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Weekly Chest CasesArchive of Old Cases

Case No : 828 Date 2013-09-09

  • Courtesy of Young Eun Bahn, Chang Min Park / Seoul National University Hospital
  • Age/Sex 62 / M
  • Chief ComplaintRecurrent hemoptysis and cough for 5 months
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initial chest PA

Diagnosis With Brief Discussion

Diagnosis
Pulmonary paragonimiasis
Radiologic Findings
Initial chest PA shows irregular tubular-shaped opacity in the RUL apex. Chest CT image taken in the same month shows tubular shaped subpleural lesion with internal low density. The lesion reveals neither definite enhancement nor adjacent chest wall invasion, except mild adjacent focal pleural thickening. Ground-glass opacities are also seen around the lesion. Two months later, the lesion shows cavitary change with increase in size. The patient received anti-tuberculous treatment, but he had recurrent hemoptysis and had to visit ER after 1 month. Follow-up CT scan demonstrates that cavity wall becomes more thickened. The patient underwent RUL lobectomy. In the pathology, the specimen showed chronic granulomatous inflammation with necrosis and cavity formation. Parasite eggs consistent with paragonimus westermani were found in the specimen. The AFB staining revealed no acid-fast bacilli. The patient turned out to have blood eosinophilia and a history of ingestion of the raw sweetfish.
Brief Review
Pleuropulmonary paragonimiasis is a food-borne parasitic disease caused by the lung fluke Paragonimus westermani, which is endemic in Southeast Asia and the Far East. Human infection results from ingestion of raw freshwater crab or crayfish infected with the metacercaria. They excyst in the small intestine, and the larvae penetrate the intestinal wall and enter the peritoneal space. Next they penetrate the diaphragm and pleura and enter the lung in 3-8 weeks, where they mature to adult flukes. The symptoms of the patients before admission are variable, including blood-tinged sputum, cough, dyspnea, chest pain, and fever. Some patients are asymptomatic. The common CT findings include pleural effusion, hydropneumothorax, pulmonary nodules or air-space consolidation, and cysts. The round low-attenuation cystic lesions (5-15 mm) filled with either fluid or gas, within the consolidation are characteristic findings and the subpleural linear opacities or a tubular structure communicating with a cyst are suggestive of worm migration tracks. In a study of experimentally induced pulmonary paragonimiasis in 21 cats by Im et al, the appearance of pulmonary lesions varied with the stage of the infection and the surrounding tissue reaction. Early findings, which were caused by the migration of juvenile worms, included pneumothorax or hydropneumothorax, focal air-space consolidation, and linear opacities. Later findings resulting from worm cysts included thin-walled cysts, mass-like consolidation, nodules, or bronchiectasis. Kim et al., reported the characteristic findings of 31 paragonimiasis patients, with poorly marginated subpleural or subfissural nodule of about 2 cm in diameter that frequently contains a necrotic low-attenuation area and the constellation of focal pleural thickening and subpleural linear opacities leading to a necrotic peripheral pulmonary nodule. Pulmonary paragonimiasis can mimic lung cancer by showing a high FDG uptake on FDG PET. The finding of blood eosinophilia can be helpful in the diagnosis of pleuropulmonary paragonimiasis because of its relatively high sensitivity.
References
1. Yokogawa M. Paragonimus and paragonimiasis. Adv Parasitol 1965; 3:99-158.
2. Im JG, Whang HY, Kim WS, Han MC, Shim YS, Cho SY. Pleuropulmonary paragonimiasis: radiologic findings in 71 patients. AJR 1992; 159:39-43.
3. Kim TS, Han J, Shim SS, Lee IH, Lee KS, Kwon OJ. Pleuropulmonary paragonimiasis: CT findings in 31 patients. AJR 2005;185(3):616
Keywords
Lung, infection, Parasitic infection,

No. of Applicants : 78

▶ Correct Answer : 41/78,  52.6%
  • - University of British Columbia , Canada Amr Ajlan
  • - Oita University, Faculty of Medicine , Japan Fumito Okada
  • - Scans world , India Philson Mukkada
  • - Dongnam Institute of Radiological and Medical Sciences , Korea (South) Dae-Wook Yeh
  • - Chonbuk University Hospital , Korea (South) Sungkwan Kim
  • - Niigata City General Hospital , Japan Takao Kiguchi
  • - otsu municipal hospital , Japan kenjirou iwaya
  • - Onomichi municipal hospital , Japan Hirofumi Mifune
  • - the first affiliatited hospital of nanjing medical univercity , China Hai Xu
  • - Hallym sacred heart hospital , Korea (South) JIHYUN KIM
  • - Myongji hospital , Korea (South) Ji Ye Lee
  • - SNUH , Korea (South) Eui Jin Hwang
  • - Seoul National University Hospital , Korea (South) YongSub Song
  • - Yokohama-asahi-chuo-general hospital , Japan Kyoko Nagai
  • - Kyung Hee University Hospital , Korea (South) Ji Hye Jang
  • - Dongtan Sacred Heart Hospital , Korea (South) Younghwan Ko
  • - Asan medical center , Korea (South) Hyun Joo Lee
  • - Asan medical center , Korea (South) yoonyoung choi
  • - Asan medical center , Korea (South) Sang Young Oh
  • - Asan Medical Center, Ulsan University , Korea (South) Mi Young Kim
  • - AMC , Korea (South) park jong chun
  • - ASAN MEDICAL CENTER , Korea (South) CHONG HYUN SUH
  • - Severance hospital, shinchon , Korea (South) yeojin lee
  • - GHICL , France manuel toledano
  • - GHTM ,STANLEY MEDICAL COLLEGE,CHENNAI , India siva raja
  • - Kyoto University , Japan Akihiko Sakata
  • - Kizawa Memorial Hospital , Japan Yo Kaneko
  • - Niigata University , Japan Atsushi Uehara
  • - CHU Poitiers , France CHAN paul
  • - IRSA La Rochelle , France Denis Chabassiere
  • - Fukuyama city hospital , Japan Ryotaro Kishi
  • - All India Institute of Medical Sciences , India Ashish Gupta
  • - Medical College Chest Hospital,Thrissur,Kerala , India Raveendran TK
  • - Ishikawa Matto Central Hospital , Japan Manabu Akimoto
  • - IRCCS Istituto Oncologico - Bari , Italy Carlo Florio
  • - Shiga University of Medical Science , Japan Akitoshi Inoue
  • - NASA SCANS , India RAKESH BHATIA
  • - Kyungpook National University Hospital , Korea (South) Jaekwang Lim
  • - GHOL, Hopital de Nyon , Switzerland Benoit Rizk
  • - CNUH , Korea (South) Kim Soo Hyun
  • - TCM HOSPITAL OF ZIGONG , China Cao Cunyou
▶ Correct Answer as Differential Diagnosis : 7/78,  9.0%
  • - Kyung Hee University Hospital at Gangdong , Korea (South) Seong Jong Yun
  • - radiologist, aditya imaging centre , India vivek patel
  • - McGill University Health Center , Canada Alexandre Semionov
  • - Tokyo Metropolitan Police Hospital , Japan Akifumi Hagiwara
  • - Nagasaki University Hospital, Department of Pathology , Japan TOMONORI TANAKA
  • - IRSA LA ROCHELLE , France, Metropolitan BIGOT
  • - chp st martin , France Mariotte benoit
▶ Semi-Correct Answer : 1/78,  1.3%
  • - sahyadri speciality hospital , India kothareddy dileepreddy
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