Risk factors and clinical features for pulmonary paragonimiasis-associated pneumothorax.

BACKGROUND: Pulmonary paragonimiasis, a food-borne zoonotic helminthiasis, is a parasitic disease of the lung caused by infection with trematodes species of the genus Paragonimus. Although pneumothorax has been reported as occuring with paragonimiasis, to date no study has been performed concerning the clinical features and predictive risk factors for this condition. METHODS: This retrospective study, which aims to fill this gap, was conducted at Jeonbuk National University Hospital. All patients (aged ≥19 years) were diagnosed with paragonimiasis between May 2011 and December 2021. Medical records were reviewed and information concerning age, sex, vital signs, underlying diseases, clinical signs and symptoms, laboratory findings, radiologic findings, treatment, and clinical outcomes was collected. An odds ratio (OR) for the risk factors associated with pneumothorax was calculated using the binary logistic regression model. RESULTS: Among 179 consecutive patients diagnosed with pulmonary paragonimiasis, the postive rate of pneumothorax was 10.6% (19/179). Pneumothorax occurred mostly in the right lung (78.9%, 15/19), and intrapulmonary parenchymal lesions showed an ipsilateral relationship with pneumothorax (94.7%, 18/19). Fifteen patients (78.9%, 15/19) of pneumothorax associated with pulmonary paragonimiasis are accompanied by pleural effusion. Most of patients with pneumothorax (89.5%, 17/19) underwent chest tube insertion as a first treatment. Three patients (15.8%) showed relapses but in no case was a death recorded. Asthma (odds ratio [OR] 8.10, 95% confidence interval [CI] 1.43-45.91), chest pain (OR 8.15, 95% CI 2.70-24.58), and intrapulmonary lesions (OR 8.94, 95% CI 1.12-71.36) were independent risk factors for pulmonary paragonimiasis-associated pneumothorax. CONCLUSIONS: Our findings suggest that clinicians should keep in mind the possibility of pneumothorax when approached by patients with pulmonary paragonimiasis complaining of chest pain, accompanied by intrapulmonary lesions or with asthma as an underlying disease.

[Case of Abdominal Colicky Pain Caused by Hepatic Paragonimiasis].

In Korea, the prevalence of paragonimiasis has decreased markedly since 1970 and is now rarely encountered. Although the lung is the primary site of paragonimiasis, ectopic infestation can occur in other sites. The central nervous system is the most commonly involved ectopic site, accounting for only approximately 1% of all paragonimiasis patients. Therefore, the liver is an extremely rare site of ectopic infestation. The authors experienced the case of a 55-year-old female with hepatic paragonimiasis who presented with abdominal colicky pain.

Exudative pleural effusion caused by lung fluke infection: A practical diagnostic approach.

OBJECTIVES: Pleural effusion caused by lung fluke is a rare etiology of exudative pleural effusion (EPE), which is often misdiagnosed or delayed. We aim to summarize the diagnosis and treatment course of EPE caused by lung fluke infection and put forward a practical diagnosis approach. METHODS: We retrospectively analyzed the diagnosis and treatment of 14 cases of EPE caused by lung fluke infection diagnosed by enzyme-linked immunosorbent assay of serum antibodies or egg detection. RESULTS: All patients (100%) with an absolute count of eosinophils in peripheral blood exceeded 0.5 × 109/l, and 10 patients (71.4%) had a history of special ingestion. Eosinophilic PE occurred in 11 patients (78.6%), pleural biopsy of medical thoracoscopic demonstrated eosinophils infiltration in nine patients (64.3%), and parasite eggs in one patient. All patients showed positive intradermal tests for Paragonimus-specific antigens and enzyme-linked immunosorbent assay of serum antibodies to Paragonimus. CONCLUSION: For patients with unexplained PE, lung fluke infection should be highly suspected when pleural fluid or pleural biopsy shows eosinophilic PE or eosinophils infiltration, especially for patients with certain diet history.

A Cluster of Paragonimiasis with Delayed Diagnosis Due to Difficulty Distinguishing Symptoms from Post-COVID-19 Respiratory Symptoms: A Report of Five Cases.

Paragonimiasis caused by trematodes belonging to the genus Paragonimus is often accompanied by chronic respiratory symptoms such as cough, the accumulation of sputum, hemoptysis, and chest pain. Prolonged symptoms, including respiratory symptoms, after coronavirus disease 2019 infection (COVID-19) are collectively called post-COVID-19 conditions. Paragonimiasis and COVID-19 may cause similar respiratory symptoms. We encountered five cases of paragonimiasis in patients in Japan for whom diagnoses were delayed due to the initial characterization of the respiratory symptoms as a post-COVID-19 condition. The patients had consumed homemade drunken freshwater crabs together. One to three weeks after consuming the crabs, four of the five patients were diagnosed with probable COVID-19. The major symptoms reported included cough, dyspnea, and chest pain. The major imaging findings were pleural effusion, pneumothorax, and nodular lesions of the lung. All the patients were diagnosed with paragonimiasis based on a serum antibody test and peripheral blood eosinophilia (560-15,610 cells/µL) and were treated successfully with 75 mg/kg/day praziquantel for 3 days. Before diagnosing a post-COVID-19 condition, it is necessary to consider whether other diseases, including paragonimiasis, may explain the symptoms. Further, chest radiographic or blood tests should be performed in patients with persistent respiratory symptoms after being infected with COVID-19 to avoid overlooking the possibility of infection.

Pleuropulmonary Paragonimiasis with Multiple Nodules in the Pleura.

An asymptomatic 47-year-old woman was admitted with pleural effusion and pulmonary infiltrates 1 month after ingesting raw wild boar and deer meat. Both her blood and pleural fluid were eosinophilic. Thoracoscopy revealed multiple nodules of the pleura, and biopsy samples of the nodules showed necrosis with epithelioid cell granulomas. An enzyme-linked immunosorbent assay was positive for antibodies against Paragonimus westermani, and the patient was successfully treated with praziquantel. This is the first reported case of pulmonary or pleuropulmonary paragonimiasis where several pleural nodules were observed. The detection of pleural nodules on thoracoscopy can contribute to the prompt and accurate diagnosis of paragonimiasis.

Intracranial Pseudoaneurysm Caused by Cerebral Paragonimiasis in Pediatric Patients.

BACKGROUND: We investigated the proportion of pediatric patients with cerebral paragonimiasis and intracranial hemorrhage who have intracranial pseudoaneurysms. METHODS: Images of 17 pediatric patients with cerebral paragonimiasis that first manifested as secondary intracranial hemorrhage were evaluated. All patients underwent computed tomographic angiography before surgery. A diagnosis of cerebral paragonimiasis was confirmed based on a positive Paragonimus-specific antibody test in serum samples from all 17 patients. Cerebral paragonimiasis in five of the 17 patients was further confirmed by histopathological examination of surgical specimens. RESULTS: Computed tomographic angiographic images for six of the 17 patients (35.3%) showed the presence of intracranial pseudoaneurysms. Follow-up computed tomographic angiographic scans two years later showed that two of the six patients had persistent pseudoaneurysms and underwent aneurysmectomy. The diagnosis of pseudoaneurysm was confirmed by histopathological examination postsurgery. In another two of the six patients, the pseudoaneurysm lesions were absorbed and could no longer be seen on three- to six-month follow-up scans. The final two patients with pseudoaneurysms are still under follow-up. Intracranial pseudoaneurysms with various degrees of surrounding hemorrhage were frequently observed at first manifestation. CONCLUSIONS: The rupture of intracranial pseudoaneurysms is a common characteristic feature of secondary intracranial hemorrhage caused by cerebral paragonimiasis in pediatric patients.

Diagnosis and Treatment of Hemorrhagic Cerebral Paragonimiasis: Three Case Reports and Literature Review.

AIM: To investigate the clinical manifestations and radiologic characteristics in diagnosing and treating hemorrhagic cerebral paragonimiasis. MATERIAL AND METHODS: The study retrospectively analyzed the data of three cases of hemorrhagic paragonimiasis who received treatment in the hospital from January 2014 to March 2017. All three patients were diagnosed with paragonimiasis by positive detection of paragonimiasis antibody. Based on the imaging data, the disease was confirmed as hemorrhagic cerebral paragonimiasis. One of the three patients was treated with oral praziquantel alone, one with praziquantel and thoracentesis, and one with praziquantel in combination with closed thoracic drainage and craniotomy. RESULTS: All the lesions disappeared after computed tomography scan during the follow-up. Two of the three patients had no dysneuria, and one had mild dysneuria. CONCLUSION: Hemorrhagic cerebral paragonimiasis should be diagnosed as early as possible using antibodies against paragonimiasis for patients with unexplained intracerebral hemorrhage, especially young patients with atypical imaging findings and multiple systemic lesions. It is possible to avoid craniotomy and improve the cure rate by the early, full-dose, and sufficient course of anti-parasitic treatment.

Case Report: Paragonimiasis Presenting with Pericardial Tamponade.

We report an unusual case of paragonimiasis in a Nepali patient presenting with massive pericardial effusion and pericardial tamponade. The patient reported neither the consumption of crabs or crayfish nor the consumption of wild animal meat, which are the usual sources of infection. It is suspected that the source of infection was instead the ingestion of raw live slugs as part of a traditional medicine treatment.

Diagnosis and surgical management of pericardial effusion due to paragonimiasis.

OBJECTIVES: The pericardial effusion (PE) caused by paragonimiasis is rarely reported. This study aims to present experience in the diagnosis and surgical management of PE due to paragonimiasis. METHODS: Medical records of 57 children who were diagnosed with PE due to paragonimiasis and underwent surgery at Children's Hospital of Chongqing Medical University between January 2012 and August 2018 were retrospectively reviewed. RESULTS: The average age of this group was 7.6 ± 3.0 years. Patients were mainly from Chongqing and Sichuan areas. ELISA for Paragonimus skrjabini in all 57 patients showed positive results. Moderate or large PE were identified in 12 and 45 patients, respectively. All patients underwent surgery either by pericardectomy or thoracoscopic surgery. Pathological exams indicated massive eosinophil infiltration in all 57 specimens. After 3-4 courses of praziquantel therapy, the clinical outcomes were satisfactory. CONCLUSIONS: Typical endemic history, eosinophilia and multiple serous effusion raise suspicions of paragonimiasis. Once moderate to large PE is identified in patients with paragonimiasis, surgical treatment is necessary.

Bronchodilator Reversibility Occurring during the Acute Phase of Paragonimiasis westermani Infection.

A 43-year-old woman was referred to our hospital with peripheral blood hypereosinophilia and abnormal chest X-ray findings. Her pleural effusion revealed hypereosinophilia and a low glucose level. She was diagnosed with pulmonary paragonimiasis based on an elevated antibody level of Paragonimiasis westermani. Although she had no medical history of allergic disorders, a pulmonary function test revealed bronchodilator reversibility. After praziquantel therapy, her symptoms, hypereosinophilia in peripheral blood, and pleural effusion were improved. A repeated pulmonary function test after praziquantel therapy showed a negative bronchodilator response. Pulmonary paragonimiasis may induce bronchodilator reversibility during the acute phase of infection.

[Clinical analysis of 50 cases of serous cavity effusion related with paragonimiasis].

OBJECTIVE: To analyze the clinical characteristics of serous cavity effusion related with paragonimiasis, so as to improve the physician's ability of the clinical diagnosis and treatment. METHODS: The clinical data of 50 cases of serous cavity effusion related with paragonimiasis diagnosed in a hospital in recent 3 years were collected and retrospectively analyzed. RESULTS: Among the 50 patients, there were 35 males and 15 females, and 35 children and 15 adults. Eighteen patients had a clear history of exposure to the foci. Among the children, the respiratory symptoms accounted for 68.6% (24/35), gastrointestinal symptoms for 22.9% (8/35), and no apparent symptoms for 8.6% (3/35); among the adults, the respiratory symptoms accounted for 93.3% (14/15) and the abdominal distention for 6.7% (1/15). The paragonimus antibody was positive in all the patients. The chest radiography or CT showed pulmonary inflammatory exudation and serous cavity effusion. Eosinophilia in blood was found in 25 cases, a large number of eosinophils in serous cavity effusion were found under microscopy in 12 cases, and eosinophil infiltration of pleura was found in 7 cases. All were cured after the patients received chemotherapy (praziquantel) and drainage fluid. CONCLUSIONS: The clinical manifestations of paragonimiasis are not very specific and paragonimiasis is often accompanied with serous cavity effusions. Clinically, paragonimiasis is easily misdiagnosed as tuberculosis or cancer. We should consider about the possibility of paragonimiasis when eosinophil is high in blood, serous cavity effusion and pleura.

Scrotal Paragonimiasis in adults: Two case reports and review of literature.

RATIONALE: Paragonimiasis is a parasitic disease caused by Paragonimus in the lungs; it can be divided into intrapulmonary type and extrapulmonary type. Adult patients with scrotal paragnonimus are rarely seen clinically and not widely reported in the literature. Here, we report 2 cases of scrotal paragonimiasis in adults and their treatment process. PATIENT CONCERNS: Two young males sought medical advice because of scrotal masses. Both patients had the previous history of eating uncooked river crabs and presented with palpable quasicircular nodules of about 1.5 × 1.0 cm in testicles, which were well-defined, resilient in tenderness. The bilateral inguinal lymph nodes were not enlarged. DIAGNOSIS AND INTERVENTIONS: The 2 patients underwent scrotal mass resection; postoperative pathology examination confirmed scrotum paragonimiasis. Both the patients were administered praziquantel after operation. OUTCOMES: They were followed up for 1 year and 4 years, respectively; both recovered well, free from recurrence. Scrotum color Doppler ultrasound examination found no obvious abnormality. LESSONS: Adult patients with scrotum paragonimiasis are rarely seen clinically. Moreover, its clinical manifestations are not typical that leads to missed diagnosis and misdiagnosis. Diagnosis of the disease needs to combine with disease histories, manifestations, and relevant auxiliary examinations. But the diagnosis can be confirmed only by histopathological examination. The main method for treatment of scrotal paragonimiasis is antiparasitic treatment. However, health education is crucial to prevent this disease and relapse.

Takotsubo cardiomyopathy associated with Paragonimiasis westermani.

An 11-year-old boy collapsed during morning assembly at his junior high school. The automated external defibrillator detected ventricular fibrillation and provided shock delivery. He was successfully resuscitated and reverted to sinus rhythm. Electrocardiography showed ST-T elevation in the precordial leads. Echocardiography and angiography demonstrated akinesia of the apex and mid-wall of the left ventricle with preserved contraction of the basal segments, which suggested Takotsubo cardiomyopathy. The patient and his family had often eaten uncooked crab, and his father had a past history of infection with Paragonimiasis westermani. The patient had had a persistent cough and chest pain for several weeks. Chest radiograph showed cystic cavities in the left upper lung. Microbiological examination of the sputum demonstrated an egg of P. westermani and immunological assay showed a raised antibody titre to P. westermani. On the12th day of admission, he developed seizures, and magnetic resonance imaging demonstrated cerebral involvement. After the administration of praziquantel for 3 days, the clinical manifestations improved immediately, and echocardiography normalised within 3 weeks. The patient was discharged on the 32nd day + and follow-up was normal. Takotsubo cardiomyopathy following a potentially fatal arrhythmia is a rare cardiac complication associated with pulmonary and central nervous system infection by P. westermani.

A Case of Ectopic Peritoneal Paragonimiasis Mimicking Diverticulitis or Abdominal Abscess.

Paragonimiasis is a parasitic disease caused by Paragnonimus species. The primary site of infection is the lung, and extrapulmonary involvement is also reported. When infected with Paragonimus westermani, which is the dominant species in Korea, the central nervous system is frequently involved along with the liver, intestine, peritoneal cavity, retroperitoneum, and abdominal wall. Ectopic paragonimiasis raises diagnostic challenge since it is uncommon and may be confused with malignancy or other inflammatory diseases. Here, we report an ectopic paragonimiasis case initially presented with recurrent abdominal pain. The patient developed abdominal pain 3 times for the previous 3 years and the computed tomography (CT) of the abdomen revealed fluid collection with wall enhancement. Recurrent diverticulitis was initially suspected and part of the ascending colon was resected. However, the specimen showed intact colon wall without evidence of diverticulitis and multiple parasite eggs and granulomas were found instead. The size of about 70 µm, the presence of an operculum and relatively thick egg shell suggested eggs of Paragonimus species. With appropriate exposure history and a positive antibody test, the definitive diagnosis was made as peritoneal paragonimiasis.

Electromagnetic Navigational Bronchoscopy Spares a Drunken Crab From the Surgeon's Knife.

Surgical resection is traditionally the preferred treatment for fluorodeoxyglucose-avid peripheral pulmonary nodules that grow over time. However, new technologies, including electromagnetic navigational bronchoscopy (ENB), provide an opportunity to confirm or possibly exclude a cytologic cancer diagnosis, before resection. We present a case of a 56-year-old North American man who presented with a fluorodeoxyglucose-avid pulmonary nodule and sought a second opinion after being recommended thoracotomy with lobectomy. The peripheral nodule was biopsied using ENB and pathologic evaluation of the lesion demonstrated parasitic eggs with features of Paragonimus westermani. No evidence of malignancy was found. The radiographic abnormalities resolved after treatment with praziquantel. Using a minimally invasive procedure with ENB, we successfully diagnosed pulmonary infection with P. westermani, a rare infectious cause of peripheral pulmonary lesions in a patient without travel to an endemic area. Furthermore, an alternative diagnosis to cancer was established, sparing this patient an unnecessary thoracotomy with right middle lobectomy.

Familial Mediterranean Fever with Rheumatoid Arthritis Complicated by Pulmonary Paragonimiasis.

A 42-year-old woman presented with an intermittent fever and chest and back pain, and an abnormal chest shadow was detected. She was diagnosed with paragonimiasis caused by Paragonimus westermani. Praziquantel therapy improved the abnormal chest shadow, but did not relieve her symptoms. She was also diagnosed with familial Mediterranean fever (FMF), and colchicine therapy resolved her symptoms. She subsequently developed arthralgia and morning stiffness in her hands. We also diagnosed the patient with rheumatoid arthritis (RA), and corticosteroid and salazosulfapyridine therapy improved her symptoms. The existence of paragonimiasis complicated the diagnosis of FMF. The coexistence of FMF and RA is very rare, but does exist.