Results
Among the eight children, five were boys. The age ranged from 6 to 12 years. Cough was present in seven children; it was dry in four and wet or productive in three cases. Fever was present in five children. Other symptoms were chest pain, hemoptysis and dyspnea. On examination, localized chest findings were present in six children. Five of them had reduced breath sounds with dullness on percussion, while one had bronchial breathing. One child had been treated as empyema 2 years back in another hospital, and another child had received treatment for lung abscess. They presented to our hospital because of non-resolution. Table 1 presents a summary of the clinical findings.
All children presented to us with chest xrays and CT scans done elsewhere. Xrays showed cystic lesion in one patient, homogenous consolidation with rounded contours in two and non-specific localized consolidation in the other five cases. CT scan showed fluid filled cystic lesions in two, while the others showed consolidation with or without central cavitation. One child also had a right paratracheal cystic lesion. The radiographic findings are summarized in Table 1. Four children had an eosinophil count above 500 per microlitre. Hydatid serology was positive in six children. One child had an additional cyst in segment V of the liver.
Flexible fibreoptic bronchoscopy showed white or yellow glistening membranes occluding the main, lobar or segmental bronchi, in all but one patient. The location corresponded to the involved lobe identified on imaging. BAL specimens were carefully obtained in seven children.
There were no systemic adverse events during any of these procedures, including hemodynamic instability, anaphylactic reaction or other post procedure complications. However, in one child, there was a gush of fluid return during BAL that turned mildly haemorrhagic and required prolonged suctioning. No other intervention was required in this child.
Cytopathologic examination of seven BAL specimens showed acellular lamellated membranes in two specimens, and non-specific inflammatory cells in the remaining five. Membranes were brightly positive on Periodic acid-Schiff (PAS) stain. Two BAL specimens had solid fragments wherein histopathologic examination showed acellular eosinophilic lamellated membrane representing hydatid ectocyst in both. Hydatid germinal layer could also be seen in one of them. Cytologic examination in these two specimens did not show any hydatid elements. Thus pathologic confirmation was obtained in four of seven BAL specimens.
Seven children were referred for surgery and histopathology of the excised cysts confirmed hydatid disease. The patient who did not have membranes on bronchoscopy had a normal BAL examination. This child had positive serology and was treated for hydatid without surgery.
Bronchoscopy showed membranes in two children with negative serology. Overall, flexible bronchoscopy with BAL analysis could confirm the diagnosis in seven of eight children patients prior to surgery.