Left Ventricular Echinococcosis With Peripheral Embolization
A 20-year-old man from Rumania was admitted with signs of acute peripheral limb ischemia and reduced vigilance. Ultrasound and angiography showed complete occlusion of the right femoropopliteal artery. Thrombectomy revealed specimens of amorphous lamellar shell-like structures among thrombotic material (Figure, A). Cranial CT scan suggested unilateral thalamic bleeding (Figure, B). Echocardiography showed a large cystic tumor (45×20 mm) adherent to the posterolateral wall of the left ventricle and to the posterior leaflet of the mitral valve (Figure, C). Laboratory findings were pathognomic for Echinococcus cysticus with a titer of 1:3200 and concomitant relative eosininophilia of 19%. Positive flow signs within the cystic tumor apparent by color Doppler echocardiography suggested previous rupture and leakage of infectious scolices. Contrast echocardiography revealed a patent foramen ovale, a possible pathway for this unusual primary site of a hydatid cyst. No cystic structures were found in the lung, liver, or spleen. Liquor was free of E cysticus antigen or clonal immunoglobulin expansion, indicating no primary cerebral echinococcal manifestation. Fecal samples were repeatedly negative for ovae.
Despite combined antihelmintic therapy with albendazole (400 mg BID) and praziquantel (900 mg BID), repeated echocardiography suggested cardiac daughter cyst development with ongoing leakage of scolices. Parasitic titer levels confirmed continuous florid infection. Consequently, in toto surgical extirpation of the hydatid cyst was performed and bioprosthetic mitral valve replacement was necessary (Figure, D). During 15 months of follow-up, cystic cerebral de novo lesion formation was observed supratentorially and infratentorially by magnetic resonance without decline in parasitic titer.
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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