OS 213: Human Disease and Treatment 3(Circulation

and Respiration)
LEC 13: PARAGONIMUS WESTERMANII
Exam 1 | Dr. Sonia Salamat | 25 January 2013
OUTLINE
I. Paragonimus
Westermanii
A. Anatomy
B. Life Cycle
II. Vectors
A. Primary Host
B. Secondary Host
C. Metacercaria

III.Paragonomiasis
A. Acquisition
B. Distribution

Vitellaria: bilateral, extensive branching

Ceca: wave on side of adult worm

Egg

PARAGONIMUS WESTERMANII
Lung fluke
Paragonimus westermanii
Member of the flatworms, Platyhelminthes and Class
Trematoda

Live Worms

Broadly ovoid
Operculum cap-like
Opposite the operculum is the abopercular end; this is
the thickened area
Unembryonated when deposited
Golden brown
Eggs produced exit feces because we swallow sputum
11B eggs in sputum

Life Cycle

Figure 1. Paragonimus westermanii live worm

Plump and ovoid

7.5 to 12 mm long
Up to 1.2 cm long
5 mm thick
4 mm wile
Reddish brown

Anatomy

Figure 2. Paragonimus sp. Adult Lung Fluke.

Diagnostic stage is the unembryonated egg

Will develop into embryonated egg once in reaches
water
Miracidia lives within the first intermediate host which is
a snail
Miracidium as it develops into several larval stages
(sporocysts, rediae, cercariae) will undergoe several
division. Thus, remember that a miracidium is not
really equal to a cercaria.
The second intermediate host can vary from crayfish to
crabs etc depending on the area. Their common
characteristic is that they are all crustaceans. So, it is
not species specific. In the Philippines, our second
intermediate host is the small crab, Sundathelpusa.
Adults reside embedded to the cystic cavities in the
lungs eggs excreted in sputum/feces.
Does not go through circulation/mesenteric vessels.
Instead, they penetrate intestinal wall and peritoneal
cavity.

VECTORS

(Key: AC=acetabulum (ventral sucker); OV=ovary;

CE=cecum; TE=testes; OS=oral sucker; UT=uterus;
EB=excretory bladder)

Posterior oral sucker

Posterior testes (R and L)
Ovary (R and L)
Single ventral sucker which is hard to locate
Uterus: tightly coiled rosette

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OS 213: Human Disease and Treatment 3(Circulation

and Respiration)
LEC 13: PARAGONIMUS WESTERMANII
Exam 1 | Dr. Sonia Salamat | 25 January 2013
Figure 5. Sundathelphusa

Metacercaria

Figure 3. Paragonimus sp. vectors

Primary: Antemelania

First
intermediate
host:the
snails
Antemelaniaasperata; Antemelaniadactylus

Miracidium enters snail one sporocyst stage

2 redial stagecercaria emerges exit snail to infect 20
host

Cercaria
o Covered with spines and has an ellipsoidal body
with small tail
o Stylet present at dorsal side of the oral sucker

Figure 4.Antemelania

Secondary: Sundathelphusa

Second intermediate host:mountain crab

Sundathelpusaphilippina
o Cercaria penetrates soft parts
o Encysts metacercaria in the gills, body muscles,
viscera, legs
o Crab may be infected by eating infected snails

Definitive host(man) acquires infection by

eating raw or insufficiently cooked crabs harboring
metacercaria

Metacercaria is round and measures from 381457 micrometers

After ingestion, metacercaria excysts in

duodenum of host
o Cysteine proteinases secreted by metacercarias
excretory bladder help in excystment and host
immune modulation

Adolescent worm then penetrates the

intestinal wall, into the peritoneal cavity, where it
wanders about and embeds itself in the abdominal
wall for several days

Afterwards, returns to coelom, migrates

through diaphragm to pleural cavity and into the
lungs where it becomes encapsulated and develops
into adulthood

Completion of development in the

definitive host: 65-90 days

Can persists in man up to 20 years or

more

Can also infect dogs, cats, rats

PARAGONOMIASIS
Lung fluke disease that must be differentiated from TB,
which presents with similar symptoms. The two
diseases may occur simultaneously (Great mimic of
TB).
Zoonotic infection
An emerging food-borne parasitosis caused by
Paragonimus spp.
A trematodiasis, or fluke infection, which is among the
neglected tropical diseases (NTDs) according to
WHO.
NTDs are old diseases which have been around for quite
some time but have been neglected because: 1)
there is no program to address them, 2) there is no
budget, and 3) they are not prioritized because of
the general thinking that they are rare.
History of ingestion of inadequately raw, cooked or
pickled crustaceans, abdominal pain, nausea,
vomiting, diarrhea, testicular pain, and/or CNS
manifestations are reported findings.
Patients may develop significant hemoptysis or
extensive pulmonary infiltration comparable to PTB
infection.
Demonstration of lung fluke eggs on sputum
examination remains as the gold standard in
diagnosis.
If you want to examine you have to look for the stool na
may eggs
When they are mature enough, it will go out
Public health and economic impact of paragonimiasis
are considerable in terms of:
o Morbidity (people remain sick for a long time
because of misdiagnosis),
o Loss of productivity (no work, no school),
o Absenteeism from work and school,
o Health care costs (paying up for anti-TB drugs
when in fact, there is no TB at all), and
o Agricultural losses (those usually afflicted live in
agricultural areas) (WHO, 1995)

Acquiring Paragonimiasis

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OS 213: Human Disease and Treatment 3(Circulation

and Respiration)
LEC 13: PARAGONIMUS WESTERMANII
Exam 1 | Dr. Sonia Salamat | 25 January 2013

Eating raw crustaceans

Marinate crustaceans in brine/rice wine and then eat
Eating only salted crustacean
Contaminate fingers and utensils with metacercariae
while cooking
Poor food preparation and handling

Distribution in the Country

Considered as endemic in the country
Davao, Davao Oriental, Leyte, Samar, Sorsogon,
Camarines Norte, Camarines Sur, Cotabato, Basilan,
Mindoro, Zamboanga del Norte
16.3% Pulmonary TB patients in Sorsogon were infected
with Paragonimus (1999)
Symptomatology same as TB
Worldwide population rise: 292 x 106
Sources: freshwater crab, crayfish, wild boar meat (as
seen in North America)

Symptoms

Productive cough
Hemoptysis, dyspnea
Chest and back pain
Fever, anorexia, weight loss
Easy fatigability, weakness
Paragonimus and TB cannot be differentiated clinically

Chest X-Ray Findings

Lung infiltrates
Nodules
Calcifications
Pleural thickening
Pleural effusion
These can also be found in TB or other cases

Extrapulmonary Organs affected by

Paragonimus

Liver
Intestinal Wall
Mesenteric Lymph Nodes
Muscles
Testes
Brain (when infected, can result in granuloma formation
with eggs)
Peritoneum
Pleura

Diagnostic Tests
Microscopic exam of sputum and stool
Antibody detection (serology/immunology) but not
available in the Philippines
Histopathology (Biopsy) of brain involvement
Future diagnostic tests:
o Biomarkers
o Molecular Bio Approaches
Serologic Tests
o ELISA
o Complement fixation
o Immunoblot
o Indirect Hemaglutination Test
Other tests
o Intradermal Skin Testing
o Other Imaging Procedures (not definitive): CT and
MRI
Necessary to do multiple diagnostic tests especially for
extrapulmonary cases

Mara, Mel, Mich

Treatment
Drug of Choice: Praziquantel 25 mg/kg three times daily
for 2-3 days, free from DOH provided you have a
positive sputum smear for Paragonimus.
Effective against pulmonary paragonimiasis and all
forms of ectopic infection.
Table 1. High cure rates (Harinasuta & Bunnag, 90; Keiser and
Utzinger, 04):

Treatment
1 day
2 days
3 days

Cure Rate
71.4%
89.5%
100.0%

If there is pleural effusion, drainage must be performed

prior
to
praziquantel
treatment
(NakamuraUchiyama et al., 2002).
Praziquantel can be obtained free from DOH. Positive
test
results
needed
to
obtain
the
drug.
Unfortunately, since Praziquantel is also drug of
choice for schistosomiasis, we are rapidly depleting
the supply for schistosomiasis treatment programs
along the way.
Follow up of Treated Patients
Repeat sputum exam 90 days after treatment.
Lung fluke infection demonstrated even after
treatment may be due to:
o Heavy lung fluke burden or heavy intensity of
infection that may need re-treatment
o Possibility of re-infection that will require
diagnosis and re-treatment: 10-12% reinfection
rate after 1-2 years
Alternative drugs: Bithionol and Trielabendazole (not
available in the Philippines)
Adjunctive treatment
o Anticonvulsants (for extrapulmonary and brain)
o Steroids (to decrease swelling)
o Decompress cranial pressure
Surgery not first treatment of choice
Treatment Using Other Drugs
Triclabendazole
This is now the drug of choice according to WHO.
10 mg/kg for two doses in a single day (WHO, 2004)
10 mg/kg single dose: high cure rates, better tolerated
than praziquantel, better compliance (Calvopina,
1998)
Not available here because Switzerland company of
triclabendazole wants to know how many patients of
paragonimiasis are here in the Philippines, but we
cannot give them a number.

Paragonomiasis: A Continuing Problem

Discharge of human excreta water contamination
leading to infection of snails and crustaceans
Consumption of undercooked food (cultural practices,
social economics)
Poverty
For people from developed countries: Travel patterns,
Exotic food

Prevention
Early diagnosis and appropriate treatment
Capability building in public health and TB laboratories
especially in known endemic areas
Control of intermediate hosts may not be feasible

UPCM 2016 A: XVI,

WalangKapantay!

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OS 213: Human Disease and Treatment 3(Circulation

and Respiration)
LEC 13: PARAGONIMUS WESTERMANII
Exam 1 | Dr. Sonia Salamat | 25 January 2013
Abstaining from eating raw, freshly salted, or
inadequately cooked crabs or crayfish
Boiling and frying of infected crustaceans Cook food
well
Chemotherapy To stop cycle
Improved access to Sanitation
Infection Education Committee
Integrated control
END OF TRANSCRIPTION
Greetings:
Mara: Thank you Katha for your notes.

Mara, Mel, Mich

Mel: Benign week is so benign! 2 modules to go

before vacation!
And because I havent been greeting the past
transes we had, here goes my long greet: Hello to
the very awesome GABA! When will we do our Level
7 Bonding: Church Hopping? Congrats to the
Concepcions for the Paeng-like bowling prowess,
Fres and her Fres ball and Hannah The Striker Co.
Thank you for being our awesome adviser, Rae!
Lets go to Binondo next weeeeeeek! Hello Aca and
Patti! Hi Royce (binigay ko kay Banzweezee yung
lumpia. Hihi zorrehh)! Hi seatmates forever Jay-v,
Ivan, Regina! Caffeina ulit next week? Hi Vince! Hi
elective-mates sa Forensic Patho! And hello Mara
and Mich!!!

UPCM 2016 A: XVI,

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