A Complication of an Intramyocardial Echinococcal Cyst
A23-year-old man originally from Angola presented to an outlying hospital with a 1-day history of palpitations, dyspnea, and near-syncope. In the ambulance, he developed recurrent ventricular tachycardia. In the emergency room, he was started on intravenous metoprolol and amiodarone. His physical examination was within normal limits. His ECG showed underlying normal sinus rhythm with runs of ventricular tachycardia (Figure 1⇓). His laboratory values were significant for a white blood cell count of 17.4×103/μL with no eosinophilia. Serology was negative for both Echinococcus and Cysticercosis.
The transesophageal echocardiogram (Figure 2⇓) showed a large, echolucent cyst that compressed the anterior free wall of the left ventricle. A CT scan of the thorax (Figure 3⇓) demonstrated an 8×7×6.5-cm cystic lesion on the dorsal aspect of the aortic root and the anterolateral aspect of the left ventricle. The patient was referred to cardiothoracic surgery for resection of a presumed pericardial cyst by lateral thoracotomy. After careful inspection in the operating room, the cyst was found to be intramyocardial. The operation was aborted once it was decided that a safer approach for such a cyst would be a median sternotomy with the patient on cardiac bypass. This was performed 2 days later. In the operating room, the cyst was carefully isolated, infused with 3% normal saline, and surgically resected (Figure 4⇓). Pathological analysis of the contents of the cyst was positive for scolices (Figures 5⇓ and 6⇓) diagnostic of Echinococcus. The patient was started on albendazole, and his white blood cell count declined. Since his discharge from hospital, the patient has remained free of ventricular tachycardia.
The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.
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