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Disease
Human paragonimiasis is acquired through ingestion of raw or undercooked crabs or crayfish, and
is usually a lung infection. After ingestion, metacercariae excyst in the small intestine and release
larvae that penetrate the duodenal wall and enter the peritoneal cavity. The larvae migrate for
approximately 1 week, then penetrate the diaphragm, enter the pleural cavity, and migrate directly
through lung tissue to reach the bronchi. There they form cystic cavities and develop into adult
worms in 5-6 weeks. The adult parasites are reddish brown and ovoid, measuring 7.5-12 mm by 46 mm. Adult worms induce an inflammatory response in the lungs, generating a fibrous cyst that
contains a purulent, bloody effusion and eggs released by the flukes which are passed into the
environment via expectoration, or may be swallowed and passed with feces. When deposited in
fresh water, eggs hatch to release miracidiae, which then invade specific snail hosts. Thousands of
cercariae are later released from the infected snail, which encyst (as metacercariae) in the gills,
muscles, legs, and viscera of freshwater crustaceans (crabs or crayfish).

Diagnosis
The clinical picture of chronic paragonimiasis resembles chronic bronchitis or tuberculosis.
Persons may cough up coffee-colored or blood-tinged sputum, often accompanied by chest pain
and/or shortness of breath. The sputum may be peppered consisting of clumps of eggs produced
by the adult fluke living in the lung.
Peripheral eosinophilia is common and can be intense, especially during the early larval migration
stages. Many patients have a spectrum of abnormalities on chest radiographs: lobar infiltrates,
coin lesions, cavities, calcified nodules, hilar enlargement, pleural thickening and effusions. Ringshaped opacities of contiguous cavities giving the characteristic appearance of a bunch of grapes
are highly suggestive of pulmonary paragonimiasis. Central nervous system disease may provide
similar "grapebunch" findings, characteristically seen in the temporal and occipital lobes on
computed tomography of the brain. CNS involvement occurs in up to 25% of hospitalized patients
and may be associated with Paragonimus-induced meningitis. CNS symptoms may include
headaches, seizures, and visual disturbances. Paragonimus flukes may also invade the liver,
spleen, intestinal wall, peritoneum, and abdominal lymph nodes.
Sputum examined microscopically may reveal Paragonimus eggs released by the flukes in the
lungs. Keep in mind that the acid-fast stain that is used for TB testing of sputum destroys eggs.
The eggs may also be found by multiple stool exams on different days as a result of coughed-up
eggs that are swallowed. The microscopic eggs are yellowish brown, 80-120 m long by 45-70 m
wide, thick-shelled, and with an obvious operculum. Serologic tests can be especially useful for
early infections (prior to maturation of flukes) or for ectopic infections where eggs are not passed
in stool.
Ectopic lesions from aberrant migration of flukes can involve any organ, including abdominal
viscera, the heart, and the mediastinum. The infection can also affect the liver, spleen, abdomen,
and skin. The most clinically recognizable ectopic lesions arise from cerebral paragonimiasis,
which, in highly endemic countries, more commonly affects children. These children present with

eosinophilic meningoencephalitis, seizures, or signs of space-occupying lesions. Many patients

with central nervous system disease also have pulmonary infections. P.skrjabini often produces
skin nodules, subcutaneous abscesses, or a type of creeping eruption known as "trematode larva
migrans."

Treatment
Praziquantel is the drug of choice: adult or pediatric dosage, 25 mg/kg given orally three times
per day for 2 consecutive days.
Alternative: Triclabendazole, adult or pediatric dosage, 10 mg/kg orally once or twice. For
cerebral disease, a short course of corticosteroids may be given with the praziquantel to help
reduce the inflammatory response around dying flukes.
Triclabendazole is not commercially available in the United States, it is not approved by the Food
and Drug Administration. However, it is available through CDC, under an investigational protocol.

Praziquantel
Oral praziquantel is available for human use in the United States.

Note on Treatment in Pregnancy

Praziquantel is pregnancy category B. There are no adequate and well-controlled studies in
pregnant women. However, the available evidence suggests no difference in adverse birth
outcomes in the children of women who were accidentally treated with praziquantel during mass
prevention campaigns compared with those who were not. In mass prevention campaigns for
which the World Health Organization (WHO) has determined that the benefit of treatment
outweighs the risk, WHO encourages the use of praziquantel in any stage of pregnancy. For
individual patients in clinical settings, the risk of treatment in pregnant women who are known to
have an infection needs to be balanced with the risk of disease progression in the absence of
treatment.
PregnancyCategoryB: Either animal-reproduction studies have not demonstrated a fetal risk
but there are no controlled studies in pregnant women or animal-reproduction studies have shown
an adverse effect (other than a decrease in fertility) that was not confirmed in controlled studies in
women in the first trimester (and there is no evidence of a risk in later trimesters).

Note on Treatment During Lactation

Praziquantel is excreted in low concentrations in human milk. According to WHO guidelines for
mass prevention campaigns, the use of praziquantel during lactation is encouraged. For individual
patients in clinical settings, praziquantel should be used in breast-feeding women only when the
risk to the infant is outweighed by the risk of disease progress in the mother in the absence of
treatment.

Note on Treatment in Pediatric Patients

The safety of praziquantel in children aged less than 4 years has not been established. Many
children younger than 4 years old have been treated without reported adverse effects in mass
prevention campaigns and in studies of schistosomiasis. For individual patients in clinical
settings, the risk of treatment of children younger than 4 years old who are known to have an
infection needs to be balanced with the risk of disease progression in the absence of treatment.

WHORecommendations
(http://whqlibdoc.who.int/publications/2006/9241547103_eng.pdf)
(http://www.cdc.gov/Other/disclaimer.html)

Triclabendazole
Triclabendazole is not commercially available for human use in the United States.

Note on Treatment in Pregnancy

Triclabendazole has not been assigned a pregnancy category by the FDA. Data on the use of
triclabendazole in pregnant women are limited, although the available evidence suggests low risk
of congenital anomalies. In large-scale interventions for which the World Health Organization
(WHO) has determined that the benefit of treatment outweighs the risk, WHO allows use of
triclabendazole to pregnant women only in clinical settings where medical staff can monitor for
complications.

Note on Treatment During Lactation

It is not known whether triclabendazole is excreted in breast milk. Triclabendazole should be used
with caution in breastfeeding women.

Note on Treatment in Pediatric Patients

The safety of triclabendazole in children has not been established. In mass treatment programs for
which the WHO has determined that the benefit of treatment outweighs the risk, WHO allows use
of triclabendazole to school-age children, though use in children age 4 years and younger is
limited to clinical settings where medical staff can monitor for complications.

Page last reviewed: January 10, 2013

Page last updated: January 10, 2013
Content source: Global Health - Division of Parasitic Diseases and Malaria
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