pulmonary manifestations of echinococcus and other parasites
TRANSCRIPT
Pulmonary manifestations Pulmonary manifestations of of EchinococcusEchinococcus
and other parasitesand other parasites
Esther FreemanEsther FreemanHarvard Medical SchoolHarvard Medical School
Radiology ClerkshipRadiology ClerkshipSeptember 17, 2007September 17, 2007
Our patient Ms. ROur patient Ms. R
29 year old female presenting with left29 year old female presenting with left--sided sided inspirational chest pain and inspirational chest pain and ““bubblingbubbling””
soundsound
1 year ago, had left1 year ago, had left--sided rib/chest/LUQ painsided rib/chest/LUQ pain
SmokerSmoker
No known history of traumaNo known history of trauma
HIV negativeHIV negative
Lived in St. Petersburg Russia until she was 17Lived in St. Petersburg Russia until she was 17
Remote travel to Turkish resort, Virgin IslandsRemote travel to Turkish resort, Virgin Islands
Fever of 101.5 F Fever of 101.5 F
Patient R: Complex Mass on PA CXRPatient R: Complex Mass on PA CXR
BIDMC, PACS
Patient R: Complex mass on PA CXRPatient R: Complex mass on PA CXR
=thin walled cavity
= hyperdense solid component
BIDMC, PACS
Patient R: Complex mass on lateral CXRPatient R: Complex mass on lateral CXR
BIDMC, PACS
Differential diagnosis of a cystic Differential diagnosis of a cystic structure in the lung parenchymastructure in the lung parenchyma
InfectionInfection
AbcessAbcess
TBTB
AspergillosisAspergillosis
PneumocystisPneumocystis
pneumonia (PCP)pneumonia (PCP)
EchinococcusEchinococcus
SuperSuper--infected congenital lesions, such asinfected congenital lesions, such as
BronchogenicBronchogenic
cystcyst
Congenital cystic Congenital cystic adenomatoidadenomatoid
malformation (CCAM)malformation (CCAM)
SquamousSquamous
cell carcinoma:cell carcinoma:
PrimaryPrimary
MetastasisMetastasis
Emphysema Emphysema
PostPost--traumatic traumatic bullaebullae
Patient R: Complex mass on Patient R: Complex mass on nonnon--contrast chest CTcontrast chest CT
BIDMC, PACS
Patient R: Complex mass on chest CT w/ contrastPatient R: Complex mass on chest CT w/ contrast
BIDMC, PACS
BIDMC, PACS
Patient R: Complex mass on chest CT w/ contrastPatient R: Complex mass on chest CT w/ contrast
Has our differential changed?Has our differential changed?
InfectionInfection
AbcessAbcess
TBTB
AspergillosisAspergillosis
PneumocystisPneumocystis
pneumonia (PCP)pneumonia (PCP)
EchinococcusEchinococcus
SuperSuper--infected congenital lesions, such asinfected congenital lesions, such as
BronchogenicBronchogenic
cystcyst
Congenital cystic Congenital cystic adenomatoidadenomatoid
malformation (CCAM)malformation (CCAM)
SquamousSquamous
cell carcinoma:cell carcinoma:
PrimaryPrimary
MetastasisMetastasis
Emphysema Emphysema
PostPost--traumatic traumatic bullaebullae
The mass is thin-walled with an air crescent sign:
Companion Patients 1 & 2: Companion Patients 1 & 2: Lung Abscess on CXR and CTLung Abscess on CXR and CT
RadioGraphics 2005;25:1183-1195 http://www.mevis.de/~hhj/Lunge/xSammlungInf2Fr.html
Companion Patient 1 Companion Patient 2Thick-walled abscess with an air fluid level
Companion Patients 3 & 4: Companion Patients 3 & 4: CavitaryCavitary TB on CXR and CTTB on CXR and CT
Radiographics. Tuberculosis from head to Toe. 2000;20:449-470
Companion Patient 3 Companion Patient 4
Thick-walled Infiltrate with multiple cavities
Companion Pt 5: Mobile Companion Pt 5: Mobile aspergillomaaspergilloma
within pulmonary within pulmonary
cystic cavity (CT)cystic cavity (CT)
“Air crescent sign”
Radiographics. Spectrum of Pulmonary Aspergillosis: Histologic, Clinical, and Radiologic Findings. 2001;21:825-837
Companion Patient 5
Companion Pt 5: Mobile Companion Pt 5: Mobile aspergillomaaspergilloma
within pulmonary within pulmonary
cystic cavity (CT)cystic cavity (CT)
“Air crescent sign”
Radiographics. Spectrum of Pulmonary Aspergillosis: Histologic, Clinical, and Radiologic Findings. 2001;21:825-837
Companion Patient 5
Companion Pt 6: PCP Pneumonia Companion Pt 6: PCP Pneumonia (CT)(CT)
Radiographics Sider et al. 1993. 13 (4): 771.
Companion Patient 6
Companion Patient 7: Companion Patient 7: BronchogenicBronchogenic
Cyst on CXR and CTCyst on CXR and CT
Radiographics. Congenital Anomalies of the Tracheobronchial Tree, Lung, and Mediastinum: Embryology, Radiology, and Pathology. 2003;24:e17
Companion Patient 7
Companion Patient 8: Complicated Companion Patient 8: Complicated bronchogenicbronchogenic
cyst on CXR and CTcyst on CXR and CT
RadiographicsRadiographics..
Congenital Anomalies of the Congenital Anomalies of the TracheobronchialTracheobronchial
Tree, Lung, and Tree, Lung, and Mediastinum:EmbryologyMediastinum:Embryology, Radiology, and Pathology. 2003;24:e17 , Radiology, and Pathology. 2003;24:e17
Companion Patient 8
Thick-walled, air fluid level
Companion Pts 9, 10, &11: Companion Pts 9, 10, &11: Congenital cystic Congenital cystic adenomatoidadenomatoid
malformation (CCAM)malformation (CCAM)
Radiographics Rosado-de-Christenson and Stocker 11 (5): 865. Radiographics. Berrocal et al. 2003;24:e17
Companion Patient 9
Companion Patient 11: Infected w/ air fluid levels
Companion Patient 10
Companion Pt 12: Primary Companion Pt 12: Primary SquamousSquamous Cell Carcinoma on CTCell Carcinoma on CT
Radiographics. Hartman et al. 17 (2): 377. (1997)
Companion Patient 12Multiple, thick-walled cavities
Companion Patients 13 & 14: Companion Patients 13 & 14: CavitatingCavitating
metastases of metastases of squamoussquamous
cell carcinoma on CXR and CTcell carcinoma on CXR and CT
Radiographics. Atypical Pulmonary Metastases: Spectrum of Radiologic Findings. 2001;21:403-417
Companion Patient 13
Companion Patient 14
Companion Patient 15: Companion Patient 15: BullousBullous emphysema on CXR and CTemphysema on CXR and CT
Radiographics. 2002;22:S119-S135 Companion Patient 15: Hx
of IV drug use and smoking
Companion Patient 16: Companion Patient 16: PneumatocelePneumatocele
(post trauma)(post trauma)
Radiographics. Pneumomediastinum Revisited. 2000;20:1043-1057
Companion Patient 16: thick-walled pneumatocele
w/ air fluid level
Companion Patient 17: Companion Patient 17: PneumatocelePneumatocele
(post staph)(post staph)
Radiographics. Kuhlman et al. Abnormal Air-filled Spaces in the Lung. 13 (1): 47. (1993)
Companion Patient 17
LetLet’’s return to Patient Rs return to Patient R
She returned to the hospital 10 days later with worsening symptoms
22ndnd
presentation to hospitalpresentation to hospital
Worsening chest pain radiating to left shoulderWorsening chest pain radiating to left shoulder
ChillsChills
Increasing Increasing ““cough attackscough attacks””
Negative Weinberg reaction Negative Weinberg reaction
Patient R: Complex mass on PA CXR Patient R: Complex mass on PA CXR over timeover time
BIDMC, PACS
Day 1 Day 10
Patient R: Complex mass on CXR Patient R: Complex mass on CXR over timeover time
Day 1 Day 10vs.
BIDMC, PACS
Patient R: Mass on nonPatient R: Mass on non--contrast chest CTcontrast chest CT
(2(2ndnd
presentation to hospital)presentation to hospital)
BIDMC, PACS
Patient R: Patient R: Mass on nonMass on non--contrast chest CTcontrast chest CT (2(2ndnd
presentation to hospital)presentation to hospital)
BIDMC, PACS
Narrowed Differential DiagnosisNarrowed Differential Diagnosis
InfectionInfection
EchinococcusEchinococcus
AbscessAbscess
SuperSuper--infected congenital lesions, such asinfected congenital lesions, such as
BronchogenicBronchogenic
(congenital) cyst (congenital) cyst
Congenital cystic Congenital cystic adenomatoidadenomatoid
malformation malformation
Diagnosis:Diagnosis: EchinococcusEchinococcus
((HydatidHydatid
Disease)Disease)
EchinococcusEchinococcus
EchinococcusEchinococcus
= = cestodecestode
(tapeworm)(tapeworm)
Cystic Cystic echinococcusechinococcus: :
EchinococcusEchinococcus
granulosusgranulosus, E , E multilocularismultilocularis, E , E vogelivogeli
Infection from ingesting foods/fluids contaminated Infection from ingesting foods/fluids contaminated w/eggw/egg--containing fecescontaining feces
Released larvae (Released larvae (oncospheresoncospheres) invade bowel wall, ) invade bowel wall, migrate to portal system initiallymigrate to portal system initially
In lung, can be In lung, can be unilocularunilocular, alveolar or polycystic, alveolar or polycystic
EchinococcusEchinococcus
(E (E GranulosusGranulosus))
users.unimi.it/parassit/immagini.htm http://www.atlas.or.kr/
EchinococcusEchinococcus
life cyclelife cycle
Radiographics. Hydatid Disease: Radiologic and Pathologic Features and Complications 2000;20:795-817
EchinococcusEchinococcus
worldwideworldwide
Red = E granulosus; Black = E multilocularis; Green = E vogeli
Martinez, S. et al. Radiographics 2005;25:135-155
Companion Patients 18 & 19: Companion Patients 18 & 19: EchinococcusEchinococcus
in the liver on CTin the liver on CT
Radiographics. Hydatid Disease: Radiologic and Pathologic Features and Complications 2000;20:795-817
Companion Patient 18 Companion Patient 19
Routes to lungRoutes to lung
TransdiaphragmaticTransdiaphragmatic
Parasite migrates from liver to pleural cavityParasite migrates from liver to pleural cavity
HematogenousHematogenous
spreadspread
Direct Direct hematogenoushematogenous
dissemination to lung possibledissemination to lung possible
1010--30% of patients have only lung involvement30% of patients have only lung involvement
Companion Patient 20 & 21: Companion Patient 20 & 21: UnilocularUnilocular vs. polycystic vs. polycystic echinococcusechinococcus
on CTon CT
Unilocular cystic: E granulosus
(lung involvement more common)
Polycystic: E vogeli
(lung involvement rare)
Martinez, S. et al. Radiographics 2005;25:135-155
Companion Patient 20
Companion Patient 21
Pathology: Pathology: EchinococcalEchinococcal
Lung CystLung Cyst
www.atlas.or.kr
Typical Clinical Presentation Typical Clinical Presentation of lung involvementof lung involvement
Asymptomatic for months Asymptomatic for months ––
yearsyears
CoughCough
HemoptysisHemoptysis
BilioptysisBilioptysis
Chest painChest pain
FeverFever
Symptoms relating to complications (next slide)Symptoms relating to complications (next slide)
ComplicationsComplications
Hepatic complications:Hepatic complications:
Rupture & anaphylaxisRupture & anaphylaxis
InfectionInfection
ExophyticExophytic
growthgrowth
Peritoneal seedingPeritoneal seeding
TransdiaphragmaticTransdiaphragmatic
migrationmigration
Perforation into hollow visceraPerforation into hollow viscera
BiliaryBiliary
communicationcommunication
Portal vein involvementPortal vein involvement
Abdominal wall invasionAbdominal wall invasion
HematogenousHematogenous
spreadspread
Pulmonary complications:Pulmonary complications:
PEPE
PneumothoraxPneumothorax
Rupture & anaphylaxis (less Rupture & anaphylaxis (less severe)severe)
Bacterial infection of cyst postBacterial infection of cyst post--
rupturerupture
TreatmentTreatment
AlbendazoleAlbendazole, , MebendazoleMebendazole, , PraziquantelPraziquantel
Long courseLong course
Ideally, preIdeally, pre--surgerysurgery
SurgerySurgery
Other Parasitic Infections with Other Parasitic Infections with Thoracic Manifestations Thoracic Manifestations
ProtozoaProtozoa
AmebiasisAmebiasis
MalariaMalaria
TrypanosomiasisTrypanosomiasis
NematodesNematodes
AscariasisAscariasis
StrongyloidiasisStrongyloidiasis
DirofilariasisDirofilariasis
CestodesCestodes
Cystic Cystic echinococcosisechinococcosis
TrematodesTrematodes
SchistosomiasisSchistosomiasis
ParagonimiasisParagonimiasis
Protozoa: MalariaProtozoa: Malaria
P P falciparumfalciparum, P , P vivaxvivax, P , P ovaleovale, P , P malariaemalariae
Fever, chills, sweating, anemia, leucopenia, Fever, chills, sweating, anemia, leucopenia, splenomegalysplenomegaly
Diagnosis: Diagnosis: trophozoitestrophozoites
within erythrocytes on within erythrocytes on
smearsmear
Pulmonary manifestation: ARDSPulmonary manifestation: ARDS
http://www.dpd.cdc.gov/dpdx/HTML/ImageLibrary/Malaria_il.htm
Companion Patient 22:Companion Patient 22: P P falciparumfalciparum malaria malaria --
ARDSARDS
Martinez, S. et al. Radiographics 2005;25:135-155
TrematodesTrematodes: : SchistosomiasisSchistosomiasis
S S hematobiumhematobium, S , S mansonimansoni, S , S japonicumjaponicum
22ndnd
cause of mortality due to parasitescause of mortality due to parasites
Infection from skin exposure to water infected Infection from skin exposure to water infected w/ w/ cercariaecercariae
excreted by snailsexcreted by snails
Penetrate skin, migrate to lung then liverPenetrate skin, migrate to lung then liver
http://www.dpd.cdc.gov/dpdx/HTML/ImageLibrary/Schistosomiasis_il.htm
Lifecycle of Lifecycle of schistosomiasisschistosomiasis
Martinez, S. et al. Radiographics 2005;25:135-155
SchistosomiasisSchistosomiasisDay 1-2 SKIN
Day 4-7: LUNG
Day 8: PORTAL
Schistosomulum
http://www.brown.edu/Courses/Bio 160/Projects1999/schisto/schistobody.html
Companion Patient 23: Early Companion Patient 23: Early pulmonary pulmonary schistosomiasisschistosomiasis
on CTon CT
Martinez, S. et al. Radiographics 2005;25:135-155
Companion Patient 24: Advanced Companion Patient 24: Advanced pulmonary pulmonary schistosomiasisschistosomiasis
--
corcor
pulmonalepulmonale
Protozoa: Protozoa: AmebiasisAmebiasis
EntamoebaEntamoeba
histolyticahistolytica
33rdrd
cause of mortality from parasitescause of mortality from parasites
Liver Liver abcessabcess
most common non intestinalmost common non intestinal
PleuropulmonaryPleuropulmonary
involvement next most involvement next most
common manifestationcommon manifestation
Direct from liver Direct from liver abcessabcess
HematogenousHematogenous
spreadspread
AspirationAspiration
AmebiasisAmebiasis
lifecyclelifecycle
Companion Patients 25 & 26: Companion Patients 25 & 26: AmebiasisAmebiasis
Martinez, S. et al. Radiographics 2005;25:135-155
Companion Patient 25 Pleural effusion, consolidation
Companion Patient 26 Elevation of hemidiaphragm, consolidation, cavitation
LetLet’’s return to our s return to our patient, Ms. Rpatient, Ms. R
She underwent left lower lobectomy
Patient R: CXR Patient R: CXR s/ps/p
lobectomylobectomyDay 12 (course), post op day 2Day 10 (course), immed post surg
PAPortable AP semi-upright
Patient R: CXR Patient R: CXR s/ps/p
lobectomylobectomyDay 28 (course), post op day 18
In conclusionIn conclusion……
A Dipylidum
caninum
says goodbye…
http://ipath.blogs.com/photos/uncategorized/tapeworm_1.jpg
AcknowledgementsAcknowledgements
Mara Barth, MD Mara Barth, MD
With many thanks for reviewing this case with meWith many thanks for reviewing this case with me
Martin Martin GoyenecGoyenec, MD, MD
For first introducing me to Ms. RFor first introducing me to Ms. R’’s imagess images
Gillian Lieberman, MDGillian Lieberman, MD
NycaNyca
BowenBowen