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.

Paragonimiasis pulmonar. Reporte de caso pediátrico / Pulmonary paragonimiasis. Pediatric case report

La paragonimiasis es una parasitosis provocada por varias especies de Paragonimus, un trematodo que se transmite a través del consumo de cangrejos poco cocidos o crudos y que se ha encontrado en áreas tropicales y subtropicales de América, Asia y África. Esta infección afecta, principalmente, los pulmones y provoca manifestaciones clínicas y radiológicas muy similares a la tuberculosis pulmonar, por lo cual siempre debe incluirse dentro del diagnóstico diferencial. Se presenta el caso de una niña escolar de 7 años de edad, hospitalizada con el diagnóstico de paragonimiasis pulmonar, quien presentó evolución favorable luego de recibir tratamiento con triclabendazol.

Paragonimiasis is a parasite infection caused by several species of Paragonimus, a trematode that is transmitted through the consumption of raw or undercooked crabs and that has been found in the subtropical areas of America, Asia and Africa. This infection mainly affects the lungs, causing clinical and radiological manifestations very similar to pulmonary tuberculosis, so it should always be included in the differential diagnosis. We present the case of a 7-year-old school patient, hospitalized with the diagnosis of pulmonary paragonimiasis, who had a favorable evolution after receiving treatment with triclabendazole.

Unresolving Pneumonia with Pleural effusion: Pulmonary Paragonimiasis.

Paragonimiasis is a zoonosis caused by many species of Paragonimus commonly P. westermani. Human get infected by eating raw, salted, pickled, smoked, partially cooked crustaceans (crayfish or crabs). Clinical manifestations ranges from non-specific symptoms like pain abdomen, diarrhea, urticarial rashes, fever to pleuropulmonary symptoms like cough, hemoptysis, chest pain and dyspnea. A 48 years, female presented at TUTH emergency with fever on and off for nine months, cough and shortness of breath for three months, lethargy, malaise and urticaria with history of raw crab intake one month prior to the onset of symptoms. Blood and pleural fluid analysis revealed raised total counts with eosinophilia and x-ray showed bilateral infiltration of lower lobes with pleural effusion. Diagnosis was confirmed by microscopic examination of sputum for Paragonimus. She responded well to Praziquantel. Pulmonary paragonimiasis must be considered in the differential diagnosis of unresolving pneumonia and unexplained hypereosinophilia.

Paragonimiasis in Children in Southwest China: A retrospective case reports review from 2005 to 2016.

BACKGROUND: Paragonimiasis infection has no specific symptoms or typical radiologic findings, leading to the possibility of misdiagnosis. Thus, the objective of this study was to analyze clinical and radiological features, and treatment outcome of paragonimiasis in children in Southwest China to improve the awareness of this disease. METHODS: We retrospectively reviewed the records of children diagnosed with paragonimiasis in West China Second University Hospital between 2005 and 2016. The confirmed diagnosis of paragonimiasis was based on epidemiology history and seropositivity for paragonimiasis and/or detection of paragonimus eggs. Clinical, laboratory, and imaging findings of patients were examined in order to summarize risk factors, clinical characteristics, and treatment outcomes of these patients. RESULTS: A total of 123 patients were included; of them 112 (91.1%) lived in villages and 72 (58.5%) had a history of consuming freshwater crabs. Patients with paragonimiasis most frequently showed respiratory symptoms, including cough (26.0%, 32/123) and tachypnea (16.3%, 20/123), and gastrointestinal symptoms, including abdominal pain (26.8%, 33/123), abdominal distention (22.8%, 28/123), and vomiting (13.0%, 16/123). Laboratory examination showed elevated white blood cell (WBC) counts in the peripheral blood in 89 (72.4%) patients and eosinophilia in 102 (82.9%) patients. Tuberculosis (TB) coinfection was found in 4 (3.3%) patients. Main imaging findings included: effusions (90.4%), lymphadenopathy (40.4%), pulmonary ground-glass opacities (36.2%), cystic lesions (18.1%), and pleural thickening (17.0%). Twenty-nine patients (23.6%) received more than 1 course of praziquantel (PZQ). Additionally, 4 (19.0%) of 21 patients who were discharged from the hospital without complete treatment required rehospitalization for residual serous effusions. Moreover, patients from pericardial effusion group showed longer hospital stays and less elevated WBC counts than those from nonpericardial effusion group. CONCLUSION: Paragonimiasis should be considered in patients from endemic areas, especially in those with gastrointestinal and/or respiratory symptoms, elevated WBC count, eosinophilia, and serous effusions. Additionally, longer hospital stay may be necessary in cases of paragonimiasis associated with pericardial effusions.

[Clinical, pathologic and radiologic analysis of paragonimiasis in children].

Objective: To analyze the clinical, pathological and radiological characteristics of paragonimiasis in children for accurate diagnosis and therapy. Methods: A total of 31 patients with paragonimiasis treated from 2002 to 2016 were selected, including 17 cases from migrant areas and 14 cases from Wenzhou area. Results: In migrant children group, the serum IgE was significantly higher than that in Wenzhou area group [(2 379±944) IU/mL∶(1 552±1 121) IU/mL, t=-2.23, P<0.05], and the duration of therapy was remarkable longer [(13.8±6.5) days∶(9.9±3.4) days, t=-2.15, P<0.05]. Among all cases, 10 showed polyserositis including pleural effusion, ascites and pericardial effusion at different degrees on chest CT scans. Five cases with cerebral paragonimiasis were confirmed by MR imaging. Most of the lesions were located in the parietal lobe with slight low signal on T1WI but high signal on T2WI surrounded by disproportionate edema. Annular enhancement was prominent by Gd-DTPA. Paragonimiasis serum antibody was positive in all cases by ELISA. Pathologic features included formation of irregular lacunae or sinus tracts, presence of paragonimus bodies, and eosinophilic infiltration in the adjacent tissues. Conclusions: Clinical manifestations of paragonimiasis are complex and non-specific in children.In migrant children group, clinical manifestations are diverse, more serious with more complications and difficulties in treatment, while patients in Wenzhou area group have favorable prognosis and less complicated treatment. The early diagnosis and timely treatment should be determined by patient's detailed history, eosinophilic count, radiologic findings and immunological test to avoid serious complications.

Declining prevalence of pulmonary paragonimiasis following treatment & community education in a remote tribal population of Arunachal Pradesh, India.

BACKGROUND & OBJECTIVES: In India, human pulmonary paragonimiasis is an important public health problem in the northeastern (NE) region. In 2005 we reported a hyperendemic focus of paragonimiasis in a remote tribal village in the hills of Changlang district in Arunachal Pradesh. The community was made aware of the disease and all active cases were treated. This study was aimed to assess the decline in the prevelance of paragonimiasis in the same area after a re-survey done in 2011 after a gap of six years. METHODS: Re-surveys were carried to determine the reduction in the prevalence of paragonimiasis. Community education was given to the villagers to raise their awareness about paragonimiasis. A total of 624 individuals including 301 children (age 15 yr) were included in the study. Sputum and stool samples were examined for eggs of lung flukes. Serum samples were screened for IgG antibodies against lung fluke antigen by ELISA. RESULTS: A significant (P<0.001) decline in the prevalence of paragonimiasis was found. There was decline in both ELISA positivity and egg positivity. Antibody positivity against excretory-secretary (ES) antigen in children (age 15 yr) fell down from earlier 51.7 to 15.9 per cent and in individuals 16 - 30 yr of age the serological prevalence fell down from 22.4 to 8.2 per cent and in individuals aged th > 31 yr, the decline in prevalence was from 15.3 to 3.7 per cent. Gender-wise analysis revealed that the decline in ELISA positivity was similar in both genders and fell down from 33.9 to 11.5 per cent in males and from 29.8 to 10.7 per cent in females. Similarly, there was a significant decline rate in egg positivity also. INTERPRETATION & CONCLUSIONS: The strategy of hotspot targeted active paragonimiasis case detection and treatment of infected cases together with community education appears to be feasible methods to achieve control of paragonimiasis in this region.

Pulmonary Paragonimiasis Mimicking Tuberculosis.

Paragonimiasis is a disease which is frequently misdiagnosed as pulmonary tuberculosis. In the areas where people eat crab/crayfish this disease should be considered in the differential diagnosis to avoid antituberculosis treatment for a non-tubercular condition. We are reporting a case of pulmonary paragonimiasis who had been treated for tuberculosis.

Hemorrhagic stroke and cerebral paragonimiasis.

BACKGROUND AND PURPOSE: We retrospectively analyzed the clinical and imaging characteristics, diagnosis, and treatment outcomes of 10 patients with hemorrhagic cerebral paragonimiasis (CP), and we evaluated the influence of Paragonimus infection on cerebrovascular damage. METHODS: Ten patients (7 male and 3 female; median age 15.7 years, range 4-46 years) with hemorrhagic CP were diagnosed between April 2009 and January 2013. All patients underwent the head computed tomography scans and 9 patients underwent MRI examinations. Four patients underwent computed tomographic angiography, magnetic resonance angiography, and digital subtraction angiography. Liquid-based cytological examination of cerebrospinal fluid was performed in 7 patients. Follow-up examinations were performed for 9 cases for a period of 12 to 62 months. RESULTS: Hemorrhagic CP accounted for 37% of CP cases (10/27). No patients were initially diagnosed with CP. The major symptoms of hemorrhagic CP included acute headache, vomiting, hemiparalysis, epilepsy, blurred vision, sensory impairment, and tinnitus. Four cases were surgically treated. Most symptoms markedly improved, but fine motor dysfunction and mental dysfunction remained in 3 surgical patients. CONCLUSIONS: Hemorrhagic stroke typically occurred during the acute stage and in the early stages of further Paragonimus migration. Delay of treatment increased the risk of initial and recurrent stroke.

Massive pleural effusion due to paragonimiasis: biochemical, cytological, and parasitological findings.

Paragonimiasis is an important food-borne parasitic zoonosis caused by trematode species of the genus, Paragonimus occurring in many parts of the world except in Australia and Antarctica. In India, it is an emerging parasitic disease, which is endemic in the northeast states where people have a common practice of eating raw or inadequately cooked freshwater crabs. In these states, Paragonimus heterotremus has been identified as the major causative agent of the human paragonimiasis. The most common clinical form of the disease is pulmonary paragonimiasis; however, extra-pulmonary manifestations are not uncommon. Here, we report a case of primary massive unilateral pleural effusion due to paragonimiasis. The diagnosis was confirmed by finding Paragonimus ova in the pleural fluid. The patient was successfully treated with repeated thoracocentesis and a course of praziquantel.

Paragonimiasis.

Human paragonimiasis is caused by nine species of Paragonimus, namely, P. westermani, P. africanus, P. heterotremus, P. kellicotti, P. mexicanus, P. siamensis, P. skrjabini, P. skrjabini miyazakii, and P. uterobilateralis. Cerebral or spinal involvements are most common in P. westermani, and can also occur in P. skrjabini, P. skrjabini miyazakii, and P. mexicanus. In P. westermani, cerebral paragonimiasis comprises about 45% of all extrapulmonary paragonimiasis cases, and accounts for about 1% of all paragonimiasis patients. In cerebral paragonimiasis, seizure, headache, visual disturbance, and motor and sensory disturbances are the five major clinical symptoms. The most commonly performed diagnostic procedures for cerebral infections are serological tests to detect circulating antibodies or antigens using ELISA or immunoblotting, and radiological examinations, including plain skull x-rays, brain CT, and MR scans. The drug of choice is praziquantel at the dose of 25mg/kg three times daily for 2-3 days. In severe infections, a second set of treatment may be needed. Triclabendazole can be used in P. uterobilateralis, P. mexicanus, and P. skrjabini infections with the dose of 10mg/kg twice a day; however, its efficacy in P. westermani infection, in particular cerebral infections, remains to be elucidated.

Systematic teaching method to enhance the effectiveness of training for paragonimiasis.

The clinical symptoms of human paragonimiasis are complex and variable, and patients can easily be misdiagnosed. Pagumogonimus skrjabini is the species causing this disease found only in China. A 2002 epidemiological survey showed that the rate of paragonimiasis was 21·96% in the migration areas of the Three-Gorge Reservoir, Chongqing, China. Therefore, there is a need to train medical workers to treat individuals in these areas. The Third Military Medical University (TMMU) in Chongqing built a comprehensive and systematic teaching method, which included teaching students about the basic biology of the organism, guiding students to use appropriate diagnostic tests and participate in scientific research to develop diagnostic kits, and visiting endemic areas to provide on-site teaching. The use of on-site teaching is an innovative approach for training undergraduate medical students in human parasitology. Three improvements were implemented during the on-site teaching component of the program: (1) systematizing the learning process; (2) integrating formal knowledge with clinical experience; and (3) enhancing students' knowledge of medical ethics. Based on a survey, 95% of students believed that this systematic teaching system gave them a more comprehensive grasp of knowledge on P. skrjabini, and graduate students were able to provide early diagnosis of P. skrjabini cases in this remote region. Students also participated in the research and development of a P. skrjabini diagnostic kit, for which a patent has been applied, and during the on-site teaching process, data were collected for the government and health sector to assist in public-health planning and decision-making for this disease.

Cerebral paragonimiasis: a retrospective analysis of 89 cases.

PURPOSE: We reviewed the clinical and follow-up data of 89 cases with cerebral paragonimiasis and summarized the disease characteristics, diagnostic strategies and treatment experience, with an expectation of establishing standard diagnosis and treatment for cerebral paragonimiasis. METHODS: A total of 89 cases (age: 2-64 years) of cerebral paragonimiasis admitted and treated in our hospital in the past 10 years were included in this study. The clinical symptoms were manifested by headache, epilepsy, paralysis, etc. In order to confirm the diagnosis, we performed imaging examinations (e.g., CT and MRI) and laboratory tests (ELISA and eosinophil counting). Seventy-two patients received oral administration of praziquantel only, 16 cases received surgical resection of the lesions and 33 cases received appropriate anti-epileptic therapies. The diagnostic, treatment and follow-up data were statistically analyzed. RESULTS: Follow-up was performed for 73 cases for a period of 6-48 months and the original symptoms were markedly improved without recurrence. 15 patients were lost to follow-up after discharge. One patient died of epilepticus insult, high fever and convulsions. Although 4 patients still had seizures within 6 months of treatment, seizure frequency was significantly reduced. Histopathological evaluation demonstrated inflammatory changes with esoinophilic infiltration in all 16 patients who underwent surgical resection. CONCLUSIONS: Young patients (age: <18 years) are more likely to have cerebral hemorrhage. SWI imaging contributes to the diagnosis of hemorrhagic lesions. Cerebral paragonimiasis can cause epilepsy, especially grand mal seizures.

Paragonimus & paragonimiasis in India.

Ever since the discovery of the first indigenous case in 1981, paragonimiasis has gained recognition as a significant food borne parasitic zoonosis in India. The data available on the occurrence of paragonimiasis, until today, may be just the tip of an iceberg as the study areas covered were restricted to Northeast Indian States. Nevertheless, the results of research on paragonimiasis in India have revealed valuable information in epidemiology, life cycle, pathobiology and speciation of Indian Paragonimus. Potamiscus manipurensis, Alcomon superciliosum and Maydelliathelphusa lugubris were identified as the crab hosts of Paragonimus. Paragonimus miyazakii manipurinus n. sub sp., P. hueit'ungensis, P. skrjabini, P. heterotremus, P. compactus, and P. westermani have been described from India. P. heterotremus was found as the causative agent of human paragonimiasis. Ingestion of undercooked crabs and raw crab extract was the major mode of infection. Pulmonary paragonimiasis was the commonest clinical manifestation while pleural effusion and subcutaneous nodules were the common extra-pulmonary forms. Clinico-radiological features of pulmonary paragonimiasis simulated pulmonary tuberculosis. Intradermal test, ELISA and Dot-immunogold filtration assay (DIGFA) were used for diagnosis and epidemiological survey of paragonimiasis. Phylogenitically, Indian Paragonimus species, although nested within the respective clade were distantly related to others within the clade.

Pleuropulmonary paragonimiasis with intrathoracic mass.

Pleuropulmonary paragonimiasis is a food-borne parasitic disease caused by the lung fluke Paragonimus westermani or other species of Paragonimus, which is endemic in Southeast Asia. It presents mainly pleural effusion or intrapulmonary nodules with respiratory symptoms. However, here we describe an exceedingly rare case of Paragonimus westermani with a mass in the pleural cavity. A 47-year-old man, who had presented with chest pain nine months earlier, was found to have right pleural effusion on detection survey computed tomography. He had a history of asbestos exposure and river fishing as a hobby and was confirmed to have Paragonimus westermani by immunodiagnosis. Because of a high level of hyaluronic acid in pleural effusion, he underwent a thoracoscopic examination. The pleura of the thoracic wall thickened greatly and showed no malignant lesion on biopsy. A white mass measuring 8 cm in diameter showed in the pleural cavity, which partially connected with the diaphragm and pulmonary pleura of the lower lobe. The postoperative pathological examination reported that the intrathoracic mass was a lesion that contained necrotic tissue enveloped with a fibrin capsule, which was thought to be formed by paragonimus.

História natural da infecção por Paragonimus: abordagem clínica e ecológica / Natural history of Paragonimus’ infection: clinical and ecological approach

A paragonimíase é uma doença zoonótica, não-contagiosa, produzida por trematódeos do gênero Paragonimus. O homem e outros animais infectam-se ao ingerir crustáceos de água doce — crus, mal cozidos ou em conserva — ou, ainda, água e/ou alimentos contaminados com metacercárias. Apresenta evolução crônica e acometimento predominantemente pulmonar, ainda que sejam descritas descritas alterações extrapulmonares. Podem surgir sinais e sintomas como tosse com expectoração sanguinolenta, febre intermitente, dor torácica, suores noturnos e, mais raramente, astenia, anorexia e perda de peso. Como principais métodos diagnósticos destacam-se o exame a fresco do escarro e/ou das fezes do paciente e os testes imunológicos. O tratamento é realizado com praziquantel. A infecção, habitualmente, tem bom prognóstico.

Parasitic worms of the central nervous system: an Australian perspective.

The diagnosis and management of parasitic diseases of the central nervous system (CNS) is difficult, even for infectious diseases physicians and neurologists. Furthermore, few overviews of the spectrum of causative helminths and clinical syndromes have been published. In the present study, we review the seven most common parasitic diseases of the CNS: (i) cysticercosis, (ii) neuroschistosomiasis, (iii) paragonimiasis, (iv) angiostrongyliasis, (v) hydatid disease, (vi) sparganosis and (vii) gnathostomiasis. Major syndromes of parasitic disease of the CNS and their differential causes are discussed, including: (i) cystic lesions, (ii) enhancing granulomas (with and without creeping subcutaneous eruptions), (iii) eosinophilic meningoencephalitis and (iv) spinal cord disease. Specific risk factors that predispose to these infections are also discussed and particular attention is drawn to the situation in Australia.