A 19-year-old male, with no significant past medical history presented to the emergency room with severe headache, blurred vision and confusion. Headaches began 2 months prior, with acute worsening with changes in vision for the last 3 days. He did not report fevers, cough, shortness of breath or chest pain. Originally from Honduras, the patient moved to the United States 6 months prior to presentation. He denied illicit drug use, recent trauma or injury. He denied consumption of raw seafood or shellfish. He did not report any contact with animals.
His vital signs on admission were within normal limits. Physical examination was remarkable for decreased visual acuity in both eyes with complete loss of peripheral vision in right eye. Extraocular movements remained intact. No other focal neurological deficits were noted. Initial laboratory findings revealed a normal total white blood cell count with peripheral eosinophilia of 1230/microL. Serum interferon-gamma release assay for mycobacterium tuberculosis was positive, HIV test was negative. He received the Bacille Calmette -Guerin (BCG) vaccine as a child.
A non-contrast computed tomography (CT) of the head revealed an acute parenchymal hemorrhage in the left parieto-occipital region. These findings were confirmed with Magnetic Resonance Imaging (MRI) of the brain (Fig. 1). A diagnostic cerebral angiogram did not reveal aneurysm, arteriovenous malformation, or fistula. Echocardiography did not show any evidence of endocarditis. CT angiography of the head and neck was unremarkable except for bronchiectasis in the right upper lobe of the lung. These findings prompted a CT of the chest that showed bilateral ground-glass infiltrate with cystic thin-walled linear tracks in the right upper lobe, some of which communicated with the pleural space (Fig. 2).
Subsequently he underwent a diagnostic bronchoscopy followed by a lumbar puncture. Bronchoscopic alveolar lavage (BAL) remained negative for routine bacterial, fungal, acid-fast organisms, as well as ova and parasites. Cerebrospinal fluid (CSF) analysis revealed pleocytosis with white cell count of 315/microL, and 4% eosinophils. CSF protein and glucose were within normal limits. CSF cultures, meningitis/encephalitis polymerase chain reaction (PCR) panel as well as stain for ova and parasites was negative. Serum cysticercosis antibody as well as strongyloidiasis antibody remained negative. The serum paragonimiasis antibody by immunoblot performed at the Centers for Disease Control (CDC) laboratory came back positive. He was treated with praziquantel, along with a tapering dose of corticosteroids and anti-epileptic medication, which he tolerated well. He was discharged home in stable condition.
At his 1 month follow up visit, he reported complete resolution of headache, a significant improvement in vision loss with some residual deficit on right lateral peripheral vision.
Axial CT chest: Linear tracts and subpleural cystic lucencies present in the right upper lobe(red arrows). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article. ).