Journal of Postgraduate Medicine Medknow Publications and Staff Society of Seth GS Medical College and KEM Hospital, Mumbai, India ISSN: 0022-3859 EISSN: 0972-2823 Vol. 57, Num. 3, 2011, pp. 255-256

Journal of Postgraduate Medicine, Vol. 57, No. 3, July-September, 2011, pp. 255-256

Letter

A fluke occurrence of paramount significance

D Gude¹, DP Bansal²

¹ Department of Internal Medicine, Medwin Hospital, Nampally, Hyderabad, Andhra Pradesh, India
² Department of Pulmonology and Critical Care, Medwin Hospital, Nampally, Hyderabad, Andhra Pradesh, India
Correspondence Address: D Gude, Department of Internal Medicine, Medwin Hospital, Nampally, Hyderabad, Andhra Pradesh , India, letsgo.dilip@gmail.com

Code Number: jp11070

PMID: 21941073
DOI: 10.4103/0022-3859.85225

Sir,

Paragonimiasis affects more than 21 million ^[1] worldwide, and in India, pockets of the north east have reported infections, but none so far from the south. We report one such case from Andhra Pradesh (AP). A 68-year-old male, native of Vijayawada, AP, diagnosed of immune thrombocytopenic purpura 5 years ago and on immunosuppression for the same, presented with fever and shortness of breath from two weeks. There was a history of occasional seafood intake mainly prawns and crabs, optimally cooked (although eating at hotels does not guarantee the same) and a history of travel to Mumbai, Chennai, and Bangalore. His temperature was 100 F and blood pressure 140/90 mm Hg. Right sided basal crepts were heard on auscultation. High-resolution computerized tomography (HRCT) chest showed patchy consolidation in the right lower lobe with multiple faint nodular opacities in both the upper zones [Figure - 1]. Broad spectrum antibiotics and antifungals were started and antitubercular therapy was planned. Labs showed hemoglobin (Hb)-7 gm/dL, total white blood cells (TWBC)-6700/mm ³ , with eosinophils-12%, erythrocyte sedimentation rate (ESR)-75 mm/1 ^st hour. Bronchoscopic alveolar lavage was done, which on high power microscopy showed a motile lung fluke (Paragonimus westermani- [Figure - 2]. Sputum was negative for eggs of paragonimus/AFB. Praziquantel (25 mg/kg/dose every 8 hours for 2 days) was started and over the next few days, fever subsided.

P. westermani causes a potentially serious infection in the population predisposed to having crab/cray fish in the food chain. There are very few reports of paragonimiasis in India (a total of 39 cases) with the data mostly available from Arunachal Pradesh and Manipur. A study done in Manipur researched the intra-specific genetic diversity of infective stage of P. westermani using randomly amplified polymorphic DNA analysis. ^[2]

A full-length gene encoding a novel serine protease inhibitor of P. westermani (PwSERPIN) is found to play an important role in the activities of the parasite. ^[3] Raw/under cooked crabs/cray fish, when eaten, propagate the metacercariae which excyst in the duodenum, penetrate the gastrointestinal wall, and migrate to the pulmonary parenchyma. The pulmonary localization is typical and is the primary event in paragonimiasis. The most common extrapulmonary sites are the brain, abdomen and subcutaneous tissues and the respective local symptoms often accompany pulmonary symptoms. An 8-year-old male patient diagnosed of cerebral paragonimiasis that mimicked tuberculoma was reported from Nagaland. ^[4]

The chest pain, cough, low grade fever, hemoptysis, and nonspecific radiological findings in chest X-rays are often mistaken for tuberculosis (as in our case). The diagnostic dilemma would deepen with a coinfection of tuberculosis in these patients. Clinical grounds, peripheral eosinophilia (12% in our case; higher in acute settings), imaging (showing calcified or uncalcified lung cysts, multilocular cavities, pleural thickening, pleural effusions, pneumonia and/or hilar enlargement), microscopy (eggs or the adult worm in sputum/bronchoalveolar lavage (BAL)/stool), serology (enzyme-linked immunosorbent assay [ELISA] being >90% sensitive and 100% specific ^[5] ) and biopsy of cerebral, intraabdominal or subcutaneous nodules depicting the worms are the various modalities that pin point a definitive diagnosis.

Treatment recommendations include praziquantel or triclabendazole although preventive strategies involving proper health education, hygiene, avoiding raw crab/cray fish consumption are better ways to eradicate the infection.

We highlight the relatively under-rated infection of paragonimiasis which often escapes a clinician′s radar and we reinforce the need for an open mind with high index of clinical suspicion when deciphering such presentations.

References

1.	Nkouawa A, Okamoto M, Mabou AK, Edinga E, Yamasaki H, Sako Y, et al. Paragonimiasis in Cameroon: Molecular identification, serodiagnosis and clinical manifestations. Trans R Soc Trop Med Hyg 2009;103:255-61.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.	Narain K, Devi RK, Mahanta J. Paragonimus and paragonimiasis: A new focus in Arunachal Pradesh, India. Curr Sci 2003;84:985-7.  Back to cited text no. 2
3.	Hwang JH, Lee WG, Na BK, Lee HW, Cho SH, Kim TS. Identification and characterization of a serine protease inhibitor of Paragonimus westermani. Parasitol Res 2009;104:495-501.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.	Singh TS, Khamo V, Sugiyama H. Cerebral paragonimiasis mimicking tuberculoma: First case report in India. Trop Parasitol 2011;1:39-41.  Back to cited text no. 4
5.	Sohn BS, Bae YJ, Cho YS, Moon HB, Kim TB. Three cases of paragonimiasis in a family. Korean J Parasitol 2009;47:281-5.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]

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