J Korean Med Sci.  2012 Nov;27(11):1428-1432. 10.3346/jkms.2012.27.11.1428.

The Return of an Old Worm: Cerebral Paragonimiasis Presenting with Intracerebral Hemorrhage

• Koh EJ
• Kim SK
• Wang KC
• Chai JY
• Chong S
• Park SH
• Cheon JE
• Phi JH

• KMID: 2157958
• DOI: http://doi.org/10.3346/jkms.2012.27.11.1428

Abstract

Paragonimiasis is caused by ingesting crustaceans, which are the intermediate hosts of Paragonimus. The involvement of the brain was a common presentation in Korea decades ago, but it becomes much less frequent in domestic medical practices. We observed a rare case of cerebral paragonimiasis manifesting with intracerebral hemorrhage. A 10-yr-old girl presented with sudden-onset dysarthria, right facial palsy and clumsiness of the right hand. Brain imaging showed acute intracerebral hemorrhage in the left frontal area. An occult vascular malformation or small arteriovenous malformation compressed by the hematoma was initially suspected. The lesion progressed for over 2 months until a delayed surgery was undertaken. Pathologic examination was consistent with cerebral paragonimiasis. After chemotherapy with praziquantel, the patient was monitored without neurological deficits or seizure attacks for 6 months. This case alerts practicing clinicians to the domestic transmission of a forgotten parasitic disease due to environmental changes.

Keyword

Cerebral Paragonimiasis; Intracerebral Hemorrhage; Diagnosis

MeSH Terms

Animals
Anthelmintics/therapeutic use
Brain/parasitology/pathology
Cerebral Hemorrhage/*etiology
Child
Dysarthria/etiology
Facial Paralysis/etiology
Female
Humans
Magnetic Resonance Imaging
Paragonimiasis/*diagnosis/drug therapy/parasitology
Paragonimus/isolation & purification
Praziquantel/therapeutic use
Tomography, X-Ray Computed
Vascular Malformations/etiology
Anthelmintics
Praziquantel

Figure

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  Fig. 1 Brain images of the patient at initial presentation (June 2011). (A) A pre-contrast CT scan reveals an acute intracerebral hemorrhage with surrounding edema in the left frontal lobe. (B) Left frontal lesion shows hypointensity with surrounding hyperintensity on a T2-weighted MR image. (C) On a T1-weighted MR image, the lesion shows hypointensity with curvilinear hyperintensity. These findings suggest an acute to early subacute hematoma. (D) A contrast-enhanced T1-weighted MR image demonstrates a faint, encircling ring enhancement (arrows).

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  Fig. 2 Follow-up imaging studies obtained two months after the initial onset of symptoms (August 2011). (A) A T2-weighted MR image reveals a chronic hematoma with extensive surrounding edema in the left frontal area. (B) There are newly emerging conglomerated, bubbly enhancing lesions at the posterior aspect of the hematoma on a contrast-enhanced T1-weighted MR image (arrows). (C) A FDG-PET image reveals a metabolic defect in the left frontal lobe (arrowheads).

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  Fig. 3 Surgical and pathologic findings (August 2011). (A) An operative photograph shows a hemorrhagic cyst located in the middle frontal gyrus just anterior to the precentral gyrus (arrows). (B) Hematoxylin and eosin staining reveals an egg of Paragonimus (arrow) along with granulomatous inflammation (× 200). Note the thick asymmetric shell with a flattened side (arrow). (C) A chest CT scan (September 2011) reveals conglomerated, thin-walled cystic lesions with a nodule at the apex of the right upper lobe (arrow).

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  Fig. 4 Follow-up imaging studies after antihelminthic treatment (December 2011). (A) A T2-weighted MR image shows no recurred lesion (arrow). (B) A chest CT scan reveals interval disappearance of the cavitary lesions in the right upper lobe with fibrotic scar change.

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  Fig. 5 The patient's mother was later diagnosed with pulmonary paragonimiasis. (A) A chest CT scan shows bronchiectasis with mild ground-glass opacity in the left upper lobe (October 2011). (B) A chest radiograph reveals hydropneumothorax in the left lung (February 2012).

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