대한흉부영상의학회 Weekly Chest Cases

Case No : 885 Date 2014-10-13

Courtesy of Won Jin Choi, Sang Young Oh, Hyun Joo Lee, Kyung-Hyun Do / Asan Medical Center
Age/Sex 46 / F
Chief ComplaintPersitent mild cough and sputum for years, PHx: anti TB medication due to TB pleurisy(10 years ago)

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initial chest PA

Diagnosis With Brief Discussion

Diagnosis: Paragonimiasis
Radiologic Findings: Initial chest PA shows focal irregular nodular opacity with subtle cavitary portion in the LULZ, small nodular opacity in LMLZ and LLLZ.
Chest CT images taken in the same day show multifocal nodular lesion with internal low attenuation portion or cavitary change in LUL and LLL. No definite evidence of pleural effusion.
Coronal reconstructed image shows internal small cavitary portion of the nodular lesion, more clearly.
Two weeks later, follow-up chest PA shows slightly decreased size of nodular lesion with small cavitary portion in LULZ, increased extent of focal nodular opacity in LMLZ.

The patient underwent bronchoscopic exam with bronchial washing. The bronchial washing cytology showed eggs of paragonimus westermani.
Brief Review: Human paragonimiasis is caused by the trematode Paragonimus westermani or other Paragonimus species through the ingestion of raw or partially cooked freshwater crabs or crayfish infected with the metacercaria. The main endemic areas are east Asia, Southeast Asia, Latin America (primarily Peru), and Africa (primarily Nigeria). Many cases have been reported in the United States among Indo-Chinese and Latin American immigrants. It is believed that 195 million people are at risk, and 20.7 million are infected in endemic areas.
The lung is the target organ, although cutaneous and cerebral paragonimiasis have also been described. Patients present with fever, chest pain, and respiratory symptoms such as chronic cough and hemoptysis.
Diagnosis is confirmed by detecting parasite eggs in the sputum, pleural fluid, or feces; in addition, larvae can often be found at bronchial brushing. Intradermal and serologic tests are also available. Tuberculosis is the main alternative in the differential diagnosis.
Radiologic findings correlate well with the stage of the disease. The penetration of juvenile worms through the diaphragm into the pleural cavity can cause pleural effusion or pneumothorax. Once the parasites get to the lung, patchy airspace consolidation can occur, a phenomenon that reflects the presence of an exudative or hemorrhagic pneumonia which can cavitate. Contrast material–enhanced CT performed during this stage may show hypoattenuating fluid-filled cysts surrounded by hyperattenuating consolidation in the adjacent lung. Linear areas of increased opacity or hyperattenuation indicate peripheral atelectasis or worm migration. Worm cysts, whose diameters range from 0.5 to 1.5 cm, are better visualized after the consolidation resolves and manifest as either solitary or multiple nodules or gas-filled cysts depending on their content and their communication with the airway. Chest radiographic and CT findings include a ring shadow usually less than 3 mm thick and a crescent-shaped area of increased opacity or hyperattenuation within the cyst that represents worms attached to the wall. Complications of cysts include pleural effusion, empyema, and pneumothorax.
References: 1. Martnez S, Restrepo CS, Carrillo JA, et al. Thoracic Manifestations of Tropical Parasitic Infections: A Pictorial Review. RadioGraphics. 2005; 25:135-155.
2. Kim TS, Han J, Shim SS, et al. Pleuropulmonary Paragonimiasis: CT Findings in 31 Patients. AJR 2005;185:616–621
3. Shim SS, Kim Y, Lee JK, et al. Pleuropulmonary and abdominal paragonimiasis: CT and ultrasound findings. Br J Radiol. 2012;85(1012):403-10
4. Jeon K, Koh W, Kim H, et al. Clinical Features of Recently Diagnosed Pulmonary Paragonimiasis in Korea. Chest. 2005;128(3):1423-1430
Keywords: Lung, Infection, Parasitic infection,

No. of Applicants : 64

▶ Correct Answer : 26/64, 40.6%

- Scans world , India Philson Mukkada
- Oita University, Faculty of Medicine , Japan Fumito Okada
- Samsung medical center , Korea (South) Hyun Su Kim
- Seoul National University Hospital , Korea (South) Sang Min Lee
- kangbuk samsung , Korea (South) jihyun kim
- The University of Tokyo Hospital , Japan Takeyuki Watadani
- Kyoto University , Japan Akihiko Sakata
- McGill University Health Center , Canada Alexandre Semionov
- SNUH , Korea (South) Eui Jin Hwang
- Severance hospital , Korea (South) Beomseok Sohn
- Deptt of Radiodiagnosis & Imaging, PGIMER chandigarh , India Ram Galwa
- Kizawa Memorial Hospital , Japan Yo Kaneko
- National Hospital Organization Okinawa Hospital , Japan Yasuji Oshiro
- Chonnam university hospital , Korea (South) Park Joonyoung
- DAYA General Hospital,Thrissur,Kerala , India Raveendran TK
- University of British Columbia , Canada Amr Ajlan
- 異⑸ , Korea (South) Yunhee Jang
- ssims&rc , India akhila d
- Onomichi municipal hospital , Japan Hirofumi Mifune
- ZIGONG TCM HOSPITAL OF CHINA , China Cao Cunyou
- IRSA La Rochelle , France Denis Chabassiere
- 異⑸ , Korea (South) sooncheul baek
- Seirei Hamamatsu General Hospital , Japan Kenichi Mizuki
- 異⑸ , Korea (South) Junghwan Kim
- CNUH , Korea (South) Kim Soo Hyun
- Medicheck health care , Korea (South) Chae Lim

▶ Correct Answer as Differential Diagnosis : 9/64, 14.1%

- The University of Tokyo Hospital , Japan Akifumi Hagiwara
- Kyung Hee University Hospital at Gangdong , Korea (South) Seong Jong Yun
- Niigata City General Hospital , Japan Takao Kiguchi
- The University of Tokyo Hospital , Japan Toshihiro Furuta
- Onomichi Municipal Hospital , Japan Yoshihisa Masaoka
- CLINIQUE STE CLOTILDE , Reunion patrick MASCAREL
- Nagasaki University Hospital, Department of Pathology , Japan TOMONORI TANAKA
- Shiga University of Medical Science , Japan Akitoshi Inoue
- Pneumologia Universitaria, Policlinico di Bari , Italy Mario Damiani

대한흉부영상의학회 Korean Society of Thoracic Radiology

Archive of Old Cases

Case No : 885 Date 2014-10-13

Discussion

No. of Applicants : 64