CHEST Guidelines-A-Young-Man-With-Hemoptysis-and-Cavitary-Lung-Lesi

A-Young-Man-With-Hemoptysis-and-Cavitary-Lung-Lesi

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This document presents a case study of a man in his 20s with mild fatigue, intermittent hemoptysis, and cavitary lung lesions, initially suspected to have culture-negative tuberculosis. Despite adherence to a TB treatment regimen, his symptoms recurred, leading to further investigation.<br /><br />The patient had emigrated from a South American country to the United States three years prior, and his initial tests, including a positive PPD test but a negative QuantiFERON-TB Gold test, did not conclusively diagnose tuberculosis. Other diagnostic tests showed elevated eosinophils and IgE levels but negative results for ova and parasites and for various other potential infections.<br /><br />CT scans revealed changes in cavitary lesions over time, but culture for AFB remained negative. Ultimately, a CT-guided lung biopsy, combined with the patient's clinical presentation, revealed eosinophilic infiltrates and led to the diagnosis of pulmonary paragonimiasis, a disease caused by Paragonimus, a parasite transmitted through undercooked shellfish. This condition is rare in the United States but more prevalent in regions such as Asia and parts of the Americas, including South America.<br /><br />The error in the initial diagnosis was discussed in terms of cognitive biases, including availability, anchoring, confirmation, and framing biases, which can impede a clinician's ability to correctly diagnose atypical cases. The case highlights the importance of considering a broader differential diagnosis when there is evidence that does not fully support the initially suspected condition. <br /><br />After a confirmation of the Paragonimus infection through CDC testing, the patient was successfully treated with praziquantel, which led to full clinical and radiographic recovery. Clinical insights concluded include the need for awareness of peripheral eosinophilia and lower lung zone lesions as indicators to consider paragonimiasis, especially in patients from endemic regions.

Keywords

pulmonary paragonimiasis

cavitary lung lesions

eosinophilic infiltrates

Paragonimus

cognitive biases

differential diagnosis

praziquantel treatment

peripheral eosinophilia

South America

under-recognized infections