Paragonomiasis

Brijesh Singh Yadav

brijeshbioinfo@gmail.com
Disease Type: Parasitic Disease
Common Name: Paragonomiasis
Causative Agent: P. westermani
Disease Discription:
Paragonomiasis is the result of an infection with one or other lung flukes of the genus
paragonimus, usually P. westermani. (There are 15 other species of
paragonimus, which can infect man.) The infection is found throughout the
tropics but particularly in Asia, and is usually mistaken for tuberculosis.
Paragonimiasis is acquired by eating raw or inadequately cooked crabs,
crayfish, and occasionally from eating animals which also enjoy fresh water
crabs. The life cycle is similar to that of schistosomiasis, and includes warm
water snails, but there is no direct infection of man. Clinically, the majority of
patients, even with heavy infections, are not ill. The minority will complain
about chest pain, chronic cough and chocolate-coloured sputum, while
remaining remarkably well in general health. At this stage the sputum often
contains multiple recognizable eggs of P. westermani.[2]

Figure. Paragonomiasis.
a) Bilateral interstitial and basal consolidation in a patient with paragonomiasis.
b) Tomography of the right upper chest showing the nodular and fibrotic pattern of
paragonomiasis. This is indistinguishable from tuberculosis.
Causative Agent:
Pathogen Name: Paragonimus westermani
Pathogen Description:

Paragonimus westermani is a lung fluke and is most prominent in Asia and South
America. It was discovered from two Bengal tigers that died in zoos in Europe in 1878.
Several years’ later, infections in humans were found in Formosa.

Taxonoimic Classification:
Domain: Eukaryota
Kingdom: Animalia
Phylum: Platyhelminthes
Class: Trematoda
Subclass: Digenea
Family: Paragonimidae
Genus: Paragonimus
Species: P. westermani Adult Paragonimus westermani

Other Pathogenic speices:

Paragonimus africanus, P. bangkokensis, P. heterotremus, P. hueitungensis, P. kellicotti,
P. mexicanus, P. miyazakii, P. ohirae, P. philippinensis, P. sadoensis, P. skrjabini, P.
uterobilateralis

Morphology and toxin production:

Many different species of Paragonimus all with some different levels of human host
adaptability. Eggs expectorated in sputum into fresh water hatch as ciliated miracidia
which penetrate specific snails and multiply within. Free-swimming cercaria leave the
snail and penetrate fresh water crabs and crayfish, infecting any that consume them. The
consumed metacercaria penetrate the human small intestine wall and migrate to the lungs
where they mate and live for a number of years laying eggs which are expectorated or
swallowed. [1]

Size, shape, and color resembles a coffee bean when alive. Adult worms are 7.5 mm to 12
mm long and 4 mm to 6mm wide. The thickness ranges from 3.5 mm to 5 mm. The skin
of the worm (tegument) is heavily covered with scalelike spines. The oral and ventral
suckers are similar in size, with the later placed slightly pre-equatorially. The excretory
bladder extends from the posterior end to the pharynx. The lobed testes are adjacent from
each other located at the posterior end, and the lobed ovaries are off-centered near the
center of the worm (slightly postacetabular). The uterus is located in a tight coil to the
right of the acetabulum, which is connected, to the vas deferens. The vitelline glands,
which produce the yolk for the eggs, are widespread in the lateral field from the pharynx
to the posterior end. By viewing the tegumental spines and shape of the metacercariae,
one could distinguish between the ~30 species of Paragonumus spp.[3]

adult Paragonimus 7-12 mm long Paragonimus egg 80-120 µm long

History:
It was discovered from two Bengal tigers that died in zoos in Europe in 1878. Several
years’ later, infections in humans were found in Formosa.
Epidemiology:

Prevalent in the Far East; also areas in Central America and Africa. Transmission is
related to the consumption of raw fresh water crabs and crayfish which contain the larvae
(metacercaria) of Paragonimus.

Disease Host: Human and other animal

Disease Transmission:
Transmission via eating infected crabs and crayfish.Adult worms live in the lungs. Eggs
pass to the outside with the sputum. If sputum is swallowed, eggs may also be found in
faeces. Once in the outside world and in water, miracidia (first-stage larvae) emerge from
the eggs. They penetrate snails, where they undergo a transformation. After 3 to 5 months
cercariae (second-stage larvae) leave the snail and penetrate crabs. Here the cercariae
develop into metacercariae (third-stage larvae). It is this form which is infectious for the
definitive host. Paragonomiasis is a zoonosis of carnivorous animals. Humans are only an
exceptional host. They become infected by eating raw fresh-water crabs and river
crayfish which contain infectious metacercariae. Excystation occurs in the duodenum.
The larvae bore through the intestinal wall and migrate via the abdominal cavity to the
lungs. There they develop into adult worms. The worms form a cavity 1 to 4 cm in
diameter. Egg-laying begins 8 to 10 weeks after infection. The worms rarely migrate to
ectopic sites.[6]

The eggs are excreted unembryonated in the sputum, or alternately

they are swallowed and passed with stool . In the external
environment, the eggs become embryonated , and miracidia hatch
and seek the first intermediate host, a snail, and penetrate its soft
tissues . Miracidia go through several developmental stages inside
the snail : sporocysts , rediae , with the latter giving rise to many
cercariae , which emerge from the snail. The cercariae invade the
second intermediate host, a crustacean such as a crab or crayfish,
where they encyst and become metacercariae. This is the infective
stage for the mammalian host . Human infection with P. westermani
occurs by eating inadequately cooked or pickled crab or crayfish that
harbor metacercariae of the parasite . The metacercariae excyst in
the duodenum , penetrate through the intestinal wall into the
peritoneal cavity, then through the abdominal wall and diaphragm into
the lungs, where they become encapsulated and develop into adults
(7.5 to 12 mm by 4 to 6 mm). The worms can also reach other organs
and tissues, such as the brain and striated muscles, respectively.
However, when this takes place completion of the life cycles is not
achieved, because the eggs laid cannot exit these sites. Time from
infection to oviposition is 65 to 90 days.
Infections may persist for 20 years in humans. Animals such as pigs,
dogs, and a variety of feline species can also harbor P. westermani. [5]

Signs and symptoms of disease:

Mild infections are asymptomatic. In the acute stage (invasion and migration of the
larvae) there may be diarrhoea, abdominal pain, urticaria and eosinophilia. This is
followed by fever, thoracic pain, cough, dyspnoea and malaise. The chronic illness
resembles chronic bronchitis and TB. There is spasmodic cough (especially after
exertion) with expectoration of blood stained sputum, as well as dyspnoea sometimes
with wheezing and pleural pain. When the parasite is located in an ectopic site (brain,
subcutis, etc.) the symptoms depend on the place where the worms are. www.itg.be

Diagnosis:

To properly diagnosis this parasite infection is by looking at the sputum and finding the
eggs. Sometimes eggs are shed in the feces. Radiological methods can be used to X-ray
the chest cavity and look for worms. This method is easily misdiagnosed, because
pulmonary infections look like tuberculosis, pneumonia, or spirochaetosis. A lung biopsy
can also be used to diagnose this parasite. An assay that detects worm antigens using
monoclonal antibody can also be used to diagnosis. The drug of choice is praziquantel. [4]

P. westermani in tissue. P. westermani head.

Diagnosis is by detecting the eggs. The eggs often need to be concentrated (e.g. mix
sputum + water + potassium hydroxide, then centrifuge and examine the sediment).
Differential diagnosis includes tuberculosis of the lungs, pulmonary abscess, chronic
bronchitis, melioidosis, and lung carcinoma and lung metastases. If sputum is swallowed,
eggs may also be found in the faeces.

Treatment:

Praziquantel 75 mg/day for 3 days is very effective. In cases of cerebral localisation

higher doses must be given but only under the protection of steroids due to the risk of
epileptic fits secondary to perilesional oedema.
Prevention of disease:

Not eating raw fresh water crabs can dramatically reduce the chance of infection.

Geographical Distribution:
The parasite occurs in Southeast Asia and the Far East, in Central and West Africa. In
America its distribution is limited to Central America and the north of South America.
Usually P. westermani is reported, but there are a number of other species which can
cause infection in humans. www.itg.be

Refrence:
www.medicine.mcgill.ca
1.
www.medcyclopaedia.com
2.
3. Foundations of Parasitology” Larry S. Roberts and John Janovy, Jr., seventh
edition McGraw Hill 2005, pages 279-283.
4. Emerging and Reemerging Helminthiases and the Public Health of China” Peter J. Hotez,
Feng Zheng, Xu Long-qi, Chen Ming-gang, Xiao Shu-hua, Liu Shu-xian, David Blair,
Donald P. McManus, and George M. Davis
5. http://www.cdc.gov/ncidod/eid/vol3no3/hotez.htm
6. www.itg.be
7.