Sarah Jung, PharmD, , MS, BCCCP
Critical Care Clinical Pharmacist Specialist
WellStar Kennestone Hospital
Atlanta, Georgia
Disclosure information not submitted.
Eli Feen, MD
Neurocritical Care Physician
Wellstar Kennestone Hospital, United States
Disclosure information not submitted.
Title: Paragonimiasis-associated intracerebral hemorrhage
Case Report Body:
Introduction: Paragonimus is a parasitic flatworm acquired by eating raw or undercooked crab or crayfish. After ingestion, larvae penetrate the intestinal wall and diaphragm into the lungs – where they form cystic cavities, mature into adult fluke worms, and may migrate to other organ systems. Due to its overall rarity, paragonimiasis can be confused with pulmonary tuberculosis or malignancy, delaying diagnosis and treatment. We describe a case of cerebral paragonimiasis.
Description: A 19-year-old male from Honduras with no past medical history presented to the emergency department with headaches over several weeks with increasing frequency and severity, vision loss, and confusion. Computed tomography (CT) scan of his head revealed a left parieto-occipital intraparenchymal hemorrhage of 20 mL in volume with vasogenic edema and trace subarachnoid hemorrhage. CT angiogram of head and neck was normal but showed incidental bronchiectasis of the right upper lobe. Glasgow Coma Scale score was 15, vitals were stable including oxygenation, and labs were significant only for eosinophilia. Cerebral angiography showed no vascular abnormalities. On hospital day 3, he developed fevers, and CT chest, abdomen, and pelvis was completed. It revealed ovoid lucencies, cystic thick-walled spaces, and groundglass infiltrates in the right lung, and left kidney infarct – all suggestive of active infectious processes. Bronchoscopy and lumbar puncture were performed and additional labs obtained. On day 8, empiric praziquantel and prednisone were started for a three-day course, and the patient was discharged home on day 10. Subsequently, Paragonimus antibodies were confirmed in his serum.
Discussion: Per the Centers for Disease Control, up to 25% of hospitalized patients with Paragonimus may have central nervous system (CNS) involvement. Symptoms may not present initially, and worms can continue reproducing for many years. Definitive diagnosis requires detection of serum antibodies or Paragoniumus in sputum or feces. Treatment with praziquantel or triclabendazole yields high cure rates. Steroids may be added to prevent inflammatory reactions to dying flukes. Though Paragonimus is mostly endemic to Asia, CNS pathology with peripheral eosinophilia should prompt investigation of coexisting pulmonary pathology suggestive of paragonimiasis.