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