We present a case of a 29 year old Caucasian male with an intermittent productive cough of 3 years duration with focal bronchiectasis.
He is a seafood chef with no significant past medical history except for extensive travel throughout Asia and Africa with multiple ingestions of raw seafood. He was in his usual state of health until 3 years ago when he developed a productive cough with associated hemoptysis. A CT scan of the chest was obtained which revealed consolidation of the right middle lobe and superior segment of the right lower lobe with bronchiectasis. An evaluation by an outside pulmonologist led to several courses of oral antibiotics and two bronchoscopies for persistent symptoms. The only positive cultures from the bronchoscopies yielded Haemophilus influenzae and enterobacter cloacae. However, despite multiple regimens of antibiotics he remained symptomatic with a productive cough and occasional hemoptysis. He was referred to our institution and we evaluated his bronchiectasis with a sweat chloride test, aspergillus IgE levels, sputum cultures, as well as alpha one anti-trypsin level. None of the tests were diagnostic, and he underwent a bronchoscopy which revealed normal airways and subsequent cultures grew normal respiratory flora. He continued to have a persistent productive cough and was ultimately referred for a lobectomy for focal bronchiectasis. The tissue biopsy revealed bronchiectasis with granulomas formed around polarizable parasite eggs. A cross section of the sample revealed a worm suggestive of P. Westermani. He was treated with a short course of praziquantel with eventual resolution of symptoms.
Often the initial symptoms of paragonimiasis infection are epigastric with abdominal pain correlating with the migrating larvae stage. As the larvae enter the pleural cavity, symptoms consistent with pleurisy may be observed. Radiographically, there is often bilateral involvement, with or without pleural effusion, but may be normal in 10–20% of people. The clinical symptoms correlating with the migration of the worm through the lung include cough, chest pain, malaise, and hemoptysis1. Associated images on x-ray will reveal migratory, transient infiltrates with no specific lobar predilection. As the worm matures, the patient may have recurrent hemoptysis, often chocolate colored and with a distinct odor. The mature worms settle down and cysts form around them2 . The mechanism is thought to be obstruction of the arteriole or venule by the eggs of the worm, which leads to ischemic infarct. There is then an expansion of the small airway by the intraluminal parasite. The cyst can be filled with hemorrhagic fluid and thus appear as a mass-like consolidation. There have been described tubular structures that communicate with the cysts. These either represent bronchiectatic airways or the worm tracks laid down as the result of the migration2 . The main CT finding of pleuropulmonary paragonimiasis have been described as air space consolidation and pulmonary nodules1. Consolidations are thought to represent the early stages of the disease, whereas nodules, cysts, and bronchiectasis are thought to represent the later stages of the disease.Our patient had CT findings of mild, localized bronchiectasis which was later confirmed grossly. We postulate that the recurrent infections were in part due to obstruction caused by the intraluminal parasite or its eggs. The subsequent recurrent infections and inflammation likely resulted in the eventual destruction of the airways as he had no other risk factors for bronchiectasis. The source of the infection was determined to be due to the patient’s consumption of live crabs.
This case represents an unusual cause of bronchiectasis. In patients with the appropriate history, paragonimiasis infection should be included in the differential diagnosis for bronchiectasis.
Ali Massoumi, No Financial Disclosure Information; No Product/Research Disclosure Information