|Year : 2013 | Volume
| Issue : 1 | Page : 85-86
Pulmonary hydatid disease with coexistent aspergillosis: An incidental finding
S Agarwal1, S Bohara1, A Thakran1, P Arora1, R Singh2, PN Agarwal2
1 Department of Pathology, Maulana Azad Medical College, Bahadur Shah Zafar Marg, New Delhi, India
2 Department of Surgery, Maulana Azad Medical College, Bahadur Shah Zafar Marg, New Delhi, India
|Date of Submission||12-Jun-2012|
|Date of Acceptance||04-Aug-2012|
|Date of Web Publication||15-Mar-2013|
Department of Pathology, Maulana Azad Medical College, Bahadur Shah Zafar Marg, New Delhi
Source of Support: None, Conflict of Interest: None
There are only a few case reports in the literature on the coexistence of aspergillosis and echinococcosis. We report a case of a 45-year-old immunocompetent patient who presented with a history of intermittent fever and cough with haemoptysis. Chest x-ray and CECT showed a large cystic lesion in right lower lobe with multiple floating membranes. Histopathological examination of cyst wall revealed the laminated membrane of hydatid cyst along with infiltration of its wall with septate fungal hyphae with acute angle branching suggestive of aspergillosis.
Keywords: Aspergillus, hydatid, lung
|How to cite this article:|
Agarwal S, Bohara S, Thakran A, Arora P, Singh R, Agarwal P N. Pulmonary hydatid disease with coexistent aspergillosis: An incidental finding. Indian J Med Microbiol 2013;31:85-6
|How to cite this URL:|
Agarwal S, Bohara S, Thakran A, Arora P, Singh R, Agarwal P N. Pulmonary hydatid disease with coexistent aspergillosis: An incidental finding. Indian J Med Microbiol [serial online] 2013 [cited 2020 Apr 9];31:85-6. Available from: http://www.ijmm.org/text.asp?2013/31/1/85/108740
| ~ Introduction|| |
Aspergilloma is a saprophytic infection which colonises pre-existing lung cavities which are formed as a result of diseases such as tuberculosis, sarcoidosis, bronchiectasis, lung abscess and cavitary neoplasia. Co-existence of fungi with echinococcal (hydatid) cyst is seen more commonly in immunocompromised patients.  Such a coexistence of hydatid cyst with fungi resembling Aspergillus is extremely rare and has been documented in only five case reports till date.8 We report a case of hydatid cyst in the lung with coexistent invasive aspergillosis in a 45-year-old female with a normal immune status and no significant past or present history of any other disease.
| ~ Case Report|| |
A 45-year-old female presented to the hospital with a six-month history of intermittent fever and cough with haemoptysis. There was no history suggestive of Tuberculosis. Patient was a non-alcoholic and non-smoker. Her general physical examination and laboratory examination were normal. Chest examination revealed decreased chest movements and breath sounds on right side with dullness in the infra-scapular region. Patient was non-reactive for human immunodeficiency virus and sputum smears were negative for acid-fast bacilli and fungus.
Chest x-ray showed irregular thick-walled cystic area in right lower zone with blunting of right cardiophrenic angle suggestive of effusion. Rest of the lung fields were clear [Figure 1]a. CECT revealed a large cystic lesion in right lower lobe with multiple floating membranes in dependent patient like hydatid cyst with minimal right pleural effusion and consolidation of adjacent lung parenchyma [Figure 1]b. No abnormality was detected in any other organ. Clinicoradiological diagnosis of hydatid cyst was made. Patient underwent surgery and specimen was sent for histopathological examination. Grossly, we received a cut open cystic structure measuring 8 × 8 cm devoid of contents [Figure 2]a. Histopathological examination of cyst wall revealed the laminated membrane of hydatid cyst along with Echinococcus hooklets and infiltration of its wall with septate fungal hyphae with acute angle branching, consistent with aspergillosis [Figure 2]b. These fungal hyphae were positive with periodic acid-Schiff and Grocotts methenamine silver. Culture studies were positive for Aspergillus fumigatus.
|Figure 1: (a) Chest x-ray showing irregular thick-walled cystic area in right lower zone with blunting of right cardiophrenic angle suggestive of effusion. (arrow) (b) CECT showing a large cystic lesion in right lower lobe with multiple fl oating membranes in dependent patient like hydatid cyst with minimal right pleural effusion and consolidation of adjacent lung parenchyma. (arrow)|
Click here to view
|Figure 2: (a) Gross specimen showing a cut open cystic structure measuring 8× 8 cm devoid of contents. (b) Histopathological examination of cyst wall revealing the laminated membrane of hydatid cyst and infi ltration (arrow) of its wall with septate fungal hyphae with acute angle branching, consistent with aspergillosis. (Haematoxylin and Eosin stain, ×400 magnifi cation)|
Click here to view
| ~ Discussion|| |
Hydatid cyst is a zoonotic disease most commonly caused by Echinococcus granulosus, while Echinococcus multilocularis is the most common cause of pulmonary involvement. Human beings acquire the disease by ingesting the parasite eggs and are the intermediate hosts. Liver and lungs are most commonly affected organ; however, infection can occur in any organ of the body.  Aspergillosis is a saprophytic fungal infection most commonly caused by A. fumigatus. Aspergillus may cause allergic pulmonary aspergillosis, aspergilloma, and semi-invasive and invasive aspergillosis.  Typically, aspergilloma develop in cavities formed as a result of tuberculosis, sarcoidosis, bronchiectasis and lung abscess. Immune suppression and structural pulmonary defects may predispose to this infection. There are only a few case reports in the literature on the coexistence of aspergillosis and echinococcosis. ,,,,
Aspergillus tends to invade the blood vessels; therefore, the most common symptom in pulmonary aspergillosis is haemoptysis which was present in our patient as well. Such a coexistence of hydatid cyst with fungi resembling Aspergillus is extremely rare and has been documented in only few case reports till date. It is important that we do not confuse this condition with colonisation sometimes seen after hydatid cystectomy that is no different from aspergilloma forming in preformed lung cavities.  The pathogenesis of this association remains unknown, but the cavity needs to be in communication with the airways so that fungal spores can colonise the cavity space. Although patients with immune deficiencies are prone to aspergillosis, the coexistence of Aspergillus and hydatid cyst has been reported in both immunocompromised and immunocompetent patients. Our patient was immunocompetent and no underlying pathology in the lungs that may predispose to aspergillosis was found. Study by Kocer et al. has shown that pulmonary echinococcosis leads to higher susceptibility to saprophytic fungal co-infection than echinococcosis located in other sites of the body. Although radiological imaging procedures can accurately diagnose both echinococcosis and aspergillosis, our case was reported as having an 'infected hydatid cyst' by CT. It is important to identify both these infections for the adequate management of these patients. Our patient was immunocompetent and no post-operative complication or dissemination of either infection occurred. Although the co-infection has been an incidental finding in our patient, a very high index of suspicion is needed to predict the superimposed mycosis. Haemoptysis, which is more profuse in aspergillosis and does not occur in hydatid disease alone, may be such an indicator. Definitive diagnosis would be by histology or a positive culture, but serological markers may be useful.
Since reports appearing in literature are very few in number, there are no reliable data on the optimum management of these patients. Our patient was immunocompetent and no post-operative complication or dissemination of either infection was noted. However, in cases with ruptured cysts, especially in immunocompromised patients, the patient may be at risk of further Aspergillus infection, which may even advance to the invasive form.  Although rare, the co-existence may be life threatening and close follow-up and prophylactic chemotherapy for aspergillosis may be useful to prevent further complications. 
| ~ Conclusion|| |
The co-existence of hydatid cyst with aspergillosis is rare and the radiological diagnosis may or may not be helpful in detecting the fungal co-infection, so the authors recommend a cautious approach while excising all the hydatid cysts to prevent risk of rupture or any further complications.
| ~ References|| |
|1.||Manzoor MU, Faruqui ZS, Ahmed Q, Uddin N, Khan A. Aspergilloma complicating newly diagnosed pulmonary echinococcal (hydatid) cyst: A rare occurrence. Br J Radiol 2008;81:279-81. |
|2.||King CH. Cestodes (tapeworms). In: Mandell GL, Bennett JE, Dolin R, editors. Mandell, Douglas and Bennett's principles and practice of infectious diseases. 5 th ed. Philadelphia, USA: Churchill Livingstone; 2000. p. 2956-64. |
|3.||Sabonya RE. Fungal disease including pneumocystis. In: Churg AM, Myers JL, Talezaar HD, Wright JL, editors. Thurlbeck's pathology of the lung. 3 rd ed. New York, USA: Thieme; 2005. p. 283-315. |
|4.||Date A, Zachariah N. Saprophytic mycosis with pulmonary echinococcosis. J Trop Med Hyg 1995;98:416-8. |
|5.||Kini U. Invasive mycosis of a pulmonary hydatid cyst in a non-immunocompromised host. J Trop Med Hyg 1995;98:404-6. |
|6.||Gupta N, Arora J, Nijhawan R, Aggarwal R, Lal A. Aspergillosis with pulmonary echinococcosis. Cytojournal 2006;3:7. |
|7.||Kocer NE, Kibar Y, Guldur ME, Deniz H, Bakir K. A retrospective study on the coexistence of hydatid cyst and aspergillosis. Int J Infect Dis 2008;12:248-51. |
|8.||Vaideeswar P, Vyas M, Katewa A, Bhaskar M. Piggyback mycosis: Pulmonary hydatid cyst with a mycotic co-infection. Mycoses 2010;53:265-8. |
|9.||Aydemir B, Aydemir C, Okay T, Celik M, Dogusoy I. An aspergilloma in echinicoccal cyst cavity. Thorac Cardiovasc Surg 2006;54:353-5. |
|10.||Mullhall PP. Treatment of a ruptured hydatid cyst of lung with mebendazole. Br J Dis Chest 1980;74:306-8. |
[Figure 1], [Figure 2]