Tuberc Respir Dis.  2014 Apr;76(4):175-178.

A Case of Pleural Paragonimiasis Confused with Tuberculous Pleurisy

• Song J
• Hong G
• Song JU
• Kim W
• Han SG
• Ko Y
• Chang B
• Jeong BH
• Eom JS
• Lee JH
• Jhun BW
• Jeon K
• Kim HK
• Koh WJ

Abstract

Here, we report a case of pleural paragonimiasis that was confused with tuberculous pleurisy. A 38-year-old man complained of a mild febrile sensation and pleuritic chest pain. Radiologic findings showed right pleural effusion with pleural thickening and subpleural consolidation. Adenosine deaminase (ADA) activity in the pleural effusion was elevated (85.3 IU/L), whereas other examinations for tuberculosis were negative. At this time, the patient started empirical anti-tuberculous treatment. Despite 2 months of treatment, the pleural effusion persisted, and video-assisted thoracoscopic surgery was performed. Finally, the patient was diagnosed with pleural paragonimiasis based on the pathologic findings of chronic granulomatous inflammation containing Paragonimus eggs. This case suggested that pleural paragonimiasis should be considered when pleural effusion and elevated ADA levels are observed.

Keyword

Adenosine Deaminase; Paragonimiasis; Pleural Effusion; Tuberculosis

MeSH Terms

Adenosine Deaminase
Adult
Chest Pain
Eggs
Humans
Inflammation
Ovum
Paragonimiasis*
Paragonimus
Pleural Effusion
Sensation
Thoracic Surgery, Video-Assisted
Tuberculosis
Tuberculosis, Pleural*
Adenosine Deaminase

Figure

• 

  Figure 1 A 38-year-old man with pleural effusion who was diagnosed with pleural paragonimiasis. (A) Chest radiography showed pleural effusion. (B) Chest computed tomography showed pleural thickening with pleural effusion. (C) Subpleural consolidation.

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  Figure 2 The resected empyema sac. (A) Gross examination showed that the pleura were thickened by diffuse fibrosis (H&E stain, ×2). (B) Parasitic eggs surrounded by granulomatous inflammation (H&E stain, ×40). (C) Ovoid parasitic eggs with a thick shell in the granuloma (H&E stain, ×200).

Reference

1. Nakamura-Uchiyama F, Mukae H, Nawa Y. Paragonimiasis: a Japanese perspective. Clin Chest Med. 2002; 23:409–420.

2. Jeon K, Koh WJ, Kim H, Kwon OJ, Kim TS, Lee KS, et al. Clinical features of recently diagnosed pulmonary paragonimiasis in Korea. Chest. 2005; 128:1423–1430.

3. Song JU, Um SW, Koh WJ, Suh GY, Chung MP, Kim H, et al. Pulmonary paragonimiasis mimicking lung cancer in a tertiary referral centre in Korea. Int J Tuberc Lung Dis. 2011; 15:674–679.

4. Boland JM, Vaszar LT, Jones JL, Mathison BA, Rovzar MA, Colby TV, et al. Pleuropulmonary infection by Paragonimus westermani in the United States: a rare cause of eosinophilic pneumonia after ingestion of live crabs. Am J Surg Pathol. 2011; 35:707–713.

5. Lee YC, Rogers JT, Rodriguez RM, Miller KD, Light RW. Adenosine deaminase levels in nontuberculous lymphocytic pleural effusions. Chest. 2001; 120:356–361.

6. Jimenez Castro D, Diaz Nuevo G, Perez-Rodriguez E, Light RW. Diagnostic value of adenosine deaminase in nontuberculous lymphocytic pleural effusions. Eur Respir J. 2003; 21:220–224.

7. Krenke R, Korczynski P. Use of pleural fluid levels of adenosine deaminase and interferon gamma in the diagnosis of tuberculous pleuritis. Curr Opin Pulm Med. 2010; 16:367–375.

8. Kagawa FT. Pulmonary paragonimiasis. Semin Respir Infect. 1997; 12:149–158.

9. Im JG, Whang HY, Kim WS, Han MC, Shim YS, Cho SY. Pleuropulmonary paragonimiasis: radiologic findings in 71 patients. AJR Am J Roentgenol. 1992; 159:39–43.

10. Slemenda SB, Maddison SE, Jong EC, Moore DD. Diagnosis of paragonimiasis by immunoblot. Am J Trop Med Hyg. 1988; 39:469–471.

11. Xu ZB. Studies on clinical manifestations, diagnosis and control of paragonimiasis in China. Southeast Asian J Trop Med Public Health. 1991; 22:Suppl. 345–348.

12. Vidamaly S, Choumlivong K, Keolouangkhot V, Vannavong N, Kanpittaya J, Strobel M. Paragonimiasis: a common cause of persistent pleural effusion in Lao PDR. Trans R Soc Trop Med Hyg. 2009; 103:1019–1023.

13. Taniguchi H, Mukae H, Matsumoto N, Tokojima M, Katoh S, Matsukura S, et al. Elevated IL-5 levels in pleural fluid of patients with paragonimiasis westermani. Clin Exp Immunol. 2001; 123:94–98.

14. Porcel JM, Esquerda A, Bielsa S. Diagnostic performance of adenosine deaminase activity in pleural fluid: a single-center experience with over 2100 consecutive patients. Eur J Intern Med. 2010; 21:419–423.