An 11-year-old girl was admitted to our hospital in July 2019, when the recurrent chest pain, cough, and fever she had been experiencing for 13 months worsened. At first, the patient was admitted to a local hospital with chest pain, a cough and fever for 8 days in June 2018. Routine blood tests indicated leukocytosis of 15.69 x 109/L, high eosinophil of up to 14.3%, a high platelet count of 456 x 109/L, and raised C-reaction protein levels of up to 150.6 mg/L. Tests for tuberculin pure protein derivative was negative. A chest CT showed an abscess in the middle and lower lobes of the right lung, thickening of adjacent pleura, a small amount of pleural effusion, enlargement of the right hilar, and mediastinal lymph nodes (Figure 1A). A chest ultrasonography revealed pleural effusion 0.7 cm wide in the right pleural cavity, a 3.0 x1.5 cm hypoechoic mass in the lower lobe of the right lung, and pericardial effusion. The patient received a right thoracotomy exploration, which showed pleural adhesions cauterization, right thoracic abscess clearance, and intercostal nerve block closure. Antibiotics ceased to be effective after 4 months of treatment. Pulmonary tuberculosis was considered, and anti-tuberculosis treatment (isoniazid and rifampicin) was administered for 4 months after admission. The patient was discharged 2 weeks later and was given an anti-tuberculosis drug for the following 6 months.
Later, the patient was admitted to another hospital, as she was still suffering from chest pain, a cough and a fever 2 months after she was originally discharged. Her symptoms and laboratory tests were similar to those of described above, except that an echocardiography revealed that she had a large pericardial effusion (2.4 cm depth of the maximal diastolic separation) with increased echogenicity within fluid, which suggested exudative effusion. A chest CT revealed large PEs and light pleural effusion on the left (Figure 1B). Furthermore, tests for a tuberculosis infection were all negative. A thoracoscopy and partial pericardiectomy were performed, and a pericardium biopsy revealed chronic suppurative inflammation with granulation tissue hyperplasia. The echocardiography showed that PE had disappeared after the pericardiectomy. Antibiotics and anti-tuberculosis treatment were administered continuously. The patient was discharged because her symptoms abated after 1 month from her admission to the hospital (Figure 2). After discharge, she experienced intermittent chest pain accompanied by a frequent fever and a cough but was not hospitalized for 5 months. She was re-admitted to the hospital, and a bronchoscopy was performed without significant improvement. Following this, the patient was transferred to our hospital for further diagnosis and treatment.
She had no history of ingesting freshwater crabs or crayfish, but was born in Yunnan province where paragonimiasis is a severe public health issue. Her heart and lungs auscultation were normal. Her liver and spleen were also impalpable. No enlarged lymph nodes or obvious subcutaneous nodules were found in her whole body. After admission, a white blood cell count of 11.56 x 109/L and eosinophils of up to 17% were noted. All tuberculosis-related tests (PPD test, T-spot, sputum smear for acidophilus and DNA of Mycobacterium tuberculosis) were negative. Renal and hepatic function tests were normal. A chest ultrasonography revealed pleural effusion of 0.5 mm depth in the left lung. No pericardial effusion was noted by a chest CT; however, ELISA for Paragonimus was positive, which confirmed the diagnosis of paragonimiasis. She was given 600 mg of praziquantel 3 times a day. After treatment, pleural effusion was reduced and her symptoms improved. The patient was discharged after 3 days of praziquantel therapy. The patient received another course of praziquantel therapy in the outpatient clinic 1 week later. The patient's chest pain accompanied by a fever and a cough did not recur.