Published by Basra Journal of Surgery in March 1998 Abstract: Pleural hydatidosis is almost always secondary to pulmonary or hepatic hydatid cysts. Primary hydatid disease of the pleura (i.e. originating from larvae transported by blood and landing upon pleural surfaces) is denied to exist . The extrusion of lung hydatid into the pleura is relatively a rare condition. The reported incidence in the literature is 1 out of 189 cases and 2.41 of 246 cases. Emergence of intact small cysts might be possible, but the larger cysts usually rupture. This is followed by massive pneumothorax, as air enters freely via the bronchial openings. Large amounts of fresh hydatid fluid pours over the pleural surfaces and anaphylactic reaction may follow. Untreated bronchopleural fistulae are unlikely to close and empyaema thoracis certainly ensues. Herein, we report a case of empyaema secondary to intrapleural rupture of lung hydatid cyst. The incidence, pathology, symptomatology and methods of management are discussed.

1. Bas J Surg. Vol 4 No. 1 March 1998 p72-74.
Empyaema Thoracis Secondary to Intrapleural Rupture of Pulmonary Hydatid
Cyst: A Case Report.
BY
Prof. Abdulsalam Y Taha
Introduction:
Pleural hydatidosis is almost always secondary to pulmonary or hepatic hydatid
cysts. Primary hydatid disease of the pleura (i.e. originating from larvae
transported by blood and landing upon pleural surfaces) is denied to exist 1. The
extrusion of lung hydatid into the pleura is relatively a rare condition 1, . The
reported incidence in the literature is 1 out of 189 cases and 2.41 of 246 cases 1.
Emergence of intact small cysts might be possible, but the larger cysts usually
rupture. This is followed by massive pneumothorax, as air enters freely via the
bronchial openings. Large amounts of fresh hydatid fluid pours over the pleural
surfaces and anaphylactic reaction may follow 1, 3-6. Untreated bronchopleural
fistulae are unlikely to close and empyaema thoracis certainly ensues. Herein, we
report a case of empyaema secondary to intrapleural rupture of lung hydatid cyst.
The incidence, pathology, symptomatology and methods of management are
discussed.
Case 1:
A 17 years old unmarried Iraqi girl had been admitted to another hospital a
month earlier with sudden shortness of breath and left-sided chest pain. Chest
radiograph at that time revealed completely collapsed left lung and hydro
pneumothorax. She had been managed by insertion of apical and basal chest
tubes. Air leak persisted. Fever developed, with pus being continually drained via
the tubes. Antituberculous drugs were given without s response. She was then
transferred to the Department of Thoracic and Cardiovascular Surgery in Basrah
University Teaching Hospital. She looked toxic with mild shortness of breath. The
chest tubes drained thick pus with minimal air leak (Bronchopleural Fistula). The

2. chest film showed thickened parietal and visceral pleurae, gas-fluid level (
pyopneumothorax) and completely collapsed lung. The HB was 11.1 g/dl, the
leukocyte count= 13900 cell/cmm, ESR= 115 mm/hr, FBS= 90 mg/dl and blood
urea= 20 mg/dl. Culture and sensi=vity test of pus revealed a mixed growth of
Klebsiella and E Coli slightly sensitive to rifampicin. The patient was operated
upon via le? posterolateral 5th space thoracotomy (single lumen endotracheal
tube general anaesthesia). Apart from the marked thickening of pleural surfaces
and foul smelling pus filling the pleural space, the surprising finding was the
laminated membrane of ruptured hydatid cyst floating in the empyaema cavity.
Multiple small bronchial fistulae were seen in the left upper lobe. The membrane
and pus were removed. Decortication was performed. The fistulae were closed by
0-silk sutures. The lung was healthy and expandable. The chest was closed with 2
drainage tubes. The postoperative course was uneventful apart from mild wound
infec=on managed conserva=vely. She was discharged home 3 weeks later in a
perfect health.
Figure 1. le?-sided pyopneumothorax. Figure 2. Postoperative CXR.
Discussion:
Rupture of pulmonary hydatid into the pleura is a distinct clinical entity which
requires a considerable clinical awareness to be recognized 1. It is relatively rare.
Bakir and Al-Omeri (1969) described 5 cases 5 while another case was reported by
Jesiot, Romanoff and Yaacob (1972) 6. The clinical picture is dominated by
pneumothorax and anaphylactic reaction. The pneumothorax can be of the

3. tension type; the collapsed lung throwing the edges of the opened pericyst cavity
into folds which act as a valve 1. The anaphylactic reaction results from absorption
of hydatd fluid via the pleura into the circulation. The combination of massive
pneumothorax and anaphylaxis may prove fatal 1,6. The condition is almost always
misdiagnosed as tuberculosis, due to the prevalence of tuberculosis in many areas
of the world endemic to hydatid disease 1. In the acute phase, the management
consists of parenteral steroids (for anaphylaxis) and placement of chest tubes 1,3.
Preoperative diagnosis is difficult; however, certain observations give hints.
Besides residence in an area endemic to hydatid disease, the drainage of crystal
clear fluid via the chest tube, the presence of pieces of laminated membrane (
plugging the tube sometimes), the persistent air leak ( which may necessitates
second or even a third tube) and features of anaphylaxis like urticaria and
bronchospasm, are helpful 1. The chest radiograph may show irregular gas-fluid
level due to the laminated membrane floating in the pleural space 1. Examination
of pleural fluid for scolices may be positive 1. Eosinophilia may be a valuable
pointer in the investigation of pleural effusions of doubtful origin if the source
was a rupture of a pulmonary hydatid 3. The definitive diagnosis and treatment is
by thoracotomy. Even if the patient recovers from the initial ill effects of the
pneumothorax, spontaneous closure of the bronchial openings is unlikely. Once
empyaema is added to the picture, expansion of the lung becomes even more
unlikely. Nothing short of thoracotomy can help these patients in the acute or
chronic phase. The time to do a thoracotomy is as soon as the patient has
recovered from the hazards of the pneumothorax and possible allergic
manifestations 1.
References:
1. Saidi F., Surgery of Hydatid Disease. W.B. Saunders Co. Ltd. London.
1976.
2. Rakower J and Milwidsky H. Hydatid Pleural Disease: Case Report.
American Review of Respiratory Diseases. 1964; 90: 623-631.
3. J Leigh Collis, D.B Clarke and R Abbey Smith. Human Pulmonary Hydatid
Disease in d, Abreu, s Practice of Cardiothoracic Surgery. Edited by
Edward Arnold. 1976; p.1544.

4. 4. R.A. Clark. Pulmonary Hydatid Disease, in Essential Surgical Practice.
Edited by A. Cushieri, G.R. Giles and A.R. Moosa, Wright. London. 1988;
p 562.
5. Bakir F and Al-Omeri M A. Echinococcal Tension Pneumothorax. Thorax.
1969; 24: 547-556.
6. Jesioter M, Romanoff H and Yaacob B. Pneumothorax Following
Rupture of a Primary Pleural Hydatid Cyst. J of Thoracic and
Cardiovascular Surgery. 1972. 63: 594-598.
Correspondence to:
Prof. Abdulsalam Y Taha
Head of Department of Thoracic and Cardiovascular Surgery
College of Medicine
University of Sulaimani
Sulaimani
Region of Kurdistan
Iraq
Mobile: 00964 770 151 0420
E mail: salamyt_1963@hotmail.com