CHRONIC CEREBRAL PARAGONIMIASIS COMBINED WITH ANEURYSMAL SUBARACHNOID HEMORRHAGE

The American Journal of Tropical Medicine and Hygiene, Nov 2003

A 67-year-old Korean woman attended our hospital complaining of a severe headache. A brain computed tomography scan showed conglomerated, high-density, calcified nodules in the left temporo-occipito-parietal area and high-density subarachnoid hemorrhage in the basal cisterns. Magnetic resonance imaging of the brain shows multiple conglomerated iso- or low-signal intensity round nodules with peripheral rim enhancement. She underwent craniotomies to clip the aneurysm and remove the calcified masses. Paragonimus westermani eggs were identified in the calcified necrotic lesions. Results of parasitic examinations on the sputum and an enzyme-linked immunosorbent assay for P. westermani were all negative. The patient presented with headache and dizziness that had occurred for more than 30 years. She had not eaten freshwater crayfish or crabs. However, she had sometimes prepared raw crabs for several decades. Overall, this case was diagnosed as chronic cerebral paragonimiasis, in which she may have been infected through the contamination of utensils during the preparation of the second intermediate hosts, combined with a cerebral hemorrhage.

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CHRONIC CEREBRAL PARAGONIMIASIS COMBINED WITH ANEURYSMAL SUBARACHNOID HEMORRHAGE

JUK-DONG CHOO 0 1 2 BUMN-SUK SUH 0 1 2 HYUN-SUNG LEE 0 1 2 JONG-SOO LEE 0 1 2 CHANG-JUNE SONG 0 1 2 DAE-WHAN SHIN 0 1 2 YOUNG-HA LEE 0 1 2 0 Department of Neurosurgery, Sun General Hospital , Daejeon , Republic of Korea; Department of Diagnostic Radiology, and Department of Parasitology, College of Medicine, Chungnam National University , Daejeon , Republic of Korea 1 Reprint requests: Young-Ha Lee, Department of Parasitology, Col- lege of Medicine, Chungnam National University , 6 Munhwa-dong, Jung-gu Daejeon 301-131 , Republic of Korea 2 Authors' address: Juk-Dong Choo, Bumn-Suk Suh, Hyun-Sung Lee, and Jong-Soo Lee, Department of Neurosurgery, Sun General Hos- pital , 10-7 Mok-dong, Jung-gu, Daejeon 301-070 , Republic of Korea. Chang-June Song, Department of Diagnostic Radiology, College of Medicine, Chungnam National University , 640 Daesa-dong, Jung-gu Daejeon 301-131 , Republic of Korea. Dae-Whan Shin and Young-Ha Lee, Department of Parasitology, College of Medicine, Chungnam National University , 6 Munwha-dong, Jung-gu Daejeon 301-131, Re- public of Korea A 67-year-old Korean woman attended our hospital complaining of a severe headache. A brain computed tomography scan showed conglomerated, high-density, calcified nodules in the left temporo-occipito-parietal area and high-density subarachnoid hemorrhage in the basal cisterns. Magnetic resonance imaging of the brain shows multiple conglomerated iso- or low-signal intensity round nodules with peripheral rim enhancement. She underwent craniotomies to clip the aneurysm and remove the calcified masses. Paragonimus westermani eggs were identified in the calcified necrotic lesions. Results of parasitic examinations on the sputum and an enzyme-linked immunosorbent assay for P. westermani were all negative. The patient presented with headache and dizziness that had occurred for more than 30 years. She had not eaten freshwater crayfish or crabs. However, she had sometimes prepared raw crabs for several decades. Overall, this case was diagnosed as chronic cerebral paragonimiasis, in which she may have been infected through the contamination of utensils during the preparation of the second intermediate hosts, combined with a cerebral hemorrhage. - Paragonimiasis is an infection by the genus Paragonimus, the most common of which is Paragonimis westermani, the oriental lung fluke. Paragonimus westermani is a common human parasite in the Far East, and is particularly prevalent in Korea, China, Japan, and Taiwan. Paragonimiasis results from the ingestion of a raw or insufficiently cooked second intermediate hosts such as freshwater crayfish, crabs, or shrimp, where the encysted metacercarial stage occurs. The metacercariae excyst in the small intestine and penetrate the wall into the abdominal cavity, which then migrate through the viscera and diaphragm to the lungs. The lung is the principal habitat in the human host. The erratic migrations of the juvenile flukes result in ectopic paragonimiasis in various organs, frequently in the peritoneal and pelvic cavities, the diaphragm, the subcutaneous tissues, and the brain.1,2 The most serious erratic migration is a cerebral paragonimiasis, where the fluke enters the cranial cavity through the jugular or carotid foramen and usually invades the temporal and occipital lobes of the brain. Cerebral paragonimiasis is serious and is sometimes fatal, although symptoms of ectopic infections are solely dependent on the infected sites and the number of parasites therein.24 There are many factors known to cause intracranial hemorrhage including head trauma, hypertensive hemorrhage, coagulopathy, aneurysm, and arteriovenous malformation. Parasitic infections can also cause an intracranial hemorrhage, which have been reported for Plasmodium, Toxoplasma, sparganum, cysticercosis, and Paragonimus.510 We report a combined case of a chronic cerebral paragonimiasis and an intracranial hemorrhage. A 67-year-old Korean woman was admitted to the Sun General Hospital in Daejeon, Republic of Korea on March 4, 2002 complaining of severe headache and drowsiness for the previous hour. A plain skull lateral view revealed radiopaque, conglomerated, calcified nodules in the temporo-occipitoparietal area (Figure 1A). Computed tomographic (CT) scans of the brain also showed conglomerated high-density calcified nodules with underlying focal encephalomalacia in the left temporo-occipito-parietal area and a subarachnoid hemorrhage in the basal cisterns (Figure 1B). A right lateral internal carotid cebebral angiogram showed a saccular aneurysm in the posterior communicating artery (Figure 1C). Magnetic resonance images (MRI) of the brain show conglomerated iso- or low-signal intensity round nodules with a peripheral rim enhancement in the left temporo-occipito-parietal area in both the T1- and T2-weighted axial images (Figure 1DF). A chest radiograph showed mild right pleural thickening, but there was no active lesion. From these radiologic findings, (...truncated)


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JUK-DONG CHOO, BUMN-SUK SUH, HYUN-SUNG LEE, JONG-SOO LEE, CHANG-JUNE SONG, DAE-WHAN SHIN, YOUNG-HA LEE. CHRONIC CEREBRAL PARAGONIMIASIS COMBINED WITH ANEURYSMAL SUBARACHNOID HEMORRHAGE, The American Journal of Tropical Medicine and Hygiene, 2003, pp. 466-469, 69/5,