An Unusual Case of Hemoptysis in the Midwest

Abstract

INTRODUCTION: Hemoptysis is a common reason for referral to pulmonologists. We present an unusual case of hemoptysis in the Midwest. CASE PRESENTATION: A 29-year-old male with a past history of childhood pleomorphic xanthoastrocytoma presented for evaluation of hemoptysis for one year. He reported coughing up 2-10 ml blood daily, increasing in frequency. He denied dyspnea, fevers, night sweats, or weight loss. He smoked cigars rarely. He denied any exposure to tuberculosis or recent travel out of Missouri. He works construction and reported exposure to dust, but denied any exposure to toxic inhalants. Previous workup included a chest CT that revealed a left upper lobe (LUL) 1.5 cm nodule with satellite micronodules followed by a nondiagnostic bronchoscopy. He was referred to us for further evaluation after five months. Chest CT showed no change, and repeat BAL was negative for any growth on AFB or fungal cultures. Two weeks later, he developed left sided pleuritic chest pain. Repeat CT revealed LUL nodule had become denser with cavitation and extension into the pleura in addition to a small left sided pleural effusion. (Figure 1) CT guided biopsy revealed mild fibrosis with extensive eosinophilic and lymphoplasmacytic inflammation in addition to foreign bodies consistent with parasite eggs. (Figure 2) Based on the size and morphology of the ova, a diagnosis of Paragonimus k ellicotti was suspected. Upon further history, he reported periodically floating on the Current River while drinking alcohol. He eats boiled crawfish during these trips, but denies ingestion of raw crustaceans. He had eosinophilia of 16%, and serology for Paragonimus westermani from the Center for Disease Control was positive. He was treated with praziquantel with resolution of hemoptysis. DISCUSSION: Paragonimiasis is caused by ingestion of undercooked fresh water crustaceans. Paragonimus k ellicotti is the cause in North America and has been associated with eating raw crayfish from rivers in southern Missouri. Patients typically present with fever, cough, pleural effusions, and eosinophilia1. Our patient presented with hemoptysis and cavitary lung nodule. Diagnosis is made by serology or by visualization of eggs in sputum. Our patient is the first known case to be diagnosed by serology and tissue pathology. Serology was positive for P. westermani which cross-reacts to P. k ellicotti. CONCLUSIONS: It is important to keep a broad differential when a patient presents with hemoptysis and consider unusual infectious etiologies.