Arciaga, Frances Geline R.

June 30, 2021

2MD Parasitology I

SGD CASE:
General data: L.A. 17 year old boy, Filipino, Roman Catholic, residing at Caloocan City, consulted for the first time at
MCU-FDT Hospital.

Chief complaint: cough up of blood

History of present illness:

Four months prior to consult, patient ate undercooked shellfish (crabs) which was sent by his grandmother
from Bulacan after which he noted to have abdominal pain and diarrhea. No other associated signs and symptoms,
no medication was taken and no consult was done.
Three months prior to consult, patient experienced dry cough and low-grade fever. He was given
paracetamol 500mg which provided temporary relief.
One week prior to consult, patient started to have productive cough (rusty colored), chest pain and sweats.
Patient was taken to local hospital and RT-PCR for Covid was requested which came back negative. Patient was sent
home without medications.
Few hours prior to consult, patient noted to have two episodes of hemoptysis about 15 ml hence consulted
at MCU Hospital.

Other Pertinent Data:

Family of patient lives in a rented apartment. Grandparents are renting different rooms on the other side of the
apartment. His parents are also fond of eating shell fish such mussels and crabs. Diarrhea, Covid- 19 and TB are
prevalent diseases in the community. His grandfather on the paternal was noted to have on and chronic cough and
a chronic smoker.

Physical examination:
General survey: Patient is awake, oriented, well nourished, not in cardio-respiratory distress.
Vital Signs: Heart rate: 89 beats/min. BP: 110/70 mmHg RR: 25 breaths/min Temp: 37.7C
Anthropometrics: Weight: 65 kg Height: 175cm BMI: 21.2kg/m2
Skin: dry, warm to touch, fair skin turgor, CFT: less than 2 sec. No clubbing.
Chest/Lungs: symmetrical, no retractions, with equal tactile and vocal fremitus, with course rales and occasional
wheezes
Heart: adynamic precordium, no thrills, heaves or lift, PMI 5th ICS (L) midclavicular line. no murmur
Abdomen: flat, soft, no visible vessels and peristalsis, normoactive bowel sounds. No tenderness, tympanitic with
no direct & rebound tenderness.
Extremities: grossly normal

Laboratory work up:

CBC: revealed hemoglobin to be 12.6 g%
WBC count of 13, 000 /cumm, Eosinophilia of 12%, Platelet count 180,000/ cumm
AFB Smear: negative ABF bacilli
 The sputum showed operculated egg of elongated immature ova with flat operculum, posterior
thickening at posterior end
 Charcot-Leyden crystals were demonstrated in early morning sputum specimen
Bacteriology: No cultural growth
Mantoux test was negative.
Chest xray: ill-defined opacities on the left upper lobe
Guide Questions:
1. What are the salient features of the case?

Salient features in the case are:

a) Patient had abdominal pain and diarrhea.
b) Patient experienced dry cough and low-grade fever.
c) Patient started to have productive rusty colored cough, chest pain and sweats.
d) Patient noted to have two episodes of hemoptysis about 15 ml.

2. What are the different clinical infections to consider? Give reasons to rule in and rule out.

Differential Diagnosis can be: Bacterial Pneumonia

Rule In: Rule out:
● Chest pain ● Dyspnea
● Productive cough (rust-colored sputum) ● Anorexia
fever ● Weight loss
● Adventitious breath sounds (rales/crackles, ● Rigors
rhonchi, or wheezes) ● Hyperthermia or hypothermia
● Chills ● Tachypnea
● Malaise ● Use of accessory respiratory muscles
● hemoptysis ● Tachycardia or bradycardia
● nausea ● Central cyanosis
● vomiting ● Altered mental status
● diarrhea ● Altered sensorium
● abdominal pain ● Decreased exercise tolerance

Other Differential Diagnoses:

● Acute Respiratory Distress Syndrome ● Cutaneous Larva Migrans
● Amebic Meningoencephalitis ● Fascioliasis
● Ascariasis ● Histoplasmosis
● Aspergillosis ● Strongyloidiasis
● Asthma ● Taenia Infection
● Bronchiolitis ● Whipworm

3. What is your final diagnosis?

Patient has a Paragonimus westermani infection.

Paragonimus is a parasitic lung fluke (flat worm). Cases of illness from this infection occurs after
a person eats raw or undercooked infected crab or crayfish. Paragonimus infection also can be very
serious if the fluke travels to the central nervous system, where it can cause symptoms of meningitis.

Epidemiology: Paragonimus westermani and several other species are found throughout eastern,
southwestern, and southeast Asia; P. africanus is found in Africa, and P. mexicanus in Central and South
America. There are several species of Paragonimus in other parts of the world that can infect
humans. Some human cases of infection have been associated with eating raw crayfish on river raft trips
in the Midwest. Paragonimus has caused illness after ingestion of raw freshwater crabs.
MOT: The infection is transmitted by eating infected crab or crawfish that is either, raw, partially cooked,
pickled, or salted. The larval stages of the parasite are released when the crab or crawfish is digested.
They then migrate within the body, most often ending up in the lungs. In 6-10 weeks, the larvae mature
into adult flukes.

Signs and Symptoms: Adult flukes living in the lung cause lung disease. After 2-15 days, the initial signs
and symptoms may be diarrhea and abdominal pain. This may be followed several days later by fever,
chest pain, and fatigue. The symptoms may also include a dry cough initially, which later often becomes
productive with rusty-colored or blood-tinged sputum on exertion. The symptoms of paragonimiasis can
be similar to those of tuberculosis.

4. Illustrate the life cycle of the parasite correlating to the clinical signs and symptoms of the patient
thru a concept map.

When humans ingest raw infected

crustaceans, larval flukes develop in the
small intestine and penetrate the
intestinal wall into the peritoneal cavity
30 minutes to 48 hours after excysting.
They then migrate into the abdominal
wall or liver, where they undergo
further development. Approximately 1
week later, adult flukes’ reenter from
the abdominal cavity and penetrate the
diaphragm to reach the pleural space
and lungs. The eggs may then be
expectorated or swallowed.

5. What are the different laboratory procedures to request and expected results to the disease you
considered?

a) Sputum Exam – Eggs of P.westermani will show as yellowish brown, 80-120 µm long by 45-70 µm
wide, thick-shelled, and with an obvious operculum.
b) CBC Count - usually reveals eosinophilia in 10-30% of patients with paragonimiasis. The degree of
eosinophilia is significantly higher in patients who have pleurisy. Leukocytosis with eosinophilia
occurs early in the course of disease but then resolves over time. Total WBC count remains in the
normal range or slightly elevated despite remarkable eosinophilia.
c) Lung Biopsy - reveal adult worms or eggs.
d) Chest Radiography - chest films are normal in 13-20% of confirmed cases but in radiographic
abnormalities it may include ring shadows, which represent cavitating lesions, fibrosis, nodules or
linear infiltrates with calcified foci, loculated pleural effusions, and pleural thickening
 a. Migration of larvae can result in pneumothorax with consolidation or exudative pleural
effusions. During fluke maturation nodular or cystic lesions predominantly develop in the
periphery of the middle and lower lobes. Bronchiectasis can also occur. Following
treatment lesions gradually disappear over 3-26 months.
e) CT Scan / MRI - of the head may reveal cerebral calcification, cystic lesions, or hydrocephalus.
Chronic cerebral paragonimiasis may be suspected by the presence of a "soap bubble lesion," with
scattered calcifications.
f) Serology – Complement Fixation Test is sensitive and is most useful following therapy because
antibody levels fall 6-12 months after effective treatment.
g) CSF - reveals bloody or turbid fluid containing numerous eosinophils.
h) Thoracentesis - infected pleural fluid is usually serosanguineous and has more than 1000 red cells
with accompanying eosinophilia. The fluid is usually an exudate with a low glucose level. Parasitic
eggs are rarely detected in the sediment of pleural effusions.

6. What is/are your plan/s of treatment?

 Praziquantel 25 mg/kg orally 3 times a day for 2 days is the drug of choice for paragonimiasis.
o Praziquantel is used to treat extrapulmonary infections, but multiple courses may be
required.
 Triclabendazole is an acceptable treatment in areas where it is available; dosage is 10 mg/kg orally
once postprandially or, for severe infections, 2 doses of 10 mg/kg given postprandially 12 hours
apart.
 For cerebral infections, a short course of corticosteroids may be given with praziquantel to reduce
the inflammatory response induced by dying flukes.
 Surgery may be needed to excise skin lesions or, rarely, brain cysts.

7. What are your preventive measures?

a) People should take necessary precautions to avoid infection with the protozoan.
b) Raw or undercooked crayfish, crabs, shellfish or other infected crustaceans should not be eaten
unless when properly cooked as they may contain the infective form of the parasite.
c) Infected persons should be properly treated; and defecation in rivers and other water sources
should be discouraged by providing good toilets and latrines especially in public places.
d) Adequate cooking of crayfish, crabs, shellfish and other crustaceans before consumption is critical
to preventing infection with Paragonimus species.
e) Advocacy and education of the general public is critical to the prevention of the disease especially
in endemic regions.
f) Prevention programs should promote more hygienic food preparation by encouraging safer
cooking techniques and more sanitary handling of potentially contaminated seafood.

Reference/s:
CDC - Paragonimiasis - General Information - Frequently Asked Questions (FAQs)
PARAGONIMIASIS: PATHOGENESIS, CAUSATIVE AGENT, LAB DIAGNOSIS, PREVENTION
AND CONTROL - Microbiology Class
Paragonimiasis Workup: Laboratory Studies, Imaging Studies, Other Tests (medscape.com)
Paragonimiasis - Infectious Diseases - MSD Manual Professional Edition (msdmanuals.com)