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Parasitic infestations affect millions of the worlds population. Global immigration and climate
change have led to changes in the natural distribution of parasitic diseases far removed from
endemic areas. A broad spectrum of helminthic and protozoal parasitic diseases frequently affects
the respiratory system. The wide varieties of clinical and radiographic presentations of parasitic
diseases make the diagnosis of this entity challenging. Pulmonologists need to become familiar
with the epidemiology, clinical presentation, pathophysiologic characteristics, and bronchoscopic
ndings to provide proper management in a timely fashion. This review provides a comprehensive view of both helminthic and protozoal parasitic diseases that affect the respiratory system,
especially the airways.
CHEST 2014; 145(4):883895
Abbreviations: BALF 5 BAL fluid; DEC 5 diethylcarbamazine; ELISA 5 enzyme-linked immunosorbent assay;
PAH 5 pulmonary artery hypertension; TPE 5 tropical pulmonary eosinophilia
Nematodes
Nematodes, also known as roundworms, have a symmetrical, tube-like body with an anterior mouth and a
longitudinal digestive tract.
Ascariasis
Ascaris lumbricoides is one of the most common
parasitic infestations, affecting . 1 billion of the worlds
population and causing . 1,000 deaths annually.1 A
lumbricoides is transmitted via the feco-oral route. An
Ascaris larva migrates to the lungs through either the
lymphatics or the venules of the portal system. Larval
ascariasis causes Lfers syndrome, a concomitance
of wheezing, pulmonary inltrations, and eosinophilia.2
It can cause alveolar inammation, necrosis, and hemorrhage. Diagnosis of an ascariasis infestation during its
larval phase is difcult. The sputum may show numerous eosinophils; stool examination, however, remains
negative for eggs during the larval stage.3 The diagnosis requires a high degree of suspicion. Occasionally,
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883
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Infective Form
Endemic Area
Mode of Transmission
Ingestion
Hookworm (Ancyclostoma
duodenale) (Necator
americanus)
Larva
Tropical and
subtropical areas
Skin penetration
Strongyloidiasis
(Strongyloides stercoralis)
Filariform larvae
Tropical and
subtropical areas
Skin penetration
Syngamosis (Mammomonogamus
laryngeus)
Eggs or adult
worms
Ingestion
Larva
Tropical and
subtropical areas
Mosquito-borne
infection
Tropical pulmonary
eosinophilia (Brugia malayi)
(Wuchereria bancrofti)
Larva
Tropical and
subtropical areas
(South and
Southeast Asia)
Mosquito-borne infection
Larva
Worldwide
Ingestion
Larva
Worldwide
Ingestion
Cercarial larvae
East Asia,
South America,
Sub-Saharan Africa
Skin penetration
Trematodes
Schistosomiasis
(Schistosoma species)
Pulmonary Presentation
Eosinophilic
pneumonia, cough,
wheezing, dyspnea
Eosinophilic
pneumonia, cough,
wheezing, dyspnea,
alveolar hemorrhage
Bronchoscopic
Evaluation
Treatment
Presence of parasite
in the airways
Mebendazole and
albendazole
Presence of hookworm
in sputum, a
marked eosinophil
predominance
from BAL
Bloody BAL and
presence of parasite
from BAL under
microscopic
examination
Presence of parasite
in the airways
Mebendazole and
albendazole
None (self-limited)
BAL shows
eosinophils more
than 50% of
the total cells
Diethylcarbamazine
N/A
Diethylcarbamazine
Cough, pulmonary
inltrates, dyspnea
due to respiratory
muscles involvement
N/A
Mebendazole
Pulmonary
hypertension and
Katayama fever
An eosinophil
predominance from
BAL in the absences
of parasites
Praziquantel
Eosinophilic
pneumonia, cough,
wheezing, dyspnea,
hyperinfection
syndrome
Foreign body-like
lesion in bronchus,
nocturnal cough
Cough, chest pain,
fever, dyspnea, mild
eosinophilia, and
lung nodules
Eosinophilic
pneumonia, cough,
wheezing, dyspnea,
restrictive pattern on
spirometry, decreased
diffusion lung capacity
Eosinophilic pneumonia,
episodic wheezing
Ivermectin and
albendazole
Removal through
bronchoscopy
(Continued)
885
Therapeutic
bronchoscopy
and dapsone
Bronchoscopy
revealed pinkish
mulberry-like
rhinosporidiosis
mass in the airway
Spores
Mesomycetozoea
Rhinosporidiosis
(Rhinosporidium seeberi)
South Asia
Ingestion of
contaminated
water
Strawberry-like,
nasopharyngeal
polyps, epitasis,
nasal congestion
Surgical removal of
cysts, followed
by mebendazole
and albendazole
Bronchoscopic
examination reveals
sac-like cyst in the
airway
Chest pain, cough,
hemoptysis, pleural
lesion, expectoration
of cyst contents,
and hypersensitivity
reaction
Ingestion
Worldwide
(especially Middle East)
Eggs
Cestodes
Hydatid disease
(Echinococcus granulosus)
Treatment
Praziquantel and
triclabendazole
Bronchial stenosis due
to mucosal edema
and mucosal
nodularity
Fever, cough,
hemoptysis, chest
pain, and pleural
effusion
Ingestion of
infested crustaceans
Southeast Asia,
South America,
Africa
Metacercaria
(infective larvae)
Paragonimiasis (Paragonimus
species)
Bronchoscopic
Evaluation
Pulmonary Presentation
Mode of Transmission
Parasite
Infective Form
Endemic Area
Table 1Continued
886
Figure 1. A, Hookworm larva in the sputum sample (wet smear, original magnication 3 88). Morphologically, hookworm larvae have long
buccal cavities, whereas Strongyloides larvae have short buccal cavities. (Reprinted with permission from Beigel et al.9) B, Bloody aliquot
from BAL sample and Strongyloides larvae from BAL (hematoxylin and eosin [H&E], original magnication 3 200). Note: short buccal
cavity distinguishes Strongyloides from the hookworm (inset) (H&E, original magnication 3 400). C, Strongyloides larvae (arrow) present
in alveolar space in lung with diffuse alveolar damage (H&E, original magnication 3 400). D, Bronchoscopic ndings in anterior basal
segment of right lower lobe. The syngamosis male is smaller and attached to the copulatory bursa of the female body (arrow). The parasite
can be seen in bronchoscopy because they reside in the bronchial mucosa. (Reprinted with permission from Kim et al.19) E, Cross-sections
of coiled Dirolaria worms within involved artery causing surrounding infarction of lung tissue. Note the smooth cuticle at the external
layer (Movat stain, original magnication 3 200). F, Schistosomal ova in the lung biopsy specimen. The arrow points to ova within the
granulomatous reaction (H&E, original magnication 3 100).
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887
Figure 2. A, Bronchoscopic ndings showed mucosal nodularity on the right upper lobe (RUL). (Reprinted with permission from Jeon et al.51)
B, Microscopic examination of bronchial tissue obtained from the RUL bronchus showing thickening of the basement membrane and
chronic inammation with eosinophilic inltration (H&E, original magnication 3 200). (Reprinted with permission from Jeon et al.51)
Inset: Paragonimus kellicotti egg in a BAL sample. The arrow points to the operculum ridges of the egg (Papanicolaou, original magnication 3 400). (Image courtesy by Gary Procop, MD.) C, Granulomas in the pleura in a patient with paragonimiasis. The arrow points to
a light brown egg within the granuloma (H&E, original magnication 3 100). (Image courtesy by Gary Procop, MD.) D, Protruded hydatid
cyst from left lower lobe bronchus. (Image courtesy by Farid Rashidi, MD.) E, Echinococcus cyst fragments in lung biopsy specimen. The
arrows highlight the collapsed chitinous layer of a death hydatid cyst (H&E, original magnication 3 44). F, Echinococcus cyst fragments
in lung biopsy specimen. The fragmented ecchinococus cyst with collapsed chitinous layer resides within the granulomatous reaction
(H&E, original magnication 3 200). See Figure 1 legend for expansion of other abbreviation.
888
Special Features
Schistosomiasis
Five schistosomes species cause disease in humans:
Haematobium, Mansoni, Japonicum, Intercalatum,
and Mekongi.7 After malaria, schistosomiasis is the most
common cause of mortality among parasitic infections,
annually affecting 200 million individuals worldwide.1
Schistosoma haematobium resides in the urinary bladder, whereas Schistosoma mansoni and Schistosoma
japonicum reside in the mesenteric beds.34 Humans
become infested through the skin from contact with
fresh water containing Schistosomal cercaria (infecjournal.publications.chestnet.org
Paragonimiasis
Paragonimus species, including westernmani, cause
paragonimiasis that usually involves the lungs. The
mode of transmission is ingestion of the metacercaria
(infective larvae) from undercooked crustaceans. Undercooked meat of crab-eating mammals (wild boars, rats)
can infect humans as an indirect route of transmission.48
The larvae penetrate the intestinal wall and migrate
through the diaphragm and the pleura into the bronchioles.49 The eggs are produced by the mature adult
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889
Echinococcosis
Echinococcus granulosus and multilocularis are the
parasite species that cause hydatid disease in humans.
E granulosus is endemic in sheep-herding areas of the
Mediterranean, Eastern Europe, the Middle East, and
Australia. An estimated 65 million individuals in these
areas are infected.1 Humans become accidental hosts
either by direct contact with the primary hosts (usually
dogs) or by the ingestion of food contaminated with
feces, containing parasite eggs.34 The larvae reach the
lymphatics of the intestines and the bloodstream and
then migrate to the liver, the main habitat in human
hosts.
Two different presentations of echinococcosis are
noted: (1) cystic hydatidosis and (2) alveolar echinococcosis. An ecchinococcal infection becomes symptomatic after 5 to 15 years, secondary to local compression
or dysfunction of the affected organ. Pulmonary cysts
expand at a rate of 1 to 5 cm/y, and calcication is less
common.54 Pulmonary symptoms from the intact cyst
890
Figure 4. A, Bronchoscopy revealed pinkish mulberry-like rhinosporidiosis mass in the right main stem bronchus. (Reprint with permission
from Singh et al.64) B, Microscopic examination of the resected specimen shows bronchial subepithelium with sporangia of Rhinosporodium;
lled with small round endospores (H&E, original magnication 3 100). (Reprint with permission from Singh et al.64) C, Amebic lung
abscess from lung biopsy specimen. The arrows point to trophozoites of Entamoeba histolytica (H&E, original magnification 3 200).
D, Transbronchial needle biopsy specimen of a mediastinal lymph node shows histiocytes containing abundant Leishmania amastigotes
(arrows) (H&E, original magnication 3 1,000). Inset shows a close-up view of an amastigote. Its ovoid shape, eccentric nucleus, and kinetoplast are discerned (same magnication as image). (Reprint with permission from Kotsifas et al.68) E, Lung infected with Toxoplasmosis
gondii (arrow) with diffuse alveolar damage (H&E, original magnication 3 100). Inset shows bradyzoites of T gondii present in cytoplasm
of alveolar macrophage (H&E, original magnication 3 1,000). See Figure 1 legend for expansion of abbreviation.
journal.publications.chestnet.org
891
parenchymal and bronchial disease. The lung parenchyma around a hydatid cyst is often affected by the
lesion and may exhibit chronic congestion, hemorrhage,
and interstitial pneumonia, which often resolve after
the surgery.57 Spillage of hydatid uid must be avoided
to prevent secondary hydatidosis. Medical therapy may
have a role in poor surgical candidates and in intraoperative spillage of uid from a hydatid cyst. Antihelminthic agents, such as mebendazole or albendazole,
have shown only 25% to 34% cure rates.58 The drawback of antihelminthic therapy is that it weakens the
cyst wall and increases the risk of rupture. In addition, if the parasite dies because of the drug, the cyst
membrane may remain within the cavity and lead to
secondary complications, including infections.59 Percutaneous treatment by puncture-aspiration-injectionreaspiration has rarely been used in pulmonary cysts
because of the risk of anaphylactic shock, pneumothorax, pleural spillage, and bronchopleural stulae.60
Pulmonary alveolar echinococcosis is a rare but
severe and potentially fatal form of echinococcosis but
it is restricted to the Northern Hemisphere. The liver
is the rst target for the parasite, with a long, silent
incubation period. Pulmonary involvement results
from either dissemination or the direct extension of
the hepatic echinococcosis with intrathoracic rupture
through the diaphragm into the bronchial tree, pleural
cavity, or mediastinum. Chest radiograph or CT scanning may aid in the diagnosis. ELISAs and indirect
hemagglutination assay are available and offer early
detection in endemic areas. Radical resection of
localized lesions is the only curative treatment yet, is
rarely possible in invasive and disseminated disease.
Mebendazole and albendazole can be used, but the
required treatment duration need is a minimum of
2 years after the radical surgery.61
Mesomycetozoea
Mesomycetozoea is a group of organisms at the
border of the animal-fungal kingdom.62 They appear
in host tissues as sphere-shaped spores.
Rhinosporidiosis
Rhinosporidiosis is a chronic granulomatous infectious disease caused by Rhinosporidium seeberi. This
condition has a high prevalence in South Asia, especially
Sri Lanka.63 Patients usually present with recurrent
polypoidal, friable, hemorrhagic, lesions. The common sites of involvement are the nose and nasopharynx.
However, lesions can involve the tracheobronchial
tree, leading to partial or complete airway obstruction (Figs 4A, 4B).64 CT imaging is the preferred
study because it denes the extent of disease. Therapeutic bronchoscopy plays a major role in bronchial
rhinosporidiosis.
Dapsone is the only medication to arrest the maturation of the sporangia, but the lesions may recur after
months or years.65 Follow-up bronchoscopy is recommended to monitor signs of recurrence.
Protozoal Parasites
Protozoa parasites are single-celled organisms that
are mostly intracellular in humans (Table 2). Pulmonary
amebiasis is caused by Entamoeba histolytica trophozoites invading the intestinal mucosa and entering the
bloodstream, effecting systemic infection. Pleuropulmonary amebiasis occurs mainly by local extension from
the amoebic liver abscess. Patients usually present with
fever, right-upper-quadrant abdominal pain, and cough.
Sterile pleural effusion, lung abscess, hepatobronchial
Protozoal Parasites
Endemic Area
Pulmonary
amebiasis
Worldwide
Ingestion
Pulmonary
leishmaniasis
Asia, Africa,
Central and
South America
Sand y-borne
infection
Pulmonary
toxoplasmosis
Worldwide
Ingestion
892
Presentation
Fever, right upper
quadrant abdominal
pain, lung abscess,
hepatobronchial
stula
Pneumonitis, pleural
effusion, mediastinal
lymphadenopathy
Generalized
lymphadenopathy,
interstitial pneumonia,
diffuse alveolar
damage
Bronchoscopic Evaluation
Treatment
Metronidazole
Pentavalent antimonials
and liposomal
amphotericin B
Pyrimethamine and
sulfadiazine
Special Features
References
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