Imported Familial Pulmonary and Cerebral Paragonimiasis in Korea: Cases and Literature Review from a Clinical Grand Round Conference

Abstract

Paragonimiasis, most commonly caused by Paragonimus westermani, is endemic in East and Southeast Asia and commonly transmitted through ingestion of raw or undercooked freshwater crab or crayfish. While pulmonary manifestations predominate, extrapulmonary involvement such as cerebral paragonimiasis can occur. We describe three cases of imported familial pulmonary and extrapulmonary paragonimiasis from Southeast Asia and diagnosed in Korea. A 12-year-old boy presented with dizziness, headache, nausea, and vomiting. Brain magnetic resonance imaging revealed a hemorrhagic mass-like lesion with leptomeningeal enhancement, and chest tomography showed serpiginous tubular opacities with multifocal consolidations. Laboratory evaluation revealed marked eosinophilia (46.2%). Further history revealed habitual consumption of raw crayfish while residing in Cambodia. Serology was positive for P. westermani and Clonorchis sinensis IgG. Treatment with albendazole and praziquantel resulted in resolution of symptoms and normalization of eosinophil counts. Further evaluation identified similar findings in his parents who were misdiagnosed as tuberculosis and cerebral hemorrhage, and the family was treated with praziquantel. This familial cluster highlights the importance of detailed dietary and travel history in patients with eosinophilia and neurological symptoms. This case was discussed at the Clinical Grand Round of the Korean Society of Infectious Diseases on November 7, 2024.

Keywords: Crayfish; Paragonimiasis; Parasite; Tuberculosis.

Figure 1. Radiologic findings of pleuropulmonary and cerebral paragonimiasis in a 12-year-old male presenting with severe headache. (A) Axial T2-weighted FLAIR brain MRI shows a hyperintense lesion with internal hemorrhage in the left parietal lobe (arrow). (B) Contrast-enhanced sagittal T1-weighted MRI demonstrates adjacent localized leptomeningeal enhancement (arrow], suggestive of localized meningoencephalitis. (C, D) Chest CT in lung window reveals a serpiginous tubular structure in the right upper lobe apex, consistent with a worm migration tract, seen on both coronal (C) and axial (D) images. (E) Multiple subpleural consolidations are noted in the right middle and left lower lobes (arrows). (F) Diffuse pleural thickening in the right anterior thorax (*) with a subpleural nodule at the right minor fissure (arrowhead) and linear opacities in the right upper lobe anterior segment (arrow). (G) Additional subpleural nodule along the right major fissure (arrow). (H) Follow-up chest CT obtained 8 months later demonstrates interval improvement of previous pulmonary lesions, with residual subpleural consolidation in the left upper lobe (arrow) and decreased subpleural nodule along the right minor fissure (arrow).

FLAIR, fluid-attenuated inversion recovery; MRI, magnetic resonance imaging; CT, computed tomography.

Figure 3. Family members’ medical history and imaging findings.

(A) Father’s chest radiograph at the time of empyema diagnosis shows left-sided pleural effusion with lung collapse and an air–fluid level. (B) Coronal T2-weighted FLAIR brain MRI demonstrates a hyperintense lesion with internal hemorrhage in the right frontal lobe, and axial contrast-enhanced T1-weighted MRI shows adjacent localized leptomeningeal enhancement (arrow), suggestive of localized meningoencephalitis. (C) Mother’s initial axial chest CT scan during post-tuberculosis exposure screening reveals multiple subpleural ground-glass opacities and nodular consolidations (arrow), findings compatible with pulmonary paragonimiasis. FLAIR, fluid-attenuated inversion recovery; MRI, magnetic resonance imaging; CT, computed tomography.

Figure 2. Timeline of family members’ symptoms and signs during the diagnostic process.

CT, computed tomography; MRI, magnetic resonance imaging.