Rare case of Pulmonary Paragonimiasis in Jubail City

Rare case of Pulmonary Paragonimiasis in Jubail City | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Rare case of Pulmonary Paragonimiasis in Jubail City Salah A.M. Ali, Randa Ibrahim Ahmed, Mohamed Deeb, Mahmoud Hassan, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6797090/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Pulmonary Paragonimiasis is caused by a trematode of genus Paragonimus and typically results from the consumption of raw or improperly cooked crustacea, especially crabs and crayfish. The disease is frequently, misdiagnosed in non-endemic areas and alternative diagnoses such as tuberculosis and malignancy usually considered. Herein, we report a case of forty-one-year old, Filipino male with pulmonary paragonimiasis complicated by epidydimo orchitis and scrotal abscess. This is first case report of Pulmonary paragonimiasis in Saudi Arabia and first case complicated by scrotal abscess worldwide. Paragonimiasis Paragonimus Westermani Lung Epididymo-orchitis Scrotal abscess Positron Emission Tomography Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Pleuropulmonary paragonimiasis is a food-borne parasitic disease caused by the lung fluke Paragonimus Westermani , which is endemic in Southeast Asia and the Far East [1]. In the recent years the disease is seen in nonendemic areas due to the international travel and expansion of world food trade [2]. Human infection results from ingestion of raw freshwater crab or crayfish infected with the metacercaria [3]. The primary site of infection is the lung, and extrapulmonary involvement is also reported. The central nervous system is frequently involved along with the liver, intestine, peritoneal cavity, retroperitoneum, and abdominal wall [4]. Epididymo-orchitis and scrotal abscesses due to Paragonimus Westermani have not been described before in the literature. Ectopic paragonimiasis raises diagnostic challenge since it is uncommon and may be confused with malignancy or other inflammatory diseases. Pulmonary Paragonimiasis has not been reported in Saudi Arabia despite the presence of large number of expatriates from endemic areas. We report a case of pulmonary paragonimiasis complicated by epididymo-orchitis and scrotal abscess diagnosed at Mouwasat Hospital Jubail. Case History Forty-one-year-old Filipino driver presented to the emergency department with breathlessness, cough productive of yellowish sputum, fever, body aches and painful scrotal swelling for 4 weeks. He reported no hemoptysis or weight loss. He was known diabetic for 4 years on oral hypoglycemic but not compliant with his diabetes medications. Heavy smoker with 20 pack years. Married and his family in Philippines. No history of contact with tuberculosis. He is originally from San Juan, Batangas province in Philippines and migrated to Saudi Arabia 13 years ago. Last vacation to the Philippines was one and half year earlier. The physical examination revealed unwell middle age man with Respiratory Rate 28/minute, Pulse 126/minute regular. Blood Pressure 110/65, Temperature. 38 ºC. Oxygen saturation 90 on room air. He was not pale or Jaundiced. Neck examination was normal. Chest revealed bilateral crackles posteriorly at lung bases. The heart, abdomen, CNS and lower limbs were normal. Examination of the genitalia revealed scrotal swelling mainly on the left side. The swelling was warm and overlying skin was red. Laboratory testing revealed leukocytosis WBC 17.7 X 10 3 cells / µL, Neutrophils 17 X 10 3 cells / µL (94%), Lymphocytes 0.5 X 10 3 cells / µL (4.5%), Monocytes 0.2 X 10 3 cells / µL (1.5%). Eosinophils 0 X 10 3 cells / µL (0%), Hemoglobin 15 g /dL and Platelets 168X10 3 / µL. Random blood glucose 520 mg/dl and Hemoglobin AIC was 14. Urinalysis glucose 4+ acetone 2+. Blood gases On air PH 7.43, PCO 2 36, PO 2 43, Act HCO 3 23, STD HCO 3 24, BE – 0.5, CT CO 2 20 mmol/L, O 2 Saturation 87%, Lactate 6.3 mm/l. IGE 379 IU/ml, Blood Urea Nitrogen 23 mg/dl, Creatinine 1mg/dl, Na 121mmol/dl, K 4.9 mmol/dl, Cl 83 mmol/dl, Total protein 5.5 gm/dl, Albumin 2.2gm/dl, Total bilirubin 1.5 mg/dl, Direct 1mg/dl, Indirect 0.5 mg/dl, Alanine aminotransferases 26 U/L, Aspartate aminotransferase 32 U/L, Alkaline Phosphatase 613 U/L, Gamma Glutamyl Transferase 396 U/L. Ferritin 2000 ng/ml, Lactate Dehydrogenase 308 U/L. Presepsin 2413 pg/ml and procalcitonin 52 ng/ml. Tests results for hepatitis B surface antigen and antibodies to hepatitis B surface antigen, hepatitis C virus and HIV were negative. QuantiFERON plus was negative. Chest Xray showed bilateral multiple airspace cavitating opacities and linear shadows (Fig.1A). The patient was admitted to the hospital and commenced on intravenous fluids, insulin, intravenous ceftriaxone and azithromycin. The blood glucose was controlled, hyponatremia corrected, and the lactate returned to normal. was PCR for COVID 19 negative. Three sputum samples were negative for acid fast bacilli and tuberculin test was negative. He felt better and CT scan chest demonstrated multiple scattered peripheral, variable sized cavitating nodules and consolidation. In addition, irregular linear interstitial lines are seen in the mid and lower zones. (Fig.1 B, C,D). MRI brain and abdomen were normal. MRI pelvis showed scrotal abscess (Fig 2) Whole body FDG PET/CT demonstrated an area of increased FDG uptake density within the upper pole of right lung lobe and pelvic image shows linear area of increased FDG uptake suggestive of scrotal abscess as well as infected right spermatic cord (Fig 3). Diagnostic work up started for differential diagnosis of multiple cavitating pulmonary lesion. Aspergillus fumagatus antibodies were negative. Angiotensin converting enzyme level 67 u/ml, alpha feto protein 1.86 IU/ml, carcinoembryonic antigen 1.67 IU/ml. ANCA C&P, rheumatoid factor was negative. Echinococcus granulosis antibodies were negative. In view of the history of travelling from endemic area diagnosis of Paragonimus Westermani was considered. A fresh sputum sample was examined for ova by wet examination, showed ova of Paragonimmus Westermani . (Fig.4). Definitive diagnosis of Paragonimus infection was confirmed by the presence of parasite ova in the sputum. Serological test for Paragonimus westermani was requested.Additional history from the patient revealed that is fund of eating raw freshwater crab and crayfish dishes locally known as kinilaw and kinagang. The patient underwent surgery and the scrotal abscess was drained and left inguinal orchidectomy was performed (Fig 5). The ova were found in the scrotal abscess Fig.5 The abscess and blood culture revealed no bacterial growth. The patient was treated with praziquantel 25mg/kg three timed daily for three days. The histopathology or the resected testicle and spermatic cord showed diffuse suppurative and xanthomatous inflammation involving paratesticular tissue epididymis and spermatic cord and partially the testicle which showed atrophic changes. No ova were detected. (Fig. 5) Discussion P ulmonary paragonimiasis is a parasitic disease of the lung and is caused by infestation with Paragonimus Westermani lung flukes, or other species of Paragonimus [1]. In the genus Paragonimus , there are more than 50 different species of which 9 are known to cause infections in humans [5]. Paragonimus westermani is the most common species causing Human infection. The estimated number of people infected with the human lung fluke is 23 million globally [2], with 293 million people at risk for infection with Paragonimus species [6]. Human infection results from ingestion of raw freshwater crab or crayfish infected with the metacercaria. The incubation period may vary from 1 to 2 months or even longer [3]. The parasite from the human gut passes through several organs and tissues to reach the lungs [7]. Adult worms live in the lungs and the eggs are voided in the sputum or feces [7]. The eggs hatch in the fresh water to release miracidiae which are ingested by the first intermediate host, freshwater snails [7]. The miracidiae develop into cercariae in the snail and are released into the water [7]. The cercariae then invade the second intermediate host, crustaceans (crayfish or crabs), and develop into infective metacercariae [7]. The primary site of infection is the lung, and extrapulmonary involvement is also reported. No case report of epidydimo orchitis nor scrotal abscess. Here, we presented a case of pulmonary Paragnonimiasis complicated by ectopic perineal infection in the form of abscess in the scrotum and vas deferens. This is first case report of Paragonimus westermani infection in Saudi Arabia and the first report in the literature of Paragonimus westermani complicated by scrotal abscess. The diagnosis of pulmonary paragonimiasis was considered in this patient in the diagnostic workup of pulmonary cavitating nodules, because he came from Philippines. It is an endemic area of paragonimiasis and local food habits of consuming raw fresh water crab and cray fish facilitate the infestation by Paragonimus Westermani [8]. Definitive diagnosis was established by the presence of Paragonimus ova in the sputum. The microbiologist was alerted to the possibility of this infection. The absence of eosinophilia was notable in this patient which may draw the attention of physicians away from considering parasitic infestations as diagnostic possibility. Eosinophilia is usually absent the late stages of infections [9]. Immunological test, commonly, ELISA is used to measure antibodies to Paragonimus species. However, a positive ELISA test does not always imply that active infection is present, since it took 4 to 18 months for the antibody level to decrease to a normal level [10]. FDG Pet Scan showed increased uptake in the lung (SUV max = 2.9 ) , inguinal canal and scrotum (SUV max = 3.14). Paragonimiasis is a relatively rare cause of pulmonary disease; there have been only a few reported cases of pulmonary paragonimiasis as a cause of false-positive results on FDG-PET examinations [11]. The scrotal abscess was drained surgically and left orchidectomy was performed. The pus examination showed ova of Paragonimus Westermani FIG (5B). The histopathology of the testes showed suppurative inflammation with atrophic changes. No granulomata or parasite ova were detected FIG (5C). Although the lung is the most common site of infection, other organs such as the central nervous system, liver, intestine, peritoneal cavity, retroperitoneum, and abdominal wall are also known to be involved [7]. In many cases, mass-like lesions or abscess were found in the involved organs. Malignancy is a concern, so surgical resection is usually performed to treat the abscess and to exclude the malignancy. In our patient the scrotal abscess was surgically drained and left orchidectomy was performed. The pus examination showed ova of parasite confirming that the abscess was due to Paragonimus Westermani . Routine culture of the pus revealed no bacterial growth. The pus Scrotal abscess due to Paragonimus infection has not been described in the literature. It is treated like any other abscesses by drainage, antibiotics and praziquantel for the parasite. The diagnosis of Pargonimus Westermani should be considered in patients with sterile scrotal abscesses travelling from endemic areas. The diagnosis of Paragonimus infection in non-endemic areas is often challenging. This is due unfamiliarity of the healthcare professionals with the disease and atypical clinical presentations. In addition, laboratories often don’t have the required technology, skill nor expertise in confirming the diagnosis. In view of the presence of large number of expatriates from endemic areas in Saudi Arabia mandates the health care professionals to be aware of the disease and to consider the diagnosis when dealing with a suggestive clinical presentation. Conclusion This the first case report in literature of scrotal abscess caused by Paragonimus Westermani in an adult male and the first case report of Paragonimus Westermani in Saudi Arabia. This case highlights the importance of considering Paragonimus Westermani infection in the differential diagnosis of cavitating pulmonary lesions and perineal abscesses in patients travelled from endemic areas. The increased immigration from endemic areas has enhanced the likelihood of encountering this disease and healthcare professionals in Saudi Arabia should conceive this diagnostic possibility. Laboratory diagnostic tests should be made available. Declarations Author Contribution All authors contributed equally to this work Acknowledgement Mouwasat hospital Jubail staff References [1] Yokogawa M. Paragonimus and Paragonimiasis. Adv Parasitol 1965; 3:99–158 [2] Fischer PU, Weil GJ. North American paragonimiasis: Epidemiology and Diagnostic Strategies. Expert Rev Anti Infect Ther 2015;13:779e86. [3] T. S. Singh, H. Sugiyama, and A. Rangsiruji, “Paragonimus & paragonimiasis in India,” Indian Journal of Medical Research , vol. 136, no. 2, pp. 192–204, 2012 [4] Chai JY. Paragonimiasis. Handb Clin Neurol 2013; 114: 283-296 [ 5 ] Narain K, Agatsuma T, Blair D. Paragonimus. In: Liu D, Editor. Molecular detection of Foodborne Pathogens. Boca Raton, Florida, USA: CRC Press Taylor & Francis Group; 2010. p. 827e37. [6] Keiser J, Utzinger J. Emerging Foodborne Trematodiasis. Emerg Infect Dis 2005;11:1507e14 [7] F. Nakamura-Uchiyama, H.Mukae, and Y. Nawa, “Paragonimiasis:a Japanese perspective,” Clinics in Chest Medicine , vol. 23, no. 2, pp. 409–420, 2002. [8] https://www.who.int/foodborne_trematode_infections/paragonimiasis/en/ [9] YANG SP, HUANG CT, CHENG CS, CHIANG LC. The clinical and roentgenological courses of pulmonary paragonimiasis. Dis Chest 1959; 36:494. [10] Cho SY, Kim SI, Kang SY, Kong Y, Han SK, Shim YS, Han YC. Antibody changes in Paragonimiasis patients after praziquantel treatment as observed by ELISA and immunoblot. Korean J Par­asitol 1989; 27: 15-21. [11] Ie Ryung YOO, Hyun Jin PARK, Joo HYUN O, Yong An CHUNG, Hyung Sun SOHN, Soo Kyo CHUNG and Sung Hoon KIM.Two cases of pulmonary paragonimiasis on FDG-PET CT imaging Annals of Nuclear Medicine Vol. 20, No. 4, Additional Declarations No competing interests reported. The patient provided informed consent to publish this case report. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 09 Jun, 2025 Reviews received at journal 09 Jun, 2025 Reviewers agreed at journal 06 Jun, 2025 Reviews received at journal 04 Jun, 2025 Reviewers agreed at journal 04 Jun, 2025 Reviewers invited by journal 04 Jun, 2025 Editor assigned by journal 04 Jun, 2025 Submission checks completed at journal 03 Jun, 2025 First submitted to journal 01 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6797090","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":466270087,"identity":"8d9ea8b3-443e-4c0e-a4ac-c10a61afe2b6","order_by":0,"name":"Salah A.M. 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Interstitial changes with band atelectasis right lower zone with small right effusion. CT chest (\u003cstrong\u003eB\u003c/strong\u003e, \u003cstrong\u003eC\u003c/strong\u003e) demonstrated multiple scattered peripheral cavitating nodules and consolidation which are pleural based with pleural thickening. Irregular linear \u0026nbsp;interstitial lines and shadowing more evident at right lung.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6797090/v1/9ff091aa7bee03e617e0e0e9.png"},{"id":84215277,"identity":"9fd71f19-4ded-4235-a4f4-ccc3ab1c39da","added_by":"auto","created_at":"2025-06-09 10:37:50","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":144225,"visible":true,"origin":"","legend":"\u003cp\u003eMRI Pelvis showed abscess containing air (arrow) in the scrotum and left inguinal canal (yellow arrow)\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6797090/v1/69cd55bf26748f4a3be674d9.png"},{"id":84216591,"identity":"b7f9e640-c90d-4b91-83ef-3563af8e01a2","added_by":"auto","created_at":"2025-06-09 10:45:50","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":201417,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA\u003c/strong\u003e. Coronal CT image of the chest abdomen and pelvis. \u003cstrong\u003eB.\u003c/strong\u003e Coronal PET/CT fusion image shows an area of increased FDG uptake corresponding to CT scan finding of a soft tissue density within the upper pole of right lung lobe \u0026nbsp;associated with multiple bilateral cavitary lung lesions surrounded by dense areas of consolidation more prominent on the right lung; all showing increased FDG uptake on PET imaging. CT scan shows mild right pleural effusion, not showing FDG uptake on PET imaging. Abdomen and pelvis: - PET scan shows linear area of increased FDG uptake corresponding to CT scan findings of scrotal abscess as well as infected right spermatic cord.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6797090/v1/935a00f2982c75bb69641344.png"},{"id":84215305,"identity":"93c68457-07b4-4ae6-b38d-c33e391c5e3e","added_by":"auto","created_at":"2025-06-09 10:37:51","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":673926,"visible":true,"origin":"","legend":"\u003cp\u003e(A, B, C) Eggs of \u003cem\u003eParagonimus Westermani\u003c/em\u003e in unstained wet mounts. \u003cem\u003eParagonimus Westermani\u003c/em\u003e eggs range from 80-120 µm long by 45-70 µm wide. \u0026nbsp;They are yellow-brown, ovoid or elongate, with a thick shell, and often asymmetrical with one end slightly flattened. \u0026nbsp;At the large end, the operculum is clearly visible. \u0026nbsp;The opposite (abopercular) end is thickened. \u0026nbsp;The eggs are unembryonated when passed in sputum or feces. (D) reddish colored \u003cem\u003eParagonimus\u003c/em\u003eeggs in Ziehl-Neelsen stained sputum (100 magnification)\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-6797090/v1/6d2cd6c21dc659246ebcdfc8.png"},{"id":84216593,"identity":"53fb3c4b-e1d9-44b2-a643-27ce6d01c013","added_by":"auto","created_at":"2025-06-09 10:45:50","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":705870,"visible":true,"origin":"","legend":"\u003cp\u003e(A) Abscess drained from the left scrotal sac .(B ) \u003cem\u003eParagonimus\u003c/em\u003e ova in the pus.( C )Section through the testicle diffuse suppurative and xanthomatous inflammation involving paratesticular tissue epididymis and spermatic cord and partially the testicle which showed atrophic changes. No ova or granulomata were detected.\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-6797090/v1/0e8d7b58709e62d01c3de4b1.png"},{"id":84217318,"identity":"e35318fa-fd81-48d5-9e8b-b9123617198c","added_by":"auto","created_at":"2025-06-09 10:53:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3007560,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6797090/v1/d6c8c220-9f47-431c-9762-8c77225ae556.pdf"}],"financialInterests":"\u003cp\u003eNo competing interests reported.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eThe patient provided informed consent to publish this case report.\u003c/p\u003e","formattedTitle":"Rare case of Pulmonary Paragonimiasis in Jubail City","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePleuropulmonary paragonimiasis is a food-borne parasitic disease caused by the lung fluke \u003cem\u003eParagonimus Westermani\u003c/em\u003e, which is endemic in Southeast Asia and the Far East [1]. \u0026nbsp;In the recent years the disease is seen in nonendemic areas due to the international travel and expansion of world food trade [2]. \u0026nbsp;Human infection results from ingestion of raw freshwater crab or crayfish infected with the metacercaria\u0026nbsp;[3]. \u0026nbsp;The primary site of infection is the lung, and extrapulmonary involvement is also reported. The central nervous system is frequently involved along with the liver, intestine, peritoneal cavity, retroperitoneum, and abdominal wall\u0026nbsp;[4]. \u0026nbsp;Epididymo-orchitis and scrotal abscesses due to \u003cem\u003eParagonimus Westermani\u003c/em\u003e have not been described before in the literature. Ectopic paragonimiasis raises diagnostic challenge since it is uncommon and may be confused with malignancy or other inflammatory diseases. Pulmonary Paragonimiasis has not been reported in Saudi Arabia despite the presence of large number of expatriates from endemic areas.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe report a case of pulmonary paragonimiasis complicated by epididymo-orchitis and scrotal abscess diagnosed at Mouwasat Hospital Jubail.\u003c/p\u003e"},{"header":"Case History","content":"\u003cp\u003eForty-one-year-old Filipino driver presented to the emergency department with breathlessness, cough productive of yellowish sputum, fever, body aches and painful scrotal swelling for 4 weeks. \u0026nbsp;He reported no hemoptysis or weight loss. He was known diabetic for 4 years on oral hypoglycemic but not compliant with his diabetes medications. Heavy smoker with 20 pack years. Married and his family in Philippines. No history of contact with tuberculosis.\u003c/p\u003e\n\u003cp\u003eHe is originally from San Juan, Batangas province in Philippines and migrated to Saudi Arabia 13 years ago. Last vacation to the Philippines was one and half year earlier.\u003c/p\u003e\n\u003cp\u003eThe physical examination revealed unwell middle age man with Respiratory Rate 28/minute, Pulse 126/minute regular. \u0026nbsp;Blood Pressure 110/65, Temperature. \u0026nbsp;38 \u0026ordm;C. Oxygen saturation 90 on room air. He was not pale or Jaundiced. \u0026nbsp;Neck examination was normal. \u0026nbsp;Chest revealed bilateral crackles posteriorly at lung bases. \u0026nbsp;The heart, abdomen, CNS and lower limbs were normal. Examination of the genitalia revealed scrotal swelling mainly on the left side. The swelling was warm and overlying skin was red.\u003c/p\u003e\n\u003cp\u003eLaboratory testing revealed leukocytosis WBC 17.7 X 10\u003csup\u003e3\u003c/sup\u003e cells\u003cstrong\u003e/\u003c/strong\u003e\u0026micro;L, Neutrophils 17 X 10\u003csup\u003e3\u003c/sup\u003e cells\u003cstrong\u003e/\u003c/strong\u003e\u0026micro;L (94%), Lymphocytes 0.5 X 10\u003csup\u003e3\u003c/sup\u003e cells\u003cstrong\u003e/\u003c/strong\u003e\u0026micro;L (4.5%), Monocytes 0.2 X 10\u003csup\u003e3\u003c/sup\u003e cells\u003cstrong\u003e/\u003c/strong\u003e\u0026micro;L (1.5%). Eosinophils 0 X 10\u003csup\u003e3\u003c/sup\u003e cells\u003cstrong\u003e/\u003c/strong\u003e\u0026micro;L (0%), Hemoglobin 15 g /dL and Platelets 168X10\u003csup\u003e3\u003c/sup\u003e\u003cstrong\u003e/\u003c/strong\u003e\u0026micro;L. Random blood glucose 520 mg/dl and Hemoglobin AIC was 14. Urinalysis glucose 4+ acetone 2+. Blood gases On air PH 7.43, PCO\u003csub\u003e2\u003c/sub\u003e 36, PO\u003csub\u003e2\u003c/sub\u003e 43, Act HCO\u003csub\u003e3\u003c/sub\u003e 23, STD HCO\u003csub\u003e3\u003c/sub\u003e 24, BE \u0026ndash; 0.5, CT CO\u003csub\u003e2\u003c/sub\u003e 20 mmol/L, O\u003csub\u003e2\u003c/sub\u003e Saturation 87%, Lactate 6.3 mm/l. IGE 379 IU/ml, Blood Urea Nitrogen \u0026nbsp;23 mg/dl, Creatinine 1mg/dl, Na 121mmol/dl, K 4.9 mmol/dl, Cl 83 mmol/dl, Total protein 5.5 gm/dl, Albumin 2.2gm/dl, Total bilirubin 1.5 mg/dl, Direct 1mg/dl, Indirect 0.5 mg/dl, Alanine aminotransferases 26 U/L, \u0026nbsp; Aspartate aminotransferase \u0026nbsp;32 U/L, Alkaline Phosphatase \u0026nbsp;613 U/L, Gamma Glutamyl Transferase 396 U/L. Ferritin 2000 ng/ml, Lactate Dehydrogenase 308 U/L. Presepsin 2413 pg/ml and procalcitonin 52 ng/ml. Tests results for hepatitis B surface antigen and antibodies to hepatitis B surface antigen, hepatitis C virus and HIV were negative. QuantiFERON plus was negative. Chest Xray showed bilateral multiple airspace cavitating opacities and linear shadows (Fig.1A).\u003c/p\u003e\n\u003cp\u003eThe patient was admitted to the hospital and commenced on intravenous fluids, insulin, intravenous ceftriaxone and azithromycin. The blood glucose was controlled, hyponatremia corrected, and the lactate returned to normal. was PCR for COVID 19 negative. Three sputum samples were negative for acid fast bacilli and tuberculin test was negative. He felt better and CT scan chest demonstrated \u0026nbsp; multiple scattered peripheral, variable sized cavitating nodules and consolidation. In addition, irregular linear interstitial lines are seen in the mid and lower zones. (Fig.1 B, C,D). MRI brain and abdomen were normal. MRI pelvis showed scrotal abscess (Fig 2)\u003c/p\u003e\n\u003cp\u003eWhole body FDG PET/CT demonstrated an area of increased FDG uptake density within the upper pole of right lung lobe and pelvic image shows linear area of increased FDG uptake suggestive of scrotal abscess as well as infected right spermatic cord (Fig 3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDiagnostic work up started for differential diagnosis of multiple cavitating pulmonary lesion.\u003c/p\u003e\n\u003cp\u003eAspergillus fumagatus antibodies were negative. Angiotensin converting enzyme level 67 u/ml, alpha feto protein 1.86 IU/ml, carcinoembryonic antigen 1.67 IU/ml. ANCA C\u0026amp;P, rheumatoid factor was negative. Echinococcus granulosis antibodies were negative.\u003c/p\u003e\n\u003cp\u003eIn view of the history of travelling from endemic area diagnosis of \u003cem\u003eParagonimus Westermani\u003c/em\u003e was considered. \u0026nbsp;A fresh sputum sample was examined for ova by wet examination, showed ova of \u003cem\u003eParagonimmus Westermani\u003c/em\u003e. (Fig.4).\u003c/p\u003e\n\u003cp\u003eDefinitive diagnosis of \u003cem\u003eParagonimus\u003c/em\u003e infection was confirmed by the presence of parasite ova in the sputum. Serological test for \u003cem\u003eParagonimus westermani\u003c/em\u003e was requested.Additional history from the patient revealed that is fund of eating raw freshwater crab and crayfish dishes locally known as kinilaw and kinagang.\u003c/p\u003e\n\u003cp\u003eThe patient underwent surgery and the scrotal abscess was drained and left inguinal orchidectomy was performed (Fig 5). The ova were found in the scrotal abscess Fig.5 The abscess and blood culture revealed no bacterial growth.\u003c/p\u003e\n\u003cp\u003eThe patient was treated with praziquantel 25mg/kg three timed daily for three days.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe histopathology or the resected testicle and spermatic cord showed diffuse suppurative and xanthomatous inflammation involving paratesticular tissue epididymis and spermatic cord and partially the testicle which showed atrophic changes. No ova were detected. (Fig. 5)\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e \u003cb\u003eP\u003c/b\u003eulmonary paragonimiasis is a parasitic disease of the lung and is caused by infestation with \u003cem\u003eParagonimus Westermani\u003c/em\u003e lung flukes, or other species of \u003cem\u003eParagonimus\u003c/em\u003e [1]. In the genus \u003cem\u003eParagonimus\u003c/em\u003e, there are more than 50 different species of which 9 are known to cause infections in humans [5]. \u003cem\u003eParagonimus westermani\u003c/em\u003e is the most common species causing Human infection. The estimated number of people infected with the human lung fluke is 23\u0026nbsp;million globally [2], with 293\u0026nbsp;million people at risk for infection with \u003cem\u003eParagonimus\u003c/em\u003e species [6].\u003c/p\u003e \u003cp\u003eHuman infection results from ingestion of raw freshwater crab or crayfish infected with the metacercaria. The incubation period may vary from 1 to 2 months or even longer [3].\u003c/p\u003e \u003cp\u003eThe parasite from the human gut passes through several organs and tissues to reach the lungs [7]. Adult worms live in the lungs and the eggs are voided in the sputum or feces [7]. The eggs hatch in the fresh water to release miracidiae which are ingested by the first intermediate host, freshwater snails [7]. The miracidiae develop into cercariae in the snail and are released into the water [7]. The cercariae then invade the second intermediate host, crustaceans (crayfish or crabs), and develop into infective metacercariae [7]. The primary site of infection is the lung, and extrapulmonary involvement is also reported. No case report of epidydimo orchitis nor scrotal abscess.\u003c/p\u003e \u003cp\u003eHere, we presented a case of pulmonary \u003cem\u003eParagnonimiasis\u003c/em\u003e complicated by ectopic perineal infection in the form of abscess in the scrotum and vas deferens. This is first case report of \u003cem\u003eParagonimus westermani\u003c/em\u003e infection in Saudi Arabia and the first report in the literature of \u003cem\u003eParagonimus westermani\u003c/em\u003e complicated by scrotal abscess.\u003c/p\u003e \u003cp\u003eThe diagnosis of pulmonary paragonimiasis was considered in this patient in the diagnostic workup of pulmonary cavitating nodules, because he came from Philippines. It is an endemic area of paragonimiasis and local food habits of consuming raw fresh water crab and cray fish facilitate the infestation by \u003cem\u003eParagonimus Westermani\u003c/em\u003e[8]. Definitive diagnosis was established by the presence of \u003cem\u003eParagonimus\u003c/em\u003e ova in the sputum. The microbiologist was alerted to the possibility of this infection. The absence of eosinophilia was notable in this patient which may draw the attention of physicians away from considering parasitic infestations as diagnostic possibility. Eosinophilia is usually absent the late stages of infections [9]. Immunological test, commonly, ELISA is used to measure antibodies to \u003cem\u003eParagonimus\u003c/em\u003e species. However, a positive ELISA test does not always imply that active infection is present, since it took 4 to 18 months for the antibody level to decrease to a normal level [10]. FDG Pet Scan showed increased uptake in the lung (SUV max\u0026thinsp;=\u0026thinsp;2.9\u003cb\u003e)\u003c/b\u003e, inguinal canal and scrotum (SUV max\u0026thinsp;=\u0026thinsp;3.14). Paragonimiasis is a relatively rare cause of pulmonary disease; there have been only a few reported cases of pulmonary paragonimiasis as a cause of false-positive results on FDG-PET examinations [11]. The scrotal abscess was drained surgically and left orchidectomy was performed. The pus examination showed ova of \u003cem\u003eParagonimus Westermani\u003c/em\u003e FIG (5B). The histopathology of the testes showed suppurative inflammation with atrophic changes. No granulomata or parasite ova were detected FIG (5C).\u003c/p\u003e \u003cp\u003eAlthough the lung is the most common site of infection, other organs such as the central nervous system, liver, intestine, peritoneal cavity, retroperitoneum, and abdominal wall are also known to be involved [7]. In many cases, mass-like lesions or abscess were found in the involved organs. Malignancy is a concern, so surgical resection is usually performed to treat the abscess and to exclude the malignancy. In our patient\u003c/p\u003e \u003cp\u003ethe scrotal abscess was surgically drained and left orchidectomy was performed. The pus examination showed ova of parasite confirming that the abscess was due to \u003cem\u003eParagonimus Westermani\u003c/em\u003e. Routine culture of the pus revealed no bacterial growth. The pus Scrotal abscess due to \u003cem\u003eParagonimus\u003c/em\u003e infection has not been described in the literature. It is treated like any other abscesses by drainage, antibiotics and praziquantel for the parasite.\u003c/p\u003e \u003cp\u003eThe diagnosis of \u003cem\u003ePargonimus Westermani\u003c/em\u003e should be considered in patients with sterile scrotal abscesses travelling from endemic areas.\u003c/p\u003e \u003cp\u003eThe diagnosis of \u003cem\u003eParagonimus\u003c/em\u003e infection in non-endemic areas is often challenging. This is due unfamiliarity of the healthcare professionals with the disease and atypical clinical presentations. In addition, laboratories often don\u0026rsquo;t have the required technology, skill nor expertise in confirming the diagnosis. In view of the presence of large number of expatriates from endemic areas in Saudi Arabia mandates the health care professionals to be aware of the disease and to consider the diagnosis when dealing with a suggestive clinical presentation.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis the first case report in literature of scrotal abscess caused by \u003cem\u003eParagonimus Westermani\u003c/em\u003e in an adult male and the first case report of \u003cem\u003eParagonimus Westermani\u003c/em\u003e in Saudi Arabia.\u003c/p\u003e \u003cp\u003eThis case highlights the importance of considering \u003cem\u003eParagonimus Westermani\u003c/em\u003e infection in the differential diagnosis of cavitating pulmonary lesions and perineal abscesses in patients travelled from endemic areas.\u003c/p\u003e \u003cp\u003eThe increased immigration from endemic areas has enhanced the likelihood of encountering this disease and healthcare professionals in Saudi Arabia should conceive this diagnostic possibility. Laboratory diagnostic tests should be made available.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll authors contributed equally to this work\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eMouwasat hospital Jubail staff\u003c/p\u003e"},{"header":"References","content":"\u003cp\u003e\u003csup\u003e[1]\u0026nbsp;\u003c/sup\u003eYokogawa M. Paragonimus and Paragonimiasis. \u003cem\u003eAdv Parasitol\u0026nbsp;\u003c/em\u003e1965; 3:99\u0026ndash;158\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e[2]\u003c/sup\u003e Fischer PU, Weil GJ. North American paragonimiasis: Epidemiology and Diagnostic Strategies. Expert Rev Anti Infect Ther 2015;13:779e86.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e[3]\u0026nbsp;\u003c/sup\u003eT. S. Singh, H. Sugiyama, and A. Rangsiruji, \u0026ldquo;Paragonimus \u0026amp; paragonimiasis in India,\u0026rdquo;\u0026nbsp;\u003cem\u003eIndian Journal of Medical Research\u003c/em\u003e, vol. 136, no. 2, pp. 192\u0026ndash;204, 2012\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e[4]\u0026nbsp;\u003c/sup\u003eChai JY. Paragonimiasis. Handb Clin Neurol 2013; 114: 283-296\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e[\u003c/sup\u003e\u003csup\u003e5\u003c/sup\u003e\u003csup\u003e]\u0026nbsp;\u003c/sup\u003eNarain K, Agatsuma T, Blair D. Paragonimus. In: Liu D, Editor. Molecular detection of Foodborne Pathogens. Boca Raton, Florida, USA: CRC Press Taylor \u0026amp; Francis Group; 2010.\u003c/p\u003e\n\u003cp\u003ep. 827e37.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e\u0026nbsp;[6]\u0026nbsp;\u003c/sup\u003eKeiser J, Utzinger J. Emerging Foodborne Trematodiasis. Emerg Infect Dis 2005;11:1507e14\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e[7]\u003c/sup\u003e F. Nakamura-Uchiyama, H.Mukae, and Y. Nawa, \u0026ldquo;Paragonimiasis:a Japanese perspective,\u0026rdquo;\u0026nbsp;\u003cem\u003eClinics in Chest Medicine\u003c/em\u003e, vol. 23, no. 2, pp. 409\u0026ndash;420, 2002.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e[8]\u0026nbsp;\u003c/sup\u003e https://www.who.int/foodborne_trematode_infections/paragonimiasis/en/\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e[9]\u003c/sup\u003e YANG SP, HUANG CT, CHENG CS, CHIANG LC. The clinical and roentgenological courses of pulmonary paragonimiasis. Dis Chest 1959; 36:494.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e[10]\u003c/sup\u003e Cho SY, Kim SI, Kang SY, Kong Y, Han SK, Shim YS, Han YC. Antibody changes in Paragonimiasis patients after praziquantel treatment as observed by ELISA and immunoblot.\u003c/p\u003e\n\u003cp\u003eKorean J Par\u0026shy;asitol 1989; 27: 15-21.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e[11]\u003c/sup\u003e Ie Ryung YOO, Hyun Jin PARK, Joo HYUN O, Yong An CHUNG, Hyung Sun SOHN, Soo Kyo CHUNG and Sung Hoon KIM.Two cases of pulmonary paragonimiasis on FDG-PET CT\u003c/p\u003e\n\u003cp\u003eimaging Annals of Nuclear Medicine Vol. 20, No. 4,\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"the-egyptian-journal-of-bronchology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [The Egyptian Journal of Bronchology](https://ejb.springeropen.com/)","snPcode":"43168","submissionUrl":"https://submission.nature.com/new-submission/43168/3","title":"The Egyptian Journal of Bronchology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Paragonimiasis, Paragonimus Westermani, Lung, Epididymo-orchitis, Scrotal abscess, Positron Emission Tomography","lastPublishedDoi":"10.21203/rs.3.rs-6797090/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6797090/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003ePulmonary \u003cem\u003eParagonimiasis\u003c/em\u003eis caused by a trematode of genus \u003cem\u003eParagonimus\u003c/em\u003e and typically results from the consumption of raw or improperly cooked crustacea, especially crabs and crayfish. The disease is frequently, misdiagnosed in non-endemic areas and alternative diagnoses such as tuberculosis and malignancy usually considered. Herein, we report a case of forty-one-year old, Filipino male with pulmonary paragonimiasis complicated by epidydimo orchitis and scrotal abscess. This is first case report of Pulmonary paragonimiasis in Saudi Arabia and first case complicated by scrotal abscess worldwide.\u003c/p\u003e","manuscriptTitle":"Rare case of Pulmonary Paragonimiasis in Jubail City","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-09 10:37:45","doi":"10.21203/rs.3.rs-6797090/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-06-09T17:30:33+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-09T16:42:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"199682905091870702893559786181361227122","date":"2025-06-06T07:28:32+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-04T07:27:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"100841289544413760200673137098204448196","date":"2025-06-04T07:25:26+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-04T07:20:52+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-04T07:16:19+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-04T01:02:34+00:00","index":"","fulltext":""},{"type":"submitted","content":"The Egyptian Journal of Bronchology","date":"2025-06-01T17:38:35+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"the-egyptian-journal-of-bronchology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [The Egyptian Journal of Bronchology](https://ejb.springeropen.com/)","snPcode":"43168","submissionUrl":"https://submission.nature.com/new-submission/43168/3","title":"The Egyptian Journal of Bronchology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"451590c0-6bd5-4f64-8e74-ae4514b8d112","owner":[],"postedDate":"June 9th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-06-12T03:08:05+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-09 10:37:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6797090","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6797090","identity":"rs-6797090","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}