Epidemiology[edit]

Reservoir hosts of Paragonimus spp. include numerous species of carnivores including

felids, canids, viverrids, mustelids, some rodents and pigs. Humans become infected after
eating raw freshwater crabs or crayfish that have been encysted with the metacerciaria.
Southeast Asia is more predominately more infected because of lifestyles. Raw seafood is
popular in these countries. Crab collectors string raw crabs together and bring them miles
inland to sell in Taiwan markets. These raw crabs are then marinated or pickled in
vinegar or wine to coagulate the crustacean muscle. This method of preparation does not
kill the metacercariae, consequently infecting the host. Smashing rice-eating crabs in rice
paddies, splashing juices containing metacercariae, can also transmit the parasite, or
using juices strained from fresh crabs for medicinal uses. This parasite is easily spread
because it is able to infect other animals (zoonosis). An assortment of mammals and birds
can be infected and act as paratenic hosts. Ingestion of the paratenic host can lead to
infection of this parasite.
Paragonimus westermani is distributed in southeast Asia and Japan. Other species
of Paragonimus are common in parts of Asia, Africa and South and Central America. P.
westermani has been increasingly recognized in the United States during the past 15
years because of the increase of immigrants from endemic areas such as Southeast Asia.
Estimated to infect 22 million people worldwide.[3]

Morphology[edit]

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 m long by 45 to 70 m

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.

Diagnosis[edit]
Diagnosis is based on microscopic demonstration of eggs in stool or sputum, but these
are not present until 2 to 3 months after infection. However, eggs are also occasionally
encountered in effusion fluid or biopsy material. Furthermore, you can use morphologic
comparisons with other intestinal parasites to diagnose potential causative agents. Finally,
antibody detection is useful in light infections and in the diagnosis of extrapulmonary
paragonimiasis. In the United States, detection of antibodies to Paragonimus
westermani has helped physicians differentiate paragonimiasis from tuberculosis in
Indochinese immigrants.[3]
Additionally, 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.

Life cycle[edit]
Unembryonated eggs are passed in the sputum of a human or feline. Two weeks
later, miracidia develop in the egg and hatches. The miracidia penetrate its
first intermediate host(snail). Within the snail mother sporocyst form and produce many
mother rediae, which subsequently produce many daughter rediae which shed crawling
cercariae into fresh water. The crawling cercariae penetrate fresh water crabs and encyst
in its muscles becoming metacercaria. Humans or felines then eat the infected crabs raw.
Once eaten, the metacercaria excysts and penetrates the gut, diaphragm and lung where it
becomes an adult worm in pairs.
The first intermediate hosts of the Paragonimus westermani are freshwater snails

Paragonimus has a quite complex life-cycle that involves two intermediate hosts as
well as humans. Eggs first develop in water after being expelled by coughing
(unembryonated) or being passed in human feces. In the external environment, the
eggs become embryonated. In the next stage, the parasite miracidia hatch and invades
the first intermediate host such as a species of freshwater snail. Miracidia penetrate its
soft tissues and go through several developmental stages inside the snail but mature
into cercariae in 3 to 5 months. Cercariae next invade the second intermediate host
such as crabs or crayfish and encyst to develop into metacercariae within 2 months.
Infection of humans or other mammals (definitive hosts) occurs via consumption of
raw or undercooked crustaceans. 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.
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.[3]

What are the signs and symptoms?

Adult flukes living in the lung cause lung disease. After 2-15 days, the initial signs and
symptoms may be diarrhea and abdominal pain. This may be followed several days later
by fever, chest pain, and fatigue. The symptoms may also include a dry cough initially,
which later often becomes productive with rusty-colored or blood-tinged sputum on
exertion. The symptoms of paragonimiasis can be similar to those of tuberculosis.

How is Paragonimus infection diagnosed?

The diagnosis is usually made by identifying Paragonimus eggs in the sputum or

sometimes in the stool (from ingesting eggs after coughing them up, then passing the
eggs in the stool).

Paragonimiasis Symptoms
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