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Ann Thorac Surg 2001;71:372-373
© 2001 The Society of Thoracic Surgeons

Case report

Hydatid disease of rib

Nurettin Karaoglanoglu, MDa, Metin Gorguner, MDb, Atilla Eroglu, MDa

a Department of Thoracic Surgery, Erzurum, Turkey
b Department of Chest Diseases, Atatürk University, School of Medicine, Erzurum, Turkey

Accepted for publication May 17, 2000.

Address reprint requests to Dr Karaoglanogu, Department of Thoracic Surgery, Medical Faculty, Atatürk University, 25000 Erzurum, Turkey
e-mail: nkaraoglanoglu{at}hotmail.com


   Abstract
Top
 Abstract
Introduction
 Comment
 References
 
Osseous hydatidosis, especially when located in the rib, is a very rare disease. In 1978, only 39 costal echinococcosis cases were published. The course of the disease is generally slow and laboratory tests are frequently negative. Diagnosis is generally made through the combined assessment of clinical, radiologic, and laboratory data. Living in a rural area is an important risk factor for the disease. The gold standard for therapy is radical removal of the involved ribs or chest wall. We present the case of a 63-year-old herdsman with costal echinococcosis and a review of the literature.


   Introduction
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 Abstract
 Introduction
Comment
 References
 
Hydatid disease is primarily an illness of residents in rural areas who frequently come into contact with carnivores, sheep, and cows. Echinococcus granulosus is extremely widespread, with high rates of infection in eastern and southern Europe, the Middle East, northern Africa, and South America [1]. Turkey is also a very important area to be studied for this disease [2]. The osseous hydatidosis, especially when located in the rib, is a very rare disease. This study is a case report of a 63-year-old patient with costal echinococcosis, along with a review of the literature. To our knowledge, we found that this case is only one of a few documented reports of hydatid disease of the rib in Turkey.

A 63-year-old patient who had a cough and an infected fistulation on his left chest wall was admitted to our hospital. His complaints had begun 12 years earlier. He lived in a rural area in east Anatolia and was in contact with sheep and sheep dogs as a herdsman for approximately 40 years. He had also smoked 1 pack of cigarettes per day for twenty years.

On examination he had a pulse rate of 98 beats per minute, a blood pressure of 120/70 mm Hg, a temperature of 37.5°C, and a respiratory rate of 24 breaths per minute. He had a manifest fistula entrance of his left lower hemithorax. Examination of his chest revealed reduced expansion of the thoracic cage on inspiration, dullness to percussion, and reduced breath sounds over the left lower hemithorax on auscultation.

The computed tomography scan showed a sharply demarcated cystic lesion on the posterior rib at upper level (Fig 1).



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  		Fig 1. The computed tomography scan demonstrating a cystic lesion sharply demarcated on the posterior rib at upper level.

 
Routine biochemical studies were normal except the increased white blood cells, 14,100/µL, with 78% of neutrophilia. Serologic tests for Echinococcus granulosus were negative.

There was no microbiologic reproduction in the culture of material obtained from the fistula entrance. Cytologic examination demonstrated predominantly neutrophiles, and cytology was also negative for malignancy.

An operation was planned and performed on the patient for the total resection of the fifth rib and partial resection of the sixth rib. Serratus anterior and Latissimus dorsi muscles were used as a flap to fill the defect. Figure 2 shows the resection material of the fifth rib, which was pathologically confirmed as a hydatid cyst. There were no complications postoperatively. Albendazole (800 mg per day; Andazol, Biofarma, Istanbul, Turkey) was administered after the operation. The patient clearly improved and was discharged from the hospital. At the 6-month follow-up, the patient was healthy.



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  		Fig 2. Photomicrograph showing trabeculae of bone and germinative membrane (Hematoxylin-eosin stain, x 40).

 

   Comment
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 Abstract
 Introduction
 Comment
References
 
Hydatid disease of the bone is a rare form. The costal localization, on the other hand, is of particular interest because of its capacity to destroy the bone matrix and infiltrate the adjacent tissues. It has been reported that the course of this disease is generally slow and laboratory tests are frequently negative. Diagnosis can be obtained through the combined assessment of clinical, radiologic, laboratory, and anamnestic data as was seen in our case. Living in a rural area should reinforce the suspicion of this disease [3]. Ousehal and colleagues [4] also noticed that magnetic resonance imaging, in addition to its diagnostic role of showing cystic images, has an important role in verifying the extent of the disease and the degree of medular sufferance.

In 1978, Panahi [5] reported that 39 costal echinococcosis cases were published. Rong and Nie [6] presented 20 cases of hydatid disease of bone revealed by roentgenogram examination during the period of 1957 to 1980. The ribs were involved with 2 of the patients. In subsequent years, Stamatis and Greschuchna [7] also published studies of 14 patients with hydatid disease of the lung and chest wall that had operations at the Ruhrlandklinik in Essen, Germany since 1976. In two of these patients, echinococcosis of the rib was seen. These patients resided in Mediterranean countries, the clinical symptoms were not very marked, and the specific laboratory tests were seldom positive.

To our knowledge, our identical case is only one of a few documented reports of hydatid disease of the rib in Turkey [8, 9]. In a recent study, Savas and coworkers [9] presented computerized tomography and magnetic resonance imaging findings of a costal hydatid cyst causing spinal cord compression. They also claimed magnetic resonance imaging was not only useful for determining the spinal extension of the disease, but also gave important information about the texture of the cyst.

The gold standard for therapy is radical removal of the ribs or chest wall involved [7]. It has been proposed that better results are obtained by combining surgical procedures with mebendazole (Vermazol; I.E. Ulagay, Istanbul, Turkey) or albendazole for preoperative and postoperative prophylaxis, and that large doses over a long period of time will result in a good clinical approach and to reduce the incidence of recurrence [3].


   References
Top
 Abstract
 Introduction
 Comment
 References
 

  1. Petersen C., Mills J. Parasitic infections. In: Murray J.F., Nadel J.A., eds. Textbook of respiratory medicine. Philadelphia: WB Saunders Company, 1994:1201-1243.
  2. Dogan R., Yuksel M., Cetin G., et al. Surgical treatment of hydatid cysts of the lung: report on 1055 patients. Thorax 1989;44:192-199.[Abstract/Free Full Text]
  3. Di Gesu G., Massaro M., Picone A., La Bianca A., Fiasconaro G. Bone echinococcosis. Minerva Med 1987;78:921-931.[Medline]
  4. Ousehal A., Adil A., El Azhari A., Kadiri R. Spinal cord compression disclosing rib hydatidosis. J Radiol 1995;12:1093-1095.
  5. Panahi F. Costal echinococcosis. Report of one case and review of the literature. Sem Hop 1978;54:1389-1392.[Medline]
  6. Rong S.H., Nie Z.Q. Hydatid disease of bone. Clin Radiol 1985;36:301-305.[Medline]
  7. Stamatis G., Greschuchna D. Echinococcus cysticus costalis: report of 2 cases and review of the literature. Pneumologie 1989;43:213-216.[Medline]
  8. Ozdemir N., Akal M., Kutlay U., Yavuzer S. Chest wall echinococcosis. Chest 1994;105:1277-1279.[Abstract]
  9. Savas R., Calli C., Alper H., et al. Spinal cord compression due to costal echinococcus multilocularis. Comput Med Imaging Graph 1999;23:85-88.[Medline]



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