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|Year : 2003 | Volume
| Issue : 1 | Page : 120-121
Stroke: A rare presentation of cardiac hydatidosis
Singh NP, Arora SK, Gupta A, Anuradha S, Sridhara G, Agarwal SK, Gulati P
Department of Medicine, Maulana Azad Medical College and Lok Navak Hospital, MR Centre, New Delhi
D-II /356, Pandara Road, New Delhi-110003
A 13-year-old boy presented with acute stroke leading to right-sided hemiparesis. A contrast CT scan of the brain showed a hemorrhagic infarct in the left basal ganglia region with surrounding edema. Echocardiography showed a hydatid cyst in the right atrial chamber extending into the left atrium. A single hepatic hydatid was also seen.
|How to cite this article:|
Singh N P, Arora S K, Gupta A, Anuradha S, Sridhara G, Agarwal S K, Gulati P. Stroke: A rare presentation of cardiac hydatidosis
. Neurol India 2003;51:120-1
Hydatid disease is a parasitic disease caused by the larval stages of echinococcus granulosus and the most common sites of involvement are liver and lungs. Cardiac hydatidosis is a rare disease even in the endemic areas and though most of the patients may remain asymptomatic, a number of serious and lethal complications have been described., We report a young boy who presented with acute stroke in association with intracardiac hydatid cysts.
A 13-year-old boy presented with sudden onset right hemiparesis which was not associated with headache, vomiting, seizures or fever. There was no history of chest pain, cough, hemoptysis or dyspnoea. On examination, there was no anemia, jaundice, lymphadenopathy or engorgement of neck veins. Chest and abdominal examinations were normal. Cardiovascular examination revealed a normal first heart sound, a widely split second heart sound and an ejection systolic murmur heard intermittently in the left parasternal area. Right he had a hemiparesis.
Hemoglobin was 11.5 gm/dL, total leucocyte count was 9x 109/L with 2% eosinophils and the erythrocytes sedimentation rate was 20 mm in the first hour. Chest radiograph was unremarkable. An ECG recording showed left atrial enlargement with a right bundle branch block. A contrast enhanced CT scan of the head revealed a hemorrhagic infarct in the left basal ganglia with surrounding edema and compression of the frontal horn of the left lateral ventricle [Figure - 1]. The two-dimensional echocardiography, CT of thorax and a subsequent thoracic MRI scan demonstrated a large bilobed cystic mass of size 5.7 x 6.5 cm in the lumen of the right atrium extending into the left atrium through the septum [Figure - 2]. All the cardiac valves and other cardiac chambers were normal. Ultrasonography of the abdomen showed hepatomegaly with a cystic lesion of size 6.4 x 4.7 cm with multiple daughter cysts on the postero-superior surface of the liver. Serum Elisa for echinococcus was reactive.
At the time of publication, the patient was awaiting surgical excision of the cardiac cysts.
Cardiac hydatidosis is an uncommon form of hydatid disease with a frequency of 0.5-2%. Cardiac involvement occurs by spread from systemic or pulmonary circulation, though contiguous spread from neighboring organs is also proposed. The clinical presentation depends upon the number, site and size of the cardiac hydatids. Patients may be symptomatic and cardiac hydatidosis incidental or they may present with complications like valvular dysfunction, coronary artery disease, tamponade, pulmonary embolism, left ventricular outflow obstruction or even sudden death., Among all the cardiac chambers, left ventricle involvement is the most.
The diagnosis of cardiac hydatidosis is best made by 2-D echocardiography which shows cystic masses with central echolucent areas and smooth walls. Occasionally, solid masses or multiloculated cysts may be seen. The movement of cyst contents with change in posture is considered specific for hydatid cysts. Thoracic CT and MR scans are increasingly recognized as elective diagnostic modalities.
Central nervous system involvement is reported in 1-2% of all echinococcal infections, mainly in children. Brain involvement may occur secondary to dissemination from a cardiac source or may present as primary brain cyst in patients with cardiac shunts. Small rents in the mother cysts (which later seal spontaneously) are surmised to release daughter cysts into the circulation, which reach other organs like the brain and cause neurological syquaelae. Development of daughter cysts in the infarcted areas has been documented on repeat CT scanning in sonic of these patients. Most of the brain hydatids are in the supratentorial compartment, in the middle cerebral artery territory. The development of symptoms and neurological deficit is usually late and is due to mass effect. However, presentation of cardiac hydatidosis as acute stroke due to embolization is exceptionally rare and only isolated reports exist in literature.,, In two of these cases, a repeat cranial CT revealed cyst development in the territory of the infarct while in one patient, the diagnosis was confirmed on necropsy. The present patient also has a similar clinical profile of a cardiac hydatid cyst with left basal ganglia infarct due to embolization of fragments from the cardiac cyst. There was no development of daughter cysts in the infarcted area on repeat CT scanning performed 1 month after the stroke in the present patient.
In view of high risk of associated complications, cardiac hydatid cysts require surgical removal, even in patients with multi organ involvement. Pre and postoperative treatment with albendazole in doses of 10-40 mg/kg has been tried and recommended.
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