North American paragonimiasis: epidemiology and diagnostic strategies

Paragonimiasis misdiagnosed as liver abscess: A case report

BACKGROUND

Paragonimiasis is a typical food-borne zoonotic disease. Hosts acquire Paragonimus infection through the ingestion of raw or undercooked crayfish and crab. The clinical manifestations of the disease are varied, and it is often misdiagnosed or missed. The diagnosis of paragonimiasis should be considered comprehensively. Praziquantel is the first choice for treatment, and albendazole can be used in combination with repeated courses in severe cases.

CASE SUMMARY

We report a case of liver paragonimiasis that was misdiagnosed as an abscess. The patient presented with fatigue and poor appetite for 2 months, and was diagnosed with liver abscess in the local hospital. After 6 months, the patient visited our hospital because of recurrent abdominal pain and was diagnosed with liver paragonimiasis based on epidemiological history, clinical presentations, and laboratory findings. He was treated with praziquantel (25 mg/kg) three times a day for 3 days; however, the symptoms still presented after treatment. He was treated with oral praziquantel and albendazole for one further course. Follow-up suggested that the treatment was effective and the symptoms improved.

CONCLUSION

The combination of albendazole and praziquantel may improve the therapeutic efficacy of paragonimiasis.

Paragonimiasis

Paragonimiasis is a zoonotic disease caused by lung flukes of the genus Paragonimus. Humans usually become infected by eating freshwater crabs or crayfish containing encysted metacercariae of these worms. However, an alternative route of infection exists: ingestion of raw meat from a mammalian paratenic host. Adult worms normally occur in pairs in cysts in the lungs from which they void their eggs via air passages. The pulmonary form is typical in cases of human infection due to P. westermani, P. heterotremus, and a few other species. Worms may occupy other sites in the body, notably the brain, but lung flukes have made their presence felt in almost every organ. Ectopic paragonimiasis is particularly common when infection is due to members of the P. skrjabini complex. Human paragonimiasis occurs primarily in the tropics and subtropics of Asia, Africa, and the Americas, with different species being responsible in different areas (Table 6.1).

The Accumulation of Toxic Elements (Pb, Hg, Cd, As, and Cu) in Red Swamp Crayfish (Procambarus clarkii) in Qianjiang and the Associated Risks to Human Health

Due to rapidly expanding crayfish consumption worldwide, the food safety of red swamp crayfish (Procambarus clarkii) is of great concern. China is the largest consumer and producer of crayfish globally. As of yet, it is unknown whether the main crayfish production cities in China are within safe levels of toxic heavy metals and metalloids. For 16 consecutive years, Qianjiang city ranked first in China in processing export volumes of red swamp crayfish. This study presents a comprehensive analysis of the enrichment levels and associated health risks of the species in Qianjiang. In our research, samples of four crayfish tissues, including the head, hepatopancreas, gills, and muscles, were collected from 38 sampling sites distributed in Qianjiang to evaluate the concentration levels of five heavy metals (Pb, Hg, Cd, As, and Cu). The concentration levels of all five metals in muscle did not surpass the national standard. Furthermore, eight significant correlations have been found. For further in-depth assess risk of crayfish in Qianjiang, estimated daily intake (EDI), target hazard quotient (THQ), carcinogenic risk (CR), and estimated maximum allowable consumption rates (CR_mm) were evaluated in the abdomen muscle and hepatopancreas. The THQ values for each metal were found to be less than 1, while the CR values were below 10^-6. Additionally, the CR_mm for adults was determined to be 17.2 meals per month. These findings, based on the analysis of five metallic elements included in this study, suggest that the consumption of crayfish abdomen muscle in Qianjiang does not pose any significant health risks. However, it is noteworthy that certain regions exhibit elevated levels of arsenic in the hepatopancreas, surpassing the national standard, thereby rendering them unsuitable for excessive consumption. In general, the findings can be used to provide guidance for safe dietary practices in China.

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.

Endemic Paragonimus kellicotti infections in animals and humans in USA and Canada: Review and personal perspective

Infections with the lung fluke, Paragonimus kellicotti, have been diagnosed in a variety of domestic and wild animals and humans in USA and Canada. Although there are many species of Paragonimus in other parts of the world; P. kellicotti is the only species definitively diagnosed in USA and Canada. Fresh water snails (several species) and crayfish (mainly Orconectes spp.) are its intermediate hosts. Humans and animals become infected with P. kellicotti only by ingesting metacercariae encysted in the heart of crayfish. After ingestion, the fluke penetrates intestinal wall, enters peritoneal cavity, and reaches pleural cavity by direct penetration of diaphragm, 2-3 weeks post inoculation (p.i.). Young flukes penetrate lungs and become encysted in pulmonary tissue, often in pairs. Time to maturity is around 4-7 weeks p.i. Eggs are coughed up, swallowed, and are excreted in feces. Although the parasite has been known for more than a century, there has been an upsurge of human infections in the USA. Here, I review P. kellicotti infections in naturally infected hosts. Pathogenesis, diagnosis, and treatment in parasite-free cats and dogs experimentally infected P. kellicotti are reviewed to shed light on the pathogenesis of human paragonimiasis. Problems and challenges facing diagnosis of paragonimiasis, especially non-pulmonary infections, are discussed. Fluke stages are deposited in Smithsonian Museum.

Pulmonary Paragonimiasis in Native Community, Esmeraldas Province, Ecuador, 2022

Paragonimiasis is a food-borne infection caused by several species of the Paragonimus fluke. Clinical manifestations can mimic tuberculosis and contribute to diagnostic delay. We report a cluster of paragonimiasis in a community in Ecuador, where active surveillance was set up after detection of the first 2 cases.

A clinical review of human disease due to Paragonimus kellicotti in North America

Human autochthonous infections with the trematode Paragonimus kellicotti are increasingly being reported in North America, but the true prevalence and geographic distribution are unknown. Ingestion of raw crayfish is reported in most human cases, typically in the context of alcohol intoxication. Risk of infection varies depending on what part of the crayfish is ingested as metacercariae of P. kellicotti (>50% mature to adults) localize to the heart and pericardium of the crayfish. Reported human cases have manifested primarily in otherwise healthy young adults presenting with severe eosinophilic pneumonia, pleuritis, systemic symptoms, dermatologic lesions and cerebral involvement. However, it is likely that many infections go unreported due to lack of awareness, mild illness or the absence of rapid commercially available diagnostic tests. Promising advances have been made related to novel diagnostic targets. Conservation of these antigen targets among at least four Paragonimus species could make these antigens viable for diagnostic testing of P. kellicotti specifically as well as other Paragonimus species, but additional studies and funding investments are required. Public and physician awareness may have improved due to targeted education campaigns, but ongoing activities to raise awareness are needed, particularly in areas where cases have not been frequently reported to date.

Characterization and localization of antigens for serodiagnosis of human paragonimiasis

Paragonimiasis is a foodborne trematode infection that affects 23 million people, mainly in Asia. Lung fluke infections lead frequently to chronic cough with fever and hemoptysis, and are often confused with lung cancer or tuberculosis. Paragonimiasis can be efficiently treated with praziquantel, but diagnosis is often delayed, and patients are frequently treated for other conditions. To improve diagnosis, we selected five Paragonimus kellicotti proteins based on transcriptional abundance, recognition by patient sera, and conservation among trematodes and expressed them as His-fusion proteins in Escherichia coli. Sequences for these proteins have 76-99% identity with amino acid sequences for orthologs in the genomes of Paragonimus westermani, Paragonimus heterotremus, and Paragonimus miyazakii. Immunohistology studies showed that antibodies raised to four recombinant proteins bound to the tegument of adult P. kellicotti worms, at the parasite host interface. Only a known egg antigen was absent from the tegument but present in developing and mature eggs. We evaluated the diagnostic potential of these antigens by Western blot with sera from patients with paragonimiasis (from MO and the Philippines), fascioliasis, and schistosomiasis, and with sera from healthy North American controls. Two recombinant proteins (a cysteine protease and a myoglobin) showed the highest sensitivity and specificity as diagnostic antigens, and they detected antibodies in sera from paragonimiasis patients with early or mature infections. In contrast, antibodies to egg yolk ferritin appeared to be specific marker for patients with adult fluke infections that produce eggs. Our study has identified and localized antigens that are promising for serodiagnosis of human paragonimiasis.

Loop-Mediated Isothermal Amplification as Point-of-Care Diagnosis for Neglected Parasitic Infections

The World Health Organisation (WHO) has placed twenty diseases into a group known as neglected tropical diseases (NTDs), twelve of them being parasitic diseases: Chagas’ disease, cysticercosis/taeniasis, echinococcosis, food-borne trematodiasis, human African trypanosomiasis (sleeping sickness), leishmaniasis, lymphatic filariasis, onchocerciasis (river blindness), schistosomiasis, soil-transmitted helminthiasis (ascariasis, hookworm, trichuriasis), guinea-worm and scabies. Such diseases affect millions of people in developing countries where one of the main problems concerning the control of these diseases is diagnosis-based due to the most affected areas usually being far from laboratories having suitable infrastructure and/or being equipped with sophisticated equipment. Advances have been made during the last two decades regarding standardising and introducing techniques enabling diagnoses to be made in remote places, i.e., the loop-mediated isothermal amplification (LAMP) technique. This technique’s advantages include being able to perform it using simple equipment, diagnosis made directly in the field, low cost of each test and the technique’s high specificity. Using this technique could thus contribute toward neglected parasite infection (NPI) control and eradication programmes. This review describes the advances made to date regarding LAMP tests, as it has been found that even though several studies have been conducted concerning most NPI, information is scarce for others.

Comparative genomics and transcriptomics of 4 Paragonimus species provide insights into lung fluke parasitism and pathogenesis

BACKGROUND

Paragonimus spp. (lung flukes) are among the most injurious foodborne helminths, infecting ∼23 million people and subjecting ∼292 million to infection risk. Paragonimiasis is acquired from infected undercooked crustaceans and primarily affects the lungs but often causes lesions elsewhere including the brain. The disease is easily mistaken for tuberculosis owing to similar pulmonary symptoms, and accordingly, diagnostics are in demand.

RESULTS

We assembled, annotated, and compared draft genomes of 4 prevalent and distinct Paragonimus species: Paragonimus miyazakii, Paragonimus westermani, Paragonimus kellicotti, and Paragonimus heterotremus. Genomes ranged from 697 to 923 Mb, included 12,072-12,853 genes, and were 71.6-90.1% complete according to BUSCO. Orthologous group analysis spanning 21 species (lung, liver, and blood flukes, additional platyhelminths, and hosts) provided insights into lung fluke biology. We identified 256 lung fluke-specific and conserved orthologous groups with consistent transcriptional adult-stage Paragonimus expression profiles and enriched for iron acquisition, immune modulation, and other parasite functions. Previously identified Paragonimus diagnostic antigens were matched to genes, providing an opportunity to optimize and ensure pan-Paragonimus reactivity for diagnostic assays.

CONCLUSIONS

This report provides advances in molecular understanding of Paragonimus and underpins future studies into the biology, evolution, and pathogenesis of Paragonimus and related foodborne flukes. We anticipate that these novel genomic and transcriptomic resources will be invaluable for future lung fluke research.

Large Pericardial Effusion Due to Paragonimiasis in a 4-Year-Old Chinese Boy

Large pericardial effusion (PE) and bilateral pleural effusion were found in a 4-year-old Chinese boy. An emergent surgery was performed. The biopsy showed massive eosinophil infiltration. Serologic test for Paragonimus skrjabini was positive. Postoperative praziquantel therapy was effective.

Paragonimiasis

Paragonimiasis is a zoonotic disease caused by lung flukes of the genus Paragonimus. Humans usually become infected by eating freshwater crabs or crayfish containing encysted metacercariae of these worms. However, an alternative route of infection exists: ingestion of raw meat from a mammalian paratenic host. Adult worms normally occur in pairs in cysts in the lungs from which they void their eggs via air passages. The pulmonary form is typical in cases of human infection due to P. westermani, P. heterotremus, and a few other species (Table 5.1). Worms may occupy other sites in the body, notably the brain, but lung flukes have made their presence felt in almost every organ. Ectopic paragonimiasis is particularly common when infection is due to members of the P. skrjabini complex (Table 5.1). Human paragonimiasis occurs primarily in the tropics and subtropics of Asia, Africa, and the Americas, with different species being responsible in different areas (Table 5.1).

Hepatic Paragonimiasis Mimicking Hepatocellular Carcinoma

Paragonimiasis is a parasitic lung infection caused by lung flukes of the genus Paragonimus. Ectopic infection may occur but rarely involves the liver. Here, we report a case of hepatic paragonimiasis in a Chinese man who was initially suspected to have hepatocellular carcinoma. He had been previously diagnosed with chronic hepatitis B. No specific symptoms or abnormal blood test results were observed, except for a significant rise in serum alfa-fetoprotein. Magnetic resonance imaging revealed a 12-cm mass with inhomogeneous signal intensity at the left lobe of the liver. Laparoscopic left hemihepatectomy was performed. He was finally diagnosed as hepatic paragonimiasis upon pathological examination and antibody serology. The postoperative course was uneventful. He received a standard course of praziquantel and recovered well. Our case is unique in its tumor-like characteristic and protrudes the difficulty of differential diagnosis with both benignant and malignant hepatic diseases by imaging studies or non-specific symptoms. Hepatic paragonimiasis is unusual; however, it should be considered in the differential diagnosis of liver malignancy by clinicians.

Incidence of paragonimiasis in Chongqing China: a 6-year retrospective case review

Paragonimiasis is an important infectious disease in Chongqing, China. However, no epidemiological surveys of paragonimiasis have been carried out in Chongqing since it became a municipality in 1997. We conducted a retrospective case review of 683 patients who were referred to our laboratory and diagnosed as having paragonimiasis during 2010-2015. Patients were diagnosed with paragonimiasis based on immunodiagnostic tests in addition to clinical and laboratory findings. Patient data extracted from the epidemiologic form were analysed. The majority of patients were distributed on the east side of the Wujiang River, which belongs to the Three Gorges Reservoir region. Consumption of raw or undercooked freshwater crab or crayfish in the family Cambaridae was the main reason for infection. Notably, more than 50·0% of patients were diagnosed between March and July, indicating that serious clinical symptoms only appear approximately 6 months post-infection. Paragonimiasis remains a public health issue in Chongqing, and an epidemiological study of Paragonimus in the Three Gorges region is strongly recommended.

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.

Electronic supplementary material

The online version of this article (doi:10.1186/s13071-016-1785-x) contains supplementary material, which is available to authorized users.