CLINICAL PARASITOLOGY

SEM 1/MTAP 1 || 2023-2024

BATCH DIEGO

Case 11: LUNG FLUKES/ ORIENTAL LUNG FLUKE/ PARAGONIMIASIS

GENERAL CHARACTERISTICS MORPHOLOGY
CLASS TREMATODA
➢ Trematodes have flat or fleshy, leaf-like
unsegmented bodies
➢ Alimentary canal:
- present but incomplete
- without an anus
➢ Possess suckers
➢ NO hooks
➢ Sexes are separate in the schistosomes, while
the other flukes are hermaphroditic
➢ Oviparous
➢ Requires 3 hosts except schistosomes (2 hosts)
Adult lung fluke
PARAGONIMIASIS ➢ egg-shaped
➢ Oriental Lung Fluke ➢ reddish-brown
➢ 40 known species ➢ Length: 7 - 12 mm
➢ 6 infections in humans Width: 4 - 6 mm
Thickness: 3.5 - 5 mm
Paragonimus westermani ➢ resembles a coffee bean
➢ Causes 90% of paragonimiasis in Asia ➢ rounded anteriorly; tapered posteriorly
➢ Major species that causes paragonimiasis in ➢ Tegument
humans in the Philippines - single spaced spines
➢ P. siamensis - covered in scale-like spines (Paniker’s)
- only other species in the Philippines ➢ Oral sucker (Paniker’s)
- only been identified in cats - placed anteriorly
➢ Ventral sucker (Paniker’s)
Ringer (1879) - towards the middle of the body
➢ observed first case of pulmonary paragonimiasis ➢ Two testes
in humans - deeply lobed
➢ during an autopsy in Formosa - opposite each other
- Midway between ventral sucker and the
Baelz (Japan) and Manson (Formosa) (1880) posterior border of the body
➢ identified Paragonimus ova in human sputum ➢ Ovary
- anterior to the testes
Musgrave (1907) - posterior to ventral sucker
➢ described first case of human paragonimiasis in - 6 long unbranched lobes
the Philippines
➢ Vitellaria
Nakagawa (1915) - branched extensively
➢ discovered that crabs act as second
intermediate host Cercaria
➢ Two years later - succeeded in infecting the snail ➢ covered with spines
Melania libertine with Paragonimus miracidia ➢ ellipsoidal body
➢ small tail
➢ stylet is present at the dorsal side of the oral
sucker

~blckrz and frndz~

Metacercaria
➢ round
➢ measures from 381-457um

Immature egg
➢ oval
➢ yellowish-brown
➢ thick-shelled
➢ 80-118um by 48-60um
➢ flattened but prominent operculum
➢ embryonates in water, moist soil, or leached
feces

Miracidium
➢ develops within 2-7 weeks
➢ Pushes open the operculum and swims freely in
search of its appropriate snail host 1.) The eggs are excreted unembryonated in the
sputum, or alternately they are swallowed and passed
LIFE CYCLE with stool.
In the Philippines, 2.) In the external environment, the eggs become
1st intermediate host embryonated,
➢ Antemelania asperata (previously known as 3.) and miracidia hatch and seek the first intermediate
Brotia asperata) host, a snail, and penetrate its soft tissues.
➢ Antemelania dactylus 4.) Miracidia go through several developmental stages
2nd intermediate host inside the snail:
➢ mountain crab Sundathelphusa philippina 4a. Sporocysts
Definitive host 4b. Rediae, giving rise to many
➢ acquires infection by ingesting raw or 4c. Cercariae, which emerge from the snail.
insufficiently cooked crabs harboring 5.) The cercariae invade the second intermediate host, a
metacercariae crustacean such as a crab or crayfish, where they encyst
and become metacercariae. This is the infective stage
(Paniker's) for the mammalian host.
First intermediate host 6.) Human infection with P. westermani occurs by eating
➢ Fresh water snail inadequately cooked or pickled crab or crayfish that
➢ belonging to the genera Semisulcospira Brotia harbor metacercariae of the parasite.
7.) The metacercariae excyst in the duodenum,
Second intermediate host 8.) penetrate through the intestinal wall into the
➢ Fresh water crab or cray fish peritoneal cavity, then through the abdominal wall and
diaphragm into the lungs, where they become
Definitive host encapsulated and develop into adults (7.5 to 12 mm by 4
➢ Man to 6 mm).
➢ Other definitive host:
- cats, tigers, leopards, foxes, dogs, pigs, The worms can also reach other organs and tissues,
beavers, mongoose, and other such as the brain and striated muscles, respectively.
crab-eating mammals However, when this takes place completion of the life
➢ domestic animals cycles is not achieved, because the eggs laid cannot exit
these sites. Time from infection to oviposition is 65 to 90
Infective form days. Infections may persist for 20 years in humans.
➢ Metacercariae Animals such as pigs, dogs, and a variety of feline
➢ encysted in crab or cray fish species can also harbor P. westermani.
Reference: https://www.cdc.gov/dpdx/paragonimiasis/index.html
Note: also read from paniker's/belizario
 PATHOGENESIS Heavy intensity infections
In the lungs, ➢ can cause both Pulmonary and ectopic
Paragonimus worms provoke a granulomatous reaction paragonimiasis
that gives rise to the development of fibrotic cyst
containing blood-tinged purulent material, adult worms, Low Intensity infections
and eggs. ➢ Worms fail to find a mate
Most common symptoms: ➢ may end up in ectopic locations as well
Chronic cough
Classic known forms of Ectopic infection
Hemoptysis
1.) Cutaneous paragonimiasis
Other symptoms
➢ slow-moving, nodular lesion in the subcutaneous
Chest pain
tissue on the abdomen or chest
Dyspnea
Low-grade fever 2.) Cerebral paragonimiasis
Fatigue ➢ most serious complication
Generalized myalgia ➢ juvenile P. westermani may migrate from pleural
cavity to the cranial cavity
Early stages of the infection Migration worm
➢ usually asymptomatic ➢ can cause congestion, vasculitis, and capillary
➢ takes several weeks for the parasite to migrate rupture
and mature ➢ may result in exudative aseptic inflammation,
infarction, hemorrhage, and necrosis in the
Clinical symptoms are less severe after 5-6 years. subcortical areas
Chronic stage
Worms ➢ will occur liquefaction necrosis and fibrinous
➢ lie in cystic spaces gliosis
➢ surrounded by a fibrous capsule ➢ leads to cortical or subcortical atrophy and;
➢ formed by the host tissues ➢ secondary ventricular dilatation
➢ Symptoms:
These aberrant worms may localize in the: - headache
● lung pleura - meningismus
● pericardium - seizures
● myocardium - hemiparesis
● abdominal walls - blurring of vision
● liver - diplopia
● mesenteric lymph nodes - homonymous
● adrenals - hemianopsia
● urogenital organs - Aphasia
● eyes
LABORATORY DIAGNOSIS
Cysts Microscopy
➢ about a centimeter in diameter ➢ most basic and most readily available diagnostic
➢ usually in communication with a bronchus tool
➢ Definitive diagnostic is based on the detection of
Inflammatory reaction to the worms and their eggs the characteristic eggs in sputum, stool, or less
➢ lead to frequently in aspirated material from abscesses
- Peribronchial granulomatous lesions or pleural effusions.
- Cystic dilatation of the bronchi ➢ sensitivity is suboptimal
- Abscesses - detection in sputum ranging from
- Pneumonitis 37-38%
 ➢ Sputum concentration with 3% sodium
hydroxide with repeated sputum examinations
up to three times on different days
- best sensitivity for microscopic diagnosis
Chest radiographs
➢ when combined with a high index of suspicion
➢ Pleural effusions occur in almost half of the
patients
➢ not specific
- may also be seen in PTB, lung cancer,
and fungal infections
➢ PTB and paragonimiasis are usually co-endemic
(PTB should always be ruled out)
Peripheral Blood Count
➢ Total white blood cell count
- normal to elevated
➢ Eosinophilia
- more common in acute stage of
paragonimiasis
- typical for parasitic infections
➢ Elevated levels of IgE
- No correlation with the stage of the
disease
Immunological Methods
➢ Complement Fixation test
- High sensitivity for both diagnosis and
assessment of cure after therapy
➢ Intradermal test
- simple, rapid, cheap, and highly
sensitive
- may still yield positive results several
years after successful treatment
➢ Double diffusion in agarose gel
➢ Immunoelectrophoresis
DNA polymerase with strand-displacement
activity.
➢ Magnesium pyrophosphate
- the reaction by-product
- visible to the naked eye
➢ Only water is required to perform the assay
Cerebral paragonimiasis
➢ Computer Tomography (CT) scan and Magnetic
Resonance Imaging (MRI)
- conglomerated, multiple, ring-enhancing
lesions
- “Grape-cluster” appearance with
surrounding edema
- mostly on the posterior part of the brain
➢ Chronic disease
- specific soap-bubble calcifications
TREATMENT AND PROGNOSIS
Praziquantel
➢ drug of choice
➢ highly effective
➢ induces rapid contraction of trematodes
➢ alters the tegmental surface (vacuolization)
➢ changes are linked to the drug-dependent
disruption of calcium homeostasis
➢ suitable for adults and children over 4 yrs old
➢ usual dose of treatment:
- 25 mg/kg
- three times a day
- 2-3 days
➢ not recommended for pregnancy and lactation
- treatment should be given after delivery
unless intervention is essential
- breastfeeding should be avoided during
and after 72 hrs after treatment

Serodiagnosis Triclabendazole
➢ Immunoblotting (IB) ➢ a benzimidazole
- sensitivity up to 99% ➢ binds to B-tubulins of trematodes, leading to
- Has been used since 1988 depolymerization and disruption of
➢ Enzyme-linked Immunosorbent Assay (ELISA) microtubule-based processes
- sensitivity from 96% to 99% ➢ damage to the external plasma membrane and
- Most systems were developed to detect nuclear membrane
Paragonimus-specific IgG antibody ➢ dissolution of some heterochromatin,
mitochondria, and Golgi complex
Loop-mediated Isothermal Amplification (LAMP) ➢ only a single dose = better patient compliance
➢ simple, rapid, and cost-effective
➢ allows rapid amplification of DNA with high
specificity under isothermal conditions, using
Bithionol PREVENTION AND CONTROL
➢ alternative drug Avoid ingestion of raw or insufficiently cooked
➢ orally at a dose of crabs and other crustaceans, as well as meat
- 15-25mg/kg from paratenic hosts like wild pigs
- twice daily on alternative days
Safe food preparation
- 10-15 days
Changing the risky dietary habits of the
population
EPIDEMIOLOGY
Health education and promotion
Paragonimiasis has a focal distribution in limited parts of
Asia, Latin America, and Africa
REFERENCES
In the Philippines, paragonimiasis is endemic in
MAIN:
● Mindoro
Belizario, V. Y., & De Leon, W. U. (2003a). Philippine
● Camarines
● Sorsogon (16-25% in 1997) Textbook of Medical Parasitology.
● Leyte
● Samar Additional:
● Zamboanga del Norte (14.8% in 2005) Paniker, C. (2007). Textbook of Medical Parasitology. In
● Davao Oriental
● Basilan Jaypee Brothers Medical Publishers (P) Ltd.
● Cotabato
eBooks. https://doi.org/10.5005/jp/books/10920

Examples of dishes that can transmit disease:

● kinagang (crab in coconut milk)
● sinugba (grilled crab) PERSONAL NOTES
● kinilaw (raw crabs in vinegar)
● nam prik poo (crab and chilli paste in Thailand)
● crabs in brine, soy sauce or alcohol (drunken
crabs in China)
● kejang (raw crabs in soy sauce in Korea)
● ceviche (raw crabs in lemon sauce in Peru)
● sashimi (wild boar and bear meat in Japan)

Unhygienic food preparation

➢ also contributes to the transmission of the
disease

PTB(Pulmonary Tuberculosis)
➢ overlaps with paragonimiasis in paragonimiasis
endemic areas in the Philippines and other
developing countries
➢ since PTB and pulmonary paragonimiasis share
the same symptoms – misdiagnosis and
mismanagement are not uncommon
➢ Further studies are needed to elucidate