INTRODUCTION: Paragonium westermani is food borne parasite endemic to Southeast Asia. These infections in United States are commonly reported in immigrants. The route of transmission is from ingestion of uncooked crabs, crayfish or wild boar meat.
CASE PRESENTATION: 49 year old Burmese man with no past medical history of asthma was referred to our hospital due to persistent hemoptysis. He had recently emigrated from Thailand to United States. In Thailand his diet was rich in crabs. His Tuberculin skin test came back positive but sputum AFBs were negative. Chest x-ray done at that time showed right upper lobe cavity. Despite on anti-tubercular medications for 4 months he continued to have hemoptysis. He did not have any constitutional symptoms. Computed Tomography of chest showed small cavitary lesion in the right upper lobe with loculated pleural effusion along with ground glass opacity in right lung. He underwent bronchoscopy for evaluation of cavitary lung lesion which was unresponsive to antitubercular therapy. Complete blood count and bronchoalveolar lavage revealed eosinophilia. With suspicion of parasitic infection albendazole was started. On regulare follow ups in the pulmonary clinic, the patient continued to have persistent cough, hemoptysis and eosinophilia even after 7 months of treatment with albendazole. The patient underwent a repeat bronchoscopy .This time the trans bronchial biopsy showed Paragonium westermani eggs and patient was put on praziquental. Follow up Computed Tomography of chest after 2 months of treatment showed decrease in size of the cavitary lesions and infiltrates, with resolution of hemoptysis and peripheral eosinophilia.
DISCUSSION: Pulmonary Paragonimiasis is very rare in United States and has non- specific symptoms due to which there is always a delay in diagnosis. Patients frequently undergo lung biopsies for diagnosis and most of the times histopathology shows oval operculated eggs, with birefringence as seen in our patient. Radiological findings vary from pleural thickening to unilateral or bilateral effusions, and pneumothoraces. Parenchymal changes include consolidation, ground-glass opacities, nodular lesions that may cavitate. Thus the infection may mimic neoplasia, fungal, or mycobacterial infection.
CONCLUSIONS: Diagnosing atypical infections in immigrant population in United States is always a challenge which delays treatment and recovery of the patient. Pulmonary Paragonimiasis is frequently indistinguishable from Pulmonary Tuberculosis, leading to improper and inadequate treatment. High index of suspicion should be kept in mind in this era of globalization.
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Reference #2 Castilla EA, Jessen R, Sheck DN, et al. Cavitary mass lesion and recurrent pneumothoraces due to Paragonimus kellicotti infection: North American paragonimiasis. Am J Surg Pathol. 2003;27:1157-1160
Reference #3 Mukae H, Taniguchi H, Matsumoto N, et al . Clinicoradiologic features of pleuropulmonary Paragonimus westermani on Kyusyu Island, Japan. Chest 2001;120 :514-20
DISCLOSURE: The following authors have nothing to disclose: Ashima Sahni, Aiyub Patel, Maximiliano Tamae Kakazu
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