Dynamic left ventricular outflow obstruction caused by cardiac echinococcosis

Case Report: Sudden death related to unrecognized cardiac hydatid cyst

Echinococcosis, also known as hydatid disease, is a common parasitic human infestation found in sheep-breeding areas. It is caused by the larvae stage of Echinococcus granulosus, and cysts develop mostly in the lungs and the liver. Cardiac involvement is unusual and silent until acute complications or a fatal outcome occurs. Herein, we report an autopsy case of a young healthy adult who died suddenly. The autopsy revealed an external bulging on the right heart ventricle outlet with a fluid-filled cystic cavity discovered on sectioning. Dissection of other organs did not reveal other cyst locations. Histological examination ascertained the diagnosis of hydatid cyst, and death was attributed to cardiac arrhythmias. Pathologists should keep in mind that hydatid cysts can develop anywhere in the body. Solitary cardiac cyst is rare and can simulate a “silent bomb”. Unfortunately, sudden death remains the frequent manner of revelation of this disease in endemic areas.

Ventricular Tachycardia and the Cystic Heart: A Case Report

BACKGROUND

Hydatid cysts are caused by Echinococcus granulosus infection, and hydatidosis is recognized as a re-emerging zoonotic disease globally. While the liver is the most commonly affected organ, other organs can also be affected, including the heart. Because of the low sensitivity and specificity of serologic diagnostic tests, ultrasound and echocardiography are increasingly used to make the diagnosis of cardiac hydatid cyst.

CASE REPORT

We report the case of a cardiac hydatid cyst, detected by point-of-care ultrasound (POCUS), in a 79-year-old woman who presented with shortness of breath and was in ventricular tachycardia. The diagnosis was further confirmed with a computed tomography scan. Although cases of alveolar and liver hydatid cysts are seen, this is the first case of a cardiac hydatid cyst in Bhutan. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case illustrates the importance of POCUS in reaching a diagnosis, particularly in resource-poor areas where other sophisticated diagnostic tools are not easily available. A cardiac hydatid cyst must be in the differential for structural causes of dysrhythmias. This is especially so because treatment of unstable dysrhythmias in the acute setting of an emergency department has to be modified from the usual algorithm in the presence of a cardiac hydatid cyst, due to the potentially fatal risk of cyst rupture and anaphylaxis.

[Cardiac hydatid cyst. Which imaging modality for an accurate diagnosis?]

Cardiac echinococcosis is rare. Its spontaneous course is serious because of the risk of rupture. Its clinical manifestations are variable, often latent and misleading. The diagnosis is sometimes referred to by chest radiography. It is much facilitated by non-invasive imaging techniques in particular transesophageal and transthoracic echocardiography, CT scan and magnetic resonance imaging. The latter through a morphological and topographical analysis accurate diagnosis of hydatid cyst and its relationship to cardiac muscle and surrounding tissue. Through functional analysis in cine cyst movements relative to the heart wall, it confirms its free or fixed character in the heart chambers, determines its insertion area, its deformability, the risk of rupture and its impact on myocardial contraction. Our case illustrates the relative contribution of these different imaging techniques and their respective contributions to the identification of hydatid cyst of its wall, its contents, its relationship with the various tunics and heart chambers and its relations with the lungs and mediastinum.

Hydatid Disease Involved in the Heart, Liver, and Kidney That Caused Sudden Death: Case Report

Hydatid disease is a parasitic infestation caused by ingestion of eggs of echinococcal species. For Echinococcus granulosus, the definitive host is the dog, and sheeps are the usual intermediate hosts. Humans are accidental intermediate hosts, infected by ingestion of food contaminated with eggs shed by dogs or foxes. The most common organs that hydatid disease encountered are the liver and lungs. Involvement of the kidney is rare and usually accompanies the other organ involvements. Cardiac involvement of echinococcosis is also very rare. We report the case of a 31-year-old woman with a 6-year history of asthma who collapsed after strenuous activity and died despite the interventions carried out. At autopsy, cystic masses were detected in the apex of the heart, in the right kidney, and in the liver. There were no macroscopic pathologic findings in the other organs. Microscopic examination revealed the diagnosis of hydatid cyst in the heart, right kidney, and liver besides medial hypertrophy of the lung vessels. Cause of death was attributed to hydatid cyst and its complications. Patients who have symptoms akin to asthma at clinical presentation have to be further investigated for organic cardiac and pulmonary diseases such as hydatid cyst, especially in endemic countries.

A giant cardiac hydatid cyst presenting with chest pain and ventricular tachycardia in a pregnant woman undergoing cesarean section

Cyst hydatid disease is an infectious disease caused by development of the larval form of Echinococcus granulosus in humans. Cardiac involvement of this disease is a rare condition, and if present, it is most commonly located in the left ventricle. Interventricular septal involvement is observed only in 4% of these cases. Herein, we report a case of cyst hydatid located at interventricular septum causing chest pain and ventricular tachycardia during cesarean section.

Giant cardiac hydatid cyst in children: case report and review of the literature

Cardiac echinococcus is a rare affliction of the heart caused by the tapeworm Echinococcus granulosus. Primary echinococcosis of the heart represents 0.5–2% of all hydatid disease cases in endemic regions. It evolves slowly, explaining its rarity in children. We report the case of a 11-year-old child affected by a giant cardiac cyst of the left ventricle (LV). The patient underwent cardiac surgery and medical treatment. A retrospective review of the current literature was realized. We found 18 cases: the mean age was 11-years old. Nine cysts were localized in the LV, four in the interventricular septum, three in the right ventricle, and two in the right atrium. All underwent surgery except six patients. Routine echocardiographic screening may be useful in endemic regions where infestation is common. Cardiac echinococcus should be diagnosed in the early and uncomplicated stages and be removed surgically even in asymptomatic patients.

Cardiac hydatid cyst revealed by ventricular tachycardia

Hydatid disease is a human parasitic infestation caused by the larval stage of Echinococcus Granulosus. The liver and the lungs are the most common locations. Cardiac involvement is rare and accounts for 0.5-2% of all hydatid disease. We report an unusual presentation of cardiac hydatid cyst revealed by ventricular tachycardia in a patient with a history of cerebral hydatid cyst.

Left ventricular epicardial hydatid cyst compressing the left circumflex artery

Cardiac hydatid is a rare disease with varied presentation. We report a unique case of left ventricular epicardial hydatid cyst causing left circumflex artery compression. Cardiac hydatids have to be surgically treated on diagnosis because of the high risk of catastrophic rupture. We discuss the surgical principles and the other adjuncts to avoid recurrence.

An analysis of possible mechanisms of unexpected death occurring in hydatid disease (echinococcosis)

Most cases of hydatid disease in human populations are due to Echinococcus granulosus. The hydatid life cycle involves passage between definitive hosts such as dogs and intermediate hosts such as sheep. Humans become accidental intermediate hosts following ingestion of food or water contaminated with eggs or by contact with infected dogs. Although hydatid disease may remain asymptomatic, occasional cases of sudden and unexpected death present to autopsy. Causes of rapid clinical decline involve a wide range of mechanisms including anaphylaxis (with or without cyst rupture), cardiac outflow obstruction or conduction tract disturbance, pulmonary and cerebral embolism, pericarditis, cardiac tamponade, myocardial ischemia, pulmonary hypertension, peritonitis, hollow organ perforation, intracerebral mass effect, obstructive hydrocephalus, seizures, cerebral ischemia/infarction, and pregnancy complications. The autopsy assessment of cases therefore requires careful examination of all organ systems for characteristic cystic lesions, as multiorgan involvement is common, with integration of findings so that possible mechanisms of death can be determined. Measurement of serum tryptase and specific IgE levels should be undertaken for possible anaphylaxis.

[Emboligenous hydatid cyst of the right heart]

The cardiac location of the echinococcosis is rare. It is associated with complications potentially severe. Indeed, the break inside the cardiac chambers with pulmonary embolism is the inevitable complication of the echinococcosis of the right heart. Between January 1992 and January 2006, five patients were operated in the department of cardiac surgery of Sousse (Tunisia) for an emboligenous hydatid cyst of the right heart. The average age is of 30 years with extremes from 18 to 65 years. The cardio-pulmonary bypass is the technique of choice. We regretted a single death in immediate postoperative period. All the patients were controlled with an average recession of 36 months. A single late death was noticed. No recurrence was observed.

Cardiac hydatid cyst: report of two cases

Cardiac hydatid cyst is life threatening but rare. It is usually asymptomatic and has potentially lethal complications, so early diagnosis with definitive treatment is life-saving. In the present article, we report two cases. The first is a 30-year-old woman with a primary large multivesicular hydatid cyst in the left ventricle. The second is a 17-year-old woman who had multivisceral involvement with a cardiac hydatid cyst, a congenital cardiac anomaly that was an atrial septal defect complicated by pulmonary hypertension. 2-D echocardiography and magnetic resonance imaging confirmed the diagnosis. Surgical treatment was performed using extracorporeal circulation and adjunctive albendazol therapy.

Cardiac Hydatid Cyst Rupture as Cause of Death

Echinococcosis is a frequent parasitic human infection in sheep-farming areas. It is caused by the larval or the cyst stage of a tapeworm, mainly Echinococcus granulosis. Humans can be infected by ingesting tapeworm eggs, from which cysts will be developed mostly in the liver and the lung. Cardiac involvement of echinococcosis is rare and its clinical evolution is silent till the complication stage. A young adult died suddenly. The autopsy showed a ruptured hydatid cyst hollowed on the right side of the interventricular septum, protruding in the ventricle. The left pulmonary artery contained white-colored fragments of a membrane, similar to the one found in the right ventricle, associated to small vesicles. All these elements were obstructing this vessel, extending to small pulmonary arterial branches. Dissection of the other organs did not show other locations. Microscopic examinations ascertained the diagnosis of echinococcosis. Death was imputed to a right ventricular hydatid cyst rupture with pulmonary artery embolism.

Eighteen-year experience with echinococcosus of the heart: clinical and echocardiographic features in 14 patients

We present a retrospective analysis of clinical symptoms and echocardiographic features in 14 patients having cardiac hydatic cysts and screened during the 18 last years, with surgical correlations in 13. The heart was the sole location of the cyst in six patients. The revealing symptoms were precordial pain (six patients), dyspnea (two patients). A systolic murmur of false pulmonic stenosis was present in three patients. In 13 patients, two-dimensional echocardiographic images of hydatic cysts were those of masses of liquid content with a well-contrasted capsule, which was single in eight patients and multiple in five, one of which had a honeycomb appearance. The mass was solid and calcified in one patient. The outlines of the cysts were particularly sharp on transesophageal echocardiograms (six patients). The cyst size ranged from 1.8 to 11 cm in diameter. Cysts were located in the intramyocardium in 10 patients (left ventricle in four patients, interventricular septum in four patients, right ventricle in two patients), the pericardium in three and the mediatinum in one. There were a Doppler pulmonary valve gradient in three patients. Computed tomography (eight patients) and coronary arteriography (seven patients) have no additional diagnosis value than echocardiography. Nuclear magnetic resonance imaging (three patients) was helpful in determining extracardiac extension of the cysts. Transthoracic and transesophageal two-dimensional echocardiography have a central role in diagnosing cardiac hydatic cysts.

[Hydatid cyst of the heart simulating coronary ischemia]

Cardiac echinococcosis is rare despite endemic occurrence of echinococcosis in some regions of the world. Clinical presentation can vary and may be misleading. Diagnosis is facilitated by new imaging techniques. Surgery is mandatory to avoid serious complications. We report a case of cardiac echinococcosis with pseudo, ischemic clinical and electrical presentation.

Unusual recurrence of hydatid cysts of the heart: report of two cases and review of the clinical and surgical aspects of the disease

In cardiac echinococcosis, a hydatid cyst most frequently forms either solely in the heart or in the pericardium, but there are several reports of cysts forming in the liver or lung or in both. In two cases reported here, both patients developed cysts in new sites after one or more previous surgeries for hydatid cyst removal. In Case 1, the patient first underwent spleenectomy and resection of multiple cysts with no evidence of a cyst in the heart; 3 years later, there was no sign of Echinococcus in the liver, but a large inframyocardial cyst had damaged the left ventricle. In Case 2, the patient first underwent surgery to remove cysts from the pericardium, 2 years later from the anterior wall of the left ventricle, and, finally, 8 months after this second operation, from the left atrium also with no evidence of cyst formation anywhere else in the heart at the time of surgery. These cases emphasize the need for thorough and frequent reevaluation to detect new hydatid cyst formation in the heart and elsewhere caused by the Echinococcus organism.

[A hydatid cyst in the vena cava inferior and right atrium with venous flow obstruction and pulmonary dissemination]

We report the case of a 62-year-old female patient operated for a hepatic hydatid cyst that years later was found to have a hydatid cyst in the inferior vena cava and right atrium that was the source of disseminated pulmonary spread of the disease and occlusion of the inferior vena cava blood flow. Cardiac hydatid disease is very uncommon and is frequently associated with a poor prognosis. The literature for hydatid disease of the heart is reviewed and the clinical and echocardiographic relevant findings of this patient are discussed.

Echocardiographically diagnosed cardiac echinococcus complicated by embolic intraventricular thrombus

A young woman had cerebral embolism caused by an unusual complication of an asymptomatic cardiac hydatid cyst. The diagnosis of the cyst by means of echocardiography was confirmed by surgery as well as nuclear magnetic resonance, computed tomography, and serologic tests. Transesophageal echocardiography revealed a thrombus in the left ventricle that was situated aside the cyst. It was thought to be the source of an embolus. Surgical removal of the cyst was successful. Cerebral damage was reduced by administration of heparin.

A multivesicular cardiac hydatid cyst with hepatic involvement

Cardiac hydatid cyst is an uncommon lesion, mostly caused by Echinococcus granulosus. Occurrence of the disease in man appears to be limited geographically to areas where close and continuous contact exists between domesticated carnivores such as dogs and ungulates such as cattle and sheep. Generally cardiac hydatid cysts are univesicular. Here we report our clinical and surgical experience of treatment in a case of a multivesicular cardiac hydatid cyst with hepatic involvement.

Complete heart block caused by cardiac echinococcosis and successfully treated with albendazole

Images

Echinococcosis of the heart: clinical and echocardiographic features in 19 patients

We describe clinical and echocardiographic features in 19 patients with cardiac echinococcosis. Wide variability in the location and number of cysts inside cardiac cavities, septum, and pericardium is observed. The central role of two-dimensional echocardiography in making the diagnosis is stressed. This report has a significant clinical value in view of the large number of cases of a relatively rare condition.

Cardiac echinococcsis with multivisceral involvement

Cardiac hydatid cyst is an uncommon lesion. The infection, often acquired by children during play with infected dogs, is most common in sheep-raising areas of the world. We report our clinical and surgical experience in the treatment of one of the youngest reported cardiac hydatidosis patients with multivisceral involvement.

Variable coronary vasomotor responses to acetylcholine in patients with normal coronary arteriograms: evidence for localised endothelial dysfunction

OBJECTIVE

The vasomotor responses of the epicardial coronary arteries to acetylcholine were examined in patients with normal coronary arteries and chest pain.

DESIGN

Quantitative angiography was used to measure minimum lumen diameter of proximal and distal coronary artery segments at baseline, during intracoronary infusion of acetylcholine (10(-7) - 10(-3) mol/l), and following an intracoronary bolus (2 mg) of isosorbide dinitrate.

PATIENTS

Coronary arteriograms were obtained in 15 patients (mean (SEM) age 48 (10) years) with normal coronary arteries and chest pain.

MAIN RESULTS

In response to the low concentrations of acetylcholine (10(-7) - 10(-6) mol/1) 20 (61%) distal and 11 (41%) proximal segments showed dilatation (group 1), whereas 13 (39%) distal segments and 14 (52%) proximal segments showed constriction (group 2) (P < 0.05 v group 1). In group 1, the maximum dilatation induced by acetylcholine in the proximal and distal segments was 7.83 (1.19)% and 11.6 (2.2)% respectively. In group 2, the maximum constriction at higher concentration was 16.55 (3.3)% and 33.11 (11.63)% in the proximal and distal segments respectively. The two different patterns of the vasomotor response coexisted in eight (53%) of the 15 patients. Intracoronary isosorbide dinitrate caused a greater increase in the coronary luminal diameter of distal segments than in proximal segments in group 1 (25.63 (5.16)% v 12.43 (3.48)%, P < 0.01) but not in group 2 (12.65 (2.53)% v 10.82 (3.33)%.

CONCLUSIONS

Constriction and dilatation may occur in proximal and distal coronary artery segments, suggesting local areas of endothelial dysfunction, in response to acetylcholine in patients with chest pain and angiographically normal coronary arteries.

Interventricular septal hydatid cyst presenting as complete heart block

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Intracardiac hydatid cyst and sudden death in a child

Left ventricular hydatid cyst was diagnosed in a 4-year-old boy by echocardiography. The patient did not respond to oral mebendazole therapy and had a sudden death, probably due to rupture of the cyst. The occurrence of cardiac hydatid cyst and its life threatening complications are rare and have not been reported in children.

Cardiac echinococcosis: case report of unusual echocardiographic appearance

An unusual echocardiographic appearance of a cardiac echinococcal lesion confirmed intraoperatively is described in a patient with nonspecific cardiac complaints. Although previous reports have emphasized the echolucent, often multiseptated nature of echinococcal lesions, such characteristics were absent in this case. Thus, in the appropriate clinical setting, echinococcal infection should be included in the differential diagnosis of solid mass lesions of the heart because the surgical approach may need to be altered.