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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 - Tuberc Respir Dis (Seoul) (2014)

Bottom Line: She was diagnosed with smear-negative TB, and her radiologic findings improved after receiving a 6-month anti-TB therapy.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.

View Article: PubMed Central - PubMed

Affiliation: Department of Internal Medicine, Seoul Medical Center, Seoul, Korea.

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.

No MeSH data available.


Related in: MedlinePlus

(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 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.

Mentions: Follow-up chest radiograph obtained at 4-months after completion of anti-TB therapy, showed newly developed mass-like consolidation on right upper lobe (Figure 3A, D). Bronchoscopy with bronchoalveolar lavage (BAL) was performed and sent for examinations. Results of cytology, AFB stain, and polymerase chain reaction for Mycobacterium tuberculosis were negative, as were cultures for bacteria, fungi, and mycobacteria. We could not observe eggs in sputum, or BAL fluid. Bronchoscopic biopsy showed chronic inflammation with a giant cell. According to complete blood cell count finding of the patient follow-up, there was no signal of peripheral blood eosinophilia. Therefore, we recommended pathologic confirmation with thoracoscopic examination, however the patient refused it. She was re-treated with anti-TB medication, and made transient aggravation at 2 months, and subsequent improvement at 3 months after re-treatment (Figure 3B, E). Although we considered the possibility of the paradoxical response with anti-TB treatment, the patient suffered recurrent hemoptysis and her chest CT scans revealed newly developed cavitary nodules within right upper lobe at 5 months after re-treatment (Figure 3C, F). She underwent thoracoscopic pulmonary wedge resection because the lesion was not appropriate for conducting percutaneous needle aspiration or biopsy. Thoracoscopic pulmonary wedge resection was applied for the mass measuring approximately 2×2-cm size in the posterior segment of right upper lung, and the gross findings of transected specimen on operative field showed a movable parasitic worm measured about 1×0.5 cm in cavitary lesion to be surrounded with organized and yellowish pulmonary parenchymal tissue. The pathological examination reported no malignant findings in the lung, and granuloma, acute and chronic inflammatory cell infiltration with eosinophils caused by Paragonimus westermani was diagnosed (Figure 4). Enzyme-linked immunosorbent assay (ELISA) antibody was positive for anibodies against P. westermani. A subsequent discussion with the patient revealed that she had eaten raw fresh water crabs several times before immigration to Korea from China several years ago. Anti-tuberculous medication was discontinued and praziquantel 75 mg/kg/day in three divided doses for 2 days were given. She was discharged with improvement of symptoms and signs. After that event, her symptoms and radiologic findings have maintained within normal range during 1-year follow-up period.


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 - Tuberc Respir Dis (Seoul) (2014)

(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.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4217034&req=5

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.
Mentions: Follow-up chest radiograph obtained at 4-months after completion of anti-TB therapy, showed newly developed mass-like consolidation on right upper lobe (Figure 3A, D). Bronchoscopy with bronchoalveolar lavage (BAL) was performed and sent for examinations. Results of cytology, AFB stain, and polymerase chain reaction for Mycobacterium tuberculosis were negative, as were cultures for bacteria, fungi, and mycobacteria. We could not observe eggs in sputum, or BAL fluid. Bronchoscopic biopsy showed chronic inflammation with a giant cell. According to complete blood cell count finding of the patient follow-up, there was no signal of peripheral blood eosinophilia. Therefore, we recommended pathologic confirmation with thoracoscopic examination, however the patient refused it. She was re-treated with anti-TB medication, and made transient aggravation at 2 months, and subsequent improvement at 3 months after re-treatment (Figure 3B, E). Although we considered the possibility of the paradoxical response with anti-TB treatment, the patient suffered recurrent hemoptysis and her chest CT scans revealed newly developed cavitary nodules within right upper lobe at 5 months after re-treatment (Figure 3C, F). She underwent thoracoscopic pulmonary wedge resection because the lesion was not appropriate for conducting percutaneous needle aspiration or biopsy. Thoracoscopic pulmonary wedge resection was applied for the mass measuring approximately 2×2-cm size in the posterior segment of right upper lung, and the gross findings of transected specimen on operative field showed a movable parasitic worm measured about 1×0.5 cm in cavitary lesion to be surrounded with organized and yellowish pulmonary parenchymal tissue. The pathological examination reported no malignant findings in the lung, and granuloma, acute and chronic inflammatory cell infiltration with eosinophils caused by Paragonimus westermani was diagnosed (Figure 4). Enzyme-linked immunosorbent assay (ELISA) antibody was positive for anibodies against P. westermani. A subsequent discussion with the patient revealed that she had eaten raw fresh water crabs several times before immigration to Korea from China several years ago. Anti-tuberculous medication was discontinued and praziquantel 75 mg/kg/day in three divided doses for 2 days were given. She was discharged with improvement of symptoms and signs. After that event, her symptoms and radiologic findings have maintained within normal range during 1-year follow-up period.

Bottom Line: She was diagnosed with smear-negative TB, and her radiologic findings improved after receiving a 6-month anti-TB therapy.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.

View Article: PubMed Central - PubMed

Affiliation: Department of Internal Medicine, Seoul Medical Center, Seoul, Korea.

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.

No MeSH data available.


Related in: MedlinePlus