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9 - Paragonimus - Case Report
9 - Paragonimus - Case Report
Case Report
a r t i c l e i n f o a b s t r a c t
Article history: We report a case of Paragonimus westermani infection simultaneously affecting two separate organs that
Received 14 February 2018 presented as both a pulmonary cavity and adrenal mass in an immunocompromised host. A 65-year-old
Received in revised form male with a previous kidney transplant visited our clinic because of hemoptysis. Chest computed to-
4 July 2018
mography (CT) showed a pulmonary cavity and right adrenal gland mass. The Aspergillus antigen titer in
Accepted 10 August 2018
Available online xxx
bronchial lavage fluid was elevated and showed positive conversion. It was necessary to differentiate
lung cancer with adrenal gland metastasis from a fungal infection with an adrenal gland adenoma.
Positron emission tomography CT suggested benign disease, and it was misdiagnosed as pulmonary
Keywords:
Paragonimiasis
aspergillosis based on the elevated Aspergillus antigen titer in the bronchial lavage fluid. Owing to the
Paragonimus westermani adverse effects of anti-fungal treatment, the patient underwent wedge resection of the lung and
Pulmonary parasitic infection P. westermani was confirmed. A careful history revealed that the patient had eaten raw freshwater crabs 3
Adrenal gland years earlier, and a test for serum antibodies to P. westermani was positive. Despite treatment with
Praziquantel praziquantel, the adrenal mass persisted on 3-month follow-up CT. A right adrenalectomy was per-
formed and a P. westermani infection was confirmed.
© 2018 Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases.
Published by Elsevier Ltd. All rights reserved.
https://doi.org/10.1016/j.jiac.2018.08.005
1341-321X/© 2018 Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Kwon YS, et al., Paragonimus westermani infection manifesting as a pulmonary cavity and adrenal gland mass:
A case report, J Infect Chemother (2018), https://doi.org/10.1016/j.jiac.2018.08.005
2 Y.S. Kwon et al. / J Infect Chemother xxx (2018) 1e4
renal transplantation 6 years earlier. Twenty months earlier, bilat- had not changed in size and intermittent coughing up with reddish
eral spontaneous pneumothorax was diagnosed and treated with material persisted.
oxygen supplementation and right chest tube insertion. At that One year after presentation, chest CT showed that the cavitary
time, there was no demonstrable cavitary lesion in either lung and lesion had migrated from the superior segment to the lateral basal
no mass in the adrenal glands (Fig. 1A,B). Computed tomography segment of the RLL and the right adrenal mass had grown to 40 mm
(CT) of the chest when the patient presented with hemoptysis (Fig. 1E,F). Positron emission tomography showed mild hyperme-
showed a pulmonary cavity with consolidation in the right lower tabolism (standardized uptake value [SUV]max 5.8) in the RLL lesion,
lobe (RLL) and a 35-mm adrenal mass (Fig. 1C,D). Bronchoscopy was which was considered to be a benign inflammatory lesion rather
performed and empirical anti-tuberculous medication was pre- than a malignancy. The right adrenal mass showed intense hyper-
scribed because the patient had been taking immunosuppressive metabolism (SUVmax 7.7), suggesting malignancy rather than a
agents and had previously had tuberculosis. However, no organ- benign inflammatory lesion (Fig. 2). Hormone work-up for adrenal
isms were seen on a Gram stain, acid-fast stain, or direct exami- adenoma suggested a non-functioning tumor and a CT-guided ad-
nation for fungal elements, and bacterial, mycobacterial, and fungal renal mass biopsy was performed. This showed a dense eosino-
cultures were negative. Three months after starting the tubercu- philic infiltration with parasite eggs and no evidence of malignancy.
losis treatment, follow-up chest CT revealed no change in the A wedge lung resection was performed and the surgical specimen
pulmonary cavity with consolidation. The empirical tuberculous contained several ovoid structures and surrounding foreign body-
medication was stopped. type giant cells. The background showed lymphoeosinophilic
Nine months after presentation, the cavitary lesion in the RLL infiltration and granulomatous inflammation (Fig. 3A).
had grown slightly on CT (not shown) and was interpreted as an After lung resection, we took a careful history and discovered
inflammatory lesion rather than a tumor. The right adrenal mass that the patient had eaten raw crabs 3 years earlier. A serologic
Fig. 1. Serial chest CT findings of pulmonary and intra-abdominal paragonimiasis in a 65-year-old male. Twenty months before the episode of hemoptysis, (A) CT shows a bilateral
pneumothorax with no demonstrable cavity and (B) a scan of the upper abdomen showed no adrenal mass. On presentation with hemoptysis, CT shows (C) a subpleural cavitary
nodule (arrow) in the RLL superior segment and (D) a newly developed 35-mm mass (arrow head) in the right adrenal gland. At the 1-year follow-up, CT shows (E) a slight increase
in size and migration of the cavitary nodule (arrow) to the RLL lateral basal segment, and (F) the right adrenal mass (arrow head) had grown to 40 mm. CT, computed tomography;
RLL, right lower lobe.
Please cite this article in press as: Kwon YS, et al., Paragonimus westermani infection manifesting as a pulmonary cavity and adrenal gland mass:
A case report, J Infect Chemother (2018), https://doi.org/10.1016/j.jiac.2018.08.005
Y.S. Kwon et al. / J Infect Chemother xxx (2018) 1e4 3
3. Discussion
Fig. 3. Histological examination reveals (A) Paragonimus eggs in the lung parenchyma. (hematoxylin and eosin [HE] stain, x 200) (B) There is extensive necrosis of the adrenal
parenchyma and sclerosis at a low magnification (HE stain, x 40) with (C) numerous parasite eggs in the necrotic bed (HE stain, x 100). (D) The eggs are ovoid and measure
85e110 mm (HE stain, x 400).
Please cite this article in press as: Kwon YS, et al., Paragonimus westermani infection manifesting as a pulmonary cavity and adrenal gland mass:
A case report, J Infect Chemother (2018), https://doi.org/10.1016/j.jiac.2018.08.005
4 Y.S. Kwon et al. / J Infect Chemother xxx (2018) 1e4
Please cite this article in press as: Kwon YS, et al., Paragonimus westermani infection manifesting as a pulmonary cavity and adrenal gland mass:
A case report, J Infect Chemother (2018), https://doi.org/10.1016/j.jiac.2018.08.005