Cardiac hydatid cysts in a young man: A case report and a literature review

  • Authors:
    • Mircea Bajdechi
    • Dalia Manolache
    • Adrian Tudor
    • Mihnea Orghidan
    • Adriana Gurghean
  • View Affiliations

  • Published online on: July 1, 2022
  • Article Number: 550
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Cystic hydatid disease commonly affects the liver and lungs. Cardiac hydatid cysts are a rare occurrence and can cause fatal complications, including anaphylactic shock, systemic or pulmonary embolism, dissemination, arrhythmias, valvular dysfunction or sudden death. The case of a 19‑year‑old male from a rural area who was admitted to the emergency room with anaphylactic shock is presented in the current study. The patient was subsequently referred to the Department of Pneumology due to a mild fever, a dry cough and thoracic pain. Pneumonia was suspected and antibiotics were administered. As the patient didn't respond to the antibiotics, a pulmonary CT‑scan was performed, which demonstrated a bilateral pulmonary embolism of the segmental arteries and the patient was referred to the Department of Cardiology. Transthoracic echocardiography (TTE) demonstrated the presence of a right ventricular mass of ~25x18 mm, attached to its free wall, adjacent to the tricuspid valve causing no tricuspid inflow obstruction. Blood tests were positive for echinococcal infection. Considering that previous reviews had included cases published up until 2018, the present study also included a short literature review of the studies published between 2018 and 2021. The review showed that cardiac hydatid cysts are diagnosed more often in underdeveloped countries, especially in men. Transthoracic echocardiography is the most useful non‑invasive imaging technique for diagnosis. Surgery is the treatment of choice, but consideration must be given to the risk‑benefit ratio and the shared decision‑making approach. The complete surgical removal of the cyst(s) is the major prognosis factor of the cardiac manifestation. This study emphasizes the importance of considering cardiac echinococcosis as a potential diagnosis in patients from endemic or farming areas.


Human hydatid disease is caused by the larval stages of tapeworms of the genus Echinococcus. Cystic echinococcosis is a parasitic disease which infects humans when the ova, found in dog feces, are swallowed (1,2). In Europe, hydatid disease is a common health problem, especially in sheep-farming countries. Balkan countries, southern and insular Italy, and central Spain have reported high incidence rates of echinococcosis (1,2). When slowly growing cysts are found in the viscera, echinococcosis must be considered. ELISA is a test with a high sensitivity to detect antibodies against Echinococcus granulosus (3). The liver is the most frequent primary site of Echinococcus granulosus infection (60-70%), followed by the lungs (10-15%) and spleen (2). Cardiac echinococcosis is a rare occurrence and clinical manifestation depends on the location, size and integrity of the cyst (1,2). Among all infected patients, 0.5-2% exhibit cardiac involvement (4,5). The prevalence of right ventricular hydatid cysts is low (~10%) compared with the prevalence of left ventricular cysts (60%) (5). Cardiac hydatidosis can cause fatal complications, such as anaphylactic shock, systemic embolism when the cyst is located in the left ventricular outflow tract, or pulmonary embolism when it is located in the right ventricular outflow tract (6-8). Macroscopically, it has a uni- or multi-cystic cavity, filled with fluid, containing small daughter cysts and hydatid sand (9). Microscopic examinations are essential in order to establish the diagnosis. Surgery is the treatment of choice (10), but the risk-benefit ratio must be considered. The complete surgical removal of the cyst(s) is the major prognostic factor of the cardiac manifestation (3). Adjunctively, albendazole should be adimistrated several days before surgery and a few weeks after resection (11). The hydatid cyst occurrence rate is 10% after surgery, but if medical treatment is given, this rate can decrease (12). The present study emphasizes the importance of considering cardiac echinococcosis as a potential diagnosis in patients from endemic or farming areas.

Case report

The case of a 19-year-old male from a rural area, who was admitted to a local Emergency Department (Hospital of Buzau, Buzau, Romania) in April 2016 with anaphylactic shock, is presented. Considering the patient's symptoms, including a mild fever (37.5˚C), sharp right-sided thoracic pain and a dry cough, he was referred to the Department of Pneumology. Chest radiography indicated left lower lobe pneumonia and as the patient's CURB-65 (scored based on confusion; BUN, >20 mg/dl; respiratory rate, ≥30 breaths/min; blood pressure: Systolic, <90 mmHg; diastolic, ≤60 mmHg; and age, ≥65 years) score was 0, the patient received amoxicillin and clavulanic acid (875/125 mg) twice-daily for 7 days and was discharged. Over the next 10 days the patient's symptoms worsened and he was admitted again to the same hospital and a pulmonary CT scan was performed. The pulmonary CT-scan demonstrated a bilateral pulmonary embolism of the segmental arteries (Fig. 1A and B), as well as a cystic mass on the right ventricular free wall (Fig. 1C). The patient was therefore referred to the Department of Cardiology of the ‘Coltea’ Clinical Hospital (Bucharest, Romania).

Following admission to the Department of Cardiology, the patient had no fever, was hemodynamically stable, had a normal respiratory rate, had 94% oxygen saturation while breathing ambient air and exhibited barely audible respiratory sounds in his left lung basal segment, as well as fine rales. Routine laboratory tests demonstrated eosinophilia (12.2%; normal cut off, 5%), elevated D-dimer (464 ng/ml; normal cut off, 250 ng/ml) and elevated C-reactive protein (3.9 mg/dl; normal cut off, 0.3 mg/dl) levels. A standard electrocardiogram demonstrated an S1Q3T3 pattern and nonspecific intraventricular conduction delay in the inferior leads (Fig. 2). Furthermore, transthoracic echocardiography (TTE) revealed a slightly enlarged right ventricle (RV), with moderate RV systolic dysfunction, as well as a bi-lobular mass attached to the right ventricular free wall adjacent to the right ventricular inflow, without causing any inflow obstruction (Fig. 3A). Transesophageal echocardiography did not provide any additional information. Furthermore, at that time, the patient had no other organ involvement. During hospitalization, the patient received low molecular weight heparin (enoxaparin, 60 mg/0.6 ml twice-daily by subcutaneous injection) and a parasitology exam was requested. The ELISA assay (SERION ELISA Classic; SERION Diagnostics) was positive for E. granulosus IgG antibodies (10.18 U/ml; normal cut off, 1.1 U/ml) and therefore antiparasitic treatment using albendazole (400 mg, twice daily) was administered. During hospitalization, the clinical evolution improved and the patient became stable and asymptomatic. The patient was discharged with conservative treatment (albendazole, 400 mg twice-daily; levocetirizine, 5 mg twice-daily) and a recommendation for cardiac surgery evaluation, which the patient refused. In the first year of clinical evolution, the patient was assessed in the Department of Cardiology twice and was stable and asymptomatic. Serial transthoracic echocardiograms demonstrated a marked reduction in the dimensions of the RV cardiac cyst and an increase in its echogenicity (Fig. 3B).

After the first year, the patient was lost to follow-up for 2 years, and during the subsequent year, the patient presented at the Department of Pneumology with hemoptysis after abandoning the antiparasitic treatment. A pulmonary CT-scan showed bilateral central pulmonary nodules and subpleural pulmonary nodules (Fig. 1D) and the patient was referred for thoracic surgery where four hydatid cysts were excised. Histological analysis confirmed the presence of pulmonary hydatid cysts (Fig. 4) and it was recommended that the patient resume antiparasitic treatment.

Literature review

A short PubMed ( literature review on cardiac echinococcosis was performed. Search criteria included the following keywords: ‘cardiac hydatid cyst echinococcosis’. Considering that other reviews included cases that were published up until 2018 (11,13), it was determined that cases reported between 2018-2021 would be analyzed in the present study. The collected data are presented in Table I.

Table I

PubMed literature review of cases reported between 2018 and 2021.

Table I

PubMed literature review of cases reported between 2018 and 2021.

First author/s, yearAge, yearsSexCountrySymptom/sDiagnostic method/sLocalizationSize of cyst/s (mm)Medication/sSurgeryFollow-up(Refs.)
Firouzi et al, 201957MaleIranAtypical chest painTTELeft ventricle/ right AV groove107x75 27x25AlbendazoleYes-(44)
Yimamu et al, 202139MaleChinaAsymptomaticCT/TTEPericardium72x86 85x75AlbendazoleYes12 months no recurrence(49)
Singh et al, 201957MaleIndiaSyncopeTEE/CMRRight ventricle10x10Albendazole/ mebendazoleNo12 months no recurrence(50)
Separovic Hanzevacki et al, 201821MaleCroatiaPalpitations/ fatigueTTE/CMRInterventricular septum68x28x51 (by CMR)Albendazole/ praziquantelYes6 months no recurrence(51)
Emam Hadi et al, 201830FemaleIranShortness of breath, heaviness on the chest, sudden deathAutopsyInferior vena cava/right atrium/right ventricleMultiple cysts, 30 (average)---(52)
Mesrati et al, 202026MaleTunisiaMild chest pain, syncope, sudden deathAutopsyRight ventricle50x49---(53)
Kumar et al, 202032FemaleIndiaAtypical chest painTTE/CMRRight ventricle60x40 (by TTE) 35x59x45 (by CMR)AlbendazoleYesNo data(14)
Jamli et al, 202027 patients (mean age, 35 years)Male/ female, 1.7TunisiaAtypical chest pain (n=17), dyspnea (n=10), palpitations (n=16), otherTTE/TEE/ CMRRight ventricle (n=7) left ventricle (n=5) septal (n=5) otherNo dataAlbendazoleYes (all)19 patients follow-up (8.4±3.9 years) No recurrence(64)
Wadhawa et al, 201810 patients (mean age, 35.9+12.04 years)Male/ female, 1.4IndiaDyspnea (n=7), chest pain (n=7), fatigue (n=6), otherTTE/CT/ CMRLeft ventricle (n=7)/ interventricular septum (n=2)/ pericardial (n=2)40x20 (minimum) 120x110 (maximum)AlbendazoleYes (all)10 patients follow-up (2 months- 5 years) No recurrence(54)
Giri et al, 202079FemaleBhutanDyspneaTTE/CTInterventricular septum67x76x82AlbendazoleYesNo data(15)
Lu et al, 201944FemaleChinaPalpitationsCMRInterventricular septum and posterior apex of the left ventricle61x46No dataYes16 months No recurrence(65)
Kuemmerl et al, 202129MaleSouthern EuropeSyncopeCMRPericardium130AlbendazoleYes3 months No recurrence(16)
Çankaya et al, 202120FemaleTurkeyDyspnea, chest painTTE/CMRRight ventricle43x35x28AlbendazoleYesNo data(17)
Iriz et al, 202015FemaleTurkeyAtypical chest painTTE/ CT/CMRInterventricular septum57x44x42AlbendazoleYesNo data(18)
de Gregorio et al, 202150MaleItalyDyspnea, atypical chest painTTE/CT/ CMRInterventricular septum/ pericardium/ right ventricle outflow tractNo dataAlbendazoleYesNo data(8)
Singh et al, 201928MaleIndiaDyspneaTTE/CTLeft ventricle/ pericardiumNo dataAlbendazoleNoNo data(50)
Singh et al, 202125MaleIndiaDyspnea, chest painTTE/TEEInterventricular septum69x56Albendazole/ praziquatelYesDied on postoperative day zero(20)
Shakerian et al, 202134MaleIranDyspneaTTE/CTRight ventricle outflow tract40x40AlbendazoleYesNo data(21)
Alami et al, 201943MaleMoroccoDyspnea, chest painCT/MRIInterventricular septumNo dataAlbendazoleYes12 weeks No recurrence(22)
Cheng et al, 202148MaleChinaChest painTTE/CMRRight ventricle29x26AlbendazoleNoNo data(23)
De et al, 202050FemaleVietnamDyspnea, chest painChest MRILeft ventricle30x33AlbendazoleYes2 months No recurrence(24)
Rhissassi et al, 202123MaleMoroccoAsymptomaticTTE/CMRRight ventricle53x56AlbendazoleYesNo data(25)
Jain et al, 202146MaleTurkmenistanDyspneaTTE/ MRI/CTPericardiumNo dataAlbendazoleYes1 month No recurrence(26)
Madisson- Bernardo et al, 201949MaleBrazilDyspnea, atypical chest painChest MRI/ TTEPericardiumNo dataAlbendazoleNo1 year No recurrence(27)
Kaskar et al, 202014FemaleIndiaDyspneaCT/TTE/ TEERV29x12AlbendazoleYes3 months No recurrence(28)
Handran et al, 202047MaleSudanSyncopeCT/MRIInterventricular septum50x50No dataYesNo data(29)
Kohlmaier et al, 201816FemaleAustriaDyspneaTTE/CT/ MRIRV40x40Albendazole/ praziquantelYes7 months Pulmonary arterial hypertension (systolic arterial pressure, 50 mmHg)(30)
Vural et al, 201922MaleTurkeyAnginaTTE/ Cineangio- graphyLeft ventricle/ intracoronary20x20AlbendazoleYes1 year No recurrence(31)
Derbel et al, 201937MaleTunisiaAcute blurred visionCT/TTEInterventricular septum30x30AlbendazoleYesNo data(32)
Orhana et al, 201826MaleTurkeyDyspnea, hemoptysisTTERVNo dataAlbendazoleYesNo recurrence(6)
Stiru et al, 201924MaleRomaniaFacial paralysis, headachesTTE/CTInterventricular septum23x19AlbendazoleYes1 year No recurrence(33)
Sarr et al, 201965MaleSenegalLimb edemaTTE/CTPericardium86x61AlbendazoleNo2 months Fatal outcome(55)
Sonsoz and Gunes, 202032MaleTurkeyConstitutional symptomsTTE/CMRRV25x21AlbendazoleYesDied on postoperative day 2(34)
Al-Hakkak et al, 201918MaleIraqAcute right lower limb painTTE/CTLeft ventricle36x40AlbendazoleYesNo data(35)
Rossetti et al, 201815MaleArgentinaAcute right lower limb painTTELeft ventricle30x30Albendazole/ praziquantelYes2 years No recurrence(7)
Wedin et al, 202138MaleSwedenChest painTTE/TEE/ CMR/CTInterventricular septum35x65AlbendazoleYes1 year No recurrence(36)
Guha et al, 202118MaleIndiaChest pain, feverTTE/TEE/ CTInteratrial septum73x32AlbendazoleYes1 year No recurrence(37)
Verma et al, 202017MaleIndiaCough, feverCTRVNo dataAlbendazoleYesNo data(38)
Fennira et al, 201926MaleTunisiaChest pain, astheniaTTEInterventricular septum48x49AlbendazoleYes8 months No recurrence(13,39)
Zhang et al, 202031FemaleChinaCough, fever, hemoptysis, palpitationsTTE/MRIRight atrium/ pericardium25x50AlbendazoleYes1 year No recurrence(40)
Zghal et al, 202068MaleTunisiaStroke, sudden deathsTTELeft ventricle25x25-NoDied(41)
İyigün et al, 202018MaleTurkeyAsymptomaticTTE/TEE/ CMRInterventricular septum47x47x74AlbendazoleYesNo date(42)
Modani et al, 201857MaleIndiaChest painTTE/CMRInterventricular septum40x45AlbendazoleYes30 days No recurrence(43)
Berarducci et al, 202148MaleMexicoPalpitations, drowsinessTTE/CMR/ 3D CTRVNo dataNo dataYesNo recurrence(45)
Meimand et al, 202031MaleIranDyspnea, hemoptysisTTE/TEE/ CTRV48x20AlbendazoleYesDied on postoperative day 3(46)
Meimand et al, 202031MaleIranRight hemiparesisCT/MRI/ TTE/TEEInterventricular septum85x60AlbendazoleYes2 months No recurrence(46)
Vazhev et al, 201818FemaleBulgariaNo dataTTE/CTLeft ventricle63x53AlbendazoleYes1 year No recurrence(47)
Lyazidi et al, 202114FemaleMoroccoDyspnea, palpitationsTTERV47x33AlbendazoleYes6 months No recurrence(48)
Harmouchi et al, 202215N/AMoroccoCough, arthralgiaTTE/CMRRight atrium23x32AlbendazoleYesNo data(66)

[i] RV, right ventricle; TTE, transthoracic echocardiography; TEE, transesophageal echocardiography; CMR, cardiac magnetic resonance, AV, atrioventricular; PAH, pulmonary hypertension; sPAP, systolic pulmonary pressure; N/A, not available.

Cardiac hydatid cysts are more often diagnosed in men living in underdeveloped countries (1,11). Among 47 reported cases identified in the present literature review, >70% of patients were male (4-6,12-53). The median age of patients with cardiac echinococcosis was 36 years. Cardiac echinococcosis symptoms varied greatly, with chest pain and dyspnea being the most common (34%). The most common cardiac tissue involved was the RV (32%), followed by the interventricular septum (27%) and pericardium (13%) (12-50). Moreover, cardiac hydatid cysts were reported to vary in size. The largest cysts identified in the present review were >100 mm long (16,44,54), whereas the median cyst length was 47.5 mm. The most useful imaging technique was TTE. Furthermore, the review data indicated that >80% of patients underwent cardiac surgery. Most of the patients were followed-up for 12 months (surgical and non-surgical patients). A total of four patients died shortly after diagnosis; three deaths were caused by postoperative complications and one was caused by stroke (20,34,41,53).

From the present literature review it was concluded that cardiac echinococcosis is more common in men <40 years old and patients may present with various symptoms. Their size can vary greatly, reaching >100 mm in length (16,44,54). TTE is the most useful imaging technique due to its availability, reproducibility, accuracy and safety. To improve the characterization of the tumor, cardiac MRI can be performed. Surgery is the treatment of choice, but the risk-benefit ratio and shared decision making with the patient must be considered. The available data from non-surgical patients shows that three of them died shortly after diagnosis (<2 months) (19,41,55) and two of them had a good outcome (23,27). In the present case, the patient refused cardiac surgery and chose medical treatment. Albendazole is an active agent against Echinococcus and should be administrated adjunctively, pre- and post-surgery (11). No disease recurrence was observed in patients who underwent surgery and pharmaceutical treatment with albendazole.


Human hydatid cysts are caused by the larval stages of tapeworms of the genus Echinococcus (56). In most cases, multiple organs are affected. Cardiac echinococcosis appears in 0.5-2% of patients, usually with multiple organ involvement, following the invasion of the myocardium via the coronary artery (57). Most commonly cardiac hydatid cysts involve the left ventricular cavity (60%), followed by the right ventricular cavity (10-15%), pericardium (7%), the atria and the interventricular septum (2). Moreover, clinical manifestations of benign cardiac tumors depend on the size and location of the mass and the infiltration of adjacent tissues (58). Most patients with cardiac hydatid cysts are asymptomatic. Signs and symptoms of cardiac echinococcosis are nonspecific and are directly related to the location and the size of the cysts. They may develop because of compression or rupture of the hydatid cyst, which is the most important and potentially fatal complication. Generally, nonspecific chest pain is the most common symptom, whereas dyspnea following exertion is often related to multiple hydatic cysts in the lungs (59). The major complications of cardiac hydatid cysts include anaphylactic shock, cardiac tamponade, systemic or pulmonary embolism, arrhythmias, valvular dysfunction and sudden death (11). Anaphylactic shock was the first symptom in the present case, which was treated with adrenaline, according to the available protocols (60). Shortly after anaphylactic shock, the patient developed a pulmonary embolism requiring low-molecular weight heparin (enoxaparin, 60 mg/0.6 ml twice daily).

The diagnosis of hydatid cysts is based on imaging results and specific serological tests (3). The method of choice to detect cardiac hydatic cysts and determine their number, size, location and relation to other anatomical structures is 2D TTE. Cardiac MRI may be useful for improved characterization of cardiac tumors, but it requires appropriate experience to be used effectively. ELISA is the most specific serologic test that can be used and a positive result for Echinococcus antibodies confirms the diagnosis (61). Surgery is the treatment of choice (10,11), but the risk-benefit ratio must be considered and shared decision making with the patient must be taken into account. Shared decision-making is not commonly used in Romania and it depends on numerous factors, including the level of education of the patient (62). In the present case report, the patient refused cardiac surgery. If complete removal of the cysts is possible the prognosis is good, with a low rate of recurrence (11). Medical treatment with albendazole has a role in reducing the size of cysts and stopping their development and represents the only therapeutic option in inoperable cases (63).

In the present study the echocardiographic assessments at serial evaluation (four times in 3 years) documented marked reductions in the dimensions and increases in echogenicity of the right ventricular hydatid cyst under antiparasitic treatment. These results suggested a low risk of rupture; however, symptoms of pulmonary embolism occurred in the evolution of the present case. Therefore, in the absence of cardiac surgery, the prognosis and further evolution are unpredictable and long-term antiparasitic treatment and frequent clinical, imagistic and biological evaluation are required.

Cardiac echinococcosis infection can clinically have a wide range of symptoms, from none at all to sudden death. Diagnosis must be suspected in patients who come from regions where tapeworms of the genus Echinococcus are endemic. The patient in the present study lived in a rural area of an endemic country and the symptomatology at the first hospital admission was anaphylactic shock. Moreover, blood tests showed eosinophilia, which led to the consideration of a parasitic infection in the differential diagnosis. The clinical history of the patient is important and echocardiography is a reliable, safe and effective imaging method for the initial diagnosis.


Not applicable.


Funding: No funding was received.

Availability of data and materials

All data generated or analyzed during this study are included in this published article.

Authors' contributions

MB wrote the initial draft, collected data by performing the experiments, performed the review, constantly revised the article according to reviewers and participated in the final design of the article. DM was involved in the acquisition of data and described the patient evolution and management. AT performed and described the microscopic examination. MO performed the thoracic surgery, revised the initial draft and analyzed data from the literature. AG was involved in the analysis and interpretation of data, performed the literature review and revised the final manuscript. MB and AG confirm the authenticity of all the raw data. All authors read and agreed to the final manuscript.

Ethics approval and consent to participate

Ethics approval was obtained from the Medical Ethics Commission for Clinical Studies in the ‘Coltea’ Clinical Hospital (Bucharest, Romania; approval number 24216/86; 2021/12/09).

Patient consent for publication

Written informed consent for publication was obtained from the patient prior to publication at the time of admission.

Competing interests

The authors declare that they have no competing interests.



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Bajdechi M, Manolache D, Tudor A, Orghidan M and Gurghean A: Cardiac hydatid cysts in a young man: A case report and a literature review. Exp Ther Med 24: 550, 2022
Bajdechi, M., Manolache, D., Tudor, A., Orghidan, M., & Gurghean, A. (2022). Cardiac hydatid cysts in a young man: A case report and a literature review. Experimental and Therapeutic Medicine, 24, 550.
Bajdechi, M., Manolache, D., Tudor, A., Orghidan, M., Gurghean, A."Cardiac hydatid cysts in a young man: A case report and a literature review". Experimental and Therapeutic Medicine 24.3 (2022): 550.
Bajdechi, M., Manolache, D., Tudor, A., Orghidan, M., Gurghean, A."Cardiac hydatid cysts in a young man: A case report and a literature review". Experimental and Therapeutic Medicine 24, no. 3 (2022): 550.