What Findings on Chest CTs Can Delay Diagnosis of Pleuropulmonary Paragonimiasis?

PURPOSE: The purpose of this study was to investigate which findings were delayed in diagnosis with respect to chest CT findings of paragonimiasis. METHODS: This retrospective, informed questionnaire study was conducted to evaluate chest CT scans of 103 patients (58 men and 45 women; mean age 46.1 ± 14.6 years). The patients were diagnosed with paragonimiasis from 2003 to 2008 in four tertiary hospitals. Statistical analysis was performed using the chi-square test to identify differences between an initially correct diagnosis and an incorrect one of paragonimiasis on chest CT scans, for which we evaluated such variables as the location of lesion, type of parenchymal lesions, and worm migration track. RESULTS: Nodular opacities on chest CT scans were the most common findings (53/94, 56.4%). The sign of worm migration tracks was only present in 18.1% of cases (17/94). Although statistically insignificant, the form of consolidation (18/25, 72%) and mass (6/8, 75%) on CT was common in correct diagnostics, and the form of the worm migration track (12/17, 70.6%) was high in correct diagnostics. CONCLUSION: A delayed diagnosis of paragonimiasis may often be made in patients with non-nodular, parenchymal lesions who are negative for worm migration track on chest CT scans.

Human Pulmonary Dirofilariasis: A Review for the Clinicians.

Human pulmonary dirofilariasis (HPD) is a rare zoonotic disease caused by Dirofilaria immitis, the nematode responsible for canine cardiopulmonary dirofilariasis (dog heartworm). The incidence of HPD is on the rise throughout the world due to increased awareness and factors affecting the vector (mosquito). Humans are accidental hosts for D. immitis. Most patients are asymptomatic and present with an incidental pulmonary nodule that mimics primary or metastatic pulmonary malignancy. Some patients suffer from pulmonary and systemic symptoms in the acute phase of pneumonitis caused by pulmonary arterial occlusion by the preadult worms resulting in pulmonary infarction and intense inflammation. These patients may have ill-defined pulmonary infiltrate on chest radiology. Pulmonary nodules represent the end result of initial pneumonitis. There are no specific clinical, laboratory, or radiologic findings that differentiate HPD from other causes of a pulmonary nodule. Although serologic tests exist, they are usually not commercially available. The majority of patients are diagnosed by histopathologic identification of the decomposing worm following surgical resection of the lesion.

Cardiopulmonary alterations by ultrasound in a patient with uncomplicated mixed malaria infection: a case report from the Amazon Basin.

BACKGROUND: Information on cardiopulmonary complications in clinical malaria is sparse and diagnosis may be difficult in resource-limited areas due to lack of proper diagnostic tools and access to medical care. A case of pericardial effusion and pulmonary alterations assessed by ultrasound in a patient with uncomplicated mixed malaria infection is described. CASE PRESENTATION: A previously healthy 23-year-old male from the Amazon Basin was diagnosed with mixed infection of Plasmodium vivax and Plasmodium falciparum by peripheral blood smear. The patient presented with mild malaria symptoms without signs of severe malaria, but reported moderate chest pain and shortness of breath. Laboratory analyses revealed thrombocytopenia and anemia. The electrocardiogram had PR depressions and bedside ultrasound of the cardiopulmonary system showed pericardial effusion (18 mm) accompanied by multiple B-lines in the lungs, identified as vertical artifacts extending from the pleural line. Cardiac biomarkers were normal. The patient was treated according to national guidelines for malaria and suspected pericarditis, respectively. At follow-up on day 5, the pericardial effusion (9mm) and B-lines had markedly decreased. By day 21 the patient was asymptomatic, had completed the treatment, and the electrocardiogram and ultrasound findings had normalized. CONCLUSIONS: This case report highlight the usefulness of bedside ultrasound to identify cardiopulmonary involvement in patients with uncomplicated malaria and relevant symptoms.

Irreversible Ocular Lesions in a Dog With Angiostrongylus Vasorum Infection.

This report describes a 10-month-old dog with a sudden loss of vision and severe dyspnoea. The ocular examination revealed bilateral panuveitis, lens subluxation, secondary glaucoma, and retinal detachment. In addition, the ocular ultrasound showed in the vitreous body of the right eye, a small doubled-lined foreign body compatible with an intraocular parasite. Radiographs of the thorax revealed an increased opacity with mixed lung pattern (alveolar and bronchial) and thoracic ultrasonography showed several subpleural nodules. The presence of Angiostrongylus vasorum first stage larvae was confirmed with 324 larvae per gram of feces and an antigen test for the parasite (AngioDetect, IDEXX) also yielded a positive result. The severe and irreversible ocular lesions described in this case enhanced the complexity of the clinical picture of canine angiostrongylosis. Infection with the parasite should be included in the list of differential diagnoses for ocular uveitis to avoid potentially serious complications related to a missed or delayed diagnosis.

Toxocariasis Suspected of Having Infiltrated Directly from the Liver to the Lung through the Diaphragm.

A 37-year-old woman presented to our hospital with mild abdominal pain experienced for 2 months and hepatic nodules in segments 3 and 8. Peripheral blood eosinophilia was observed, and toxocariasis was serologically diagnosed. Seventeen days after the first imaging evaluation, a new lesion was found in segment 9 of the right lung, which was contiguous through the diaphragm to the hepatic nodule in segment 8. After treatment with albendazole, the liver and lung nodules disappeared. We suspect that larvae had directly invaded the lung from the liver, through the diaphragm.

Restaging Pulmonary Schistosomiasis.

Schistosomiasis is traditionally classified into an acute and a chronic phase, although a precise temporal distinction between the two phases has not been established. Lung involvement can be observed in both phases. We previously reported seven cases of pulmonary lesions due to chronic schistosomiasis in African immigrants. All cases were documented with CT scans and demonstrated complete resolution after treatment with praziquantel. Moreover, another case showed spontaneous disappearance of the nodule before treatment with praziquantel. These findings are similar to those observed in the acute phase of schistosomiasis, with well-defined or ground glass nodules that resolve spontaneously. According to these findings, we postulate the presence of an "intermediate" phase of schistosomiasis involving the lungs that can be defined as an "early chronic phase," and presents analogies to the acute phase. We also hypothesize that in the "early chronic phase," the female worms transit through the lungs where they may lay eggs. These passages not only cause transient, but also radiologically visible alterations. The pathophysiology of lung lesions in the late chronic phase is probably different: the adult worms settled in the mesenteric plexuses produce eggs for years. The eggs repeatedly migrate to the perialveolar capillary beds via portal-caval shunting. Thus, in this case it is the eggs and not the adult worms that reach the lungs in a scattered way. Based on our findings, we suggest the alternative hypothesis that the pulmonary involvement is a phase of the natural evolution of the infection, both from Schistosoma mansoni and Schistosoma haematobium.

The non-resolving lung cavity: a case of pulmonary cystic echinococcosis.

The authors report a case of a 20-year-old woman who was diagnosed with pulmonary cystic echinococcosis. She was admitted to hospital with a 1-week history of unresolving cough, coloured sputum with occasional haemoptysis and fever despite oral antibiotics. Radiology revealed a cavitating right lower lobe lung abscess. After 4 weeks of treatment, follow-up radiology showed incomplete resolution. Bronchoscopy revealed a white, avascular cystic lesion in the right lower lobe and serology testing for Echinococcus granulosus was positive. Repeat imaging eventually confirmed the cystic lesion with the 'air bubble'sign. A thorough travel history, a high index of clinical suspicion and close follow-up are essential in making a diagnosis of pulmonary cystic echinococcosis.

Fatal pulmonary acariasis in an aged indoor rhesus macaque (Macaca mulatta).

Pulmonary acariasis is a sporadic, incidental finding in colony-raised rhesus macaques (Macaca mulatta). Prophylactic treatment in indoor-raised and indoor-housed macaques is not routine due to low prevalence, lack of clinical significance, and potential risk of toxicosis. This case is an unusually severe infestation of Pneumonyssus simicola in an indoor-housed rhesus macaque, which ultimately resulted in this animal's death.

Severe Anemia and Lung Nodule in an Immunocompetent Adopted Girl with Strongyloides stercoralis Infection.

Strongyloides stercoralis is a soil-transmitted helminth widely diffused in tropical areas. Chronic infection is usually characterized by absent or mild symptoms, but immunocompromised subjects are at risk of developing a severe syndrome that can be fatal if not promptly treated. We report a case of S. stercoralis infection causing severe anemia (hemoglobin 4.9 g/dL) and a lung nodule in a 14-year-old girl of Ethiopian origin adopted by an Italian couple. Severe anemia due to strongyloidiasis has been rarely reported, and mostly in severely ill patients, whereas our patient was immunocompetent and in good general conditions. Also, lung nodules have been only occasionally described in absence of respiratory symptoms. We discuss the management of patients with these findings, and we suggest to update the screening of immigrants from countries endemic for strongyloidiasis, including serology.

Clinical characteristics and computed tomography findings of pulmonary toxoplasmosis after hematopoietic stem cell transplantation.

The prognosis of pulmonary toxoplasmosis, including disseminated toxoplasmosis involving the lungs, following hematopoietic stem cell transplantation (HSCT) is extremely poor due to the difficulties associated with early diagnosis and the rapidly progressive deterioration of multiorgan function. In our institution, we identified nine cases of toxoplasmosis, representing incidences of 2.2 and 19.6 % among all HSCT recipients and seropositive HSCT recipients, respectively. Of the patients with toxoplasmosis, six had pulmonary toxoplasmosis. Chest computed tomography (CT) findings revealed centrilobular, patchy ground-glass opacities (n = 3), diffuse ground-glass opacities (n = 2), ground-glass opacities with septal thickening (n = 1), and marked pleural effusion (n = 1). All cases died, except for one with suspected pulmonary toxoplasmosis who was diagnosed by a polymerase chain reaction assay 2 days after the onset of symptoms. In pulmonary toxoplasmosis, CT findings are non-specific and may mimic pulmonary congestion, atypical pneumonia, viral pneumonitis, and bronchopneumonia. Early diagnosis and treatment is crucial for overcoming this serious infectious complication. Pulmonary toxoplasmosis should be considered during differential diagnosis in a recipient with otherwise unexplained signs of infection and CT findings with ground-glass opacities, regardless of the distribution.

[Multiple pulmonary opacities revealing toxocariasis]. / Opacités pulmonaires multiples révélant une toxocarose.

INTRODUCTION: Toxocariasis is a parasitosis which complicates the accidental infestation of the humans by larvae of a roundworms belonging of the genus Toxocara. In adults, the discovery is often incidental during a hypereosinophilia check-up. Clinical signs are not specific and depend on affected organs. CASE REPORT: We report the case of a 53-year-old-woman who has consulted for a recent cough, after spontaneous resolution of abdominal pain. The laboratory examination isolated an hypereosinophilia and the liver sonography showed two hypoechogenic nodules. The CT-scan found bilateral lung nodules with ground glass halo. Broncho-alveolar lavage identified an eosinophilic alveolitis. Positive serologic results for toxocariasis and western blot results allowed to conclude to the diagnosis of pulmonary and hepatic toxocariasis. CONCLUSION: Although rare, pulmonary toxocariasis should be suspect in any lung eosinophilia, especially if the patient has never traveled.

Pulmonary Paragonimiasis: The Detection of a Worm Migration Track as a Diagnostic Clue for Uncertain Eosinophilic Pleural Effusion.

A 38-year-old woman with sustained right chest pain was referred to our hospital. She showed pleural effusion and peripheral blood eosinophilia. Thoracentesis revealed eosinophilic pleural effusion in which the smear, culture and cytological examinations were all negative. Although she had no notable dietary history, chest CT revealed linear opacities, which suggested the migration tracks of paragonimiasis. The diagnosis was confirmed using enzyme-linked immunosorbent assays, which showed elevated Paragonimus westermani and Paragonimus miyazakii antibody levels. After the initiation of praziquantel therapy, all clinical findings were promptly improved. The detection of a migration track may therefore be useful in the diagnosis of paragonimiasis.