a computed tomography (CT) thorax was advised to further characterize the lesion. Thoracic CT confirmed the presence of a cystic lesion in the apical part of the interventricular septum clinching the diagnosis of cardiac hydatid cyst [Figure 6], [Figure 7], [Figure 8] and further revealed two additional large cysts in the liver in both the right and left lobes of the liver, respectively [Figure 9] and [Figure 10].
Figure 6: Cardiac hydatid cyst on computed tomography thorax – coronal view

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Figure 7: Cardiac hydatid cyst on computed tomography thorax – coronal view

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Figure 8: Cardiac hydatid cyst on computed tomography thorax – sagittal view

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Figure 9: Two large hydatid cysts in the liver in the right and left lobes respectively

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Figure 10: Two large hydatid cysts in the liver in the right and left lobes respectively

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In view of the atypical location of the cardiac hydatid cyst with incidental detection of additional cysts in the liver, this case is being reported.


  Discussion Top


Although cardiac hydatid cysts can be fatal, they are rare and often asymptomatic in their early stages. Therefore, clinical suspicion is important for the correct diagnosis. Echocardiography, being reliably informative, easy-to-perform, and efficient, is the diagnostic modality of choice for cardiac echinococcosis, whereas CT and magnetic resonance imaging provide additional information about the extent and anatomic relationships of the cysts. On echocardiography, the young cyst looks anechoic with well-delineated fluid content, whereas the old cyst appears as dense echo zones (from daughter vesicles, trabeculations, and calcifications) along with anechoic zones.[8]

Cysts growing toward the epicardium can compress the small coronary arteries, disturbing blood flow. This may lead to the misdiagnosis of coronary artery disease.[9]

In the rare instances in which cardiac echinococcal cysts involve the interventricular septum, they can cause symptoms related to compression of the conduction pathway (atrioventricular block and syncopal attacks) and obstruction of the right or left ventricular outflow tract.[10],[11]

In the case being reported here, a provisional clinical diagnosis of coronary artery disease was made, in view of the clinical presentation, ischemic changes in ECG and raised cardiac enzymes. However, the routine bedside transthoracic echocardiogram done to evaluate the regional wall motion, unraveled the large hydatid cyst lodged in the apical portion of the interventricular septum. The large 40 mm × 42 mm size cyst found jutting into the right ventricle also caused significant compression onto the interventricular septum, possibly compressing the intramural coronary arteries resulting in ischemic ECG changes and symptomatology.

Combined surgical resection of an interventricular cardiac hydatid cyst, washout of the remaining cavity with hypertonic saline solution, and concurrent albendazole therapy typically can yield excellent results.[12] However, the presence of two additional hydatid cysts in the liver, in this case, makes the management more challenging.


  Conclusion Top


Hydatid cyst of the heart and, specifically, the interventricular septum is rare. The intracavitary rupture of the cyst may lead to anaphylactic reaction and profound circulatory collapse, making its diagnosis a surgical emergency. The removal of the cyst would also improve myocardial compliance and myocardial perfusion. This case is being reported to emphasize the role of bedside echocardiography, in the most unsuspecting clinical settings, in the diagnosis, and modern-day management of patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Parikh F. Echinococcosis – Cut to cure but what about control? J Assoc Physicians India 2012;60:9-10.  Back to cited text no. 1
    
2.
Pakis I, Akyildiz EU, Karayel F, Turan AA, Senel B, Ozbay M, et al. Sudden death due to an unrecognized cardiac hydatid cyst: Three medicolegal autopsy cases. J Forensic Sci 2006;51:400-2.  Back to cited text no. 2
    
3.
Soleimani A, Sahebjam M, Marzban M, Shirani S, Abbasi A. Hydatid cyst of the right ventricle in early pregnancy. Echocardiography 2008;25:778-80.  Back to cited text no. 3
    
4.
Aleksic-Shihabi A, Vidolin EP. Cystic echinococcosis of the heart and brain: A case report. Acta Med Okayama 2008;62:341-4.  Back to cited text no. 4
    
5.
Niarchos C, Kounis GN, Frangides CR, Koutsojannis CM, Batsolaki M, Gouvelou-Deligianni GV, et al. Large hydatic cyst of the left ventricle associated with syncopal attacks. Int J Cardiol 2007;118:e24-6.  Back to cited text no. 5
    
6.
Dursun M, Terzibasioglu E, Yilmaz R, Cekrezi B, Olgar S, Nisli K, et al. Cardiac hydatid disease: CT and MRI findings. AJR Am J Roentgenol 2008;190:226-32.  Back to cited text no. 6
    
7.
Umesan CV, Kurian VM, Verghese S, Sivaraman A, Cherian KM. Hydatid cyst of the left ventricle of the heart. Indian J Med Microbiol 2003;21:139-40.  Back to cited text no. 7
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8.
Atilgan D, Kudat H, Tükek T, Ozcan M, Yildirim OB, Elmaci TT, et al. Role of transesophageal echocardiography in diagnosis and management of cardiac hydatid cyst: Report of three cases and review of the literature. J Am Soc Echocardiogr 2002;15:271-4.  Back to cited text no. 8
    
9.
Tuncer E, Tas SG, Mataraci I, Tuncer A, Donmez AA, Aksut M, et al. Surgical treatment of cardiac hydatid disease in 13 patients. Tex Heart Inst J 2010;37:189-93.  Back to cited text no. 9
    
10.
Mohsen T, El Beharry N, Maree T, Akl ES. Cardiac echinococcosis of the interventricular septum in early childhood: Report of two cases. J Thorac Cardiovasc Surg 2009;137:e14-6.  Back to cited text no. 10
    
11.
Shehatha J, Alward M, Saxena P, Konstantinov IE. Surgical management of cardiac hydatidosis. Tex Heart Inst J 2009;36:72-3.  Back to cited text no. 11
    
12.
Ipek G, Omeroglu SN, Goksedef D, Balkanay OO, Kanbur E, Engin E, et al. Large cardiac hydatid cyst in the interventricular septum. Tex Heart Inst J 2011;38:719-22.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]



 

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