Cerebral paragonimiasis mimicking tuberculoma: First case report in India

Cerebral Paragonimiasis Presenting with Dementia

We report a case of an 80-year-old Korean man with chronic cerebral paragonimiasis who presented with progressive memory impairment. He suffered from pulmonary paragonimiasis 60 years ago and has been experiencing epilepsy since the age of 45. He began experiencing memory and cognitive deterioration 3 years ago. He visited the neuropsychiatric department of our hospital to check his symptoms and health from a year ago. Contrast-enhanced brain magnetic resonance imaging study revealed calcifications and cystic lesions encompassing the right temporo-occipital region. Encephalomalatic changes were also observed in the right occipital and temporal areas. The anti-Paragonimus specific IgG antibodies in his serum showed a strong positive response. The neuropsychological test results showed a Global Deterioration Scale of 4 and a Clinical Dementia Rating Scale of 1. The chronic cerebral paragonimiasis lesions in the patient's right temporo-occipital region might induce the dementic change.

A curious case of hemoptysis

Paragonimiasis is a crustacean-borne parasitic zoonosis caused by lung fluke or Paragonimus. Several endemic foci of paragonimiasis have been discovered in Northeastern India. Chronic pulmonary infection with Paragonimus is characterized by hemoptysis, which is usually mistaken for Tuberculosis (TB). Paragonimiasis is acquired by eating raw, undercooked, or pickled crabs or crayfish containing encysted metacercariae of Paragonimus. Infection can usually be confirmed by finding Paragonimus eggs in sputum or bronchoalveolar lavage. We present a rare case of paragonimiasis masquerading as hypereosinophilia, asthma, and intracerebral hemorrhage for the last three years. Paragonimiasis is a rare cause of hemoptysis outside endemic regions. A strong index of suspicion is required to diagnose paragonimiasis outside the endemic areas. Diagnosis is usually delayed because of similarity of presentation to TB. Our patient was symptomatic with hemoptysis for three years. He gave history of eating raw crayfish and crabs while on leave to his native village in Nagaland. Diagnosis was confirmed on microscopy by detection of Paragonimus ova in sputum and bronchoalveolar lavage specimens. Symptoms resolved on treatment with praziquantel (25 mg/kg TDS for three days). Patient became symptom-free after a week of treatment.

One delayed diagnosis of paragonimiasis case and literature review

Human paragonimiasis has been appearing all over the world due to increased human migration, international travel, and worldwide food trading. However, delayed and missed diagnosis rates are also increasing due to atypical clinical manifestations and the lack of disease understanding by clinical workers. We describe the case of a 43-year-old man, who was hospitalized with cough and chest pain for two months. Chest computed tomography (CT) revealed bilateral emphysema, left pleural effusion, and bilateral atelectasis. The hypereosinophilia gave us a clue; ultimately, the diagnosis of paragonimiasis was made through a diet history and a positive result of serum Paragonimus sp. immunoglobulin (Ig) G antibody. Moreover, 27 misdiagnosed paragonimiasis cases in the past decade have been reported. We draw conclusions by summarizing their characteristics for suspicious eosinophilic paragonimiasis patients; we should inquire diet history carefully, test serum IgG antibodies, and try to detect eggs. Once diagnosed, praziquantel is preferred for treatment.

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).

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).

Paragonimus & paragonimiasis in India

Ever since the discovery of the first indigenous case in 1981, paragonimiasis has gained recognition as a significant food borne parasitic zoonosis in India. The data available on the occurrence of paragonimiasis, until today, may be just the tip of an iceberg as the study areas covered were restricted to Northeast Indian States. Nevertheless, the results of research on paragonimiasis in India have revealed valuable information in epidemiology, life cycle, pathobiology and speciation of Indian Paragonimus. Potamiscus manipurensis, Alcomon superciliosum and Maydelliathelphusa lugubris were identified as the crab hosts of Paragonimus. Paragonimus miyazakii manipurinus n. sub sp., P. hueit'ungensis, P. skrjabini, P. heterotremus, P. compactus, and P. westermani have been described from India. P. heterotremus was found as the causative agent of human paragonimiasis. Ingestion of undercooked crabs and raw crab extract was the major mode of infection. Pulmonary paragonimiasis was the commonest clinical manifestation while pleural effusion and subcutaneous nodules were the common extra-pulmonary forms. Clinico-radiological features of pulmonary paragonimiasis simulated pulmonary tuberculosis. Intradermal test, ELISA and Dot-immunogold filtration assay (DIGFA) were used for diagnosis and epidemiological survey of paragonimiasis. Phylogenitically, Indian Paragonimus species, although nested within the respective clade were distantly related to others within the clade.