Case presentation
A 17-year-old male presented to the emergency department of Imam Reza
hospital of Kermanshah province of Iran. He complained of fever,
repetitive cough, dyspnea, and chest pain initiated a few hours prior to
hospital admission. He did not report any respiratory symptoms before
this. His past medical history or drug history was unremarkable. He
denied cigarette or alcohol abuse, and previous exposure to pets. He
worked on a vegetable farm with his family. His familial history was
unremarkable.
On general examination he was febrile (T=38.5 degrees Celcius), His
pulse rate was 120 beats/minute, his respiratory rate was 24, and his
blood pressure was 110/70 mmHg. His oxygen saturation was 91% on room
air. He was not in respiratory distress and did not use respiratory
accessory muscles. On respiratory system examination, respiratory sounds
were decreased on the right hemithorax. The rest of the clinical
examination including the cardiovascular system and abdomen were within
normal limits.
The results of laboratory tests on admission day were as follows:
hemoglobin of 15.6 mg/dl, white blood cell count (WBC) 12.7
x103/mm3 (differential count:
neutrophils 90%, lymphocytes 7%, monocytes 3%), platelet count 229
x103/mm3, creatinine 0.9 mg/dl,
International normalized ratio (INR) 1, partial thromboplastin time
(PTT) 28 seconds, lactate dehydrogenase (LDH) 622 IU/ml (normal:225-500
IU/ml), aspartate transaminase (AST) 62 IU/L (normal:5-40 IU/L), alanine
transaminase (ALT) 97 IU/L (normal:5-40 IU/L), alkaline phosphatase
(ALP) 123 U/L (normal:80-306 U/L), total bilirubin 0.7 mg/dL
(normal:0.2-1.4 mg/dL), direct bilirubin 0.3 mg/dL (normal:0-0.4 mg/dL),
erythrocyte sedimentation rate (ESR) 10 mm/hr, and C-reactive protein
(CRP) was positive.
A chest computed tomography (CT) scan was performed and showed a large
cavitary lesion on the middle lobe of the right lung which contained a
large amount of air, and soft tissue resembling a membrane. The imaging
findings were compatible with the hydatid cyst. Few ground glass
opacities were observed in the lower lobe of the right lung suggesting
rupture of hydatid cyst. The left lung had no pathologic lesion (Figure
1). Ultrasonography of the abdomen was normal.
He was hospitalized in the infectious disease ward for additional workup
and treatment. Albendazole was administered 400mg twice a day. A high
titer of IgM antibody against echinococcus granulosus was detected in
his serum. A thoracic surgery consult was done and surgery for resection
of the cyst was planned. On the third day of admission, his oxygen
saturation decreased to 70%, and he developed severe respiratory
distress. Body temperature was 41 degrees Celcius and blood pressure was
100/65 mmHg. He was intubated and transferred to the intensive care unit
(ICU). A Chest CT scan was performed and revealed rupture of the cyst
and diffuse ground glass opacities with centrilobular pattern in the
field of both lungs (Figure 2).
Acute respiratory distress syndrome (ARDS) was suspected.
Methylprednisolone 1gr daily was started for 3 days followed by
dexamethasone 4mg three times a day intravenously. Broad-spectrum
antibiotic therapy was started for suspected secondary bacterial
infection. Oral albendazole was continued. Five days later his oxygen
saturation decreased and pneumothorax was detected on the chest CT scan.
Therefore, a chest tube was placed in the right pleural cavity (Figure
3). Two weeks later he was extubated, and his oxygen saturation remained
within normal limits by receiving oxygen through a facial mask. The
chest tube was removed. He was discharged in stable condition four weeks
after hospital admission. Oral albendazole was continued, and he was
referred to a thoracic surgeon. He underwent resection of the cyst and
lobectomy of the right middle lobe two weeks after discharge with no
complications.