Case Presentation
A 68-year-old woman presented to a health care center with a clinical
manifestation of a slow-growing and painless lump on the right side of
the cervical region over several weeks. She had no cardiac symptoms.
History-taking revealed working in a sheep-farming area in her twenties.
Past medical and surgical history included hypertension and hepatic
hydatidectomy two years ago.
Clinical examination through ultrasound imaging revealed a 47mm×75 mm
cervical cyst expanded to superior mediastinum with neither inflammatory
response nor spasm of the cervical muscles. The cervical cyst consisted
of a bilayer membrane with several membrane-attached scolices,
indicating an active hydatid cyst (cystic echinococcosis type 1, CE1).
The lesion was lateral to the common carotid artery and posterior to the
internal jugular vein with no cervical lymphadenopathy. Besides, the
abdominal ultrasound examination showed multiple active, recurrent
hepatic cysts in both the right and left lobes (stage 1), encompassing
all liver segments. There was no evidence of biliary dilatation as well.
In the transthoracic echocardiographic (TTE), a bulging and well-defined
echo-lucent cystic mass in the interventricular septum measuring 33×42
mm was detected (figure 1). A slight compression effect was present on
the right ventricle (RV) cavity. The LV size and LV outflow tract (LVOT)
were normal, with a mild systolic dysfunction (eye-ball estimation of LV
ejection fraction = 45-5%). The valvular functions were normal, with no
pericardial effusion. Other echocardiographic findings were
unremarkable. The hydatid serology was positive, in which the
enzyme-linked immunosorbent assay (ELISA)-based qualitative assessment
of E. granulosus IgG antibodies confirmed the echinococcosis.
Finally, the patient underwent cardiac surgery using cardiopulmonary
bypass (CPB) for cystectomy to minimize the risk of spillage of cyst
contents. The CPB technique was established by cannula inserting into
the ascending aorta, superior vena cava (SVC), and inferior vena cava
(IVC) after the routine median sternotomy. Following the cold
cardioplegia, the established hypothermia was recorded at 32 °C. The
outlines of the isolated cardiac cyst seemed to be complete and clear.
Conservative procedures were further performed to sterilize and evacuate
the cyst contents. The RV cavity was entered, and the cyst was exposed
carefully. Thereafter, ten milliliters of its contents were aspirated.
An equal amount of hypertonic saline (NS 20%) was injected into the
cyst, and after several minutes, the exposed cyst was evacuated
completely (figure 2). Following successful excision and secured
hemostasis, the cyst specimen, containing 8 ml colorless turbid fluid,
was sent to the histopathological examination, which further vouched for
the diagnosis of a hydatid cyst (figure 3).