PARAGONIMUS WESTERMANI

INTRODUCTION
Paragonimus westermani is the major species of lung fluke that infects humans,
causing paragonimiasis. The species sometimes is called the Japanese lung fluke or
oriental lung fluke. Human infections are most common in eastern Asia and in South
America. Paragonimus westermani was discovered when two Bengal tigers died of
paragonimiasis in zoos in Europe in 1878. Several years later, infections in humans
were recognised in Formosa.
Paragonimiasis is a food-borne parasitic infection caused by the lung fluke. It may
cause a sub-acute to chronic inflammatory disease of the lung. It is one of the most
familiar lung flukes with the widest geographical range. It was discovered by
Coenraad Kerbert (1849–1927) in 1878.

Morphology

Paragonimus westermani. An adult of the hermaphroditic generation.

In size, shape, and color, Paragonimus westermani resembles a coffee bean when
alive. Adult worms are 7.5 mm to 12 mm long and 4 mm to 6 mm wide. The
thickness ranges from 3.5 mm to 5 mm. The skin of the worm (tegument) is thickly
covered with scalelike spines. The oral and ventral suckers are similar in size, with
the latter 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. Inspection of the tegumental spines and shape of the metacercariae
may distinguish between the 30-odd species of Paragonimus spp. but the distinction
is sufficiently difficult to justify suspicion that many of the described species are
synonyms.[4]

Egg of Paragonimus westermani

• Eggs: Paragonimus westermani eggs range from 80 to 120 µm long by 45 to
70 µm wide. They are yellow-brown, ovoid or elongate, with a thick shell, and
often asymmetrical with one end slightly flattened. At the large end, the
operculum is clearly visible. The opposite (abopercular) end is thickened. The
eggs are unembryonated when passed in sputum or feces.[3]
• Cercaria (not shown): Cercariae are often indistinguishable between species.
There is a large posterior sucker, and the exterior is spined.
• Metacercaria: Metacercariae are usually encysted in tissue. The exterior is
spined and has two suckers
• Adults: Adult flukes are typically reddish brown and ovoid, measuring 7 to
16 mm by 4 to 8 mm, similar in size and appearance to a coffee bean.They are
hermaphroditic, with a lobed ovary located anterior to two branching testes.
Like all members of the Trematoda, they possess oral and ventral suckers.

Life cycle
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.

Life Cycle:
Paragonimiasis clinical features

Paragonimiasis causes no symptoms during initial infection. Many people with

paragonimiasis never experience any symptoms. When paragonimiasis symptoms do
occur, they result from the worms’ location and activity in the body, which change
over time.
In the first month or so after someone is infected, paragonimiasis worms spread
through the abdomen, sometimes causing symptoms that can include:
• Fever
• Ill-feeling (malaise)
• Diarrhea
• Belly pain
• Itching and hives

Worms then travel from the belly into the chest. There they can cause respiratory
symptoms, such as:

• Cough
• Shortness of breath
• Chest pain (made worse by deep breathing or coughing)

Without treatment, paragonimiasis becomes chronic. It can continue for decades.

The most common long-term paragonimiasis symptom is a cough with bloody
sputum (hemoptysis) that comes and goes. Other chronic paragonimiasis symptoms
may include:
• Belly pain
• Nausea
• Vomiting
• Bloody diarrhea
• Lumps or bumps on the skin of the belly or legs that come and go over time

Some people with chronic paragonimiasis have no noticeable symptoms.

In less than 1% of people with paragonimiasis, the worms infect the brain. Symptoms
can include:
 • Headache
• Fever
• Vomiting
• Double vision
• Seizures

laboratory diagnosis
Diagnosing paragonimiasis can be difficult or delayed. That's because its symptoms
are often mild and overlap with more common conditions.

Most often, a person with symptoms has multiple tests before a doctor makes the
diagnosis of paragonimiasis. Exams and tests used to make a diagnosis include:
Patient History. Your doctor will get clues about possible paragonimiasis by looking
at the pattern in which your symptoms appeared. Your doctor will ask about your past
eating of undercooked crab or crayfish.
Physical examination. Abnormal breath sounds or belly tenderness observed with a
doctor’s examination of the chest or belly can suggest a problem and direct further
testing.
Blood tests. A high number of a specific type of white blood cells can suggest
parasitic infection. Antibodies against flukes may be present in the blood.
Sputum microscopy. Fluke eggs can be detected during examination of coughed-up
sputum under a microscope.
Chest X-ray. Nodules (spots) in the lungs, hollowed-out areas (cysts or cavities), or
fluid around the lungs (pleural effusions) may be present.
CT scan. High-resolution images of the lungs may show more detailed information
than a chest X-ray. Also,CT of the head or abdomen may be abnormal if
paragonimiasis involves the brain or liver.
MRI. Very high-definition images of the brain can identify cysts or brain swelling
caused by paragonimiasis.
Bronchoscopy . A doctor can put an endoscope (flexible tube with a camera on its tip)
through the nose or mouth into the lungs. Flukes or their eggs are collected from lung
fluid samples. The flukes or eggs may be seen under a microscope.
Thoracentesis. A doctor puts a needle through the chest wall to sample fluid around
the lungs (pleural effusion).
Stool studies. Fluke eggs may be seen in stool samples when examined under a
microscope.
A definite diagnosis of paragonimiasis is made when fluke eggs are detected in an
infected person’s sputum or stool. But the flukes may not lay eggs until two months
after you are infected. That makes early diagnosis difficult.

Management and treatment

According to the CDC, praziquantel is the drug of choice to treat paragonimiasis.[3]
The recommended dosage of 75 mg/kg per day, divided into 3 doses over 3 days has
proven to eliminate P. westermani.[12] Bithionol is an alternative drug for treatment
of this disease but is associated with skin rashes and urticaria. For additional
information, see the recommendations in The Medical Letter (Drugs for Parasitic
Infections).

prevention and control

Prevention programs should promote more hygienic food preparation by encouraging
safer cooking techniques and more sanitary handling of potentially contaminated
seafood. The elimination of the first intermediate host, the snail, is not tenable due to
the nature of the organisms habits.[2] A key component to prevention is research,
more specifically the research of everyday behaviors. This recent study was
conducted as a part of a broader effort to determine the status of Paragonimus species
infection in Laos.[23] An epidemiological survey was conducted on villagers and
schoolchildren in Namback District between 2003 and 2005. Among 308 villagers
and 633 primary and secondary schoolchildren, 156 villagers and 92 children had a
positive reaction on a Paragonimus skin test. Consequently, several types of crabs
were collected from markets and streams in a paragonimiasis endemic area for the
inspection of metacercariae and were identified as the second intermediate host of the
Paragonimus species. In this case study, we see how high prevalence of
paragonimiasis is explained by dietary habits of the population. Amongst
schoolchildren, many students reported numerous experiences of eating roast crabs in
the field. Adult villagers reported frequent consumption of seasoned crabs (Tan
Cheoy Koung) and papaya salad (Tammack Koung) with crushed raw crab. In
addition to this characteristic feature of the villagers' food culture, the denizens of this
area drink fresh crab juice as a traditional cure for measles, and this was also thought
to constitute a route for infection

References

Markell and Voge's Medical Parasitology. 9th ed. 2006. ISBN 978-0-7216-
4793-7. p. 200.
• Janovy, John; Schmidt, Gerald D.; Roberts, Larry S. (1996). Gerald D.
Schmidt & Larry S. Roberts' Foundations of parasitology. Dubuque, Iowa:
Wm. C. Brown. ISBN 0-697-26071-2.
• Muller, R. Liver and lung flukes. In: Cox FEG. The Wellcome Trust illustrated
history of tropical diseases. The Wellcome Trust, London, United Kingdom;
1996. p. 274–285.
• Manson, P. Distoma ringeri. Med. Times Gaz..
• Grove, DI. A history of human helminthology. CAB International, Wallingford,
United Kingdom; 1990. and others……...

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