PMC8022158_01
Chest X-ray upon first admission.. Cardio-mediastinal silhouette is within normal limits with the heart being normal in size.. No pleural effusion / pneumothorax/consolidative patches identified.
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An urgent ECG did not show any ischemic changes and repeated chest X ray remained clear (Fig. 1); Lab investigations however were significant for an increase in peripheral eosinophilia (12 %; absolute eosinophil count of 1.0 x 103/ uL) (Table 1).
Chest X-ray upon his most recent admission.. Mildly prominent hilar vascular markings identified (red arrows) with minimal blunting of the left costophrenic angle (blue arrows) and mild elevation of the left hemidiaphragm. But Cardio-mediastinal silhouette.
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Chest x-ray demonstrated new minimal blunting of left costophrenic angle (Fig. 2).
Chest CT upon recent admission.. Congestive pulmonary changes in the form of ground glass opacities and pleural effusion at the posterior inferior aspects of both lungs, more on the left. (Arrow heads) Circumferential pericardial effusion (red arrow).
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Computed Tomography (CT) of the thorax was done and showed bilateral pleural effusion along with congestive pulmonary changes and minimal atelectasis in both lungs and circumferential pericardial effusion of 2.5 cm thickness with no evidence of pericardial calcification (Fig. 3).
Video-assisted Thoracoscopy findings:. 1: Pleural nodules.. 2: Pericardial nodules.. 3: Thickened pericardium (white arrow).. 4: Thickened pleura and pleural nodules at the apex.. 5: Sanguineous pericardial effusion pouring out under pressure.
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A left thoracoscopy was performed and upon inspection of the thoracic cavity multiple white pearly nodules on the parietal pleura and to lesser extent on the pericardium and visceral pleura were found, the pericardium was significantly thickened and inflamed, there were adhesions between the lung and the parietal pleura posteriorly, moderate serous pleural effusion was noted and large bloody pericardial effusion under pressure was relieved upon opening the pericardium (Fig. 4).
Pleural and Pericardial Biopsy Histopathology report.. a. Light microscopic view showing well-defined epithelioid granuloma engulfing parasitic egg (H&E x400).. b. The cuticle of the parasitic egg is polarizable (H&E x400 with polarizer/analyzer lens).
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Few well-defined epithelioid granulomas are seen engulfing parasitic egg with thick cuticle (Fig. 5a) which is polarizable under polarizer/analyzer lens (Fig. 5b) compatible with Paragonimus Westermani.