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SPCI - Sociedade Portuguesa de Cuidados Intensivos

Revista Brasileira de Terapia Intensiva

AMIB - Associação de Medicina Intensiva Brasileira

OFFICIAL JOURNAL OF THE ASSOCIAÇÃO BRASILEIRA DE MEDICINA INTENSIVA AND THE SOCIEDADE PORTUGUESA DE CUIDADOS INTENSIVOS

ISSN: 0103-507X
Online ISSN: 1982-4335

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Oliveira CD, Nangino GO, Correia PC, Salomão CV, Resende MA, Peixoto LC, et al. Massa tumoral secundária a infecção por Schistosoma mansoni simulando neoplasia de pulmão: relato de caso. Rev Bras Ter Intensiva. 2009;21(4):461-464

 

 

2009;21(4):461-464
Case Reports

http://dx.doi.org/10.1590/S0103-507X2009000400018

Tumoral pulmonary mass secondary to Schistosoma mansoni infection resembling neoplasia: case report

Massa tumoral secundária a infecção por Schistosoma mansoni simulando neoplasia de pulmão: relato de caso

Cláudio Dornas de Oliveira, Glaucio de Oliveira Nangino, Paulo César Correia, Carlos Vechio Salomão, Marcelo Alencar Resende, Leonardo da Cruz Peixoto, Maurício Buzelini Nunes

Physician of Santa Casa de Belo Horizonte - Belo Horizonte (MG), Brazil

Submitted on September 7, 2009
Accepted on November 28, 2009

Corresponding author:

Cláudio Dornas de Oliveira
Santa Casa de Belo Horizonte - CTI adulto
Av. Francisco Sales, 1111 2º andar - Santa Efigênia
CEP: 31150-221 - Belo Horizonte (MG), Brasil
Fone: 55 (31) 3238-8181
E-mail: [email protected]

 

Abstract

Patients with chronic Schistosoma mansoni infection may feature a range of pulmonary symptoms and radiological findings. Eggs, and rarely adult worms, may passively enter the pulmonary circulation, usually via the portal system, where they may cause pulmonary inflammation, fibrosis, hypertension and cor pulmonale. A 25-year-old patient who lived in a schistosomiasis endemic area with a pulmonary mass suggestive of malignancy underwent exploratory thoracotomy. The mass was adherent, with no resection possibility. The lung-biopsy specimen evaluation showed several granulomas with Schistosoma mansoni eggs and hyperplasic connective tissue with no sign of malignancy. The patient had respiratory failure and hypotension immediately post-surgery. Specific treatment (praziquantel) and prednisone were given. The patient had pneumonia and septic shock. The patient was given antibiotics, vasopressors, mechanical ventilation and hemodialysis with no improvement, and subsequently died 28 days after the surgery.

Keywords: Schistosomiasis; Schistosoma mansoni; Neoplasias/secondary; Lung diseases, parasitic; Case reports

 

 

INTRODUCTION

Patients with chronic schistosomiasis may have pulmonary involvement featuring a variable range symptoms and radiological findings.(1) The lungs may be involved due to anomalous eggs migration via portal system into the pulmonary artery system (via porto-systemic anastomosis) and less commonly by adult worms migration. There are extensive parenchyma involvement cases, as well as others with predominant arteritis, with pulmonary hypertension and cor pulmonale.

Lung parenchyma involvement is mainly characterized by granulomatous reaction to Schistosoma mansoni eggs. The granulomas have no preferential location, and may be found in all lung segments and pleura. Inter-alveolar thickening and connective tissue fibrosis were also reported.(2) Lesions from dead worms are rarer, and characterized by necrotic areas surrounded by intensive exudation, usually reabsorbed and involved by cicatricial tissue.(3,4)

A case involving a young female patient with atypical pulmonary schistosomiasis faking neoplasia is presented. Aspects regarding differential diagnosis are discussed.

 

CASE REPORT

This was a 25 years old female patient who lived in endemic schistosomiasis area and was referred to a thorax surgery service with dysphagia, weight loss and exertion dyspnea. There was no relevant history of previous diseases or comorbities. The physical examination evidenced severe malnutrition, asymmetrical thorax expansion and bronchial sounds at the lower left hemithorax. Additional tests showed: chest X-ray: heterogeneous hypo-transparency at lower left lobe (Figure 1); radiographic exam with contrast and upper digestive endoscopy: signs of esophageal lower third extrinsic compression; chest CT: heterogeneous mass taking the upper the left lower lobe basal lateral and basal posterior areas, with adjacent pleural thickening (Figure 2). Presence of two similar images, but smaller, on the upper lingula segment and anterior left upper lobe (Figures 3 and 4); increased left liver lobe (non-oriented examination); spirometry: moderate restrictive respiratory disorder; bronchoscopy: extrinsic left basal bronchia compression; bronchial biopsy: non-specific bronchitis.

Surgical approach was decided. Enteral nutrition support was started, as well as preoperative evaluations. The patient underwent exploratory thoracotomy. A large mass was found, invading the parietal pleura, left lung hilum, aorta, diaphragm and left atrium, with no resection possibility. A biopsy was performed and the patient was referred for post-operative follow-up at the intensive care unit. She required mechanical ventilation and vasoactive amines from the admission. She coursed with severe restrictive ventilatory disorder, and refractory hypoxemia. The histopathology revealed thickened and fibrosed pleura, pulmonary parenchyma with fibrosis and several granulomas containing Schstosoma mansoni eggs; no lesions suggesting neoplasia were found (Figure 5). The patient underwent praziquantel 50 mg/kg single dose treatment plus prednisone 1 mg/kg/day. Echo-Doppler and the Swan-Ganz catheter evidenced pulmonary hypertension. Lower limbs duplex scan was negative for venous thromboembolism.

Subsequently she developed pulmonary infection and septic shock. Antibiotics, vasoactive amines, ventilatory support and hemodyalisis, were given with no improvement. Subsequently she died, 28 days after the surgery.

 

DISCUSSION

From a radiological point of view, chronic schistosomiasis pulmonary parenchyma changes are commonly described as: diffused infiltrate, focal opacities and micro-nodules.(5) Pulmonary nodes secondary to schistosomiasis are rare, and pose a differential diagnosis with lung neoplasia, and are frequently defined only after exploratory thoracotomy.(6-8) The term 'pseudotumoral schistosomiasis presentation' was first used in 1975 describing a pulmonary node in a patient who died, being a autopsy findings granulomatous reaction, Schistosoma mansoni eggs, and pulmonary arterioles obliteration.(9)

The presence of a large mass associated to Schistosoma infection (bilharziasis) was described in 1953 in Cairo.(10) The gross presentation during the surgery suggested lung neoplasia, requiring pneumectomy. Similarly, the histology showed fibrotic and thickened pleural tissue with cicatricial granulomas, fibrosed lung tissue, Schistosoma eggs surrounded by histiocytes, eosinophils and fibroblasts. The authors pointed out that, as first hypothesis, the lung mass producing these pathology findings was secondary to schistosomiasis. The schistosomiasis pseudo-neoplasic forms represent anomalous response to the parasite eggs. Hyperplastic connective tissue formations develop around the granulomatous formations, as a host reaction.

It is proposed that, in schistosomiasis endemic areas, pulmonary schistosomiasis is considered a differential diagnosis for complex structures, as pulmonary masses.

 

REFERENCES

1. Schwartz E. Pulmonary schistosomiasis. Clin Chest Med. 2002;23(2):433-43. Review.

2. Bogliolo L. [Schistosomiasis mansoni. Pathology]. Rev Bras Malariol Doencas Trop. 1959;11:359-424. Portuguese.

3. Barbato EC. [Schistosomal pneumopathy and chronic cor pulmonale]. Arq Bras Cardiol. 1953;6(3):195-305. Portuguese.

4. Sami AA. Pulmonary manifestations of schistosomiasis. Dis Chest. 1951;19(6):698-705.

5. Rocha RL, Pedroso ERP, Rocha MOC, Lambertucci JR, Greco DB, Ferreira CE. Forma pulmonar crônica da esquistossomose mansoni: avaliação clínico-radiológica. Rev Soc Bras Med Trop. 1990;23(2):83-9.

6. Fatureto MC, Correia D, Silva MBO, Barra MFC, Silva AV, Tarquinio DC, et al. Nódulo pulmonar esquistossomótico simulando neoplasia: relato de caso. Rev Soc Bras Med Trop. 2003;36(6):735-7.

7. Lambertucci JR, Silva LCS, Queiroz LC. Pulmonary nodules and pleural effusion in the acute phase of schistosomiasis mansoni. Rev Soc Bras Med Trop. 2007;40(3):374-5.

8. Ryan ET, Aquino SL, Kradin RL. Case records of the Massachusetts General Hospital. Case 29-2007. A 51-year-old man with gastric cancer and lung nodules. N Engl J Med. 2007;357(12):1239-46.

9. Akoun G, Huchon G, Rolland J, Barrière L, Marsac J, Ronco P, et al. [Letter: Pseudotumoral pulmonary schistosomiasis due to Schistosoma mansoni]. Nouv Presse Med. 1975;4(33):2408. French.

10. El Mallah SH, Hashem M. Localized bilharzial granuloma of the lung simulating a tumour. Thorax. 1953;8(2):148-51.

 

 

Received from Santa Casa de Belo Horizonte - Belo Horizonte (MG), Brazil.

 

 

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