Further development of bithionol therapy as a treatment for amoebic gill disease in Atlantic salmon, Salmo salar L

This study examined the efficacy of bithionol as a prophylactic or therapeutic oral treatment for Atlantic salmon (AS), Salmo salar, affected by amoebic gill disease (AGD). Furthermore, it explored the interaction of bithionol oral therapy with the current standard treatment (a freshwater bath for at least 3 h). The efficacy of three medicated feeds was determined in the trial by feeding AGD-affected AS at 1% body weight (BW) day(-1) either oil coated commercial feed (control) or prophylactic and therapeutic bithionol at 25 mg kg(-1) feed. Feeding commenced 2 weeks prior to exposure to Neoparamoeba spp. at 300 cells L(-1) and continued for 49 days post-exposure (PE). Bithionol when fed as a 2-week prophylactic or therapeutic treatment at 25 mg kg(-1) feed delayed the onset of AGD pathology and reduced the percentage of gill filaments with lesions. Administration of a 3-h freshwater bath at 28 days PE significantly reduced amoeba numbers to a similar level across all treatments; in contrast, gross gill score and percent lesioned filaments were reduced to different extents, the control having a significantly higher score than both bithionol treatments. Following the freshwater bath, clinical signs of AGD increased at a similar level across all treatments, albeit controls were significantly higher than the bithionol treatments immediately following freshwater treatment. This study demonstrated that bithionol at 25 mg kg(-1) feed, when fed as a 2-week prophylactic or a therapeutic treatment, delayed and reduced the intensity of AGD pathology and warrants further investigation as a treatment for AGD-affected AS.

Evaluation of bithionol as a bath treatment for amoebic gill disease caused by Neoparamoeba spp

This study examined the toxicity of bithionol to Atlantic salmon Salmo salar and rainbow trout Oncorhynchus mykiss in fresh- and seawater and the efficacy of bithionol as a 1h seawater bath treatment for amoebic gill disease (AGD). To examine toxicity, fish were bathed for 1, 3 and 6h in bithionol, an anti-protozoal at 0, 1, 5, 10, 25 and 35mgL(-1) with toxicity determined by time to morbidity. Efficacy was examined by bathing AGD-affected Atlantic salmon and rainbow trout for 1h at bithionol concentrations of 1-25mgL(-1). Efficacy was determined by examining gill amoeba counts and identifying percent lesioned gill filaments at 1 and 24h after bath exposure to bithionol. For both species, bithionol was determined to be toxic at 25 and 35mgL(-1) exhibiting median lethal times (LT50s) ranging from 21 to 84min. Morbidity occurred in the 5 and 10mgL(-1) treatments, however, due to sampling regime there were not enough fish available to calculate LT50s. Only bithionol at 1mgL(-1) was considered non-toxic with no signs of morbidity. Bithionol was more toxic in seawater than freshwater and had no acute effects on gill Na+/K+ ATPase and succinic dehydrogenase, or plasma osmolality and chloride concentration. Bithionol at 1mgL(-1) reduced percent lesioned gill filaments in Atlantic salmon and rainbow trout by 33 and 27 per cent, respectively, compared to the seawater control. Similarly, numbers of amoeba were reduced by 33 and 43 per cent for Atlantic salmon and rainbow trout, respectively, when compared to the seawater control. Furthermore, bithionol reduced percent lesioned gill filaments as much as did the current industry standard of freshwater. This study demonstrated that a 1h seawater bath containing 1mgL(-1) bithionol could be an improvement to the current method of treatment for AGD-affected Atlantic salmon and rainbow trout.

Indirect evidence of ectopic pancreatic fascioliasis in a human

Fascioliasis is not common in humans and, furthermore, its ectopic migration into the pancreas is extremely rare. A definitive diagnosis of ectopic fascioliasis is based on the demonstration of flukes in the affected organ. If the flukes invade the parenchyma, however, imaging studies are limited in the detection of worms and surgical identification is required. We encountered a clinical case of probable ectopic pancreatic fascioliasis diagnosed through indirect evidence. A 46-year-old Korean woman was admitted with left upper quadrant pain. She had taken praziquantel for hepatic fascioliasis, which had been diagnosed at another hospital, and then developed abdominal pain. Peripheral eosinophilia, hyperamylasemia and hyperlipasemia were documented. Abdominal computed tomography (CT) revealed multiple, hypodense foci which had coalesced, forming irregular nodules in the medial and lateral segments of the left lobe of the liver, and similar 2- to 3-cm sized, hypodense lesions in the body and isthmus of the pancreas. IgG antibody against Fasciola hepatica was positive. Bithionol was given orally, and the patient's symptoms and biochemistry then improved, with reversal of eosinophilia. Radiological studies showed normalization of the liver and pancreas at the 10th week, and the serology for Fasciola hepatica was negative at the fifth month.

Fasciola hepatica infection: clinical and computerized tomographic findings of ten patients

BACKGROUND/AIMS

Fasciola hepatica is the cause of liver infection, fascioliasis. Although rare, it is still a problem even in developed countries. In this study, the clinical and computerized tomographic findings of 10 patients diagnosed with fascioliasis are summarized.

METHODS

The medical records of the patients with fascioliasis were retrospectively examined. Clinical, laboratory findings and computerized tomographic results were recorded.

RESULTS

Abdominal pain, fever, eosinophilia and abnormal liver function tests were the most commonly encountered symptoms and signs. One patient was human immunodeficiency virus -positive with active tuberculosis. Serologic test for fasciola hepatica was positive in all patients. Nodular masses without prominent enhancement, and branching low-attenuated tubular lesions were the most commonly seen tomographic findings and were supportive for the diagnosis. All except the HIV-positive patient received bithionol therapy; six patients responded well, two lost contact with the clinic and one patient who was unresponsive to bithionol therapy received triclabendazole. During follow-up of the six patients who responded, all the clinical and radiological findings regressed.

CONCLUSION

In any patient with peripheral eosinophilia, abdominal pain and elevated liver enzymes, especially when CT reveals tubular and nodular hypodense lesions particularly in subcapsular area, F. hepatica infection should be considered. Either triclabendazole or bithionol can be used effectively for the treatment.

Infection with Fasciola hepatica

Fascioliasis, caused by the liver fluke Fasciola hepatica, is an infection that occurs worldwide, although humans are accidental hosts. F. hepatica infection comprises two stages, hepatic and biliary, with different signs and symptoms. Stool examination and ELISA can be used for the initial diagnosis. Radiographic techniques, such as computerised tomography and ultrasonography, as well as magnetic resonance imaging, are used widely for confirmation and follow-up of the disease. Invasive techniques, such as percutaneous cholangiography, endoscopic retrograde cholangiography and liver biopsy, may aid in the diagnosis but are not essential. Triclabendazole is recommended as the first-line agent for the treatment of F. hepatica infection, with bithionol as an alternative.

Fasciola hepatica infestation as a very rare cause of extrahepatic cholestasis

Fasciola hepatica, an endemic parasite in Turkey, is still a very rare cause of cholestasis worldwide. Through ingestion of contaminated water plants like watercress, humans can become the definitive host of this parasite. Cholestatic symptoms may be sudden but in some cases they may be preceeded by a long period of fever, eosinophilia and vague gastrointestinal symptoms. We report a woman with cholangitis symptoms of sudden onset which was proved to be due to Fasciola hepatica infestation by an endoscopic retrograde cholangiography.

[Fascioliasis: diagnosis, epidemiology and treatment]

Fascioliasis is a trematode, disease of liver and bile ducts of sheep, cattle, and other ruminants throughout the world that is caused by the fluke, Fasciola hepatica. Human infection has been reported in Mexico, Cuba, Puerto Rico, Chile, Peru, Uruguay, Brazil, Argentina, the US, Europe, eastern Africa, Japan and Australia. The parasite's miracidium invades one of the various Lymnaea water snail hosts. Infection results from ingestion of encysted metacercariae attached to raw watercress (Nasturtium officinale). Symptoms recorded from human cases included irregular fever, epigastric pain and abdominal tenderness, obstructive jaundice and leucocytosis with eosinophilea up to 60%. Specific diagnosis is based on recovery of the eggs in the patient's stool or from biliary tract drainage. Treatment is with emetine hydrochloride given intramusculary. Bithionol is given orally at a dosage of 30-50 mg/kg but on alternate days from 10 to 15 doses. Praziquantel is probably effective. Preventive measures include education of the public on mode of transmission of life cycle of the parasite, and dipping fresh watercress into boiling water for a few sec, or drying suspected watercress.

Paragonimiasis in Yongjia County, Zhejiang Province, China: clinical, parasitological and karyotypic studies on Paragonimus westermani

Paragonimiasis in Yongjia County, Zhejiang Province, China, has been of such public health concern that a specialized Institute for Paragonimiasis Control has been established there. The study reported here involved both parasitological research on Paragonimus westermani in the endemic areas and a clinical analysis of 94 cases of paragonimiasis. Eggs were found in sputum, feces and brain tissue in 45 cases. Twenty patients, 19 of whom where children under 10 years of age, showed hepatic injury. Treatment with praziquantel or bithionol had satisfactory results in all cases. Dimensions of the parasite eggs, metacercariae from freshwater crabs and adult flukes suggested that the form of P. westermani in Yongjia is the 'small type': a suggestion supported by karyotypic studies on gonad cells from adult flukes collected from experimentally infected animals as all were found to be diploid. In conclusion, the 'small type' or diploid form of P. westermani is the cause of paragonimiasis pulmonary symptoms in Yongjia.

Recurrent eosinophilic panniculitis associated with Fasciola hepatica infection

Eosinophilic panniculitis is characterized by a prominent infiltration of subcutaneous fat with eosinophils. We report a case of Fasciola hepatica infection presenting with eosinophilic panniculitis successfully treated with bithionol. To our knowledge, this is the first report of recurrent eosinophilic panniculitis associated with Fasciola hepatica infection.

[Paragonimiasis]

Paragonimiasis is a helminthic disease of carnivorous animals. Man is infected accidentally. It has a worldwide distribution but is mainly encountered in Southeast Asia, particularly in Korea. Other endemic areas include Africa and South America. Cerebral paragonimiasis is not rare, but pleuropulmonary manifestations are the most prevalent. They include hemoptysis (frequently rusty-colored), unilateral or bilateral pleural effusions, and pulmonary infiltrates or cavities. This constellation of symptoms often mimics those of tuberculosis. Cerebral and lung involvement has recently been investigated by CT-scan and NMR. The diagnosis is based on the identification of parasite eggs in sputum or feces, and on ELISA serology. The treatment of choice is praziquantel.

[Hepatic fascioliasis in children: uncommon clinical manifestations]

The present review has the objective to identify clinical epidemiologic characteristics and evolution for four children with Fasciola hepatica evaluated at the Pediatric Gastroenterology Unit at the Children's Health Institute, Lima, Peru, between 1988 and 1992. The first patient was a 9-year old girl who had fever, leg edema, collateral circulation and hepatomegaly, predominantly at the right lobe. The second was a 6-year old by who had upper gastrointestinal hemorrhage and fever; endoscopic diagnosis demonstrated hemobilia. The third case was a 12-year old boy who presented generalized edema. The fourth patient was a 9-year old boy with jaundice, fever and upper gastrointestinal hemorrhage. Esophageal varices and cirrhosis were present. In the four patients the diagnosis was made by the identification of parasite eggs in the feces. The first three cases responded satisfactorily to treatment with bithionol; the fourth patient died because of systemic failure.

Compartive studies on the effect of bithionol, praziqantel and triclabendazole in rabbit's fascioliasis. 1. Parasitological studies

Rabbits were infected with 30 metacercariae each. They were then divided into four batches each of two groups. One batch served as controls and the others were treated each with a drug. The first group from each batch was treated when worms were still immature, the other group was treated after maturity. The effect of the drugs was monitored by: (1) Stool examination for eggs and studying the percent of egg reduction. (2) Worm recovery at autopsy and calculating the percent of the drug efficacy. (3) Culturing some eggs and following their embryonation and hatching. Results pointed out that Triclabendazole was the best fasciolicide followed by Bithionol. Praziquantel had a negligible effect.

Paragonimus mexicanus pericarditis: report of two cases and review of the literature

The cases of two Costa Rican children with pericarditis due to Paragonimus mexicanus are reported. Clinical, epidemiological and laboratory tests are consistent with the disease. Treatment with praziquantel and bitheonol was associated with clinical cure. A review of the literature and a suggested table of diagnostic criteria are included.

Phagocytic activity of neutrophils in human fasciolosis before and after treatment

Neutrophil phagocytic function was studied in fifteen patients with chronic fasciolosis and five in the incubating phase of the disease. Results were compared with a control group. The chematactic index which is the ratio of directed to non directed migration, the (NBT) reduction test which estimates phagocytosis and the more recent and specific test the chemiluminescence which measures phagocytosis and intracellular killing were performed. The results showed that in fasciolosis chemotactic activity, NBT and chemiluminescence index were significantly increased as compared to controls. This increase was more prominent in the acute phase. In this stage, the immature parasites are in close contact with the liver tissue. With chronicity of infection, they reach the bile ducts and inflammation in the liver parenchyma subsides. At this stage a lower level of metabolites and antigens reach the tissues, while the majority pass with bile to the intestinal lumen. The indices returned to normal level after treatment of fasciolosis. This signifies disappearance of all stimuli responsible for activation of PMN phagocytes.

[Two cases of Paragonimus westermani in one family]

A 68-year-old woman and her 28-year-old son ate some rare fresh-water crabs (Eriocheir japonicus). The son became ill one month later with pleural effusion. After 10 months the mother's symptoms included cough, hemosputum and a nodular shadow on her chest X-ray. Eosinophilia was present and the Ouchterlony test showed strong bands toward Paragonimus westermani antigen in both patients. They were diagnosed as having Paragonimiasis westermani. The symptoms stopped after Bithionol administration and the bands of the Ouchterlony test also disappeared. The difference in the latent stage and clinical symptoms of these patients, who were infected at the same time, is interesting as it highlights the importance of observing other people who may have been infected with Paragonimus westermani.

Sandwich enzyme-linked immunosorbent assay for detection of excretory secretory antigens in humans with fascioliasis

A sandwich enzyme-linked immunosorbent assay has been developed for the detection of Fasciola hepatica excretory secretory (ES) antigens in stool specimens of infected humans. The assay uses antibodies against F. hepatica ES antigens. A monoclonal antibody (ES78, mouse immunoglobulin G2a) was used to capture ES antigens, and a rabbit polyclonal antibody, peroxidase conjugate, was used to identify ES antigens. Thirteen of 14 patients with parasitological evidence of fascioliasis had a detectable concentration of ES antigens (more than 15 ng/ml). None of the stool specimens from controls and from patients with parasites other than F. hepatica showed a positive reaction, suggesting the absence of cross-reactions in this assay. When the 14 patients were retested 2 months after treatment, all of the specimens from the 11 parasitologically cured patients were negative by the antigen detection assay while the specimens from the 3 patients with persisting F. hepatica eggs in their stools remained positive.

Fascioliasis: case reports and review

Fasciola hepatica, a zoonotic liver fluke, can cause disease in humans. Fascioliasis, while common in some tropical and developing countries, is uncommon in the United States. We report two cases of fascioliasis that illustrate both the hepatic and biliary stages of the disease. Clinical features and diagnostic aspects including serologic, radiographic, and histopathologic studies are emphasized. Praziquantel was ineffective in treatment of both patients. Bithionol appears to be an effective treatment for fascioliasis.

[Fasciola hepatica infestation. Biopathology and new diagnostic and therapeutic aspects]

We present here 6 patients with Fasciola hepatica infection, all from rural origin, and with the risk factors of eating wild watercress. The more common symptoms were: fever (83%), abdominal pain (100%), weight loss (83%) and generalized myalgia and joint pain (67%). All patients presented with an absolute eosinophil count above 1,000 cell/mm3. The diagnosis was established in five cases by means of serologic techniques (haemagglutination) and with direct visualization of adult worms while surgery in one case. A CT abdominal scan was performed in five patients, revealing specific lesions of tissue infiltration in four of them. Praziquantel was used in four patients, achieving clinical cure in three cases. In two patients, bithionol was used, with clinical cure in both cases. We review also some newer diagnostic and therapeutic approaches to this parasitic disease.

[Hepatic fascioliasis. Resistance to praziquantel treatment and the radiological findings]

We report a case of hepatic fascioliasis. Fever and epigastric pain was the clinical presentation. We describe the features of the ultrasound and computed tomography examination. Symptoms were persistent after praziquantel treatment. Bithionol was effective and cured the patient.

Treatment of human taeniasis in the Philippines: a review

Studies relating to the treatment of human taeniasis in the Philippines using Atabrine, bithionol, and mebendazole are reviewed. Cure rates of 93.7% for Atabrine, 85%-100% for bithionol, and 84.62% for mebendazole are reported. Aside from these studies, recent experience in the treatment of Taenia saginata infections at the Department of Parasitology, College of Public Health, is also reported. Twenty patients referred to the department were treated, 3 with bithionol, 17 with praziquantel. Of the 17 patients treated with praziquantel, the study reported cure rates of 47-88.24%.

Human fascioliasis in Egypt: effect of infection and efficacy of bithionol treatment

The present study was conducted on 14 patients with established fascioliasis. The effect of infection on the haematological and biochemical parameters was determined and the liver and gall bladder were studied by ultrasonography. Bithionol was given in the dose of 30 mg kg-1 body weight every other day for 5 doses. The therapeutic efficacy was assessed by egg and eosinophilic counts and quantitative estimation of antibody titres by indirect haemagglutination test. Results revealed that fascioliasis caused normocytic hypochromic anaemia and eosinophilia. Serum bilirubin, ALT and AST were within normal range. Ultrasonography showed a normal echogenic pattern of the liver and gall bladder. One case showed thickness of the gall bladder wall which was tender under the transiducer. Fasciola eggs disappeared completely after the 5th dose giving a cure rate of 100%. Antibody titres reached a normal level at the end of the 3rd month post treatment. Bithionol proved to be a potent fasciolicidal drug with minimal side-effects.

Concurrent infections with the ruminant nematodes Haemonchus contortus and Trichostrongylus colubriformis in jirds, Meriones unguiculatus, and use of this model for anthelmintic studies

Haemonchus contortus- and Trichostrongylus colubriformis-infected jirds (Meriones unguiculatus) are useful for anthelmintic studies. With concurrent infections of these parasites established in the jird, questions of not only anthelmintic activity, but to some extent spectrum, could be assessed in a single model system. This report outlines a model using immunosuppressed (0.02% hydrocortisone in feed) jirds concurrently infected with H. contortus and T. colubriformis. Immunosuppressed jirds were inoculated with approximately 1,000 exsheathed infective larvae of each species, treated per os on day 10 postinoculation (PI), and killed on day 13 PI. Stomachs and small intestines were removed, opened longitudinally, incubated in distilled water at 37 C for 5 hr, fixed in formaldehyde solution, and stored for subsequent examination. Contents of both organs were examined using a stereomicroscope (15-45 x). Various standard anthelmintics were evaluated in the model; modern broad-spectrum ruminant anthelmintics (benzimidazoles, febantel, ivermectin, levamisole hydrochloride, and milbemycin D) are active uniformly and in most cases at doses comparable to those required for efficacy against these parasites in ruminants. This model, using worms of 2 genera living in distinct sites, allows preliminary evaluation of anthelmintic activity and spectrum for experimental compounds in a single cost- and resource-efficient experiment.

Human fascioliasis: T cell subsets in liver before and after bithionol treatment

Liver biopsies from 5 patients with established fascioliasis, before and after bithionol treatment were studied by immunoalkaline phosphatase technique for relative distribution of T cells and their subpopulations. T cell and its subsets are defined for OKT3+ (pan T), OKT4+ (helper/inducer) and OKT8+ (suppressor/cytotoxic) cells by using mouse monoclonal antibodies. Before bithionol treatment, lymphocytic infiltration in all hepatic lesions were predominantly of OKT3+ (pan T) lymphocytes. The distribution of OKT8+ cells was moderate to severe in comparison to the few OKT4+ cells presentation. After bithionol a noticeable regression of the OKT3 lymphocytic in all liver sections. The majority of the lymphocytic infiltration was of the OKT8+ cells, in comparison to the absence of the OKT4+ ones. This may indicate that suppressor/cytotoxic lymphocytes may have a role in the immune regulation of the disease and the mode of action of bithionol is by the accentuation of this immunoregulatory effect.

Human fascioliasis: ultrastructural study on the liver before and after bithionol treatment

The pathology of human fascioliasis was studied before and after bithionol treatment using light and transmission electron microscopy. Fine needle biopsies were taken from five patients, with established fascioliasis, before and after drug administration. By light microscope the pathology of human fascioliasis was similar to that reported in experimental fascioliasis. The ultrastructural picture revealed bile ductular hyperplasia, fibrosis of portal tracts, widening of the interhepatic spaces by many microvilli and dilated Disse space with collagen fibres. Bile ductular hyperplasia may be the initial factor to fibrinogenesis, which subsequently enhance the development of the microvilli on the surface of the hepatocytes. Both light and electron microscopic studies revealed regression of the picture of fascioliasis to normal after bithionol treatment with no sign of toxicity on the liver.

[Eight cases of diphyllobothriasis]

Eight cases of diphyllobothriasis have been experienced in the Juntendo University Hospital. Seven of the 8 patients excreted tapeworm fragments. Eggs of Diphyllobothrium latum were found in the feces in 5 cases. One patient had a history of ingestion of raw trout (Sushi), and 2 raw salmon. One might have been infected in foreign countries, and 3 could not tell the source of infection. Bithoinol was administered orally to 7 patients. Four of the 7 excreted the worm and the scolex was recognized in three of the four. Neither recurrence nor abnormal findings have been recognized so far.

Pulmonary paragonimiasis in childhood--a cause of recurrent haemoptysis and pneumonia

A 2-year-old Manipuri girl had haemoptysis and a chest roentgenogram disclosed diffuse-infiltrates in the right lung. Microscopic examination of sputum and morning gastric aspirate showed numerous golden-brown, operculated ova, and microscopic examination of stool specimens confirmed these ova to be those of the lung fluke, Paragonimus westermani. She responded favourably to bithionol therapy and was asymptomatic and growing normally during follow up for one and half years.

Bithionol (Bitin) treatment in established fascioliasis in Egyptians

The present study is an evaluation of bithionol treatment in established fascioliasis. Eight patients were enrolled in the study. All were passing eggs of Fasciola spp. and seven had concomitant Schistosoma mansoni infection. The clinical and haematological findings conformed with the known picture of fascioliasis. Bitin tablets (200 mg) were administered in the dose of 30 mg kg-1 body wt every other day for five doses. Eggs were counted during and for 4 months after the end of therapy. Fasciola ova disappeared after the second or third dose giving a cure rate of 100%. Ova of S. mansoni did not show any change in number. As regards the liver function tests; bilirubin, SGOT and SGPT values were within the normal range and were not affected by treatment. A raised SAP level was observed before therapy which was significantly higher after bithionol. Creatinine phosphokinase and lactate dehydrogenase enzymes and kidney function tests showed almost normal values and were not altered by therapy. It was concluded that Bitin was a potent fasciolicidal drug in the dose used. No side effects were observed.

Human intestinal infection with Nanophyetus salmincola from salmonid fishes

Between 1974 and 1985, 10 patients were studied who presented with either gastrointestinal complaints or unexplained peripheral blood eosinophilia, and had eggs typical for N. salmincola recovered from their stools. Clinical findings in 8 of the 10 included increased frequency of bowel movements or diarrhea (6), peripheral blood eosinophilia (6), abdominal discomfort (5), nausea and vomiting (3), weight loss (2), and fatigue (2). Two were asymptomatic. Eight recalled eating fish prior to the onset of symptoms. Anthelminthic treatment consisting of three 2-g doses of niclosamide (2 patients) or two 50 mg/kg doses of bithionol (1 patient) proved effective. In the remaining individuals symptoms resolved slowly over several months.

Evaluation of ELISA for the diagnosis of paragonimiasis westermani

Possible applicability of an enzyme-linked immunosorbent assay (ELISA) for the diagnosis of paragonimiasis westermani was examined using crude extract of adult Paragonimus westermani (Pw) as the test antigen. The mean ELISA values of the sera from Pw egg-positive cases and from clinically suspected cases were more than 22 times higher than that of the healthy control. No, or only marginal, cross-reactivity was observed against Pw antigen using sera from patients with various parasitic diseases other than paragonimiasis, except that from schistosomiasis and clonorchiasis cases. When serum samples from the endemic area were tested by ELISA and double diffusion (DD), sera from skin test (ST)-positive and DD-positive cases were all positive with ELISA, whereas approximately 19% of ST-positive but DD-negative cases were positive for ELISA. Diagnosis by ELISA values correlated well with, and seemed to be more sensitive than, that by DD test. In some definite paragonimiasis cases, the ELISA value was markedly reduced after drug-treatment with bithionol. These results suggest that ELISA is useful not only in mass screening but also in the evaluation of the efficacy of drug treatment in paragonimiasis.

Pulmonary paragonimiasis: clinical features, diagnosis and treatment of 39 cases in Manipur

Thirty-nine cases of pulmonary paragonimiasis due to Paragonimus westermani were identified in Manipur, India. Recurrent haemoptysis, often increased on exertion, was the most common symptom. The clinical features and radiological appearances simulated pulmonary tuberculosis and 23 cases were treated for tuberculosis for varying periods before the final diagnosis. Young males aged 11 to 30 years comprised two-thirds of the cases. The disease was acquired by eating raw or improperly cooked crabs (Potamon deham). Intradermal tests (IDT) employing a saline extract of adult Paragonimus were a simple and reliable method of detecting present or past infection. Erythema of large size even without wheal and pseudopodia may indicate a positive IDT. Charcot-Leyden crystals (CLC) were detected in all sputum samples positive for Paragonimus ova. In patients (four) presenting with pleural effusion, Paragonimus ova were not present in the sputum, stool or pleural fluid. Bithionol (2,2'-thiobis [4,6-dichlorophenol]) orally, 40 mg/kg body-weight/day, 10 to 25 doses, cured all cases and, except in one, side effects were minimal. Relapse in one patient after six months' treatment was apparently cured by a second course of Bithionol.

Successful praziquantel treatment of paragonimiasis following bithionol failure. A case report

A patient from Southeast Asia with cough and hemoptysis was documented to have pulmonary paragonimiasis. Initial treatment with bithionol failed. The patient was then treated with praziquantel 75 mg/kg body weight a day for 2 days under an investigational protocol. Subsequent follow-up studies showed clinical improvement and indicated parasitologic cure. A concurrent asymptomatic Clonorchis infection was also cured following praziquantel treatment. Side effects were minor.

Paragonimiasis. Atypical appearances in two adolescent Asian refugees

Paragonimiasis is a parasitic disease endemic to Asia, Africa, and South America. With the increasing number of Southeast Asian immigrants arriving in the United States, physicians should be aware of the various manifestations of this disease. We describe two adolescent Asian refugees who had atypical cases of paragonimiasis. One experienced acute abdominal pain mimicking appendicitis, and the other had asymptomatic left upper-lobe cavitation.

Paragonimiasis in the United States. A report of nine cases in Hmong immigrants

Nine cases of paragonimiasis have been encountered in Laotian Hmong immigrants from Camp Ban Vinai in Thailand. Symptoms included cough, hemoptysis, and fever. Chest x-ray films showed segmental infiltrates and pleural effusions, often bilateral. The clinical presentation mimics tuberculosis. All Hmong patients with chronic infiltrates and pleural disease in whom tuberculosis has not been proven should have parasitologic and serologic evaluation to exclude paragonimiasis.

Relapse of Paragonimus westermani lung infection after bithionol therapy

Clinical trials of bithionol in treating Paragonimus westermani lung infection have been conducted in areas of endemic infection. Bithionol has been reported to cure over 90% of infected patients. We report a case of a 32-year-old Laotian man residing in Connecticut who relapsed with P. westermani pneumonitis 4 months after apparent eradication of infection with bithionol (40 mg/kg by mouth every other day for 10 doses). He was successfully treated with a second course of bithionol (40 mg/kg by mouth every other day for 15 doses). The mechanism of relapse of P. westermani infection following bithionol therapy should be evaluated.

Paragonimus westermani: a cause of cavitary lung disease in an Indochinese refugee

A Laotian immigrant with persistent cough and hemoptysis was found to have multiple small cavities on chest roentgenogram. Ova of the lung fluke Paragonimus westermani were found in the sputum, and the patient responded to bithionol therapy. Pulmonary paragonimiasis should be considered in the differential diagnosis of cavitary lung disease in Indochinese refugees entering the United States.