PARASITOLOGY

2.05 LUNG FLUKES

JENNIFER ALVARADO, MD | JUNE 28, 2022

OUTLINE • Adult worm

I. Paragonimus E. Treatment → Reddish brown
westermani F. Epidemiology → 7-12mm long, 4-6mm wide, 3.5-5mm thick
A. Morphology G. Prevention and
→ Resembles coffee bean
B. Life Cycle Control
C. Pathogenesis and → Rounded anteriorly and slightly tapered posteriorly
Clinical → Integument covered with single spaced spines
Manifestation → 2 testes: deeply lobed, located opposite each other,
D. Diagnosis midway between ventral sucker and posterior
border of body
LEGENDS → Ovary: located anterior to testes and posterior to
LECTURER BOOK 1 BOOK 2 PPT ventral sucker
→ 6 long, unbranched lobes
→ Vitellaria: branched extensively
I. PARAGONIMUS WESTERMANI
→ Coiled uterus
• Lung fluke disease/ Oriental lung fluke
→ Cercaria is covered with spines, has an ellipsoidal
• Paragonimiasis
body, and a small tail
• Pulmonary distomiasis
→ Stylet is present at the dorsal side of the oral sucker
• Endemic hemoptysis
• Parasitic hemoptysis
• Causes 90% of Paragonimiasis in Asia
→ Paragonimus siamensis (only other species in the
PH)
• Major species that causes human Paragonimiasis
• 1879 (Ringer) 1st case in humans (during autopsy):
Formosa
• 1880(Baelz): Japan
• 1880 (Manson): Formosa, ova in sputum
• 1907 (Musgrave): Phil. (described the 1st case of
paragonimiasis in the Phil.)
• 1915 (Nakagawa) discovered crabs as second
intermediate host
• 1917 (Nakagawa) succeeded in infecting Malania
libertine (snail) with Paragonimus miracidia

A. Morphology
• Egg
→ Oval, yellowish brown
→ Thick-shelled
→ 80-118um by 48-60um
→ Flattened but prominent operculum
→ Abopercular portion: opposite the operculum
→ Unembryonated at oviposition

B. Life cycle
• Immature egg embryonates in water, moist soil or
leached feces
• Miracidium develops 2-7 wks.; pushes operculum and
swims freely to seek its 1st intermediate host (snail),
Antemelania asperata or Brotia, Antemelania
dactylus

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• Inside snail, miracidium passes through 1 sporocyst → Development of fibrotic cyst containing blood-
and 2 redial stages tinged purulent materials, adult worms and eggs
• Cercaria emerge from snail and seek and infect its 2nd → Most common symptoms: chronic cough and
intermediate host, mountain crab (Sundathelphusa hemoptysis
philippina) → Chest pain, dyspnea, low grade fever, fatigue and
• Cercaria penetrates the crustacean and encyst as generalized myalgia
metacercaria in the gills, body muscles, viscera or legs → Asymptomatic: early stages
• Crab may also be infected by eating infected snails → Clinical symptoms are less severe after 5-6 years
• Definitive host acquires infection by ingesting raw or → Serious sequelae: chronic bronchiectasis and pleural
insufficiently cooked crabs harboring metacercaria fibrosis secondary to severe parenchymal and pleural
• Following ingestion of infected crustacean by the host, damage
metacercaria excyst in the duodenum of the host → Circuitous route of migration: worm localize lung
• Immature worm traverses through intestinal wall to pleura, pericardium, myocardium, abdominal wall,
peritoneal cavity, it wanders and embeds itself in the omentum, liver, mesenteric lymph nodes, adrenals,
abdominal wall (several days) urogenital organs and eyes
• Parasite returns to the coelom, migrates through the → Heavy intensity infection: cause pulmonary and
diaphragm to pleural cavity ectopic paragonimiasis
• Juvenile diploid worm wanders in pleural spaces until → Worms that fail to find mate in low intensity
it finds one or several diploid worms infection- ectopic sites
• Pair or group migrates into lung parenchyma to • Cutaneous Paragonimiasis
develop into adults (6 weeks) → Slow, moving nodular lesion in the SQ tissue on the
• Mate and lay eggs abdomen or chest
• Lung parenchyma, fibrotic capsule forms around the • Cerebral Paragonimiasis
parasite or their group → Most serious complication
• Fibrotic capsule has openings that allow the eggs to → Migrate through soft tissue along internal jugular
escape into respiratory tract vein
• Moved up and out by ciliary epithelium along with lung → Cause congestion, vasculitis and capillary rupture
exudate → Result in exudative aseptic inflammation, infarction,
• Pharynx: coughed out or swallowed to the alimentary hemorrhage, and necrosis (subcortical area)
canal to be passed out with the feces. → Conglomerated and interconnected granulomas
• Time required for completion of development in the form around the parasite, containing abscess and
definitive host = 65-90 days. eggs
• Worms persist in humans for as long as 20 years → Chronic stage: liquefaction necrosis and fibrinous
• Animal reservoir hosts: dogs, cats, field rats and rodents gliosis lead to cortical or subcortical atrophy and
• Cysteine proteases secondary ventricular dilatation
→ Have been found to play an important role in the → Headache, meningismus, seizures, hemiparesis,
development of young parasites blurring of vision, diplopia, homonymous
→ Involvement in the metacercarial excystment, tissue hemianopsia and aphasia
invasion, and immune modulation of the host
D. Diagnosis
• Microscopy
→ Most basic and available
→ Definitive diagnosis: eggs (sputum, stool , abscess,
pleural effusion)
• Chest Radiograph
→ Aid in the diagnosis
→ Lung parenchyma
lesions which may be
infiltrative, nodular,
C. Pathogenesis and Clinical Manifestations: cavitating, or
combination
• Lungs
→ Provoke granulomatous reaction → Pleural effusion ½ of
patients

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→ Not specific seen in PTB, lung cancer and fungal • Zamboanga del Norte (2005): 14.8% prevalence rate
infections • Transmission attributed to preparation of local
• CBC: eosinophilia delicacies using crab juice, eating raw or undercooked
• Increased IgE roasted crab, contaminated utensils
• WBC count: normal to increased
• Intradermal test
→ Screen patients but does not differentiate from
present to past infection
• Serological tests
→ Compliment fixation:
▪ Standard, high sensitivity for both diagnosis and
assessment of cure after therapy
▪ Able to detect more rapid declining antibody
levels after chemotherapy
→ Enzyme Immunoassay:
▪ replaced CF due to technical difficulties, 96% to
99% sensitivity G. Prevention and Control
→ Immunoblot (IB): • Avoid eating raw or insufficiently cooked crab and
▪ 99% sensitivity other crustaceans as well as meat from paratenic host
• Skull x-ray (wild pig)
→ Specific soap-bubble calcifications • Safe food preparation
• CT scan and MRI • Elimination of reservoir and intermediate host is not
→ Conglomerated, multiple ring enhancing lesions feasible
(grape clusters) • Capacity building of local health staff on the diagnosis
→ Surrounding edema, typically in one cerebral and treatment for early case detection and appropriate
hemisphere, posterior part of the brain treatment
• Loop mediated isothermal amplification (LAMP)
→ Simple, rapid and cost effective REFERENCES
→ Warm water required to perform • Dr. Alvarado’s PPT slides
→ Epidemiologic studies • Belizario
• Zeibig
E. Treatment
• Praziquantel: DOC
→ 25mg/kg TID x 2-3 days
→ higher dose for ectopic paragonimiasis
→ Cerebral involvement: short term therapy with
corticosteroid
→ It induces rapid contraction of trematodes and
alters the tegmental surface (e.g., vacuolization)
→ Linked to the drug-dependent disruption of calcium
homeostasis.
• Bithionol: alternative drug
→ 15 to 25mg/kg BID on alternate days x 10 to 15 days
• Triclabendazole: effective

F. Epidemiology
• Global distribution in freshwater crabs
• 292.8M at risk
• 20.7M infected
• Phil.: endemic in Mindoro, Camarines, Sorsogon, Leyte,
Samar, Zamboanga del Norte, Davao Oriental, Basilan
and Cotabato
• Sorsogon (1997) 16-25% infection rate

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APPENDIX

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