Diffuse Lung Disease |

Pulmonary Cysts That Come and Go: A Fluke? FREE TO VIEW

Ghanshyam Shastri, MD; Amritpal Nat, MD; Amit Sharma, MD; Amitpal Nat, MD; Michael Iannuzzi, MD
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Suny Upstate University Hospital, Syracuse, NY

Chest. 2013;144(4_MeetingAbstracts):458A. doi:10.1378/chest.1701617
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SESSION TITLE: Interstitial Lung Disease Student/Resident Case Report Posters II

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Global travel is associated with an increasing incidence of helminthic infections in non-endemic regions. We report a case of patient with pulmonary paragonimiasis in Upstate New York who presented with recurrent hemoptysis.

CASE PRESENTATION: 20 year old healthy female college swimmer was referred for evaluation of intermittent episodes of hemoptysis for 1 year. Her symptoms began after a "belly flop" incident while diving in the pool. She continued to have 1-2 episodes of quarter sized hemoptysis every other week. Associated symptoms were chest pain and shortness of breath. The patient denied alcohol, cigarette or illicit drug use. Travel history was significant for a trip to Costa Rica and Bahamas 1 year prior. Initial chest x ray was normal but computerized Tomography (CT) showed 2 cystic lesions in the right lower lobe. Vital signs, pulmonary function tests and complete blood count with differential were within normal limits. Workup for connective tissue disorders was negative. Patient was referred for bronchoscopy with bronchoalveolar lavage, brushings and washings. Cultures and cytology from the bronchial specimens came back negative. Subsequent CT scans showed interval resolution and redistribution of the cystic lesions in new areas of the lung. Further evaluation for mycobacteria, histoplasmosis & blastomycosis was negative. Patient was then referred for a CT guided biopsy. Cultures and cytology from the biopsy specimens were again negative. Paragonimus westermani antibody titers were ordered and found to be elevated at 1:32. The diagnosis of chronic pulmonary paragonimiasis was made and the patient responded well to praziquantel.

DISCUSSION: The presentation of hemoptysis after diving with the finding of cysts on chest CT led to a consideration for traumatic pneumatocele. However, given the relatively mild chest injury at the time of the dive, cysts that resolved and recurred and the recent travel history, an infectious etiology was more likely. Although stool, sputum, and bronchial washings for ova and parasites were negative, Paragonimus westermani titers were found to be elevated. Paragonimus westermani also known as the lung fluke, is acquired through the ingestion of raw or undercooked crabs or crayfish and is the most common cause of hemoptysis worldwide. Stool studies are insensitive and eosinophilia is much less common in chronic paragonimiasis. Serologic testing for anti-Paragonimus IgG however has a sensitivity of 100% and a specificity of 91%-100%.

CONCLUSIONS: This clinical vignette underscores the importance of health care providers in the United States to recognize common worldwide infections.

Reference #1: Nakamura F et al; CID 2001; 32(12):e171-e175

DISCLOSURE: The following authors have nothing to disclose: Ghanshyam Shastri, Amritpal Nat, Amit Sharma, Amitpal Nat, Michael Iannuzzi

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