A Case of Sudden Death Due to Rupture of a

Balkan Military Medical Review 2014; 17(2):70-73

ISSN: 1107-6275

BALKAN Military Medical REVIEW Case Report

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A Case of Sudden Death Due to Rupture of a Hydatid Cyst

Gulhane Military Medical School, Forensic Medicine Dept. 1 Gulhane Military Medical School Pathologyi Dept. 1 Gulhane Military Medical School Microbiology Dept. 4 Dokuz Eylül Medical School, Forensic Medicine Dept..

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DOI 10.5455/bmmr.149506

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Corresponding Author Mehmet Toygar Gulhane Military Medical School, Forensic medicine Dept. [email protected]

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Published Online April 29, 2014

Abstract Deaths due to rupture of hydatid cysts caused by Echinococcus granulosus encountered rarely, mostly in endemic areas. We report a 29-year-old man who died suddenly. A forensic autopsy was performed. The postmortem examination confirmed a ruptured cyst in the liver and a decision was made that death must have been caused by the anaphylactic shock due to rupture of this cyst. This case was presented in order to emphasize the medico-legal issues related to the diagnoses and treatments of the entities which cause sudden death encountered in primary health care services, and to document of the postmortem findings of a sudden death case due to a ruptured hydatid cyst which is rarely occurred.

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Received January 02, 2014 Accepted April 27, 2014

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Key Words Hydatid cyst, sudden death, anaphylactic shock.

INTRODUCTION

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Mehmet Toygar1, I.Ozgur Can4, Yildirim Karslioglu2, Abdullah Kilic3, Harun Tugcu1, Mukerrem Safali2

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World Health Organization claimed that symptoms of sudden death must start in first 24 hours and result in death with an aggressive progression (1). On the other hand, sudden deaths are defined as the unexpected, natural deaths, which symptoms are starting in one hour (2).

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Cystic echinococcosis (CE) in human being only occurs sporadically, the most affected regions are observed as the Mediterranean (e.g. parts of Spain, southern Italy and Sardinia), where annual incidence rates for human CE of four to eight per 100,000 have been reported, and the sheep raising areas of Great Britain (3). Sudden deaths caused by the rupture of hepatic hydatid cysts are seen rarely. (4) Hydatid cyst is a zoonotic infection which is generated by the parasite E.granulosus. (5). E. Granulosus has a

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2-6 mm length, hooked scolexes that has a 0.6 mm width, neck and 3-4 rings (5). Infections in hosts caused by adult Echinococ are named as Echinococcus. Infections caused by larvae of Echinococ in humans and animals are named as hydatid disease. The species of Echinococs seen in humans are E. granulosis and E. Multilocularis according to morphological criteria. As addition to these species, E.vogeli and E. Oligoarthrus are reported in Middle and South America after 1960’s. Hydatid Cyst is a worldwide (South America, Mediterranean countries, Middle East, Australia, Tasmania and New Zealand) disease. In Turkey, it is more common in the east and southeast regions of the country (4). The severity of the disease in humans depends on dispersion of the parasite, affected people and morbidity (5). The last host of E.granulosus is dogs and canines, intermediate hosts are sheep, kettle, other domestic animals and humans. Hydatid cyst transmits with the


%75 of E. granulosus oncospheres which gets in the circulation generally from the intestinal mucosa veins settle into the liver, %9 into the lungs, %5 into the muscles, %2 into the kidney and spleen, %1.5 into the brain, %1 into the bones, and the rest into the other parts of the body (5,7). Although it is rare, sudden deaths caused by anaphylactic shocks and ruptures of the hydatid cysts in the solid organs like lungs and livers can be seen in the endemic regions (8, 9, 10).

diameter and 0.3 cm wall thickness was observed in the right lobe (Picture 1). In the histopathological sections taken from the right lobe of liver; there was found a ruptured cyst under the capsule, daughter vesicules in the lumen and reactive changes in the neighboring liver parenchyma (Picture 2). No toxic materials could be detected in blood, urine and gastric secretion in the toxicological examination. It was decided that the cause of death was the anaphylactic shock induced by the rupture of hydatid cyst.

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eggs in the faeces of the last host (6).

This case is presented in order to put forth the postmortem findings of a rare sudden death caused by hydatid cyst rupture.

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Picture 1. A subcapsular ruptured cyst in the right lobe section of liver

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An operation was planned with the diagnosis of hytadid cysts before the patient who a 29-year-old male was having a history of bilateral lung hydatid cysts operation passed away 22 days ago. He was admitted twice to the hospital the day after operation planned day and 15th day, necessary treatment was provided after examinations. One week before the operation date, he was found lying unconscious, and he was resuscitated after respiratory arrest. He was transferred to the ED for further tests and treatment. General medical situation was bad, he was unconscious and cyanosed, pupils were fixed dilate, and blood pressure was not able to be measured at the ED. Also 2 cm laceration was observed in the left temporoparietal region. Intubated patient after 30 minutes successful cardiopulmonary resuscitation was transferred to ICU with mechanical ventilator. He passed away on his seventh day of hospitalization. Forensic autopsy was performed on prosecutions’ demand, that the case had judicial features.

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CASE REPORT

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At autopsy; in the physical examination, no traumatic lesions have been seen except the surgical attempts. No macroscopic pathology were observed at the brain’s and cerebellum’s surface. Both of the lungs were sticked to anterior and lateral wall of the thorax. On the surface of the lungs some antrachotic changes are located. There wasn’t any macroscopic pathology on the surface of the lungs and heart. Blood or any fluid (e.g. cysts fluid) was not observed in abdominal cavity. On the surface of liver, two white colored cystic structure (one of them 4x3cm, other 2x2cm) was found in the right lobe. On the surface of spleen, there was also multiple cystic structures. Liver has taken totally and put into 10% formaline. No other macroscopic pathologies were observed in other organs. When the sections of liver macroscopically were examined, a subcapsular ruptured cyst which had 6 cm

DISCUSSION Hepatic Hydatid Cyst is clinically asymptomatic in general. In symptomatic cases, the findings vary according to the localization of cyst in the liver, invasion to the neighbor tissues, seconder bacterial infections and complications. Hepatic hydatid cyst is diagnosed with clinical, radiological, histopathological and serological tests (5, 11).

Cysts can be ruptured into pleural and abdominal cavity, bile and circulation system. The ruptures into the pleural and peritoneal cavity end with death caused by anaphylactic shock generally (5, 12). The subcapsular cyst, one of the two cysts that are found in our case’s postmortem examination in the liver, was ruptured into the peritoneal cavity. In a non-traumatic and asymptomatic case, it was observed that the hydatid cyst found in the liver was not macroscopically ruptured but in the histopathological examination of the lung sections, there were scolexes in the artery. And the cause of the death was reported anaphylactic shock draining out of the contents of cyst to the intravascular zone (1). In a study from Sakhri et al, 44 of the 1411 liver hydatid cyst cases were ruptured into the thorax (8). In a case report presented by Kök, a 19 year-old male died by hemorrhagic hydatid cyst developed from a blunt

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Balkan Military Medical Review 2014; 17(2):70-73 leak (9).

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trauma to the liver region. The main cause was reported as the anaphylactic shock generated by the cystic fluid

ISSN: 1107-6275

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Picture 2. A) Fibrous cyst wall, cuticular membrane and numerous daughter vesicules B) Liver parenchyma that seems to be pressed, neighboring the cyst wall C) Daughter vesicles with the “hooklet”s in the middle D) Findings of cholestasis in the pericyctic liver parenchyma (H&E, x25(A), x100(B), x200(C & D)

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In the postmortem examinations of deaths dependent on hydatid cyst disease, cysts can be found especially in the right lobe of the liver, lungs, abdominal cavity, muscles, kidneys, spleen, bones, heart and brain (4). In our case we explored cysts in the liver and spleen.

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In examining sudden deaths suspected from anaphylactic shocks induced by hydatid cyst rupture, although clinical and radiological findings of hydatid cyst are seen, in order to eliminate doubts, postmortem examination shall be made and the cyst shall be seen macroscopically whether it is ruptured or not (4, 5). In the diagnosis and treatment of the rare causes of sudden death like a hepatic hydatid cyst rupture, some medico-legal problems can be occurred. Therefore doctors shall pay the necessary attention when they confront such a situation. Otherwise doctors will confront malpractice cases which may result heavy penalties.

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Not to be a subject of a malpractice investigation, optimal manner of approaching must be like that the patients must be examined detailed, all necessary consultations must be requested, necessary laboratory tests must be provided, and the referral chain must start at the optimum time. REFERENCES 1.

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