World Journal of Cardiovascular Surgery, 2013, 3, 108-110
http://dx.doi.org/10.4236/wjcs.2013.33020 Published Online July 2013 (http://www.scirp.org/journal/wjcs)
Aspergilloma in a Pulmonary Hydatid*
Nikhil Tiwari#, Ramesh Kaushik, Gaurav Kumar, Gautam Ganguly, Shabaz Hasnain
Department of Cardiothoracic Surgery, Military Hospital (CTC), Pune, India
Received May 6, 2013; revised June 13, 2013; accepted June 22, 2013
Copyright © 2013 Nikhil Tiwari et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Aspergilloma infection in the lung can occur in preexisting cavities and is usually seen after tuberculosis, pulmonary
infarction and bronch estasis. Occassionally aspergilloma has b een reported within a hydatid cyst. We describe a patient
with aspergilloma formed within cyst hydatid. The primary symptom in this patient was recurrent hemoptysis. In this
42-year-old male, the diagnosis was established by HRCT chest. Treatment consisted of postero-lateral thoracotomy
with a bilobectomy of lower and middle lobe. Aspergilloma is an unusual complication of hydatid cyst and results fro m
the deterioration of local defence against opportunistic infection s .
Keywords: Tuberculous Cavity; Lung Hydatid Cyst; Aspergilloma
1. Introduction
Pulmonary aspergilloma generally complicates an exist-
ing cavity that was due to tuberculosis; however, it can
develop in any kind of pulmonary cavity. Regnard et al.
reported growth of aspergilloma in a post-tuberculosis
cavity in 69% in their series [1] and rarely in hydatid cyst
cavities [2]. A review of literature shows isolated case
reports with aspergilloma invading residual cavities left
after cystectomy in lung hydatid [3,4]. Julio C. Vasquez
et al. in their article recommend anatomic lung resection
for such cases. A positive diagnosis relies on direct iden-
tification of Aspergillus species or serodiagnosis. A se-
rodiagnosis is almost always positive in chronic infec-
tions and is detected by immunoelectrophoresis or a sin-
gle precipitation with catalase activity. The rarity of as-
pergilloma within hydatid cyst probably occurs due to
the different elective site for the two diseases. The de-
velopment of aspergilloma on cyst residual cavities can
occur in the early post-operative period and alternatively
after many years. The coexistence of hydatid cyst and
aspergillosis is extremely rare [5,6] and such an associa-
tion has been reported in both immunocompromised and
immunocompetent patients.
2. Case Report
44 yrs old male presented to us with a history of recur-
rent bouts of cough with haemoptysis. He gave a history
of a diffuse right sided chest pain. He was a nonsmoker,
had undergone a six month course of ATT two years
back for pulmonary Koch. His clinical examination was
not contributory. A chest roentgenogram (Figure 1) re-
vealed a cavity in th e right mid zone (RMZ) with promi-
nent vascular markings. A high resolution CT (Figure 2)
revealed a soft tissue mass in superior segment of the
right lower lobe with a thin crescentric lucency which
changes with patient’s position suggestive of aspergil-
loma with adjacent lung consolidation. Bilateral pleural
thickening was also noted. A fibreoptic bronchoscopy re-
vealed a normal tracheobronchial tree. Fungal stains &
culture, Gram stains, pyogenic culture, AFB & MTB
cultre & a Polymerase chest reaction (PCR) of bron-
Figure 1. CXR: Cavity within the RMZ & RLZ consolida-
tion.
*Conflict of interest: Authors have no conflict of interest.
#Corresponding author.
C
opyright © 2013 SciRes. WJCS

N. TIWARI ET AL. 109
choscopic alveolar lavage from the superior segment of
RLL were negative for AFB and fungus. His spirometery
was normal. He was planned for (Rt) lower lobectomy or
a bilobectomy. While awaiting surgery he had a major
bout of haemoptysis necessitating bronchial artery em-
bolization and was taken up for surgery 48 hrs later. A
left posterolateral thoracotomy was done through the 5th
ICS. Intraoperatively extensive adhesions were noted be-
tween the chest wall and the lungs. The fissures between
upper & lower lobes were fused & RML was collapsed.
A 5 × 5 × 5 cm lesion was noted in RLL abutting the
upper lobe and densely adherent to it hence a bilobec-
tomy (RLL & RML) was done.
Grossly the cut surface showed an apical 3.5 × 3 × 2
cm cyst with a fibrous wall containing a delicate white
membrane (Figure 3). Microscopy revealed a fibrous
pericyst containing a dominated chitinous membranous
material. Septate narrow angle branching filaments and
fungal spores were seen on the outer wall as well as sur-
rounding lung showed focal edema, congestion, mixed
inflammatory infiltrate, necrosis & dilated bronchioles.
No invasion of fungal hyphae into lung parenchyma was
Figure 2. CT scan: Soft tissue mass sup segment RLL.
Figure 3. A fibrous pericyst containing a dominated chiti-
nous membranous.
noted.
Final HPE report was—Hydatid cyst (Rt) lung lower
lobe with Aspergillus colonization. Post operatively he
continued to have a prolonged drainage (150 ml) in the
intercostal drains lasting for three weeks which then sud-
denly subsided. Patient was administerd Tab Albenda-
zole 400 mg BD as pulse therapy. He has had an un-
eventful recovery with good expansion of the remaining
lung.
3. Discussion
Aspergilloma is a common form of pulmonary fungal
infection and has a tendency to occur in tubercular cavi-
ties, on rare occasions it may occur in hydatid cavities
[5-7]. The most common sites of aspergilloma and hy-
datid cyst are respectively the upper lobe and the lower
lobe of the lung. Such association has been reported in
both immunocompromised and immunocompetent pa-
tients [8]. The single most important pointer for asper-
gilloma is its mobility in different positions. The differ-
ential diagnosis of Aspergillus colonies entrapped in a
hydatid cyst is tuberculosis, malignancy, an intact hy-
datid cyst, or a necrotizing pulmonary abscess [8].
Surgery is the mainstay of treatment of this opportun-
istic pulmonary mycosis. Recommended surgical treat-
ment for aspergilloma in patients with adequate pulmo-
nary function is lung resection [9]. Anatomic lung resec-
tion is advised in pulmonary aspergilloma as there is un-
certainity in how much lung parenchyma should be re-
moved to safely resect the lesion. Hemoptysis is a known
presentation in pulmonary hydatid cyst and also pulmo-
nary aspergillosis, which was the presenting symptom in
our patient [10]. Hepatic cysts are noted in 20% of such
cases however our case did not have any hepatic cysts
[11]. In conclusion we present a rare case and suggest
that an association between aspergilloma with hydatid
must be kept in mind when dealing with pulmonary as-
pergillosis.
4. Literature Review
There are very few isolated case reports describing coex-
istence of aspergilloma in a hydatid cavity. Sameh
M’saad et al. [12] describe two such cases who initially
presented with recurrent hemoptysis. They were treated
with a postero-lateral thracotomy with wedge resection
of aspergilloma in the left upper lobe because of massive
hemoptysis. In both cases, patients progressed favourably
without antifungal therapy. They describe aspergilloma
as an unusual complication of hydatid cyst resulting from
the deterioration of local defence against opportunistic
infections. Prognosis appears to be better than aspergil-
loma within tuberculous cavities. Buzdar, M.S. et al.
describe invasive aspergillosis in a ruptured hydatid cyst

N. TIWARI ET AL. 110
[2] in a patient earlier treated for pulmonary Koch’s and
who had fever and recurrent hemoptysis and was man-
aged successfully with a wedge resection.
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