A 5-yr-old with a worsening chough since six months: LANCET
A 5-year-old reported with worsening cough that had started about 6 months earlier Chest x-ray revealed a large, ill-defined, radiolucent, cavernous lesion in the right upper lobe with a radiopaque mass in its lower part. The patient was started on antibiotics—piperacillin and tazobactam initially, with linezolid added to cover any presumed infection with community-associated methicillin-resistant Staphylococcus aureus (MRSA).

A contrast-enhanced, chest CT scan (coronal reconstruction) reveled a large cystic mass with a thick, contrast-enhancing wall in the right upper lobe. A corresponding lung window CT scan reconstruction demonstrated marked consolidation of the adjacent lung parenchyma, with curvilinear septa within the lesion—the so-called water-lily sign. These findings were highly suggestive of a ruptured Echinococcus granulosus hydatid cyst in the right upper lobe of the lung.

Additionally, no evidence of mycobacterial infection was found. However, 1 week after admission, the initially negative serology for echinococcosis became strongly positive and the patient developed eosinophilia. Additional investigations found a solitary hydatid cyst in the patient’s liver. He was therefore diagnosed with cystic echinococcosis with both pulmonary and hepatic manifestations.

As the imaging and the seroconversion provided good evidence of recent cyst rupture, the risk of further spillage of the contents of a cyst was considered high, so the patient was started on anthelmintic therapy—oral albendazone—prior to surgical resection. The patient finally went home well on albendazole.

Lessons learnt:-
• Acute rupture of pulmonary E granulosus cysts with or without superimposed bacterial infection can mimic other pulmonary infections.
• In the context of recent and continued migration of people from areas where the disease is endemic, it is important to consider this rare clinical entity in children and adults.
• Of note, serology is frequently negative even in the presence of large, nonruptured hydatic cysts and the optimal time to start albendazole treatment remains uncertain.

Source: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)32852-6/fulltext
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