1. Paragonimiasis Department of Pulmonology Yeehyung Kim M.D.

2. Introduction Paragonimiasis –Caused by lung fluke, the trematode of the genus Paragonimus –43 species of Paragonimus 12 species infect human : incidental host P. westermani –In the 1878, Kerbert : discovered from lung of Baegal tiger named after Westerman ( 당시 동물원장 ) –Most endemic area Asia, West Africa, parts of south & central America U.S.A : immigrants & visitors from endemia area –Increase in overseas traveler, popularization of ethnic dishes & expansion of worldwide trading of foods

3. Introduction –Increased risk of infection Culinary habits that include ingestion of raw, undercooked, or pickled crabs ( 게 ) or crayfish ( 가재 ) –“Drunken crabs” : live crabs immersed in liquor, in China –“goong ten” : raw crayfish salad, in Thailand –“kinoulao” : raw crabs, in Philippines –“Ke jang” : raw crab in soy sauce, in Korea Crab/Crayfish juice : Used medically for Tx of measles, asthma, & urticaria in Korea and Japan Contaminated utensils( 요리도구 ) or raw juice from the infected animals

4. Life cycle sputum stool 1 st intermediate host 달팽이 Developmental stages inside the snail External environment 2 nd intermediate host 민물게 or 가재 Or other mammals

5. Migration route Because of migration route, Various symptoms depending on the location of worms Juvenile worm Mature worm 6 weeks 5~7 days lodge 2 ~ 8 weeks

6. Pathogenesis The of the worms through the body The migration of the worms through the body to the worms & worm Ag. Inflammatory response to the worms & worm Ag.

7. Pathogenesis Travel through the pleura –Exudative pleural effusion : eosinophilic predominance Encyst and become walled off from immune system –Most cyst : in communication with bronchiole release of eggs –Cyst contents or eggs into lung parenchyma Trigger inflammatory reactions : bronchopneumonia, granuloma Histologically, eosinophilic pneumonia –Parasite die…  Cysts : fibrosis and calcification Aberrant migration to other organs : m/c CNS

8. Clinical manifestation Diarrhea Abd. discomfort Shortly after infection Pleuritic pain Pneumothorax Through diaphragm and pleura CNS involvement Headache, visual disturbance Seizure, paralysis Chronic debilitating symptoms Fever, malaise, chronic cough hemoptysis Tb…?? Misdiagnosis 50~70%

9. Pulmonary symptoms Clinical manifestation Cough Hemoptysis : rusty or chocolate sputum, bright red Chest pain Dyspnea : d/t pleural effusion

10. Subjective Sx of paragonimiasis SymptomsNo. of cases(%) Bloody sputum53 (81.0) Cough13 (20.3) Fish order12 (18.7) Chest pain11 (17.3) Dyspnea8 (12.5) Expectoration5 (7.8) epilepsy2 (3.1) 국립의료원, 1990

11. Diagnosis - radiologic finding Nodular pattern Infiltrative pattern Cavitating lesions Pleural lesions : effusion, PTX - 66.7%

12. Diagnosis - radiologic finding (a) Nodular pattern (b) Mixted pattern : nodular, infiltrative and cavitating

13. Diagnosis - radiologic finding (e) pleural effusion (f) pneumothorax

14. Diagnosis - radiologic finding Chronic pleural empyema by Paragonimiasis

15. bandlike opacity abutting the visceral pleura indicating worm migration tracks, as well as an air-filled worm cyst pneumothorax air-filled worm cyst Chest roentgenogram of a Korean adult with a large Paragonimus cyst in the Rt. lung Diagnosis - radiologic finding

17. Difficulty in radiologic finding Due to variation in radioimaging apperance of pleuro- parenchymal lesions of paragonimiasis –D–DDx from lung cancer tuberculosis fungal infections

18. Previous diagnosis & Treatmnet Previous diagnosisNumber(%) Pulmonary tuberculosis30 (46.9%) Pulmonary paragonimiasis5 (7.8%) Tuberculous pleurisy1 (1.5%) No previous examination28 (43.8) Total64 (100.0) 국립의료원, 1990

19. Diagnosis Key clue –Hx of handling or eating raw/undercooked freshwater crabs or crayfish Paragonimus eggs in sputum or stool : 40% –Multiple samples –Eggs : golden brown and operculated –BALF or brushing samples, rarely pleural effusion

20. Diagnosis

21. Egg of P. westermani yellow-brown, ovoid or elongate, with a thick shell, and often asymmetrical with one end slightly flattened. At the large end, the operculum is clearly visible. The opposite (abopercular) end is thickened. The eggs of P westermani are excreted unembryonated and may be found in the stool or sputum

22. Diagnosis Serology –ELISA or immunoblot assay using crude Ag from whole worms Parasite-specific IgG Ab, IgE Ab Circulating antigen Specific IgM –Useful for diagnosis of paragonimiasis in early stage –Intradermal test : classical methods remain (+) for many yrs after successful Tx.

23. ELISA sensitivity & specificity

24. Multiple-dot ELISA test 2 hours

25. Diagnosis Serology –To monitor clinical course or to evaluate the efficacy of Tx Quantitative measurement of parasite-specific IgG Ab by ELISA method Multi-dot ELISA : qualitative method not suitable for this purpose

26. Lab. findings Pph eosinophilia : normal or slightly elevated total WBC Elevated s-IgE The degree of pph eosinophilia ☞ the stage of paragonimiasis

28. After 6 month Stool exam. for various parasitic eggs : negative

30. Cont’d

32. Pph eosinophilia : 23% No eggs in sputum & stool ELISA : IgG Ab – strong positive

33. Pleural Bx : nonspecific granulation Pleural fluid analysis : eosinophil-dominanat After 4 month

34. Treatment Bithionol (Bitin ®, Japan) : 1 st drug –Long-term administration, S/E(diarrhea, N/V) ↑ Praziquantel (Biltricide ®, Germany) –TOC, 75mg/kg/day, for 2~3 days –Therapeutic cure rate : 95 ~ 100% Triclabendazole (Egaten ®, Swiss) –10.0 ~ 12.5mg/kg/time x 1~2 days –Alternative regimens Corticosteroids –during treatment of cerebral paragonimiasis to decrease inflammation triggered by the death of parasite

35. Considerations 1. 각국 음식의 세계화 2. 여행 및 교류의 확대 3. 유기농 음식에 대한 요구 증가