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.

Paragonimiasis Misdiagnosed as Pulmonary Tuberculosis: A Case Report.

Paragonimiasis is a zoonosis caused by the ingestion of raw or undercooked crustaceans parasitized with metacercaria of Paragonimus spp. In Peru, Cajamarca is considered an endemic region for paragonimiasis. A 29-year-old man from the department of San Martín, Peru presented with a three-year history of cough, chest pain, fever, and hemoptysis. Treatment for tuberculosis (TB) was initiated even with negative results for sputum acid-fast bacillus (AFB), due to the patient's clinical characteristics and the high prevalence of the condition in the region. After eight months, due to the lack of any clinical improvement, he was referred to a regional hospital, where Paragonimus eggs were evidenced in direct sputum cytology. The patient received treatment with triclabendazole and showed clinical and radiological improvement. It is important to consider eating habits, even in non-endemic areas, for diagnosing paragonimiasis in patients with TB symptoms who do not respond to a specific treatment.

A case of spontaneous pneumothorax due to paragonimiasis in North America with literature review.

The species, Paragonimus kellicotti , causes human paragonimiasis in North America. As a foodborne disease, human infection with P. kellicotti occurs after eating raw or undercooked crayfish containing metacercariae. Many risk factors have been described in the literature, including young adult age, male, alcohol consumption, outdoor activities involving rivers within Missouri, and ingesting raw or partially cooked crayfish. Here, we report a case of a 41-year-old male with a 5-year history of cough who presented with acute shortness of breath. Further workup showed mild eosinophilia and spontaneous pneumothorax. A definitive diagnosis was made with a lung biopsy, which showed P. kellicotti eggs. Further questioning revealed that the patient took a hunting and river rafting trip on a river in Missouri 5 years ago, though the history was negative for any crayfish consumption. Paragonimiasis should be considered in those with associated clinical features, including cough and eosinophilia, with a history of a river raft float trip in Missouri, even if the history is negative for crayfish ingestion or travel.

Massive secretions in paragonimiasis pleural effusion: a new finding concerning clinical recognition and treatment.

Some paragonimiasis patients in Chongqing, southwest China, have recently exhibited pleural effusions (PEs) with massive viscous secretions. This study aimed to investigate their clinical characteristics, thereby promoting effective treatments. A 3-year retrospective review of paragonimiasis patients who were admitted for nonhomogeneous PEs at Chongqing University Three Gorges Hospital was conducted. Epidemiological data, symptoms, laboratory and imaging findings, treatments, and outcomes were analyzed. Twenty-eight patients were identified, of which 22 (78.6%) were males and 22 (78.6%) were rural residents. Respiratory (85.7%) and constitutional (57.1%) symptoms were common. Paragonimus-specific ELISA was positive in all patients. Eosinophilia was detected in all patients in peripheral blood and PEs. Irregular hyperdense signals were observed in PEs by chest CT scans (96.4%) and ultrasonography (100.0%). Thoracic closed drainage failed in 10 patients (conservative group) because of tube blockage and was eventually replaced by video-assisted thoracoscopic surgery (VATS). Eighteen patients (surgery group) initially underwent VATS, or thoracotomy surgery, without complications. Massive secretions, described as "bean-dregs" or "egg-floccule," were detected intraoperatively, which explained the imaging findings and tube blockage. All patients recovered well after 2-3 courses of postoperative praziquantel treatment. Viscous secretions in paragonimiasis patients warrant great concern. Irregular hyperdense signals in effusions are important characteristics in CT scans and ultrasonography. Treatments such as thoracic closed drainage may fail due to viscous secretions blocking the tube; therefore, surgeries should be considered. In-depth multidisciplinary research may help determine the optimal treatment strategy and reveal the origin of these secretions.

General overview of the current status of human foodborne trematodiasis.

Foodborne trematodes (FBT) of public health significance include liver flukes (Clonorchis sinensis, Opisthorchis viverrini, O. felineus, Fasciola hepatica and F. gigantica), lung flukes (Paragonimus westermani and several other Paragonimus spp.) and intestinal flukes, which include heterophyids (Metagonimus yokogawai, Heterophyes nocens and Haplorchis taichui), echinostomes (Echinostoma revolutum, Isthmiophora hortensis, Echinochasmus japonicus and Artyfechinostomum malayanum) and miscellaneous species, including Fasciolopsis buski and Gymnophalloides seoi. These trematode infections are distributed worldwide but occur most commonly in Asia. The global burden of FBT diseases has been estimated at about 80 million, however, this seems to be a considerable underestimate. Their life cycle involves a molluscan first intermediate host, and a second intermediate host, including freshwater fish, crustaceans, aquatic vegetables and freshwater or brackish water gastropods and bivalves. The mode of human infection is the consumption of the second intermediate host under raw or improperly cooked conditions. The major pathogenesis of C. sinensis and Opisthorchis spp. infection includes inflammation of the bile duct which leads to cholangitis and cholecystitis, and in a substantial number of patients, serious complications, such as liver cirrhosis and cholangiocarcinoma, may develop. In lung fluke infections, cough, bloody sputum and bronchiectasis are the most common clinical manifestations. However, lung flukes often migrate to extrapulmonary sites, including the brain, spinal cord, skin, subcutaneous tissues and abdominal organs. Intestinal flukes can induce inflammation in the intestinal mucosa, and they may at times undergo extraintestinal migration, in particular, in immunocompromised patients. In order to control FBT infections, eating foods after proper cooking is strongly recommended.

Paragonimiasis diagnosed by CT-guided transthoracic lung biopsy: Literature review and case report.

More than 40 different species of the parasitic flatworm Paragonimus have been identified worldwide, including in Vietnam, but only 10 species are known to cause disease in humans, particularly Paragonimus westermani. Paragonimus are transmitted through the ingestion of raw foods, especially freshwater shrimp, and crab. Paragonimiasis causes pneumonia, which can present as acute or chronic, with symptoms including prolonged cough, chest pain, shortness of breath, and hemoptysis. Hematologic changes include eosinophilia and the presence of specific antibodies for Paragonimus in the blood. Diagnosis is confirmed when Paragonimus specimens or eggs are found in the sputum or pleural fluid. The specificity of imaging is not high, but imaging can be used to guide the diagnosis. After the failure of microbiological diagnostic methods, lung biopsy can be used to confirm a diagnosis of paragonimiasis. We present a paragonimiasis case associated with unique features, including epidemiologic factors, atypical clinical signs, no increases in blood eosinophils, and negative microbiological tests. Although the patient was suspected of tuberculosis or lung cancer, imaging studies were consistent with the presence of lung flukes. Three transthoracic lung biopsies were performed, and pathology revealed a cystic structure containing Paragonimus on the third biopsy.

A record of juvenile Paragonimus skrjabini miyazakii from the urinary bladder of the Japanese toad, Bufo japonicus formosus.

We found juveniles of Paragonimus in the urinary bladder of a Japanese toad (Bufo japonicus formosus) captured in Kyoto. These were molecularly identified as Paragonimus skrjabini miyazakii Kamo, Nishida, Hatsushika et Tomimura 1961. This is the first report of P. s. miyazakii found in anuran hosts in Japan, indicating that anurans can be paratenic hosts of P. s. miyazakii, as is also the case for Paragonimus skrjabini skrjabini in China. This finding suggests that definitive hosts of P. s. miyazakii can be infected by eating not only crabs or mammal paratenic hosts, but also anurans.

Exudative pleural effusion caused by lung fluke infection: case report.

The global incidence of lung fluke disease is low, and the infection is a rare cause of pleural effusion in adults. This article reports a case of exudative pleural effusion accompanied by eosinophilia in a 19-year-old male which was finally proven to be caused by lung fluke infection through antibody testing. This case highlights that lung fluke infection is an easily overlooked cause of pleural effusion. Eosinophilia is a potential marker of infection, and serological tests could further confirm the diagnosis.

Paragonimus westermani metacercariae in two freshwater crab species in Kagoshima Prefecture, Japan, as a possible source of infection in wild boars and sika deer.

Paragonimiasis is a particular foodborne parasitic disease that is endemic to southern Kyushu, including Kagoshima Prefecture, Japan. We previously detected Paragonimus westermani triploid larvae in meat samples obtained from wild boars and sika deer hunted in Akune City, Kagoshima Prefecture. These mammals act as paratenic hosts and their meat is a source of human paragonimiasis. Paratenic host mammals and humans become infected with the lung fluke, P. westermani, following consumption of second intermediate hosts, freshwater crab species, namely, Geothelphusa dehaani or Sawagani in Japanese, and Eriocheir japonica or Mokuzugani in Japanese. Therefore, this study aimed to investigate the current infection status of P. westermani in freshwater crabs in Akune City. We collected freshwater crabs from 15 locations and found that the prevalence of P. westermani metacercariae was 1.6% for Sawagani (15 of 941 examined) and 22.1% for Mokuzugani (21 of 95 examined). Based on the morphological characterization of metacercariae and molecular analyses of the internal transcribed spacer 2 region and mitochondrial 16S rRNA gene region using PCR-restriction fragment length polymorphism and sequencing, all metacercariae were identified as the triploid form of P. westermani. These results indicate that Sawagani and Mokuzugani serve as second intermediate hosts to maintain the life cycle of triploid P. westermani. Further, infection in crabs potentially leads to subsequent P. westermani infections in wild mammals, including wild boars and sika deer, both of which are considered important types of game meat in Japan.

Epidemiology of Trematode Infections: An Update.

Digenetic trematodes infecting humans are more than 91 species which belong to 46 genera all over the world. According to their habitat in definitive hosts, they are classified as blood flukes (Schistosoma japonicum. S. mekongi, S. mansoni, S. haematobium, and S. intercalatum), liver flukes (Clonorchis sinensis, Opisthorchis viverrini, O. felineus, Metorchis conjunctus, M. bilis, M. orientalis, Fasciola hepatica, F. gigantica, Dicrocoelium dendriticum, and D. hospes), lung flukes (Paragonimus westermani, P. heterotremus, P. skrjabini, P. miyazakii, P. kellicoti, P. mexicanus, P. africanus, and P. uterobilateralis), throat fluke (Clinostomum complanatum), pancreatic fluke (Eurytrema pancreaticum), and intestinal flukes (Metagonimus yokogawai, M. miyatai, M. takahashii, Heterophyes nocens, H. heterophyes, Haplorchis taichui, H. pumilio, H. yokogawai, Centrocestus formosanus, Echinostoma revolutum, E. ilocanum, Isthmiophora hortensis, Echinochasmus japonicus, E. lilliputanus, Artyfechinostomum malayanum, A. sufrartyfex, A. oraoni, Fasciolopsis buski, Gymnophalloides seoi, Neodiplostomum seoulense, Caprimolgorchis molenkampi, Phaneropsolus bonnei, and Plagiorchis muris). The mode of transmission to humans includes contact with cercariae contaminated in water (schistosomes) and ingestion of raw or improperly cooked fish (liver and throat flukes, heterophyids, and echinostomes), snails (echinostomes and gymnophallids), amphibia, reptiles (neodiplostomes), aquatic vegetables (amphistomes), or insect larvae or adults (plagiorchiids, lecithodendriids, and pancreatic fluke). Praziquantel has been proved to be highly effective against most species of trematode infections except fascioliasis. Epidemiological surveys and detection of human infections are required for better understanding of the geographical distribution and endemicity of each trematode species.

Paragonimus and paragonimiasis in Asia: An update.

Paragonimiasis, or lung fluke disease, is a typical food-borne parasitic zoonosis caused by infection with trematodes belonging to the genus Paragonimus. More than 50 species of Paragonimus have been reported throughout the world, of which seven valid species infect humans, an estimated one million people annually worldwide. Among the seven species, P. westermani, P. heterotremus, and P. skrjabini/P. s. miyazakii, distributed in Asia, are the most important species as the cause of paragonimiasis. Humans acquire infection through the ingestion of raw, pickled or undercooked freshwater crustaceans, 2nd intermediate hosts, or consuming raw meat of wild boar or deer, paratenic hosts. Infections often occur clustered in foci where dietary habits allow transmission of the parasites. Paragonimiasis typically causes a subacute to chronic inflammatory disease of the lungs. The symptoms, including chronic cough, chest pain, dyspnea and hemoptysis, mimic those of tuberculosis and lung cancer. Serologic tests are commonly used for the diagnosis of paragonimiasis, and Praziquantel is the treatment of choice. In this review, the current status of Paragonimus and paragonimiasis in Asia is outlined based on the latest information and findings. We also summarize current trends of paragonimiasis in Japan, which is one of the most endemic area of paragonimiasis in the world, for the better understanding and control of paragonimiasis.

Paragonimus and paragonimiasis in West and Central Africa: unresolved questions.

Paragonimiasis, human lung fluke disease, is a foodborne anthropozoonosis caused by the trematodes assigned to Paragonimus and is regarded by the World Health Organization as a Neglected Tropical Disease (NTD). The life cycle of this medically important parasite centres on a complex freshwater biological community that includes two intermediate hosts: a mollusc and a decapod, usually a brachyuran. Although there is a perception that the biology, symptoms, diagnosis and treatment of Paragonimus is well understood, in reality, this is not the case, especially in Africa. Much remains unknown concerning the life-cycle of the parasite, its transmission, the current epidemiology of the disease, diagnosis and the effectiveness of treatment. Furthermore, cases of paragonimiasis may be misdiagnosed as resistant tuberculosis (TB) because of the similar pulmonary symptoms and no remission after anti TB therapy. The endemic foci of human paragonimiasis in Africa have been reported mainly in the forest zones of Upper Guinea (Liberia, Guinea and Ivory Coast) and Lower Guinea (Nigeria, Cameroon, Equatorial Guinea and Gabon). Despite the perceived medical importance of paragonimiasis, relatively little attention has been paid to this NTD since its discovery in Africa in the 1960s. This review focuses on the current understanding of the life cycle and transmission of Paragonimus in Africa, discusses its diagnosis and public health importance and highlights many outstanding gaps in the knowledge that still exist for this NTD.

Hypolobocera guayaquilensis (Decapoda: Pseudothelphusidae): A New Crab Intermediate Host of Paragonimus mexicanus in Manabí Province, Ecuador.

To determine that Paragonimus sp. is actively transmitted in a tropical area of the Pacific region of Ecuador where human cases of pulmonary paragonimiasis have recently been documented, a total of 75 freshwater crabs were collected from 2 different streams in the Pedernales area of Manabí Province, Ecuador. All collected crabs were identified as Hypolobocera guayaquilensis based on morphological characteristics of the male gonopods. The hepatopancreas of each crab was examined by compressing it between 2 glass plates followed by observation under a stereomicroscope. Excysted Paragonimus metacercariae were detected in 39 (52.0%) crabs and their densities varied from 1 to 32 per infected crab. There was a positive relationship between crab size and metacercarial density. Sequences of the second internal transcribed spacer region of the ribosomal RNA gene of the Paragonimus metacercariae obtained in this study were identical to those of Paragonimus mexicanus deposited in the DDBJ/EMBL/GenBank database. Thus, the present study is the first to confirm that the crab species H. guayaquilensis is the second intermediate host of P. mexicanus in Manabí Province, Ecuador. Because this crab might be the possible source of human infections in this area, residents should pay attention to improper crab-eating habits related with a neglected parasitic disease, i.e., paragonimiasis.

Hypolobocera guayaquilensis (Decapoda: Pseudothelphusidae): A New Crab Intermediate Host of Paragonimus mexicanus in Manabí Province, Ecuador

To determine that Paragonimus sp. is actively transmitted in a tropical area of the Pacific region of Ecuador where human cases of pulmonary paragonimiasis have recently been documented, a total of 75 freshwater crabs were collected from 2 different streams in the Pedernales area of Manabí Province, Ecuador. All collected crabs were identified as Hypolobocera guayaquilensis based on morphological characteristics of the male gonopods. The hepatopancreas of each crab was examined by compressing it between 2 glass plates followed by observation under a stereomicroscope. Excysted Paragonimus metacercariae were detected in 39 (52.0%) crabs and their densities varied from 1 to 32 per infected crab. There was a positive relationship between crab size and metacercarial density. Sequences of the second internal transcribed spacer region of the ribosomal RNA gene of the Paragonimus metacercariae obtained in this study were identical to those of Paragonimus mexicanus deposited in the DDBJ/EMBL/GenBank database. Thus, the present study is the first to confirm that the crab species H. guayaquilensis is the second intermediate host of P. mexicanus in Manabí Province, Ecuador. Because this crab might be the possible source of human infections in this area, residents should pay attention to improper crab-eating habits related with a neglected parasitic disease, i.e., paragonimiasis.

Paragonimiasis in tuberculosis patients in Nagaland, India.

BACKGROUND: One of the infections that mimic tuberculosis (TB) is paragonimiasis (PRG), a foodborne parasitic disease caused by lung flukes of the genus Paragonimus. In the northeastern states of India, TB and PRG are endemic; however, PRG is rarely included in the differential diagnosis of TB. OBJECTIVE: To address limited evidence on the dual burden of TB and PRG in northeastern India, we aimed to document the prevalence of PRG among TB patients using sputum smear, stool examination for children <15 years and ELISA. DESIGN: A cross-sectional study of patients receiving TB treatment in the Médecins Sans Frontières (MSF)-supported TB programme in Mon district, in collaboration with the Regional Medical Research Centre (RMRC), Dibrugarh, Assam, between November 2012 and December 2013. RESULTS: Of 96 patients screened between November 2012 and December 2013, three (3%) had pulmonary PRG and were successfully treated with praziquantel. CONCLUSIONS: PRG should be considered in the TB diagnostic algorithms in PRG-TB dual burden areas. In case of TB-PRG co-infection, it is preferable to treat PRG first followed by anti-TB treatment a few days later.

Venison, another source of Paragonimus westermani infection.

Paragonimiasis is a typical food-borne parasitic disease, endemic in most parts of Asia, with sporadic case reports from American and African countries. The major source of infection is undercooked freshwater crab or crayfish, though consumption of wild boar meat is also responsible for the infection in Japan, because wild boar is a paratenic host for Paragonimus westermani. Recently, living juveniles of P. westermani were isolated from muscle of a sika deer, Cervus nippon, in Japan, raising the possibility that venison has been another source of infection. In order to clarify the potential contribution of venison consumption to the occurrence of paragonimiasis, we analysed dietary histories of those paragonimiasis patients in whose diagnoses we were involved between 2001 and 2015. Among 380 patients, freshwater crab had been consumed by 208 patients, wild boar meat by 190, and wild deer meat by 76 patients before the onset of the disease. Overall contribution of wild deer meat was estimated to be 6.8% to 20.0%, although in Oita and Gifu Prefectures, where a substantial proportion of patients had consumed raw venison, the contribution of venison consumption was much higher (27.5 to 62.1% and 42.1 to 78.9% in Oita and Gifu Prefectures, respectively). We demonstrated P. westermani-specific antibodies in the sera of 4 out of 160 sika deer from Gifu Prefecture, strongly suggesting that these deer were infected with P. westermani.

Conservation and diversification of the transcriptomes of adult Paragonimus westermani and P. skrjabini.

BACKGROUND: Paragonimiasis is an important and widespread neglected tropical disease. Fifteen Paragonimus species are human pathogens, but two of these, Paragonimus westermani and P. skrjabini, are responsible for the bulk of human disease. Despite their medical and economic significance, there is limited information on the gene content and expression of Paragonimus lung flukes. RESULTS: The transcriptomes of adult P. westermani and P. skrjabini were studied with deep sequencing technology. Approximately 30 million reads per species were assembled into 21,586 and 25,825 unigenes for P. westermani and P. skrjabini, respectively. Many unigenes showed homology with sequences from other food-borne trematodes, but 1,217 high-confidence Paragonimus-specific unigenes were identified. Analyses indicated that both species have the potential for aerobic and anaerobic metabolism but not de novo fatty acid biosynthesis and that they may interact with host signaling pathways. Some 12,432 P. westermani and P. skrjabini unigenes showed a clear correspondence in bi-directional sequence similarity matches. The expression of shared unigenes was mostly well correlated, but differentially expressed unigenes were identified and shown to be enriched for functions related to proteolysis for P. westermani and microtubule based motility for P. skrjabini. CONCLUSIONS: The assembled transcriptomes of P. westermani and P. skrjabini, inferred proteins, and extensive functional annotations generated for this project (including identified primary sequence similarities to various species, protein domains, biological pathways, predicted proteases, molecular mimics and secreted proteins, etc.) represent a valuable resource for hypothesis driven research on these medically and economically important species.

Demographic characteristic and analysis of pulmonary paragonimiasis in patients attending RIMS, Manipur.

BACKGROUND: Human infection by the lung fluke Paragonimus westermani is widely distributed in Africa, Asia, and South America. Transmission of the parasite to humans primarily occurs through the consumption of raw or undercooked crabs. Clinical features of recently diagnosed pulmonary Paragonimiasis show that patients present with a variety of clinical and radiological findings, frequently mimics tuberculosis and lung cancer. METHODS: Here in this study, we report a cross-sectional study of pulmonary paragonimiasis in our institute over a period of two year. RESULTS: it was observed that out of eleven cases, prevalence of paragonimiasis was almost equal among both the genders, with a mean age of 38.1 ± 16.96, affecting people from hills. Three patients were erroneously treated with antitubercular drugs without any relief. The association with eosinophilia in the peripheral blood and tissue[16] was seen in all the study subjects and majority patients had pleural fluid eosinophilia. Patients were diagnosed by serological test, Paragonimus ova in Sputum smear and Pleural fluid. All study subjects had excellent clinical responses to praziquantel given at dose of 25 mg/kg given orally 3 times daily for 3 consecutive days. CONCLUSIONS: There is a need to generate awareness among the clinicians and public regarding Paragonimiasis and to consider it in differential diagnosis of TB and carcinoma lung. Physicians should consider the possibility of paragonimiasis among patients who present with chest complaints with eosinophilia from the endemic regions.

Ultrastructure of spermatogenesis in the testis of Paragonimus heterotremus.

Lung fluke, Paragonimus heterotremus, is a flatworm causing pulmonary paragonimiasis in cats, dogs, and humans in Southeast Asia. We examined the ultrastructure of the testis of adult P. heterotremus with special attention to spermatogenesis and spermiogenesis using scanning and transmission electron microscopy. The full sequence of spermatogenesis and spermiogenesis, from the capsular basal lamina to the luminal surface, was demonstrated. The sequence comprises spermatogonia, spermatocytes with obvious nuclear synaptonemal complexes, spermatids, and eventual spermatozoa. Moreover, full steps of spermatid differentiation were shown which consisted of 1) early stage, 2) differentiation stage representing the flagella, intercentriolar body, basal body, striated rootlets, and electron dense nucleus of thread-like lamellar configuration, and 3) growing spermatid flagella. Detailed ultrastructure of 2 different types of spermatozoa was also shown in this study.