Zuber Ahmed

Ruptured Pulmonary Hydatid Cyst With Anaphylactic Shock and Pneumothorax

Hydatid cyst is a disease caused by a parasitic tapeworm, Echinococcus granulosus, and most commonly involves liver and lung. Ruptured pulmonary hydatid cyst can present a diagnostic challenge, and radiograph can be inconclusive. Anaphylactic reaction is a rare complication of ruptured pulmonary hydatid cyst. A 22-year-old male came to our emergency department in shock with symptoms of shortness of breath and altered mental status from the previous day. Radiograph showed a thin-walled circular translucent area in the right upper lung field, which was misdiagnosed as pneumothorax, and an intercostal chest tube was inserted. After 5 days, repeat radiograph revealed a cavity with an air/fluid level. The chest tube was removed and contrast-enhanced computed tomogram showed a cavity with water-lily sign, which suggests ruptured hydatid cyst. Immunoglobin-G enzyme-linked immunosorbent assay for Echinococcus was positive. The patient responded well to treatment with crystalloid infusion, supplemental oxygen, and albendazole, and then underwent surgery. Anaphylactic reaction due to rupture of a hydatid cyst is rare, but hydatid disease should be suspected in patients from areas where Echinococcus is endemic.

The vanishing lung.

A 35-year-old man presented to the emergency department (ED) with a 3-month history of increasing shortness of breath associated with reduced exercise tolerance. The patient was a smoker with more than 20 pack-years of tobacco use. He had no history of fever, night sweats, cough, hemoptysis or chest pain, and his medical history was unremarkable. Physical examination revealed a well-looking man who was alert, stable and in no respiratory distress. Vital signs were blood pressure 122/74 mm Hg, pulse 92 beats/min, respiratory rate 22 breaths/min, temperature 35.8°C and oxygen saturation 97% on room air. The patient had no pallor, cyanosis, diaphoresis, clubbing or peripheral edema. His jugular veins were not distended; however, his trachea was shifted to the right and breath sounds were diminished over the left hemithorax without dullness to percussion. The patient’s heart sounds were maximally audible over the right hemithorax. An electrocardiogram revealed normal sinus rhythm and right axis deviation without evidence of ischemia. Pulmonary function tests were consistent with an obstructive pattern (forced expiratory volume in 1 second [FEV1] = 1.71 L; 45% predicted). A posterior–anterior chest x-ray is shown in Figure 1. Question

Giant pulmonary hydatid cyst mimicking elevated diaphragm: A diagnostic dilemma

Dear Sir, Giant pulmonary hydatid cyst is a rare clinical entity and can be a diagnostic challenge on chest radiograph. Here we are reporting a case of giant pulmonary hydatid cyst which mimicked as elevated diaphragm on chest radiograph. A 45-year-female patient presented to us with complaints of right-sided chest pain, dry cough, and low-grade fever since 2 months. On vitals examination her blood pressure was 110/76 mmHg, pulse rate 100/min, respiratory rate 22/min, and temperature 38oC. There was no cyanosis, clubbing, or lymphadenopathy. On respiratory system examination, breath sound was decreased and percussion note was dull in right infrascapular and inframammary area. In laboratory investigation, total leucocyte count was 9400 cells with 65% neutrophils, 15% lymphocytes, and 17% eosinophils. The absolute eosinophils count was 1100 cells. Herliver function test and renal function test were normal. Sputum for acid fast bacilli was negative. Chest radiograph postero-anterior view was suggestive of right-sided elevated diaphragm [Figure 1]. Ultrasonography of abdomen was normal. Contrast-enhanced computed tomography of thorax revealed a large rounded, well-circumscribed loculated cyst with little remaining lung tissue on right side [Figure 2]. IgG Elisa for ecchinococcous granulosus was positive. Patient was diagnosed as a case of giant pulmonary hydatid cyst. Patient was treated by surgical resection of cyst.

Myelomatous pleural effusion: A rare presentation of multiple myeloma

Myelomatous pleural effusion is a very rare presentation of multiple myeloma. A 65‐year‐old male patient presented to us with complaints of dyspnea and left‐sided chest pain. His contrast enhanced computed tomography of the thorax showed left‐sided pleural effusion with multiple pleural nodules. His pleural fluid cytology shows malignant plasma cells with eccentric nuclei and cart wheel chromatin and a few cells showing binucleation and multinucleation suggestive of plasma cell myeloma. His pleural fluid and serum electrophoresis showed a distinct band in the gamma globulin region (M‐spike). On immunofixation of pleural fluid and serum, immunoglobulin G lambda light chain band was detected. Bone marrow aspiration showed sheets of malignant plasma cells with large and binucleated cells suggestive of multiple myeloma. The patient was diagnosed with multiple myeloma presenting as myelomatous pleural effusion. Intercostal tube drainage and then pleurodesis with talc was performed.

Recurrent pneumothorax: A rare complication of miliary tuberculosis

Context: Recurrent pneumothorax is common in cavitory pulmonary tuberculosis, but it is extremely rare in miliary tuberculosis. Case Report: A 25 year old female patient presented to us with the complains of shortness of breath since 3 days. She was also having fever and cough since 3 months. Chest roentgenogram (PA view) on admission showed a left sided pneumothorax with miliary mottling. An intercostals tube drainage was done on the left side resulting in relief of symptoms. Two days post intercostals tube drainage chest X ray (PA view) showed complete resolution of pneumothorax, and intercostals tube was removed. Patient was discharged on antitubercular drugs. After 1 month patient again presented to us with severe breathlessness, on repeat chest X ray pneumothorax again developed on left side, urgent intercostals tube drainage was done, and patient relieved immediately. Patient was kept in the hospital for 12 days and, and was discharged after intercostals tube removal. Conclusion: If a patient of miliary tuberculosis presents with shortness of breath diagnosis of pneumothorax should be considered.