Pleural hydatid disease is rare.Tension pneumothorax and empyaema are also rare. A search through the net revealed less than 60 cases over 60 yrs all over the world. Bakir F and Al-Omeri reported 5 cases of Echinococcal Tension Pneumothorax in Iraq in 1969 for the first time.To the best of our knowledge, this is the 2nd report.HEREIN, TWO LADIES WITH PNEUMOTHORAX AND EMPYAEMA SECONDARY TO INTRAPLEURAL RUPTURE OF PHC ARE PRESENTED.THE AIM OF THIS REPORT IS TO EMPHASIZE THAT INTRAPLEURAL RUPTURE OF PHC SHOULD BE CONSIDERED IN ANY PATIENT WITH PNEUMOTHORAX IN AN ENDEMIC AREA.

2. INTRODUCTION
• Pleural hydatid disease is rare.
• Tension pneumothorax and empyaema are also
rare.
• A search through the net revealed less than 60
cases over 60 yrs all over the world.
• Bakir F and Al-Omeri reported 5 cases of
Echinococcal Tension Pneumothorax in Iraq in
1969 for the first time.
• To the best of our knowledge, this is the 2nd
report.
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3. INTRODUCTION
• HEREIN, TWO LADIES WITH PNEUMOTHORAX
AND EMPYAEMA SECONDARY TO
INTRAPLEURAL RUPTURE OF PHC ARE
PRESENTED.
• THE AIM OF THIS REPORT IS TO EMPHASIZE
THAT INTRAPLEURAL RUPTURE OF PHC
SHOULD BE CONSIDERED IN ANY PATIENT
WITH PNEUMOTHORAX IN AN ENDEMIC
AREA.
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4. CASE 1
• A 17 YR OLD LADY FROM BASRAH
• ADMITTED ONE MONTH EARLIER TO
ANOTHER HOSPITAL.
• SUDDEN SOB.
• COLLAPSED LUNG WITH
HYDROPNEUMOTHORAX
• MANAGED BY APICAL AND BASAL CHEST
TUBES + ANTI-TB CHEMOTHERAPY.
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5. CHEST TUBES
DRAINED THICK
PUS.
PERSISTENT AIR
LEAK ( BPF).
ENTRAPED LEFT
LUNG.
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6. MANAGEMENT
• L POSTEROLATERAL 5TH
SPACE THORACOTOMY
• FINDINGS:
• THICKENED PARIETAL &
VISCERAL PEELS.
• FOUL SMELLING PUS.
• COLLAPSED LUNG.
• MULTIPLE BRONCHIAL
FISTULAE IN LUL
• LAMINATED MEMBRANE
FLOATING IN PLEURAL
SPACE. POSTOPERATIVE RADIOGRAPH
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7. OPERATION
• DECORTICATION OF L LUNG.
• REMOVAL OF PUS.
• REMOVAL OF LAMINATED MEMBRANE.
• CLOSURE OF BRONCHIAL FISTULAE.
• UNEVENTFUL POSTOPERATIVE COURSE.
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8. CASE 2
A LADY OF 35
FROM SAMARRA.
SOB ONE MONTH
EARLIER WHEN
SHE WAS
PREGNANT
TRNSION
PNEUMOTHORAX
MANAGED BY
CHEST TUBE.
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9. ON REFERRAL TO
OUR UNIT:
COLLAPSED LUNG.
BPF
ANTI-TB DRUGS
BEGAN IN
SAMARRA
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10. CT SCAN
THICKENED
PARIETAL &
VISCERAL PEELS.
A CAVITY IN LLL
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11. PERSISTENT LUNG
COLLAPSE DESPITE
A SECOND APICAL
CHEST TUBE.
DECORTICATION
WAS DECIDED
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12. DECORTICATION
LEFT
THORACOTOMY:
THICKENED
PARIETAL AND
VISCERAL PEELS.
LAMINATED
MEMBRANE
MULTIPLE
BRONCHIAL
FISTULAE IN LLL
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13. INTRAPLEURAL
RUPTURE OF
PHC
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14. FULLY
EXPANDED
DECORTICATED
LUNG
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15. DISCUSSION
• PRIMARY PLEURAL HD IS DENIED TO EXIST.
• IT IS ALMOST ALWAYS SECONDARY TO
PULMONARY OR HEPATIC HD.
• PHCs MAY GROW INTO GIANT
CYSTS…ELASTICITY OF LUNG.
• PHC MAY RUPTURE INTO BRONCHUS (
COMMON) OR
• INTO PLEURA ( RARE).
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16. INCIDENCE
• A SEARCH THROUGH THE NET:
• LESS THAN 60 CASES ALL OVER THE
WORLD SINCE 1950.
• ONLY SPORADIC CASE REPORTS.
• FROM COUNTRIES LIKE: TURKEY, IRAQ,
ITALY, INDIA, AUSTRALIA, SPAIN AND
GREECE.
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17. WADDLE DESCRIBED 6 CASES OF
PNEUMOTHORAX IN 478 PATIENTS
WITH PHD
AUSTRALIA 1950
Waddle N. Pulmonary hydatid disease. A
review of 478 cases reported in the Louis
Barnett Hydatid Registry of the Royal
Australasian College of Surgeons. Aust.
N.Z.J. Surg. 1950, 19, 273.

18. TOMALINO DESCRIBED 16 CASES
OF PNEUMOTHORAX
SPAIN 1959
Tomalino D. Pleural complications of
hydatidosis, pleural hydatid accident,
secondary pleural hydatidosis ( Study of 47
personal observations). Thorax, 1952, 8,
73.

19. RAKOWER J AND MILWIDSKY H
REPORTED ONE CASE
1964
Rakower J and Milwidsky H. Hydatid
Pleural Disease: Case Report. American
Review of Respiratory Diseases. 1964; 90:
623-631.

20. BAKIR F AND AL-OMERI M
DESCRIBED 5 CASES OF
ECHINOCOCCAL TENSION
PNEUMOTHORAX IN IRAQ
1969
Bakir F and Al-Omeri M A. Echinococcal
Tension Pneumothorax. Thorax. 1969; 24

21. XANTHAKIS ET AL DESCRIBED 3
CASES OF HYDROPNEUMOTHORAX
IN 88 GREEK PATIENTS
1972
Xanthakis D, Efthimidiadis M, Papadakis G,
Primikirios N, Chassapakis G, Roussaki A, Veranis
N, Akrivakis A and Aligizakis C.J. Hydatid Disease
of the Chest. Report of 91 patients surgically
treated. Thorax, 1972, 27, 517.

22. CONNELIAN ET AL DESCRIBED THE
FIRST CASE OF ECHINOCOCCAL
TENSION PNEUMOTHORAX IN UK
1979
S.J. Connelian, A.W. Jowett and
R.S.E. Wilson. Hydatid Disease
presenting as Tension
Pneumothorax. Br. J. Dis. Chest
(1979) 37, 405.

23. JESIOTER ET AL REPORTED A CASE
OF PNEUMOTHORAX FOLLOWING
RUPTURE OF A PRIMARY PLEURAL
HYDATID CYST
1972
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.
: 547-556.

24. ROLVERSORI R ET AL DESCRIBED
ONE CASE IN ITALY
1989
Rolverosi R, Daniele P, Serricchio E,
Zarrelli N, Grifa O, Accadia M.
Hydropneumothorax caused by
rupture of pulmonary hydatid cysts.
Description of a case. Radiol Med.
1989 Jun; 77 (6): 704-5.

25. AGRAWAL ET AL DESCRIBED
ONE CASE IN INDIA
1993
Agrawal RL, Jain SK, Gupta SC,
Agrawal DK, Ahmad KR, Nandi D.
Hydropneumothorax secondary
to hydatid lung disease.
Indian J Chest Dis Allied Sci.
1993 Apr-Jun; 35 (2): 93-6.

26. FAHRI ET AL DESCRIBED 16 CASES
OF PLEURAL HYDATIDOSIS OUT OF
297 PTS WITH INTRATHORACIC
EXTRAPULMONARY HD
TURKEY 1997
Fahri O~uzkaya, Yi~it Ak~ah, Cemal Kahraman, Naci Emiro~ullan,
Mehmet Bilgin and Atalay ~ahin.
Unusually located Hydatid Cysts:
Intrathoracic but Extra pulmonary.
Ann thorac Surg 1997; 64: 334-7.

27. Kürkçüoğlu IC ET AL DETECTED 5 CASES OF
TENSION HYDROPNEUMOTHORAX
SECONDARY TO RUPTURE OF OF A HC OUT
OF 185 CASES OF SPONTANEOUS
PNEUMOTHORAX TREATED IN THEIR CLINIC
BETWEEN 1992 AND 1998 (2.7%)
TURKEY 2002
Kürkçüoğlu IC, Eroğlu A, Karaoğlanoğlu N, Polat P.
Tension pneumothorax associated
with hydatid cyst rupture.
J Thoracic Imaging 2002 January; 17 (1): 78-80.

28. ERDAL ET AL DESCRIBED A RARE
CASE OF GIANT RUPTURED HC
CAUSING TENSION
PNEUMOTHORAX IN A PATIENT
WITH BLUNT THORACIC TRAUMA
TURKEY 2009
Erdal Yekeler, Onur Celik, and Cevdet Becerik . A
Giant Ruptured Hydatid Cyst Causing
Tension Pneumothorax and Hemothorax in a Patient with
Blunt Thoracic Trauma: a Rare Case Encountered in the Emergency Clinic.
The Journal of Emergency Medicine . Vol XX, No. X. pp XXX, 2009.

29. PATHOGENESIS
• PHC USUALLY HAS A PERIPHERAL LOCATION.
• THE ELASTICITY OF THE LUNG PERMITS A
HUGE SIZE.
• INTRAPLEURAL RUPTURE RESULTS IN AIR,
FLUID AND MEMBRANE ENTRY INTO THE
PLEURA.
• ABSORPTION OF FLUID RESULTS IN
ANAPHYLAXIS.
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30. PATHOGENESIS
• TENSION PNEUMOTHORAX MAY
RESULT FROM A CHECK VALVE
MECHANISM..
• COMBINATION OF MASSIVE
PNEUMOTHORAX AND
ANAPHYLAXIS MAY PROVE FATAL.
• UNTREATED.. BPF AND EMPYAEMA.
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31. MANAGEMENT
• Preoperative diagnosis is difficult.
• In most of the reported cases, the diagnosis
was made at the time of thoracotomy.
• In the acute phase:
steroids for anaphylactic reaction and
chest tube insertion for pneumothorax.
 Definite diagnosis and treatment:
thoracotomy.
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32. MANAGEMENT
• Almost always, it is
misdiagnosed as PTB ( high
prevalence of PTB in areas
endemic to PHD).
• However, certain observations
may give hints..
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33. WHICH OBSERVATIONS?
• Residence in an endemic area.
• Drainage of crystal clear fluid via chest tubes.
• Pieces of laminated membrane may plug the
tube.
• Persistent air leak despite 2 or 3 chest tubes.
• Features of anaphylaxis.
• Exam of pleural fluid for scolices may be
positive.
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34. ALSO..
• Eosinophilia
• Chest radiograph may show an irregular
gas-fluid level.
• CT scan of chest: may show the cavity of
the cyst as well as the laminated
membrane.
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35. CONCLUSIONS
• Intrapleural rupture of PHC is rare.
• Echinococcal tension pneumothorax may prove
fatal.
• It should be considered in any patient with
pneumothorax in an area endemic to PHC.
• Preoperative diagnosis is extremely difficult, though
certain observations may give hints.
• Definite diagnosis and treatment is via
thoracotomy.
• Thoracotomy should be done as soon as the patient
is stabilized and before development of empyaema.
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36. THANK YOU FOR YOUR ATTENTION
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