Asian Cardiovasc Thorac Ann 2000;8:62-63
© 2000 Asia Publishing EXchange Pte Ltd
Primary Echinococcosis of the First Rib
Abdullah Al-Qudah, MD
Section of Thoracic and Vascular Surgery
Department of General Surgery
Jordan University Hospital and Faculty of Medicine
Amman, Jordan
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For reprint information contact: Abdullah Al-Qudah, MD Tel: 962 6 515 0669 Fax: 962 6 515 0669 P.O. Box 13255, Amman 11942, Jordan.
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Abstract
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A 24-year-old man was investigated for dyspnea and swelling of the right side of the neck with pain in the right shoulder, which had developed over the previous year. Hydatid cyst of the right first rib was diagnosed by chest radiography and computed tomography. Serology for hydatid disease was negative. The cysts and the first rib were excised via a right thoracotomy. The postoperative course was uneventful. Histology revealed multilocular echinococcal lesions.
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Introduction
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Echinococcosis is prevalent throughout the world but more endemic in the Middle East.1 The liver and lungs are most frequently involved. Bone sites are rare, accoun-ting for 0.9% to 2% of all hydatid lesions.2 Echinococcosis of the first rib is extremely rare. A case is described of a young man with a hydatid cyst of the thoracic outlet, invading the first rib.
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Case Report
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A 24-year-old man was investigated for shortness of breath on exertion with dry cough, occasional low grade fever, and mild pain in the right shoulder, which had developed over the previous year. Physical examination revealed a slight swelling of the right supraclavicular fossa under which a hard oval cystic mass under tension could be palpated. Routine blood tests were normal. Total leukocyte count was 8000/mm3 with 3% eosinophils. Erythrocyte sedimentation rate was 25 mm•h–1. Liver function tests including plasma proteins were normal. The serum echinococcosis antibody titer was negative. Chest radio-graphy showed a round opacity in the apex of the right hemithorax with erosion of the anterior arch of the right first rib (Figure 1
). No calcification was seen within the mass. Computed topography of the chest showed erosion of the anterior arch of the first rib (Figure 2).
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Figure 1. Chest radiograph showing a round opacity at the apex of the right hemithorax, emerging from the thoracic outlet.
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Figure 2. Computed tomography scan of the chest, showing an oval opacity located at the anterior thoracic outlet, with complete destruction of the anterior arch of the first rib.
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After a right anterolateral thoracotomy, the apex of the lung was found to be firmly adherent to an extrapleural mass of 10 cm in diameter. After careful dissection, a large number of hydatid cysts were revealed, either adherent to the pleura or lodged on the surface of the first rib. The size of the cysts varied from a few millimeters up to 6 cm in diameter. The first rib could be seen clearly and was observed to be stripped of its periosteum. Histological examination revealed multilocular echino-coccal lesions. The patient had an uneventful recovery and was completely relieved of pain and dyspnea.
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Discussion
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Hydatidosis of the bone is a rare form of human echinococcosis and it differs from that in visceral locations because it is always primary and has the capacity to destroy the bone matrix and infiltrate the adjacent tissues, as seen in the radiograph of this patient.3 Any part of the body may be involved but the liver and lungs are the main sites of this disease. The course of the disease in bone is slow and there may be no specific signs or symptoms, so that it simulates any bony condition, as in this case. However, due to the vicinity of the stellate sympathetic ganglion, echinococcal infection of the first rib may incorporate some of the adjacent tissue. The direct impact of such a slowly growing mass is generally manifested in two ways: (1) osteolytic changes occur in the form of destruction of the periosteum so that the remaining bone is atrophic and without its trophic and anaplastic elements; (2) pressure symptoms develop due to compression of the thoracic outlet.
Laboratory tests are frequently nonspecific and diagnosis is usually based on a combined assessment of routine chest radiography, chest tomography, and computed axial tomography. As found in this patient, specific parasito-logical tests are seldom positive. Patients from a rural area should be regarded with a high degree of suspicion of this disease. The recommended therapy is total excision of the hydatid cysts and the first rib. However, local recurrence is not uncommon and improved results have been reported by combining surgery with mebendazole for preoperative and postoperative prophylaxis.3 Large doses over a long period ensure a better clinical course and reduce the incidence of recurrence. The prognosis is excellent so long as surgical treatment is performed promptly. The surgical approach may be via a supra-clavicular incision or a right posterolateral thoracotomy.4 The latter has the advantage of giving good exposure of the thoracic cavity and allowing concomitant treatment of intrathoracic lesions.
A review of the literature revealed that echinococcosis of the first rib is very rare and previous reported cases have all presented with symptoms of Pancoast's syndrome.5–7 The unusual features of this case are the occurrence of echinococcal infection of the first rib with mild dyspnea and without any clinical signs of Pancoast's syndrome.
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References
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Stathatos C, Konstaxis AN, Zafiracopolis P. Pancoast's syndrome due to hydatid cysts of the thoracic outlet. J Thorac Cardiovasc Surg 1969;58:764–8.[Medline]
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Alaoui-Yazidi A, Sibai H, Kafih A, El Meziane A. Syndrome de Pancoast et Tobias d'etiologie hydatique. Rev Mal Res 1995;12:49–52.
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Aletras H, Papconstantinou C. Pancoast's syndrome following an intrapleural rupture of a hepatic echinococcus cyst. Scand J Thorac Cardiovasc Surg 1982;16:283–7.[Medline]
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D'eshougues JR, Houel J. Syndrome de Pancoast et Tobias d'origine echinococcique. Soc Med Hosp Paris 1954; 70:59–62.
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Abstract
Introduction
