Emergency. 2018; 6 (1): e20 CA S E RE P O RT Sudden Death due to Hydatid Cyst Emboli; a Case Report Mohammad Ali Emam Hadi1, Fares Najari1∗, Leila Soleimani1 1. Department of Forensic Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Received: January 2018; Accepted: March 2018; Published online: 19 March 2018 Abstract: Echinococcosis is an infection caused in human by complex parasites that causes cystic hydatid disease. These infections are prevalent in most areas where livestock is raised in association with dogs. These parasites are found in all continents. Slowly enlarging cysts generally remain asymptomatic until their size has expanded. Here we present a case of sudden death following cyst emboli to the large veins and right heart of a young adult female. Keywords: Death, sudden; echinococcosis; embolism; case report © Copyright (2018) Shahid Beheshti University of Medical Sciences Cite this article as: Emam Hadi M, Najari F, Soleimani L. Sudden Death due to Hydatid Cyst Emboli; a Case Report. Emergency. 2018; 6 (1): e20. 1. Introduction Echinococcosis is an infection caused in human by complex parasites that causes cystic hydatid disease. These infections are prevalent in most areas where livestock is raised in as- sociation with dogs. These parasites are found in all conti- nents. Slowly enlarging Echinococcal cysts generally remain asymptomatic until their expanding size or their occupation of space affects the spleen, lung, or brain (1-3). The liver and the lungs are the most common sites of these cysts. Since a number of years elapses before cysts enlarge sufficiency to cause symptoms, they may be discovered incidentally on a routine x-ray or ultrasound study (4-6). Sudden death follow- ing embolization of cysts to the large veins is a rare compli- cation of this infectious disease. Previously, some cases have been reported in this regard (7-9). Here we report the autopsy findings of the deceased unknown woman who was referred to legal medical center of Iran with history of dyspnea for 6 hours followed by death without any further medical docu- mentation. 2. Case presentation: The deceased was a young adult female, who was referred to Kahrizak autopsy center, Tehran, Iran, by order of legal au- thority. With no significant medical history, the death was ∗Corresponding Author: Fares Najari; Department of Forensic Medicine and Toxicology, Shohadaye Tajrish Hospital, Shahrdari Street, Tajrish Square, Tehran, Iran. Postal code: 1981964771 Tel: 00989123195140 Email: fares.hospital@yahoo.com reported by neighbors and EMS to the police center in sub- urb areas of Tehran. The victim was seen 1 hour before an- nouncing dead, while she was complaining about shortness of breath and heaviness on the chest, but refusing to go to the doctor because of attributing the symptoms to air pollution and common cold. Neighbors called EMS with exacerbation of symptoms. The patient was announced dead upon arrival of EMS. The deceased didn’t have any family members and identification card (she was most probably an illegal immi- grant from east borders of Iran). The body was that of a 30 year old, well nourished, well devel- oped, female according to color of hair, skin, and teeth. There was no peripheral edema of the extremities. There was no area of congestion, cyanosis, bruise and abrasion. There was normal hypostasis in the posterior parts of body and com- plete rigor mortis. Scalp, skull, spine, membrane, and brain were normal. Trachea and larynx were normal. No fracture, pathology or hemorrhage were detected. The pleural cavities had no fluid or adhesion; however, dilated vein was noticed on the surface of left lung (figure 1). While cutting large arter- ies and large veins of the heart, multiple cysts (well defined, bubble shaped, round objects covered by shiny white mem- brane) 3 cm in diameter started to emerge rapidly and were extracted from inferior Vena Cava vein and right chambers of the heart (figure 1). The heart was 300 grams in weight, appeared normal without any ruptured cyst in the chambers. Fibrosis, hyperemia, or any sign of infarction or hypertrophy weren’t detected. Valves appeared intact. Coronary arteries were patent. There was no abnormality in large vessels. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com M. Emam Hadi et al. 2 Figure 1: Anterior view of thoracic cavity (left upper) and Liver (right upper), cysts in right atrium and Inferior vena cava (left and right lower). Lungs weighed 300 grams. Pulmonary tissue was congested. There were also several cysts in the pulmonary artery, which This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com 3 Emergency. 2018; 6 (1): e20 formed saddle emboli. Liver weight was 900 grams. The sur- face was course and adhesion bands to near structures made it hard to remove the organ en bloc (figure 1). In several cuts congestion, nutmeg liver, and multiple cysts appeared. By re- moving the liver a lot of cysts came out of inferior vena cava and occupied the abdomen cavity gall bladder, and spleen (Figure 1). Right kidney was not seen (previous surgery due to car acci- dent). Left contained 2 small simple cysts, which measured 1 cm in diameter full of yellow clear fluid. In cortex cuts, medulla, and parenchyma appeared normal. Stomach and intestines contained ingested food and their mucous was in- tact. No ischemic change was seen in the cardiac tissue and brain was reported to be normal. In the pulmonary tissue, mild to moderate alveolar edema was seen. No evidence of hydatid cyst or remnants were observed in lungs neither microscopic nor macroscopic. Toxicological samples from vitreous, gastric content, urine, liver, and bile were obtained, analyzed, and reported nega- tive for Alcohol (by GC-MS on vitreous), narcotic and other drugs (by TLC on gastric content, urine, liver, and bile). Histopathology study of liver and lung cyst samples revealed the cyst had a white thin fibrous membrane, which contained a clear fluid and some grain like particles laminated mem- brane of hydatid cyst with scolices and hooklets. BY Analyzing autopsy, histopathology, and toxicology and history data the commission of three board certified forensic specialties decided to declare “cardiac arrest due to massive emboli by multiple hydatid cysts” as cause of death. 3. Discussion An embolus is an intravascular solid, liquid, or gaseous mass that is carried by the blood to a site distant from its point of origin. The vast majority of emboli derive from a dis- lodged thrombus. Less common types of emboli include fat droplets, bubbles of air or nitrogen, atherosclerotic debris, tumor fragments, bits of bone marrow, and amniotic fluid; emboli lodge in vessels resulting in partial or complete oc- clusion. Depending on the site of origin, emboli can lodge anywhere in the vascular tree (10-12). The primary conse- quence of systemic embolization is necrosis of downstream tissue while embolization in the pulmonary circulation leads to hypoxia, hypotension, and right-sided heart failure. The consequence of embolization depends on the caliber of the occluded vessel, the collateral supply, and the affected tis- sues vulnerability to anoxia. In this case, multiple hydatid cysts originated from liver and moved through vena cava to the right side of the heart and pulmonary artery, which is compatible with definition of em- boli. We didn’t witness any hypoxic change in tissue of the brain and heart; the reason may be the rapid onset of symp- toms, which lasted only 1 hour before occurrence of death and compatible with the history. So the application of the term “sudden death” seems to be accurate for our case. It seems that along with ischemic cardiac problems and poi- sonings, cases such as the discussed one should also be con- sidered in differential diagnosis of cause of death in young patients who face sudden death without any history of un- derlying illnesses. However, late diagnosis and weak clinical suspicion to rare cases such as this one might prevent the in- charge physician from saving the life of such patients. 4. Appendix 4.1. Acknowledgements We would like to express our special thanks to the forensic center of Tehran, Iran. 4.2. Author’s contribution All authors met the four criteria for authorship contribution based on the recommendations of the international commit- tee of medical journal editors. 4.3. Conflict of interest The authors declared no potential conflict of interest with re- spect to the authorship and/or publication of this article. 4.4. Funding None. References 1. Rahman ML, Badruzzaman M, Mokhlesuzzaman A, Kabir MM, Chowdhury MMG, Hossain MA. Hydatid Cyst Of Lung. KYAMC Journal. 2017;4(2):427-30. 2. Gul Z, Liaqat F, Khattak MT, Ahmad W, Haq SZU. HY- DATID CYST OF BRAIN. Gomal Journal of Medical Sci- ences. 2014;12(3). 3. Rasheed K, Zargar SA, Telwani AA. Hydatid cyst of spleen: a diagnostic challenge. North American journal of medi- cal sciences. 2013;5(1):10. 4. Sahpaz A, Azem Irez HG, Sener MT, Kok AN. Non- thrombotic pulmonary embolism due to liver hy- datic cyst: a case report. 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The American journal of forensic medicine and pathology. 2004;25(3):262-4. 10. Nardi W, Buero A, Lozano S, Porto EA. Laparoscopic re- section of a bulky primary adrenal hydatid cyst. Journal of minimal access surgery. 2015;11(4):279. 11. Unlu Y, Ceviz M, Karaoglanoglu N, Becit N, Kocak H. Ar- terial embolism caused by a ruptured hydatid cyst in the heart: report of a case. Surgery today. 2002;32(11):989-91. 12. Odev K, Acikgozoglu S, GormÃijs N, Aribas O, Kiresi D, Solak H. Pulmonary embolism due to cardiac hydatid disease: imaging findings of unusual complication of hy- datid cyst. European radiology. 2002;12(3):627-33. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com Introduction Case presentation: Discussion Appendix References