Maladie parasitaire du poumon abdominal

　　Premièrement, cause de la maladie

　　Les cystes de Paragonimus sont les agents pathogènes de la maladie parasitaire du poumon abdominal. Les Paragonimus se parasitent principalement dans les poumons des humains, et leurs œufs sont excrétés avec la expectoration ou les selles, puis se développent en larves ciliées dans l'eau, puis pénètrent dans le premier hôte (spirochètes d'eau douce) pour se développer en larves de la queue, et les larves de la queue pénètrent dans le deuxième hôte (animal crustacé) pour se développer en cystes. Les humains sont infectés après avoir mangé des crabes d'eau douce ou des crevettes d'eau douce contaminés par des cystes non cuits, ou après avoir mangé de la viande sauvage infectée par des cystes, ou après avoir bu de l'eau de ruisseau contaminée par des cystes.

　　Deuxièmement, mécanisme de développement de la maladie

　　Les larves de Paragonimus peuvent causer des lésions mécaniques en se déplaçant ou en s'installant définitivement, et les produits métaboliques du parasite et d'autres substances antigéniques peuvent provoquer des réactions pathologiques immunitaires chez l'organisme.

　　1. Pathologie de base

　　(1) Les lésions causées par les larves de Paragonimus: Lorsque les humains avalent des crabes d'eau douce ou des crevettes d'eau douce contenant des cystes vivants, les cystes sont dissous par les fluides digestifs, les larves de la queue s'échappent, et en utilisant leurs puissants muscles de contraction et les produits sécrétés par leurs glandes, elles endommagent les tissus humains, traversent la paroi intestinale pour entrer dans l'abdomen, causant des dommages aux organes et tissus internes de l'abdomen, produisant une inflammation et une adhésion étendues. La plupart des larves traversent également le diaphragme, se déplacent dans la poitrine et irritent la pleure pour produire une inflammation de la pleure. Les larves grandissent progressivement et deviennent des adultes, finissent par entrer dans les poumons pour former des kystes, et chaque kyste contient généralement deux adultes. Les larves de Paragonimus westermani (ou Sichuan ou Shenshi) causent des dommages plus importants pendant leur migration que les larves de Paragonimus japonicus, et les réactions locales et systémiques sont plus fortes. Ce parasite ne peut pas se développer sexuellement dans l'organisme humain pour pondre des œufs, entre rarement dans les poumons pour former des kystes, et donc, les lésions principales sont des lésions sous-cutanées migratoires et une péritonite et une pleurite exsudative.

　　(2) Lesions caused by the adult worms: The number of adult worms parasitizing in the human body is generally less than 20, but can be more. The adult worms are often fixed in a certain part of the human body, but can also migrate between loose tissues, causing the range of lesions to expand and affecting more organs. The worm body can ascend from the mediastinum to the brain tissue, through the loose tissue around the great vessels of the neck, along the internal carotid artery, through the foramen magnum into the cranial cavity. However, the intracranial damage caused by the infection of Paragonimus szechuanensis (or Stilesi) is due to the invasion of the larval stage.

　　The basic pathological process of Paragonimus infection can be divided into 3 stages:

　　① Tissue destruction stage: The migration and penetration of the worm can cause linear hemorrhage and necrosis, thus forming cave-like lesions in the local tissue.

　　② Cyst formation stage: Soon after the formation of the cave-like lesions, the surrounding tissues show a reaction, mainly an inflammatory reaction with infiltration of neutrophils, eosinophils, and monocytes. Local tissue necrosis, liquefaction into brownish liquid. There is granulation tissue proliferation around, and it gradually forms a fibrous cyst wall, constituting the special lesions of this disease, known as Paragonimus cysts. The cyst contains a brownish, sticky liquid, and sometimes the worm body can be found. Microscopic examination can reveal worm eggs, Schistosoma crystals, and eosinophils, etc. Due to the migratory habit of the adult worms, the worm body can leave the cyst and form a new cyst nearby, becoming a multilocular cyst with tunnels or cavities connecting to each other.

　　③ Fibrotic scar stage: When the worm in the cyst migrates to another place or dies, and the contents of the cyst are excreted or absorbed, the surrounding granulation tissue and fibrous tissue continuously proliferate towards the center, replacing the entire cyst with fibrous tissue, forming scars. The lesions of Paragonimus rarely undergo calcification.

　　(3) Lesions caused by eggs: The eggs of Paragonimus can be found in the tunnels between cysts, as well as in the tissues through which the adult worms pass. Since the eggs cannot develop in the human body and do not secrete soluble antigens, the tissue reaction is relatively mild, only having a mechanical or foreign body stimulation effect, and it belongs to a type of foreign body granulomatous reaction.

　　2. Pathological changes in main organs and tissues

　　(1) Abdominal cavity: During the migration of the worm in the abdominal cavity, it can cause widespread inflammatory reactions and adhesions, and form cysts. There may be more than 200 cysts of various sizes, some scattered in various places, and some aggregated into masses, making the surface of the abdominal cavity rough and uneven. The serosal surface of the large and small intestines is congested and exudes, with varying degrees of adhesions, and occasionally a small amount of ascites may occur. The liver may also be damaged to some extent, and after infection with Wuchereria bancrofti, the liver may show malnutrition changes, infiltration of cells in the portal area, and mild hyperplasia of the fibrous connective tissue in the interstitium. The paragonimiasis szechuanensis (or Stilesi) often invades the liver, and the liver surface can be seen to have童虫 migrating through sinusoids or worm holes. The liver tissue can be seen to have acute eosinophilic granulomatous abscesses and areas of necrosis with hemorrhagic patches or strips, and sometimes the worm body can be seen. Microscopic examination may reveal worm eggs, Schistosoma crystals, and eosinophils, etc. Due to the migratory habit of the adult worms, the worm body can leave the cyst and form a new cyst nearby, becoming a multilocular cyst with tunnels or cavities connecting to each other.

　　(2) Thoracic Cavity: After the worm body enters the thoracic cavity, it often causes exudative pleurisy in the early stage, and over time, the pleura thickens. Dispersed or aggregated cysts can be seen within and on the surface of the thickened pleura. The lungs are the most easily invaded organs by Wieseri paragonimiasis, with the main lesions being the formation of cysts, most of which are located in the mediastinal surface or pleural sublayer of the lung surface, as well as in the superficial lung tissue. The cysts are small, like grains of rice, and can reach a diameter of 2 cm. Worm eggs, larvae, or adult worms may be found within them. If the worm body invades the bronchus, it can cause bronchiectasis, bronchopleural fistula, and pneumothorax, etc. It is rare to find worm eggs in the lungs of Sichuan (or Stiles) paragonimiasis infections.

　　(3) Brain and Spinal Cord: Some larvae can ascend along the internal carotid artery, passing through the carotid canal external aperture, carotid canal, and superior aperture of the破裂孔 into the middle fossa of the skull. After entering the cranial cavity, the worm body penetrates the brain tissue and migrates, causing tissue destruction, hemorrhage, and infiltration of inflammatory cells, and forming multilocular cysts, nodules, and scar tissue, etc. The worm body often enters the brain from the bottom of the temporal or occipital lobe, and can also invade the white matter, internal capsule, basal ganglia, and lateral ventricles, with the right brain being more common. Due to the space-occupying nature of the lesions, it can block the ventricular pathways, leading to ventricular atrophy or expansion, as well as compression of the optic nerve. A large number of worm eggs can be seen within the cysts, and the worm body may also be visible at times. If the worm body invades the epidural space of the spinal canal, it can form an epidural or intradural cystic lesion, which is more common below the 10th thoracic vertebra, and individual cases may also involve the horizontal level between the neck and chest.

　　In addition, some larvae can also parasitize in the subcutaneous tissue, muscles, orbit, pericardium, and other places, but most larvae with ectopic parasitism cannot mature and lay eggs. It takes 2 to 3 months from infection to the adult worm laying eggs, and the adult worms usually survive for 5 to 6 years, with some living up to 20 years.

　　Due to its multi-organ damage, the complications of this disease are diverse and often vary depending on the worm species infected, the site of parasitism, and the severity of infection. Generally, infected individuals have a good prognosis and little threat to life, but those with brain involvement have a poorer prognosis and may result in disability. The prognosis of Sichuan (or Stiles) paragonimiasis, which invades the brain, is better than that of Wieseri, and the后遗症 are less common. Abdominal pain, especially in the lower right abdomen, is common, with varying degrees of severity, and may also include diarrhea, liver enlargement, hematochezia, or sesame paste-like stools, in which adult worms or eggs may be found. The feeling of urgency is pronounced. Physical examination may show abdominal tenderness, occasional enlargement of the liver, spleen, and lymph nodes, as well as abdominal nodules, masses, or ascites. The abdominal masses may feel like cystic, with varying numbers and diameters of 1 to 4 cm. Sichuan paragonimiasis often forms eosinophilic abscesses within the liver, leading to liver enlargement and abnormal liver function.

　　Paragonimiasis is a systemic disease mainly involving pulmonary lesions, with complex clinical manifestations. The severity of symptoms is related to various factors such as the invasive worm species, affected organs, degree of infection, and body's response. The onset is usually gradual, and the exact infection date is often unknown, making it difficult to determine the incubation period, which can last from over a decade to just a few days, with most cases occurring within 6 to 12 months. Patients may present with symptoms such as low fever, cough, sputum with a烂桃样 appearance and blood, fatigue, night sweats, loss of appetite, abdominal pain, diarrhea, or urticaria, etc. Depending on the main organs involved, it can be classified into 4 types in clinical practice.

　　First, lung type

　　The lung is the most common site of寄生 for Wiesmann paragonimus, symptoms such as cough, hemoptysis, chest pain are most common, the typical sputum is a jam-like sticky sputum, if accompanied by necrotic lung tissue, it presents as a decayed peach-like blood sputum, 90% of patients can have recurrent hemoptysis, year-round, fluke eggs may be found in the sputum, when the paragonimus migrate into the pleural cavity, it often causes chest pain, exudative pleural effusion or pleural thickening, Sichuan paragonimus infection, cough and hemoptysis are rare, while chest pain and pleural effusion are more common, a few patients may have urticaria or asthma attacks.

　　Second, abdominal type

　　Abdominal pain, especially in the lower right abdomen, is more common, with varying degrees of severity, and may also have diarrhea, liver enlargement, hematochezia, or sesame paste-like stools, in which the adult flukes or fluke eggs may be found, the feeling of urgency is obvious, abdominal tenderness is found during physical examination, occasionally liver, spleen, lymph node enlargement and abdominal nodules, masses or ascites, the abdominal masses have a cystic feeling when touched, with different numbers, diameter of 1～4cm, Sichuan paragonimus often forms eosinophilic abscess in the liver, leading to liver enlargement and abnormal liver function.

　　Third, brain type

　　It is often caused by Wiesmann paragonimus, more common in children and young adults, in the epidemic area, its incidence rate can reach 2% to 5%, and its manifestations include:

　　1. Increased intracranial pressure symptoms:Symptoms such as headache, vomiting, obtundation of consciousness, papilledema, etc., are more common in early patients.

　　2. Destruction symptoms of brain tissue:Symptoms such as paralysis, aphasia, hemianopia, ataxia, etc., usually occur in the later stage.

　　3. Irritative symptoms:Symptoms such as seizures, visual hallucinations, abnormal limb sensation, etc., are caused by the lesion approaching the cortex.

　　4. Inflammatory symptoms:Symptoms such as chills, fever, headache, meningeal irritation, etc., are more common in the early stage of the disease.

　　Fourth, nodular type

　　It is most commonly caused by Sichuan paragonimus, with an incidence rate of 50% to 80%, which can occur in abdominal, chest, back, inguinal, thigh, scrotum, neck, orbit, and other parts, ranging from soybean to duck egg size, the nodules are typical eosinophilic granuloma, containing Schmorl's crystals or the fluke bodies can be found but no fluke eggs, about 20% of Wiesmann paragonimus patients may have this sign, the nodules are mostly located in the lower abdomen and subcutaneous or deep muscle of the thigh, 1～6cm in size, solitary or in a string, containing Schmorl's crystals, fluke bodies or fluke eggs.

　　1. Prevent human infection:Conduct extensive publicity and education in the epidemic area, eliminate the habit of eating fresh or semi-cooked crabs and clams, and do not drink raw stream water.

　　2. Control the source of infection:Completely treat patients and domestic animals with the disease. Kill animals that are harmful to humans or reservoir hosts.

　　3. Cut off the route of transmission:Manage feces, kill worm eggs in sputum and feces, and prevent worm eggs from entering water. Do not feed dogs and cats with fresh crabs or fresh clams to prevent domestic animals from being infected.

　　First, routine blood test:Leukocytes (10～30) × 10^9/L, during the acute phase, it can reach 40 × 10^9/L; eosinophils are generally increased, usually 5% to 20%, during the acute phase, it can reach more than 80%, but the increase of eosinophils is not proportional to the severity of infection, in the late cases, the increase is not obvious, and the blood picture changes in Sichuan paragonimus infection are more significant than those in Wiesmann paragonimus infection.

　　Two, Erythrocyte sedimentation rate shows moderate or high acceleration.

　　Three, Pathogen examination

　　1. Sputum smear method:Sputum of patients infected with W. malayi is often rusty, and under microscopy, eggs, eosinophils, and Schmorl's crystals can be seen. Patients infected with S. japonicum often have a large number of eosinophils and Schmorl's crystals in their sputum, and eggs are rarely found.

　　2. Feces smear method:50g of feces is filtered through a 100-mesh stainless steel sieve, and the fecal residue is filled into a quantitative central hole, leveled, and the quantitative plate is removed. A hydrophilic glass paper soaked in glycerin孔雀绿 solution is covered, and the rubber stopper is gently pressed flat to make the fecal residue evenly spread to the edge of the glass paper. After being left overnight at 30℃ room temperature, it is examined under a microscope. 15% to 40% of the infected with W. malayi have a positive result, while the infected with S. japonicum rarely has a positive result.

　　Four, Examination of body fluids

　　1. Examination of cerebrospinal fluid:In patients with cerebral type, the cerebrospinal fluid can show eosinophils, slightly increased protein content, and other normal findings.

　　2. Examination of ascites and pleural effusion:Ascites and pleural effusion are yellowish or bloody, occasionally Schmorl's crystals, cholesterol crystals, or eggs are seen.

　　Five, Immunological examination

　　1. Intradermal test:0.1ml of adult Paragonimus antigen is injected into the skin of the forearm, and the results are observed for 15-20 minutes. If the diameter of the local papule is ≥1.2cm and the erythema is ≥2.5cm, it is considered positive.

　　The intradermal test is simple to operate and the results are observed quickly. It has been used as a screening method during the general survey of patients in the epidemic area. If the intradermal test is positive, further examination and confirmation should be carried out by other methods.

　　2. Post-cercarial membrane test

　　3. Serum immunological test:There are agar double diffusion test, indirect immunofluorescence test, immunoelectrophoresis test, enzyme-linked immunosorbent assay, etc.

　　Intradermal test, post-cercarial membrane test, complement test, etc., all have sensitivity above 95%, but specificity is not high. There are cross-positive reactions with schistosomiasis, Clonorchiasis sinensis, Fasciolopsis buski, etc., while enzyme-linked immunosorbent assay has high sensitivity and specificity. Some scholars believe that if the enzyme-linked immunosorbent assay is positive and other two immunological tests are positive, the disease can be diagnosed.

　　Six, Biopsy pathological examination:Pathological examination of subcutaneous nodules or masses can show eggs or larvae, adults, and typical eosinophilic granuloma can be seen in subcutaneous masses caused by Schistosoma japonicum. Some patients may find larvae, but eggs have never been found.

　　Seven, X-ray examination:Patients with pulmonary symptoms often have abnormal chest X-ray findings.

　　1. Thickening of pulmonary vessels, pleural thickening:This is caused by the invasion of eggs into the bronchial tubes, lymphatic vessels, etc., resulting in damage to the intima, congestion and expansion, thickening of the wall or fibrosis. The lung texture becomes thickened like a network, most commonly seen in the lower and middle internal fields of both lungs, and 90% of pulmonary type infections have this manifestation.

　　2. Granular or spotted shadow:It is very similar to the blood dissemination type of pulmonary tuberculosis, but the nodules are relatively fewer, of different sizes, with blurred edges, and there are single and multiple translucent areas inside. Some can merge into a sheet, mostly located in the middle and lower lobes of the two lungs and the inner side, which can be distinguished. The pathological basis of this type is granuloma in the lung and allergic alveolitis, which is often self-limiting and usually subsides within 1 to 2 months.

　　3, Lobar shadow:It is caused by pulmonary hemorrhage or allergic pneumonia when the larva moves in the lung, and it is often absorbed after 1 to 2 weeks.

　　4, Lobar shadow:Chronic pleuropulmonary fluke disease may have shadowy blocks in the lung, with clear edges, similar to inflammatory pseudotumor, caused by granuloma of pleuropulmonary fluke disease.

　　Eight, Cranial CT:It can show the site of the lesion and the blocked area.

　　Nine, Fiberoptic bronchoscopy:It is a new method for diagnosing abdominal pleuropulmonary flukes in recent years. Due to a large number of eggshells deposited under the mucosa of the lung tissue and bronchial mucosa, there may be mucosal congestion, edema, ulcers, bronchial stenosis, and pale millet-like nodules under the mucosa. Biopsy and pressure film can find lung fluke eggs.

　　First, Dietotherapy:

　　1, Black Sesame and Poria Cocos Porridge:10 grams of black sesame, 15 grams of poria cocos, 3 slices of ginger, and 100 grams of rice. Cut the ginger into slices, crush the poria cocos, soak for half an hour, and decoct the medicine juice. Decoct twice and mix the two batches of juice. Then cook the mixed juice with rice and sesame into a thin porridge.

　　2, Lily Porridge:60 grams of lily, 100 grams of rice, and 3 slices of ginger. Clean the lily and chop it, then cook it with rice.

　　3, Lotus Leaf and Medicine Seed Duck Soup:50 grams of lotus leaf, 500 grams of fresh duck meat, and 100 grams of medicine seeds. Clean the fresh duck meat, chop it into pieces, and put it together with the medicine seeds and lotus leaf. Add water and cook until the meat is soft, without adding salt or other seasonings. Take 250 milliliters about twice a day, for 10 to 14 days in total, which has the effects of diuresis, reducing swelling, and nourishing blood and promoting fluid movement.

　　4, Mosla Porridge:10 grams of mosla, 50 to 100 grams of glutinous rice. First, wash the mosla clean, decoct the water, remove the dregs, and then add glutinous rice to cook porridge.

　　5, Red Bean and Winter Melon Fish Soup:1 fresh crucian carp of about 500 grams, 100 grams of red beans, and 200 grams of winter melon. After the fresh crucian carp and red beans are cooked half-done, add 200 grams of winter melon, and then cook until the meat is soft and the soup is clear, without adding salt or other seasonings. Filter the dregs with a cheesecloth after it is cooked. Take 250 milliliters about twice a day, for 10 to 14 days in total. It can improve plasma protein and has a strong effect of promoting diuresis and reducing swelling.

　　6, Steamed Garlic and Watermelon:60 to 90 grams of garlic, 1 watermelon of about 1500 to 2000 grams. First, use a sharp knife to dig a triangular hole in the watermelon skin, take off the garlic skin and put it into the watermelon, then use the removed watermelon skin to plug the hole, and steam it with the hole facing up. Eat the garlic and watermelon flesh while hot. Garlic has antibacterial and anti-inflammatory effects, and watermelon has the functions of cooling the body and relieving summer heat, and promoting diuresis and reducing swelling.

　　7, Steamed Frog:250 grams of frog, 3 grams of scallion whites, ginger cubes, a little rice wine, fine salt, and monosodium glutamate. Peel and remove the internal organs of the frog, place it in a bowl, add an appropriate amount of water, and add rice wine, scallions, ginger, fine salt, and cook over high heat until it is soft and well-cooked. Drink the soup and eat it, which has the effect of invigorating the body and promoting diuresis.

　　8. Goji and nanzao cooked egg:Nanzao 10 pieces, Xi枸杞 30 grams, eggs 2. Wash the goji berries and nanzao, add water in appropriate amount, simmer for 1 hour, add eggs, and boil for a moment, making it into a poached egg. Take 2 times a day, drink the soup and eat the egg. It is used for nourishing the liver and kidney.

　　9. Yam and longan stewed turtle:Yam slices 30 grams, longan meat 20 grams, one Chinese softshell turtle (about 500 grams). First, heat the turtle in warm water at 45℃ to expel its urine, then scald it to remove the intestines and head and claws; then add water in appropriate amount, and boil the turtle and meat with yam and longan meat until they are tender. Drink the soup and eat the meat, suitable for people with Yin deficiency.

　　10. Hou tuo and jujube boiled eggs:Hou tuo 20 grams, jujube 10 pieces, eggs 2. Boil hou tuo, jujube, and eggs with an appropriate amount of water, remove the shell after the eggs are cooked, and then boil it again. Boil the decoction to 1 bowl, remove the medicine residue and season it. Take 1 time a day, drink the soup and eat the egg, and take it for 15 to 20 days. It is beneficial for the liver and stomach.

　　2. Unsuitable foods:Freshwater fish and shrimp, do not distinguish between raw and cooked when processing food, cysticercus can be contaminated through cutting boards, knives, chopsticks, and other utensils, sashimi, sushi, and flavored fish porridge. Foods rich in fiber and gas-producing foods such as celery, chives, soybean sprouts, sweet potatoes, and dried beans. Alcohol and all spicy and刺激性 food.

　　3. Suitable foods:Low-fat foods such as mixed grain congee, buckwheat flour, taro, starchy dishes such as steamed sweet potatoes, sweet corn, potatoes, etc., drinks containing vinegar such as Tiandiyi No. 1, low-fat, low-cholesterol diet, eat more foods rich in zinc and magnesium, vitamin C, and prefer light, soft, easy-to-digest, and non-irritating foods.

　　1. Prevent human infection:Conduct extensive publicity and education in the epidemic area, eliminate the habit of eating fresh or semi-cooked crabs and clams, and do not drink raw stream water.

　　2. Control the source of infection:Completely treat patients and domestic animals with the disease. Kill animals that are harmful to humans or reservoir hosts.

　　3. Cut off the route of transmission:Manage feces, kill worm eggs in sputum and feces, and prevent worm eggs from entering water. Do not feed dogs and cats with fresh crabs or fresh clams to prevent domestic animals from being infected.