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CASE REPORT
Year : 2020  |  Volume : 30  |  Issue : 2  |  Page : 119-120

Multimodality imaging for diagnosis and characterization of a cardiac hydatid cyst


1 Cardiology Unit, Sandro Pertini Hospital, Rome, Italy
2 Cardiology Unit, Sandro Pertini Hospital; Department of Clinical and Molecular Medicine, Cardiology Unit, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy
3 Unitá Operativa Complessa Diagnostica Per Immagini, Ospedale “Sandro Pertini,” Rome, Italy

Date of Submission14-Feb-2020
Date of Decision03-Apr-2020
Date of Acceptance13-May-2020
Date of Web Publication18-Aug-2020

Correspondence Address:
Giovanni Maria de Matteis
Cardiology Unit, Sandro Pertini Hospital, Via Dei Monti Tiburtini, 385/389, 00157 Rome
Italy
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcecho.jcecho_14_20

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  Abstract 


Here, we report the case of a young patient admitted to the emergency department because of abdominal pain. Computed tomography revealed a mass within her right heart. Through serial multimodality imaging testing, including computed tomography, three-dimensional (2D)- and three-dimensional echocardiography, as well as cardiac magnetic resonance, the diagnosis of cardiac involvement in the course of Echinococcus granulosus infection was hypothesized.

Keywords: Cardiac hydatid disease, cardiac magnetic resonance imaging, echocardiography, multimodality imaging


How to cite this article:
de Matteis GM, Arcari L, Mustilli M, Fina P, Stingone AM, Preziosi P, Ferraiuolo G. Multimodality imaging for diagnosis and characterization of a cardiac hydatid cyst. J Cardiovasc Echography 2020;30:119-20

How to cite this URL:
de Matteis GM, Arcari L, Mustilli M, Fina P, Stingone AM, Preziosi P, Ferraiuolo G. Multimodality imaging for diagnosis and characterization of a cardiac hydatid cyst. J Cardiovasc Echography [serial online] 2020 [cited 2020 Oct 20];30:119-20. Available from: https://www.jcecho.org/text.asp?2020/30/2/119/292290




  Introduction Top


Cardiac masses are uncommon but may pose significant challenges for differential diagnosis, that should be obtained to plan appropriate treatments according to the underlying causative condition. Here we report the diagnostic and therapeutic management of a patient with a cardiac mass finally diagnosed as having cardiac involvement in the course of parasitic infection.


  Case Report Top


A 31-year-old woman, with a history of marginalization and nomadism, presented to the emergency department because of abdominal pain in her right hip. Blood tests and electrocardiogram were unremarkable. Abdominal echography revealed a mass in the liver; hence, a thoracic and abdominal computed tomography was performed, showing two masses in the liver and right ventricle (RV) consistent with a parasitic cyst. Transthoracic echocardiography (TTE) was then performed, revealing a single cardiac cystic mass with anechoic content, multilocular and nonmobile, in the context of RV inflow [Figure 1]a and Supplementary Video 1] without signs of obstruction to RV filling. Three-dimensional (3D)-TTE localized the mass within the posterior RV inflow. 3D-TTE aided discrimination between different structures, suggesting the cyst to be intramyocardial [Figure 1]b, c and Supplementary Videos 2, 3]. Finally, cardiac magnetic resonance (CMR) was performed. Cine images confirmed the location of the mass, supporting, along with 3D-TTE, the intramyocardial extension [Figure 1]d, Supplementary Video 4]. The cyst had high T2 signal intensity, consistent with static fluid content. First-pass perfusion excluded a connection between the mass and ventricular cavity, as contrast did not penetrate within the cyst lumen [Figure 1]e and Supplementary Video 5]. Late gadolinium enhancement appeared as a small rim surrounding the cyst [Figure 1]f. According to clinical history and imaging findings, the diagnosis of cardiac involvement in the course of Echinococcus granulosus (EG) infection was hypothesized. Because the patient refused surgery, she was initially treated with albendazole 400 mg twice daily, but subsequently lost at follow-up.
Figure 1: Two-dimensional echocardiography shows a single cardiac cystic mass with anechoic content, multilocular and nonmobile, in the context of right ventricle inflow (a). Three-dimensional-transthoracic echocardiography localized the mass within the posterior right ventricle inflow, possibly with intramyocardial location (b and c). View of the cyst by cardiac magnetic resonance cine-images (d), first-pass perfusion (arrow in e) and late gadolinium enhancement (arrow in f)

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  Discussion Top


Cystic echinococcosis is a zoonosis caused by EG,[1] more commonly found within the rural areas of endemic regions.[2] In the present case, the patient's history of nomadism and marginalization was consistent with EG diagnosis,[3] even in the context of a large Western European city. Cardiac echinococcosis (CE) in the course of EG infection is uncommon with an estimated rate <2%, more often affecting the left ventricle.[4] The diagnosis is based on multiparametric assessment including clinical history and serologic and imaging evaluation.[4] Of note, serology might be affected by limitations leading to false-negative results;[5] hence, cardiac imaging has a central role in the CE diagnostic workup. In our patient, two-dimensional (2D)-echocardiography was instrumental in classifying the mass as CE2 and likely active echinococcus cyst,[6] whereas 3D-echocardiography better clarified its intramyocardial location. Localizing the cyst position has important clinical correlates, as it aids surgical planning and might suggest the subsequent development of specific and more severe complications, such as pericardial tamponade in the case of pericardial rupture of the cyst.[7] Finally, CMR added on the diagnostic evaluation, confirming ultrasonographic findings, identifying the fibrotic capsule,[8] and excluding the presence of adjunctive cardiac cysts. The treatment strategy in CE is based on small reports and usually includes the surgical excision of the mass,[9] however, given the patient's reluctance, this was not possible in our case.


  Conclusions Top


We reported an uncommon case of right heart CE, in which multimodality imaging approach provided us with a comprehensive diagnostic evaluation, including accurate cyst localization, hemodynamic impact assessment, and tissue characterization. Our case suggests that irrespective of blood test findings, CE should be investigated by cardiac imaging in suspected individuals.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Consent to participate: the patient provided informed consent for the use of her records for research purpose.



 
  References Top

1.
Higuita NI, Brunetti E, McCloskey C. Cystic echinococcosis. J Clin Microbiol 2016;54:518-23.  Back to cited text no. 1
    
2.
Moro P, Schantz PM. Echinococcosis: A review. Int J Infect Dis 2009;13:125-33.  Back to cited text no. 2
    
3.
Moshfe A, Sarkari B, Arefkhah N, Nikbakht R, Shahriarirad R, Rezaei Z, et al. Seroepidemiological study of cystic echinococcosis in nomadic communities in the Southwest of Iran: A population-based study. J Immunoass Immunochem 2019;40:183-92.  Back to cited text no. 3
    
4.
Kahlfuß S, Flieger RR, Roepke TK, Yilmaz K. Diagnosis and treatment of cardiac echinococcosis. Heart 2016;102:1348-53.  Back to cited text no. 4
    
5.
Ammann RW, Eckert J. Cestodes. Echinococcus. Gastroenterol Clin North Am 1996;25:655-89.  Back to cited text no. 5
    
6.
Brunetti E, Kern P, Vuitton DA. Expert consensus for the diagnosis and treatment of cystic and alveolar echinococcosis in humans. Acta Trop 2010;114:1-16.  Back to cited text no. 6
    
7.
Kosecik M, Karaoglanoglu M, Yamak B. Pericardial hydatid cyst presenting with cardiac tamponade. Can J Cardiol 2006;22:145-7.  Back to cited text no. 7
    
8.
Kelle S, Köhler U, Thouet T, Fleck E, Nagel E. Cardiac involvement of Echinococcus granulosus evaluated by multi-contrast CMR imaging. Int J Cardiol 2009;9;131:e59-60.  Back to cited text no. 8
    
9.
Fennira S, Kamoun S, Besbes B, Ben Mrad I, Zairi I, Ben Moussa F, et al. Cardiac hydatid cyst in the interventricular septum: A literature review. Int J Infect Dis 2019;88:120-6.  Back to cited text no. 9
    


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