Pulmonary Cysts That Come and Go: A Fluke?

Abstract

Introduction Frequent global travel is associated with increasing incidence of exotic helminthic infections in non-endemic regions. We report a case of patient with chronic pulmonary paragonimiasis in Upstate New York who presented with recurrent hemoptysis and an unusual pattern of pulmonary cystic lesions on imaging. Case Presentation 20 year old healthy female was referred for evaluation of intermittent episodes of hemoptysis for 1 year. Her symptoms started after a freak diving accident when she dived on her chest. Initial chest Computerized Tomography (CT) showed 2 cystic lesions in the right lower lobe. There was no history of parasitic disease or serious illness in any member of her immediate family. Furthermore, family history was negative for bleeding disorders. The patient denied alcohol, cigarette or illicit drug use. Recent travel history was significant for a trip to Costa Rica and Bahamas where she enjoyed seaweed and sushi. Her symptoms improved but she would still complain of 1-2 episodes of quarter sized hemoptysis associated with shortness of breath. Bronchoscopy and CT guided biopsy were ultimately performed and were unremarkable. Moreover, cultures of bronchial washings and the cytology were negative. Connective tissue disorders work up was negative. Pulmonary Function Tests were normal. Initial infectious disease work up for pulmonary TB, mycoplasma, histoplasmosis & blastomycosis was negative. Subsequent CT scans showed interval redistribution and resolution of the cystic lesions in addition to a cavitary lesion. The patient was referred to infectious disease. Ultimately, the diagnosis of chronic pulmonary paragonimiasis was made and the patient responded well to praziquantel. Discussion The presentation of hemoptysis after a diving accident with the radiographic findings led us to think of a traumatic pneumatocele. However, given the cavitary lesion, the resolution and interval redistribution of the pulmonary cysts, lack of blunt force trauma usually required for a traumatic pneumatocele, and the recent travel history we shifted our focus to an infectious etiology. Although stool, sputum, and bronchial washings for ova and parasites were negative, Paragonimiasis westermani titers were found to be elevated. It is well established that serologic testing for anti-Paragonimus IgG has a sensitivity of 100% and a specificity of 91%-100%. P. westermani also known as the oriental lung fluke is acquired through the ingestion of raw or undercooked crabs or crayfish and is the most common cause of hemoptysis worldwide. This clinical vignette underscores the importance of health care providers in the United States to recognize common worldwide infections. (Table Presented).