Pulmonary Hydatid Disease with Aspergillosis - An Unusual Association in an Immunocompetent Host
Rahul Chanderhas GOYAL1, Ruchita TYAGI1, Bhavna GARG1, Atul MISHRA2, Neena SOOD1
1Department of Pathology, Dayanand Medical College and Hospital, LUDHIANA, INDIA
2Surgery, Dayanand Medical College and Hospital, LUDHIANA, INDIA
Keywords: Pulmonary hydatid cyst, Aspergillosis, Lung
Echinococcosis is a common cause of pulmonary cavities. Aspergillus fumigatus, a saprophytic fungus, can colonise pulmonary cavities caused
by tuberculosis, sarcoidosis, echinococcosis, bronchiectasis and neoplasms. Infection by Aspergillus is often seen in immunosuppressed cases.
However, co-infection of Aspergillus with pulmonary echinococcosis is unexpected and very unusual, especially in an immunocompetent
patient. We present the case of a 45-year-old immunocompetent male who came with non-resolving pneumonia and fever for 8 months and
dyspnoea since 15 days accompanied by recurrent episodes of hemoptysis since 5 days. Chest X Ray and Computed Tomography scan showed a
cystic lesion in the middle lobe of the right lung. Middle lobectomy with video-assisted thoracoscopic surgery was performed and histopathology
revealed ectocyst of Hydatid cyst which was also colonised by septate fungal hyphae exhibiting acute angled branching, morphologically
consistent with Aspergillus. Gomori Methanamine Silver and Periodic Acid Schiff stains highlighted the hyphae of Aspergillus as well as the
lamellated membranes of ectocyst and an occasional scolex of Echinococcus. Sections from surrounding lung parenchyma also showed these
fungal hyphae within an occasional dilated bronchus. Thus a diagnosis of dual infection of Aspergillosis and Pulmonary Echinococcosis was
established. The possibility of dual infection by a saprophytic fungus must be kept in mind while dealing with a case of a cavitary lesion in
long-standing and non-resolving pneumonia, even in an immunocompetent patient. Establishing the correct diagnosis of Aspergillosis with
Echinococcosis is essential for proper and complete management.
Hydatid disease or Echinococcosis is a common disease in
India caused by the larval form of Echinococcus granulosus.
Although any organ can be involved by this parasite, the
lung and liver are more frequently affected. Echinococcus
multilocularis is the species which commonly involves
the lung. Aspergillus fumigatus is a saprophytic fungus
which can colonise pulmonary cavities caused by tuberculosis,
sarcoidosis, echinococcosis, bronchiectasis and
. Infection by Aspergillus is often seen in
. Co-existence of Aspergillosis
and Hydatid disease is a rare occurrence which is seen in
We encountered a case of an immunocompetent patient
with non-resolving pneumonia and fever who was
incidentally found to harbor dual infection with Aspergillus
as well as pulmonary hydatid cyst.
A 45-year-old gentleman presented with complaints of
breathlessness since 15 days and recurrent episodes of
hemoptysis since 5 days. The patient had non-resolving pneumonia and intermittent fever for the last eight months.
He was non-diabetic and did not have any other significant
past medical history to suggest immunosuppression.
General and systemic examination was unremarkable.
He was non-reactive for HBsAg and HIV. Hemogram
was normal and there was no evidence of eosinophilia on
peripheral blood examination. No serological examination
for Aspergillus or Echinococcus was performed. Pulmonary
function tests and liver function tests were normal. Chest
X-ray showed a circumscribed cystic lesion in the middle
lobe of the right lung. Computed Tomography (CT)
scan, done outside, revealed a well-defined peripherally
enhancing thick-walled cystic lesion in the middle lobe of
the right lung. Ultrasound abdomen did not show any cysts
in the liver or any other organ. In view of non-resolving
pneumonia and respiratory symptoms, the patient was
taken up for surgery. Video-assisted Thoracoscopic Surgery
(VATS) middle lobectomy was performed and the cyst was
sent for histopathological examination along with part of
middle lobe of right lung.
Gross examination revealed a glistening white, thin cyst
measuring 4x2.5x2cm. On opening the cyst, clear fluid was drained out. A part of lung measuring 8x5x2.5cm
was also received separately in the same container. Cut
section of the lung tissue was spongy with hemorrhagic
areas. Microscopic examination of cyst wall showed
acellular, lamellated eosinophilic membrane - ectocyst
with an occasional hooklet highlighted on Gomori’s
methanamine silver (GMS) stain (Figure 1). Surprisingly,
the ectocyst also showed presence of numerous septate
hyphae with acute angled branching, conforming with
the morphology of Aspergillus (Figure 2). These findings
were further confirmed by the GMS and Periodic Acid
Schiff (PAS) stains. Thus, a diagnosis of dual infection by
Echinococus and Aspergillus was established. The sections
from lung tissue showed congestion of alveolar spaces with
large areas of necrosis containing interspersed hyphae of
Aspergillus, which were also seen to colonise an occasional
dilated bronchus. The surrounding lung parenchyma was
infiltrated by chronic inflammatory infiltrate along with
formation of lymphoid aggregates (Figure 3A-D).
Click Here to Zoom
|Figure 1: Photomicrograph showing hooklet of Echinococcus
(red arrow) along with hyphae of Aspergillus (yellow arrowhead)
Click Here to Zoom
|Figure 2: GMS stain highlighting acellular lamellated ectocyst
with fungal hyphae (GMS; x400).
Click Here to Zoom
|Figure 3: A) Section from lung showing areas of necrosis surrounded by chronic inflammatory infiltrate (H&E; x100). B) Septate fungal
hyphae of Aspergillus with acute angled branching in necrotic areas (H&E; x400). C) Hyphae of Aspergillus colonising ectocyst (H&E;
x400). D) PAS stain highlighting fungal hyphae of Aspergillus against background of ectocyst of Echinococcus (PAS; x100) .
Microbiological examination of cyst fluid or tissue was not
done as there was no clinical suspicion of fungal or parasitic
infection prior to surgery. The surgically excised tissue was
sent for histopathological examination and no material was
sent for culture studies.
In view of the dual infection, the patient was started on
Itraconazole 400 mg and Albendazole 800 mg orally, daily.
As the patient was immunocompetent, the post-operative
course was uneventful and there was no dissemination of
fungal or parasitic infection. The patient was discharged
from hospital within ten days and is on regular follow up.
Aspergillus fumigatus is a saprophytic fungus which can
cause allergic pulmonary aspergillosis, aspergilloma, and
semi-invasive and invasive aspergillosis in human beings.1
Rarely, aspergilloma may develop after months or
years in an operated hydatid cyst cavity.5,6
Only a few
case reports have described the involvement of an active
hydatid cyst cavity by Aspergillus in immunocompetent
About 60% of pulmonary hydatid disease has been reported
to affect the right lung, as was also seen in our case. While
the middle lobe was involved in our case, 50% to 60% of
pulmonary cases are seen in the lower lobes1,7,8,17.
The clinical presentation of pulmonary echinococcosis
depends on the site, size of the cyst and whether the cyst
has ruptured or is intact. Intact cyst may be an incidental
finding or may cause cough, dyspnoea and chest pain due to
compression of surrounding structures. A cyst may rupture
into a bronchus, pleura or a vessel, causing hemoptysis.
The patient may expectorate cyst contents, have recurrent
episodes of hemoptysis, productive cough, fever or even
anaphylactic shock due to aspiration of cyst contents in
such cases1,2,7,9,18. In our case, similar presenting
features were seen in the form of fever and non-resolving
pneumonia for eight months, dyspnoea since 15 days and
recurrent episodes of hemoptysis since 5 days. Eosinophilia
can occur in 40% of cases. Serological tests for Echinococcus
include Casoni’s intradermal test, hemagglutination tests,
flocculation tests, precipitin reaction, complement fixation
test. Indirect fluorescent antibody test and immune-electrophoresis have also been used18. However, there
was no eosinophilia in peripheral blood examination in our
patient. Aspergillus galactomannan Antigen (AGA) levels
may help in detecting invasive aspergillosis infection13.
However, no such serological tests were performed in this
Other organisms that are known to cause secondary
infection with hydatid cyst include Escherichia coli and
viridans group streptococci in hepatic cysts and Aspergillus
fumigatus in pulmonary cysts4. Fungal colonization
may occur because of immunosuppression, structural
defects in lungs, prior intervention or cyst rupture2,9,10.
Aspergillus may have a propensity to colonise cysts close
to the hilum as obliteration of the cavity does not occur
in these cases10. The large size of the hydatid cyst may
predispose to secondary infection, which may even result
in the formation of an abscess, causing purulent sputum6,18. However, in many instances, fungal colonization has been observed even in the absence of the above mentioned
Surgical resection is the treatment of choice for pulmonary
echinococcosis. If Aspergillus is limited to the hydatid cyst
cavity, then resection is curative for both the infections.
In our case, aspergillus was also present in the lung
parenchyma and bronchi. In such cases, oral antifungal
treatment is also required. In unresectable, recurrent or
inoperable echinococcosis, oral anti-helminthic therapy is
warranted13,18. As our patient was immunocompetent,
there was no dissemination of Aspergillus and the postoperative
stay was uneventful.
In conclusion, we hereby report an unusual occurrence
of non-resolving pneumonia caused by dual infection
comprising of Aspergillosis in a case of pulmonary
hydatid cyst, detected on histopathological examination.
Even in an immunocompetent patient, the possibility of secondary infection of a hydatid cyst cavity by saprophytic
fungus should be kept in mind for better and complete
1) Dhal I, Sahoo TP, Behera SS, Panigrahy SK, Nayak R, Ali SI.
Pulmonary hydatid cyst with Aspergillous fungal co-infection:
A rare case report and review of literature. Int J Dent Med Res.
2) Kocer NE, Kibar Y, Guldur ME, Deniz H, Bakir K. A retrospective
study on the coexistence of hydatid cyst and aspergillosis. Int J
Infect Dis. 2008;12:248-51.
3) Soubani AO, Chandrasekhar PH. The clinical spectrum of
pulmonary aspergillosis. Chest. 2002;121:1988-99.
4) Manzoor MU, Faruqui ZS, Ahmed Q, Uddin N, Khan A.
Aspergilloma complicating newly diagnosed pulmonary
echinococcal (hydatid) cyst: A rare recurrence. Br J Radiol.
5) U lasan NG, Dural K, Yildirim E, Ozisik K, Sakinci U. An
intracavitary aspergilloma after echinococcal cystectomy. J
Cardiovasc Surg (Torino). 2003;44:289-90.
6) A ydemir B, Aydemir C, Okay T, Celik M, Dogusoy I. An
aspergilloma in echinococcal cyst cavity. Thorac Cardiovasc
7) Pan JB, Hou YH, Yin PZ. A case report of hydatid cysts containing
aspergillus. J Thorac Dis. 2013;5:E25-E27.
8) A garwal S, Bohara S, Thakran A, Arora P, Singh R, Agarwal PN.
Pulmonary hydatid disease with coexistent aspergillosis: An
incidental finding. Indian J Med Microbiol. 2013;31:85-6.
9) Mahapatra S, Das R, Mohapatra C, Rath J, Behera S. Aspergillosis in
Hydatid cyst - a rare coexistence. Virol Mycol. 2012;1:106.
10) A grawal M, Uppin MS, Manasa PL, Uppin SG, Chakravarty MP,
Mishra RC, Challa S. Aspegillus colonization in hydatid cyst:
Addition of a case. Lung India. 2013;30:335-7.
11) Bal A, Bagai M, Mohan H, Dalal U. Aspergilloma in a pulmonary
hydatid cyst: A case report. Mycoses. 2008;5:357-9.
12) Gupta N, Arora J, Nijhawan R, Aggarwal R, Lal A. Aspergillosis
with pulmonary echinococosis. Cytojournal. 2006;3:7.
13) Chatterjee A, Goswami HM, Dhotre SV, Dharsandia MV,
Raval AA, Vegad MM. A retrospective study on coexistence of
pulmonary hydatid cyst and aspergillosis. Int J Microbiol Res.
14) Vaideeswar P, Vyas M, Katewa A, Bhaskar M. Piggyback mycosis:
Pulmonary hydatid cyst with a mycotic co-infection. Mycoses.
15) M’saad S, Ayedi L, Abdennader M, Bahloul N, Hentati A,
Dabbech C, et al. Aspergilloma in a hydatid cavity: A case report.
Respir Med CME. 2010;3:29-32.
16) García MB, Lledías JP, Pérez IG, Tirado VV, Pardo LF, Bellvís LM,
Varela G, Sánchez MC. Primary super-infection of hydatid cystclinical
setting and microbiology in 37 Cases. Am J Trop Med
17) Bhatia G. Echinococcus. Semin Resp Infec. 1997;12:171-86.
18) Mahmood N, Azam H, Ali MI, Khan MA. Pulmonary hydatid
cyst with complicating Aspergillus infection presenting as a
refractory lung abscess. Clin Med Insights Case Rep. 2011;4:63-8.