An Elderly Male With Bubbles in the Pleura
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A 63-year-old man presented with complaint of cough and right lower chest pain for 1 month. The cough was nonproductive and was more during exertion. It started after an episode of acute onset right lower chest pain around 1 month back which was sharp in character and had been persisting since then requiring daily analgesic use. There was no history of fever, loss of weight, loss of appetite, hemoptysis, shortness of breath or any significant occupational exposures.

On physical examination, he was well built & the rest of the general physical examination was unremarkable and vitals were stable. On chest examination, he had a dull note on percussion in the right infraaxillary area with a marked reduction in breath sounds. On abdominal examination, mild tenderness in the right upper quadrant was demonstrated. A posteroanterior chest radiograph demonstrated mild right pleural effusion. After this, a diagnostic pleural aspiration was planned to keep the possibility of TB in view of high endemicity. Point-of-care USG of the thorax was performed.

It demonstrates the free fluid in the right pleural cavity along with at least two bubble-like structures in the pleura. It also showed liver parenchyma with a multiloculated cystic lesion in the region of the right lobe of the liver which could be hydatid cyst. Therefore, bubble-like cystic lesions in the right pleural cavity indeed are the hydatid cysts which have occurred because of rupture of liver cysts into the right pleural cavity leading to the dissemination of disease. Subsequently, hydatid serology was performed, which was strongly positive, confirming the diagnosis of hydatidosis.

This patient underwent pleural aspiration from a site where no cystic lesions were seen. The pleural fluid was exudative but did not reveal any organism on cytologic examination. The patient was started on oral albendazole therapy. The patient underwent thoracotomy and pleural clearance. Removal of the liver cyst was not done in the same sitting because of the poor general status of the patient, and surgery for the same was planned. The primary management plan for uncomplicated pulmonary hydatid cysts remains surgical resection, followed by antihelminthic therapy. Pleural hydatid disease also requires surgical exploration and clearance of the pleura.