Tuberc Respir Dis.  2014 Oct;77(4):178-183. 10.4046/trd.2014.77.4.178.

A Case of Delayed Diagnosis of Pulmonary Paragonimiasis due to Improvement after Anti-tuberculosis Therapy

• Lee S
• Yu Y
• An J
• Lee J
• Son JS
• Lee YK
• Song S
• Kim H
• Kim S

• KMID: 2320575
• DOI: http://doi.org/10.4046/trd.2014.77.4.178

Abstract

Here, we report a case of pulmonary paragonimiasis that was improved with initial anti-tuberculosis (TB) therapy but confused with reactivated pulmonary TB. A 53-year-old Chinese female presented with a persistent productive cough with foul smelling phlegm and blood streaked sputum. Radiologic findings showed subpleural cavitary consolidation in the right upper lobe (RUL). Bronchoscopic and cytological examination showed no remarkable medical feature. She was diagnosed with smear-negative TB, and her radiologic findings improved after receiving a 6-month anti-TB therapy. The chest CT scans, however, obtained at 4 months after completion of anti-TB therapy showed a newly developed subpleural consolidation in the RUL. She refused pathologic confirmation and was re-treated with anti-TB medication. Nevertheless, her chest CT scans revealed newly developed cavitary nodules at 5 months after re-treatment. She underwent thoracoscopic wedge resection; the pathological examination reported that granuloma caused by Paragonimus westermani. Paragonimiasis should also be considered in patients assessed with smear-negative pulmonary TB.

Keyword

Paragonimus westermani; Tuberculosis

MeSH Terms

Asian Continental Ancestry Group
Cough
Delayed Diagnosis*
Female
Granuloma
Humans
Middle Aged
Paragonimiasis*
Paragonimus westermani
Smell
Sputum
Tomography, X-Ray Computed
Tuberculosis

Figure

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  Figure 1 The initial chest radiography at our institute shows the suspiciously small nodular opacity (arrow) in the suprahilar region of the right upper lobe.

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  Figure 2 (A, C) Lung setting of the initial chest high resolution computed tomography (CT) scans show the subpleural focal consolidation with cavitation (arrow) in the right upper lobe. (B, D) Lung setting of the chest CT scans, after receiving 6 months of anti-tuberculosis medication, shows a decrease in the extent of the subpleural consolidation with cavitation in the right upper lobe.

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  Figure 3 (A, D) Lung setting of chest computed tomography (CT) scans at four months after completion of the anti-tuberculosis medication shows the newly developed subpleural consolidations in the right upper lobe. (B, E) Lung setting of the chest CT scans at three months after re-treatment show a decrease in the extent of the pre-existing consolidations and the newly developed subpleural nodule (arrow) in the right upper lobe. (C, F) Lung setting of the chest high resolution CT scans at five months after re-treatment show the pre-existing nodule with newly developed cavitation (arrow) in the right upper lobe.

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  Figure 4 Pathologic findings of the thoracosopic wedge resection specimen and microscopic findings. (A) Histopathologic examination reveals cavitary parasitic granuloma with eggs of Paragonimus westermani and hemorrhage and acute and chronic inflammatory cell infiltration, including eosinophilis (arrow) (H&E stain, ×10). (B) Biopsy showed distorted and yellowish refractile eggs on high power view (H&E stain, ×40).

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