We report a case of paragonimiasis involving a 12-year-old Latin American boy. The diagnosis was made by fine-needle aspiration biopsy of a pulmonary nodule. Identification of the species by morphometric analysis of the eggs indicated that the infection was caused by Paragonimus mexicanus.
CASE REPORTA 12-year-old boy with a 2-year history of seizures, headaches, and intermittent hemoptysis presented to the Ben Taub General Hospital emergency room after a cluster of five seizure attacks. The boy was from El Salvador, had been in the United States for 14 months, and had been treated with phenytoin for his seizures. On presentation, his head computed tomography (CT) scan showed a calcified cystic lesion in the left anterior frontal area. The electroencephalograph was abnormal, with recurrent slow wave spikes in the left temporal lobe and a frontal slow-wave spike. He was diagnosed with symptomatic localized epilepsy with secondary generalized tonic/clonic seizures. He was started on carbamazepine (Tegretol) and followed monthly by the Neurology Service. He had been seizure free for 9 months when he presented to the emergency room for a second time with two episodes of selflimited tonic/clonic seizure at school, each lasting less than 1 minute. There was no loss of bladder or bowel control. The patient reported a 1-year history of intermittent hemoptysis. His sputum was reported to be blood streaked with no gross blood. He had an occasional productive cough but no hematemesis, nasal congestion, chest pain, or shortness of breath. He occasionally had fever but no chills or night sweats. The patient's mother reported that he had a 20-pound weight loss over the previous year. No diarrhea was reported. His physical activity was normal and he did not complain of fatigue. Headaches had been worse over the past few months; therefore, he had missed several days of school. The headaches were frontal, throbbing, and associated with photophobia. He was also complained of problems with visual acuity. He denied any syncope, vomiting, or persistent poor vision. His headaches were relieved with acetaminophen (Tylenol).His physical examination was unremarkable. His laboratory investigation documented a normal complete blood count with no eosinophilia. His metabolic panel was also normal. His cerebrospinal fluid sample had four white cells and no red cells; cerebrospinal fluid culture was negative for bacteria, fungi, and viruses. Abdominal and pelvic CT scans were normal. His chest X-ray and CT scan showed multiple lung nodules measuring up to 2.2 cm but no lymphadenopathy (Fig. 1). Pulmonary angiography showed no evidence of hypervascular tumor or arteriovenous malformation. A head CT scan revealed a focus of encephalomalacia in the left superior frontal gyrus involving the underlying white matter and a 2-to 3-mm focal calcification. A CT-guided lung biopsy using fine-needle aspiration showed abundant necrotic cellular debris surrounding numerous thick-walled parasite eggs morphologically consistent with those of the trematode or...