Adli Tıp Dergisi / Journal of Forensic Medicine, Cilt / Vol.:27, Sayı / No:2 136 137 Adli Tıp Dergisi / Journal of Forensic Medicine, Cilt / Vol.:27, Sayı / No:2
TEŞHİS EDİLEMEYEN AKCİĞER KİST
HİDATİĞİNE BAĞLI ÖLÜM:
OLGU SUNUMU
DEATH DUE TO UNDIAGNOSED PULMONARY
HYDATID CYST:
CASE REPORT
ÖZET
Hidatik hastalığı bir parazitoz olup özellikle Ortadoğu ve Akde-niz Ülkeleri gibi küçükbaş hay-van yetiştiriciliği olan bölgelerde endemiktir. Hidatik kistlerin pe-riton içi ya da pulmoner bölge içi spontan rüptürleri sonucu ciddi mortalite ve morbidite gelişebil-mektedir.
48 yaşında kadın olgu dispne şikâyeti ile Devlet Hastanesi Acil Servisine başvuru yapmış; aynı gün ilaç tedavisine başladıktan sonra kan kusma ile acil ser-vise yeniden getirilmiş ve acil serviste vefat etmiştir. Olgunun otopsisi Erzurum Adli Tıp Şube Müdürlüğü’nde yapıldı. Yapılan postmortem muayenede sağ ak-ciğerde kız vezikülleri olmayan büyük bir kist (10x5x4cm) tespit edildi.
Medikolegal otopsi sonrası elde edilen geriye dönük verilerin klinik branşlar ile paylaşımı önemlidir. Bu tür paylaşımlar sonucunda klinikte tanı konu-lamamış ancak otopsi esnasın-da tanı konulan olgularesnasın-dan elde edilen verilerin klinik branşlar-da tanı ve tebranşlar-davi yaklaşımlarının gelişimine katkı sağlayacağı dü-şünülmektedir. Olgu sunumu-muzdaki amaç ta bu paylaşımı sağlamaktır.
Anahtar Kelimeler:
pulmo-ner hidatik kist, medikole-gal otopsi, teşhis edilmeyen
ABSTRACT
Hydatid disease is a parasitosis and is endemic in many sheep-rearing regions in the world espe-cially in the Middle East and the Mediterranean countries. As a re-sult of spontaneous rupture of the hydatid cysts into the peritoneum or pulmonary region serious mor-bidity and mortality may occur. A 48-year-old woman was admit-ted to the emergency room of the State Hospital with complaints of respiratory distress; on the same day, after starting the administ-ration of medical treatment, she was taken to the emergency ser-vice again with vomiting blood and died in the emergency room. Autopsy of the case was perfor-med in Erzurum Regional Center of the Council of Forensic Medi-cine. During post-mortem exami-nation a large cyst (10x5x4cm) in
the right lung without any daugh-ter vesicle was detected.
Sharing the retrospective data obtained from medico-legal au-topsies with clinical branches is important. As a result of such sharings, the data obtained from medico-legal autopsies of the cases clinically undiagnosed but diagnosed during the medicolegal autopsy are thought to contribute the improvement of diagnosis and treatment viewpoints in clinical branches. The aim of our case presentation is to provide this sharing.
Key words: pulmonary hydatid
cyst, medico-legal autopsy, un-diagnosed
Erzurum Regional Center, The Council of Forensic Medicine, The Ministry of Justice, Erzurum, Turkiye
Correspondence to: Muhammed Ziya Kır
Adli Tıp Grup Bşk. Erzurum Adliyesi Zemin Kat 25200 Erzurum - Türkiye, e-posta: ziyakir@yahoo.com Received: February 5, 2013 / Accepted: May 23, 2013
Kır MZ, İlingi U, Karabağ G Teşhis Edilemeyen Akciğer Kist Hidatiğine Bağlı Ölüm: Olgu Sunumu
Adalet Bakanlığı, Adli Tıp Kurumu, Erzurum Grup Başkanlığı, Erzurum, Türkiye
Sorumlu Yazar: Muhammed Ziya Kır
Adli Tıp Grup Bşk. Erzurum Adliyesi Zemin Kat 25200 Erzurum - Türkiye, e-posta: ziyakir@yahoo.com Alındı: 05.02.2013 / Kabul: 23.05.2013
Muhammed Ziya Kır, Ufuk İlingi, Gökmen Karabağ Muhammed Ziya Kır, Ufuk İlingi, Gökmen Karabağ
Kir MZ, Ilingi U, Karabag G. Death due to undiagnosed pulmonary hydatid cyst: case report. J For Med 2013;27(2):136-41 doi:10.5505/adlitip.2013.19981 Kir MZ, Ilingi U, Karabag G. Death due to undiagnosed pulmonary hydatid cyst: case report.
J For Med 2013;27(2):136-41 doi:10.5505/adlitip.2013.19981
Adli Tıp Dergisi / Journal of Forensic Medicine, Cilt / Vol.:27, Sayı / No:2 138 139 Adli Tıp Dergisi / Journal of Forensic Medicine, Cilt / Vol.:27, Sayı / No:2
INTRODUCTION
Hydatid disease is a parasitic in-festation caused by Echino-coc-cus granulosus (1-3). Hydatid di-sease is an endemic problem in Turkey as well as in sheep-bea-ring regions of the World espe-cially in the Middle East and the Mediterranean countries (1-6). The lungs are the most common sites of infection in children and the liver is the most common site affected in adults (6). Although hydatid disease may be asymptomatic for many ye-ars, it can become symptoma-tic due to expansion, rupture or pyogenic infection (2,3,7). As a result of spontaneous rupture of the hydatid cysts into the pe-ritoneum or pulmonary region, serious morbidity and mortality may occur.In this study, we present a case of a spontaneous rupture of a pulmonary hydatid cyst in which the patient was admitted to the emergency room for vomiting blood and died in emergency room.
CASE REPORT
A 48-year-old woman was ad-mitted to the emergency room of the State Hospital with comp-laints of respiratory distress. The pulmonologist prescribed antibiotic and anti-inflammatory tablets and sent the patient to the radiology room to have her chest radiographs. The patient’s relatives stated that the x-ray device had been broken in the hospital; therefore, the patient
had been transferred to another hospital after starting the admi-nistration of medical treatment; however, she had not been ad-mitted by any health center at all. Thus, on the same day, while she was vomiting blood, she was taken to the same hospital’s emergency service again and died in the emergency room. Her autopsy was performed in Erzurum Regional Center of the Council of Forensic Medicine The external examination re-vealed no pathologic-traumatic findings. During autopsy, a large cyst (10x5x4cm) in the right lung without any daughter vesicle was detected (Figure 1, Figure 2). Purulent liquid leakage was noticed on the sections of the lung. No macroscopic pathology was observed in the examinati-on of other organs. Toxicological analyses of blood, urine and in-ternal organs were completely negative. The histopathological examination of the cyst and lung tissue samples confirmed the diagnosis of pulmonary hydatid cyst. Additionally, suppurating pneumonic infiltration and mi-nimal macro-vesicular hepa-tosteatosis were observed. No histopathological abnormalities were observed in other organ sections. The death was attribu-ted to the pulmonary infection.
DISCUSSION
The hydatid cyst is typically filled with clear fluid (hydatid fluid). The cyst consists of an internal cellular layer (germinal layer) and an outer acellular layer
(la-minated layer) (8). As the cyst expands gradually, a granulo-matous host reaction followed by a fibrous reaction forms a connective tissue layer, which is called a pericyst (1).
Hydatid disease is a serious he-alth problem in endemic areas like Turkey (9,10). The diagnosis and appropriate surgical the-rapy is usually delayed since most of the hydatid cysts rema-in asymptomatic until they are getting complicated (1-3,10,11). Rupture, secondary infection and suppuration can be seen as a complication (1,3). In our case, the disease progressed asymptomatically and ended in dyspnea symptoms as noted during the State Hospital’s ad-mission. Purulent liquid leakage noticed on the lung sections and suppurating pneumonic infilt-ration were indicative of secon-dary infection.
Treatment of dogs with antihel-mintics is the main procedure to control the parasite (12). In rural areas of Turkey, this treatment is not administered routinely. Besides, in rural areas, sheep are usually home-slaughtered. Thus, dogs can access to the in-fected viscera (8). Home-slaugt-her and easy access of dogs to raw meat is seen in almost all of the developing or underdevelo-ped countries in the World (12). Initially almost all of the hyda-tid cysts are asymptomatic (8). Later in time, some symptoms depending on the involved or-gan, localization of the cyst and pressure effect of the cyst on the surrounding tissues and structures develop (1,10,13).
Patients with pulmonary cysts present with symptoms of dyspnea, nonproductive cough, chest pain, and particularly in those with centrally located cysts, blood-streaked sputum (14). Rupture of the hydatid cyst may be manifested by vigorous coughing and expectoration of membranes (5,6,15). No history of previous dyspnea or any other symptom relating to the hyda-tid cyst was present in the case presented here.
Diagnosis of the hydatid cyst is mainly based on ultrasonog-raphy and computed tomog-raphy (1-3,10,11,13,16). The patient could not be diagnosed since it was not possible to ob-tain a chest x-ray as a result of unavailability of the x-ray device and failure to have a consultati-on from another hospital. Surgery is the preferred treat-ment method for the cure for the hydatid disease (3,9,11). Ruptu-re of the cyst is usually Ruptu-related to increased intracystic pressu-re (8). This may be pressu-related to a trauma, or over enlargement of the cyst (2,13). Perforation of the hydatid cyst may cause dissemi-nation of the parasite and inc-reased morbidity and mortality rates (1,2,12). In our case, dis-semination of hydatid cyst rup-ture was not determined. But in such conditions, cases lose their lives as a result of the develop-ment of a secondary infection. In endemic regions, it is useful to consider hydatid cyst disea-se for patients admitted to the emergency room with dyspnea. In a 16-case-study of hydatid diseases in Istanbul from the
retrospective analysis on au-topsy reports of a 6 year period, in which the diagnosis had been confirmed by histopathological examinations, revealed that only 4 of the 16 cases had died due to anaphylaxis caused by cyst rup-ture, and the others due to dif-ferent reasons (17). In our study,
the case died as a result of a se-condary infection and we didn’t determine cyst rupture.
While determining the diagno-sis and planning the treatment, physicians use laboratory and imaging technologies besides physical examination findings. In the presented case, the patient’s
Figure 1: Pulmonary hydatid cyst
Figure 2: Pulmonary hydatid cyst after removal
Adli Tıp Dergisi / Journal of Forensic Medicine, Cilt / Vol.:27, Sayı / No:2 140 Adli Tıp Dergisi / Journal of Forensic Medicine, Cilt / Vol.:27, Sayı / No:2 Death Due to Undiagnosed Pulmonary Hydatid Cyst: Case Report
disease could not be diagnosed on time due to failure of obtai-ning a chest x-ray and the pati-ent died in the emergency ser-vice. Poorly maintained-broken laboratory and imaging devices might cause important prob-lems especially when needed for emergency diagnosis. Such patients need to be immediately transferred to the closest fully equipped health center. In the presented case, failure of trans-ferring the patient to another fully equipped hospital either by healthcare providers or by rela-tives is an indicator of negligen-ce. Nevertheless, data obtained from medico-legal autopsies are important to share retros-pectively with clinical branches. As a result of such sharings, the data obtained from medi-co-legal autopsies of the cases clinically undiagnosed but diag-nosed during the medicolegal autopsy are thought to contribu-te the improvement of diagnosis and treatment viewpoints in cli-nical branches. The aim of our case presentation is to provide this sharing.
Adli Tıp Dergisi / Journal of Forensic Medicine, Cilt / Vol.:27, Sayı / No:2 141 Adli Tıp Dergisi / Journal of Forensic Medicine, Cilt / Vol.:27, Sayı / No:2 Death Due to Undiagnosed Pulmonary Hydatid Cyst: Case Report
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