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 ~  Abstract
 ~  Case Report
 ~  Discussion
 ~  References

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CASE REPORT
Year : 2003  |  Volume : 21  |  Issue : 2  |  Page : 139-140
 

Hydatid cyst of the left ventricle of the heart


Institute of Cardiovascular Diseases, Madras Medical Mission, Chennai - 600 050, Tamil Nadu, India

Correspondence Address:
Institute of Cardiovascular Diseases, Madras Medical Mission, Chennai - 600 050, Tamil Nadu, India

 ~ Abstract 

Hydatid disease of the heart is rare. We report a case of hydatid cyst of left ventricle in a forty year old lady where the diagnosis was made intra-operatively. The transthoracic and transesophageal echocardiography showed a mixed echogenic mass arising from the left ventricle. The diagnosis of hydatid cyst was confirmed by the demonstration of scolex and hooklets in the cyst fluid. Hydatid cyst should be a differential diagnosis for a mixed echogenic mass on echocardiography.

How to cite this article:
Umesan C V, Kurian V M, Verghese S, Sivaraman A, Cherian K M. Hydatid cyst of the left ventricle of the heart. Indian J Med Microbiol 2003;21:139-40


How to cite this URL:
Umesan C V, Kurian V M, Verghese S, Sivaraman A, Cherian K M. Hydatid cyst of the left ventricle of the heart. Indian J Med Microbiol [serial online] 2003 [cited 2017 Sep 26];21:139-40. Available from: http://www.ijmm.org/text.asp?2003/21/2/139/7996


Hydatid disease of the heart is rare, but a potentially fatal pathology. It may cause valvular dysfunction, conduction disturbances or may lead to congestive heart failure [1]. The symptoms may be nonspecific and hence establishing an early diagnosis is difficult. We report a case of hydatid cyst of left ventricular free wall in which the diagnosis was made intra-operatively.

 ~ Case Report Top

A 40 year old female presented with history of dull aching left sided chest pain and palpitation. Her pulse rate was regular and 74 per minute and blood pressure was 130/80 mm Hg. Heart sounds were normal and there was no murmur. Chest and abdominal examinations were unremarkable. The haemogram was normal. The chest X-ray showed a localised bulge at the apex of heart, ECG revealed T wave inversion in leads I, II, avL and V4 -V6. Transthoracic echocardiography demonstrated a mixed echogenic mass of 54 x 51mm on the posterolateral aspect of left ventricular free wall subpericardially. Transesophgeal echocardiograhy confirmed the findings of a mass lesion with areas of hypoechogenicity . The cardiac MRI [Figure - 1] revealed a well defined smooth marginated lesion from the myocardium of left ventricular free wall. The pericardium was seen separately from the mass and there was no evidence of intracavitary extension.
Based on the MRI findings, a diagnosis of rhabdomyoma was made and surgical excision was advised. Peroperatively, a globular cystic mass was seen arising from the lateral wall of the left ventricle. The cyst was infected with thick purulent fluid and multiple smaller cysts were seen inside. The entire cyst was removed under cardiopulmonary bypass. Microscopic examination of cyst fluid revealed moderate number of free hooklets, one scolex and plenty of pus cells [Figure:2].
The Gram stain showed numerous pus cells and there were no organisms on smear. Culture on multiple media was negative at the end of four weeks. Histopathological examination also confirmed the diagnosis of hydatid cyst. The serum by ELISA was also positive for echinococcosis. Patient was started on albendazole (400mg twice daily) and discharged on seventh postoperative day. She was advised to continue albendazole for a period of 12 weeks.

 ~ Discussion Top

Hydatid disease (echinococcosis) is caused by larvae of Echinococcus granulosus. Larvae reach the right side of the heart through thoracic duct and superior venacava; from the right ventricle the embryo passes through the pulmonary capillaries into the left ventricle, from where it could reach any part of the body through the systemic circulation. Some authors have suggested transmigration of embryo through the interatrial and interventricular septum to the left side of the heart. Larvae reach the myocardium through the coronary circulation. Cardiac infestation may be asymptomatic or may present with clinical findings depending upon the size, localization and number of cysts.
Hydatid disease of the heart occurs in 0.5 - 2% of all hydatidosis in man.[2] There does not appear to be any age limit at presentation. Cyst may cause obstruction in the chamber of the heart or induce conduction disturbance.[3] Rupture of a cardiac cyst may result in anaphylactic shock, pulmonary embolism and systemic metastasis.[4] The cyst may remain asymptomatic and may be discovered incidentally. The left ventricle, the part of the heart that has the most abundant blood supply is involved most frequently (55 - 60%). Hydatid cyst of the left ventricle is usually localised sub-epicardially and rarely ruptures into the pericardial space. In our patient, the cyst was localised to the free wall of the left ventricle. Involvement of the inter-ventricular septum is reported in 5 - 9% of the cases.[5] Echocardiography, computerised tomography and magnetic resonance imaging are valuable diagnostic tools. High index of suspicion is necessary to make the diagnosis because of the rarity of the condition. In our patient, the diagnosis was missed preoperatively. However, intra-operatively the possibility of hydatid cyst was considered and necessary precautions were taken during the excision of the mass.
Surgical removal of the hydatid cyst remains the definitive treatment.[1] Risks at surgery from leakage of fluid include anaphylaxis and dissemination of the infected scolices. The latter complication can be minimised by the instillation of scolicidal solutions like hypertonic saline or ethanol. In our patient, after opening the cyst the whole contents were sucked out and hypertonic saline was instilled into the cyst cavity. After the removal of cyst, the whole pericardial cavity was washed with hypertonic saline. Hypertonic saline does not have any effect on the conduction system of the heart. Percutaneous aspiration has been effective in many cases of hepatic echinococcosis.[6] Puncture - aspiration of cyst contents -infusion of scolicidal agents and re-aspiration (PAIR) has been used as a percutaneous treatment in the management of cystic echinococcosis of the liver , peritoneum, spleen , kidneys and muscle.[7] PAIR is contraindicated for superficially located cysts, for cysts with multiple thick internal septae and for cysts communicating with the biliary tree. To the best of our knowledge, PAIR has not been used for cardiac echinococcosis.
The present unusual case exemplifies that one has to keep hydatid cyst in the differential diagnosis of a mixed echogenic mass on echocardiography. 

 ~ References Top

1.Kaplan M, Demirtas M, Cimen S, Ozler A. Cardiac hydatid cysts with intracavitary expansion Ann Thoracic Surg 2001;71:1587-1590.  Back to cited text no. 1    
2.Dighiero J, Canabal ES, Aguirre CV, Hazan J, Horjales JO. Echinococcus disease of the heart. Circulation 1958;17:127-132.  Back to cited text no. 2    
3.Agarwal DK, Agarwal R, Barthwal SP. Interventricular septal hydatid cyst presenting as complete heart block: Heart 1996;75:(3) p266.  Back to cited text no. 3    
4.Di Bello R, Menenotez H. Intracardiac rupture of hydatid cysts of heart. A study based on three personal observations and 101 cases in world literature. Circulation 1963;27:366-374.  Back to cited text no. 4    
5.Kulan K, Tuncer C, Kulan C et al. Hydatid cyst of the interventricular septum and contribuion of magnetic resonance imaging. Acta Cardiol 1995;50:323-326.  Back to cited text no. 5    
6.Khuroo MS, Wani NA, Janil G, Kham BA, Yatto GN, Shah AH, Jeelani SG .Percutaneous drainage compared with surgery for hepatic hydatid cysts. New Eng J Med 1997;337:881-887.   Back to cited text no. 6    
7.Gargouri M, Ben Amor N, Ben Chehida F, Hammou A,Gharbi HA, Ben Cheikh M,Kchouk H,Ayachi K,Golvan JY. Percutaneous treatment of hydatid cysts. (Echinococcus granulosis). Cardiovasc Intervent Radiol 1990;13:169-173.  Back to cited text no. 7    
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2004 - Indian Journal of Medical Microbiology
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