helminthic infections with thoracic involvement, including Pulmonary pathology and pathogenesis in cases of parasitic infections can be attributed to: Soft Tissue and Bone Parasites radiography

1. Thoracic
Radiography for
Helminthic
Diseases
D. Ibrahim Abouelasaad
MD Lecture
Main Parasitology

2. Thoracic Radiography for helminthic diseases
helminthic infections with thoracic involvement, including:
1) Nematodes (Ascariasis, Strongyloidiasis, Dirofilariasis &Tropical
pulmonary eosinophilia).
2) Trematodes (Schistosomiasis & Paragonimiasis).
3) Cestodes (Hydatid disease & Cysticercosis).
Pulmonary pathology and pathogenesis in cases of parasitic infections can
be attributed to:
1) Direct damage due to parasitic infestation, or
2) Pulmonary eosinophilic infiltration (Eosinophilic Pneumonia).

3. Ascariasis • Ground-glass opacity
• Consolidation
• Pulmonary nodules
• Pneumothorax
Migratory, transient, and patchy opacities on radiographs. There is a certain
predilection for the upper lobes
Toxocariasis • Ground-glass opacity
• Consolidation
• Pulmonary nodules
• Linear opacity
The characteristic distribution is in bilateral lower lobes and in subpleural areas
Strongyloidiasis • Ground-glass opacity
• Septal thickening
• Consolidation
• Miliary pulmonary micronodules
Patchy migratory consolidations and miliary micronodule distribution are less common
manifestations. Secondary bacterial infections and hemorrhage may often overlap the
other features. ARDS is found in severe cases
Dirofilariasis • Pulmonary nodule It is often presented as a solitary pulmonary nodule (well defined, measuring 1-3 cm,
with or without central necrosis), predominating in right lung and lower lobes. It may
be associated with pulmonary infarction and necrosis
Cysticercosis • Small nodules in soft tissues
• Pulmonary nodules
• Pulmonary cavitation
• Pleural effusion
Characteristic “rice-grain” soft tissue calcifications on radiograph. Welldefined
hypoattenuated nodules, with or without central hyperattenuation (parasite head) on
CT imaging. Multiple random pulmonary nodules feature lung involvement in
disseminated cysticercosis
Echinococcosis • Pulmonary cysts
• Pleural effusion
• Pneumothorax
• Pulmonary cavitation
Cysts can contain endocysts and calcified walls. There is a predilection to right lung
and lower lobes. Pleural effusion, pneumothorax, and cavitation are associated with
rupture. Mediastinal, hepatic, or splenic cysts may be found simultaneously
Schistosomiasis • Pulmonary nodules
• Septal thickening
• Ground-glass opacity
• Fibrosis
• Pulmonary hypertension signs
Ill-defined nodules, reticulonodular infiltrate, ground-glass opacities in acute form;
fibrosis and pulmonary hypertension signs in chronic form
Paragonimiasis • Pulmonary nodules
• Consolidation
• Pulmonary cysts
• Atelectasis
• Pneumothorax
• Pleural effusion
• Linear opacities in lung
Radiologic findings vary according to the endemic location and the stage of the
disease. Consolidations are generally seen in the early stage, while nodules or cysts are
seen in the late stage
Thoracic helminthic Diseases and Their Corresponding Imaging Findings

4. Löffler's syndrome
It was first described in 1932 by Wilhelm Löffler in cases of eosinophilic
pneumonia caused by the parasites:
o Ascaris lumbricoides,
o Strongyloides stercoralis
o Hookworms
A syndrome of wheezing, fever and eosinophilia
The term tropical pulmonary eosinophilia (TPE) was first coined by Weingarten in 1943.
The pathology and pathogenesis, links with the Wuchereria antigen and the Brugia
malayi antigens
Weingarten's syndrome (Tropical pulmonary eosinophilia)
Eosinophilic Pneumonia
Acute pulmonary schistosomiasis ( Katayama fever)
Immunologically mediated and similar to that seen in other forms of
eosinophilic pneumonias.

5. • Chest radiograph shows areas of ground-glass opacity in the
right midzones and lower zones.
• (b) High resolution CT axial section shows areas of ground-
glass attenuation that corresponds to the findings in (a).
Ascaris pneumonia:
The pulmonary involvement is
suspected in patients presenting
with fever and cough with
eosinophilia and is confirmed by
identifying larvae in the sputum.
Ascaris pneumonia

6. Strongyloidiasis
o Radiologic findings as Ascaris.
o Hyper-infection syndrome can manifest with extensive consolidation, which can be
infectious, hemorrhagic.
Pulmonary strongyloidiasis:
chest radiograph demonstrates
bilateral widespread opacities
throughout the lungs with
perihilar and basilar predominance.

7. • A patient with Strongyloid larvae detected from respiratory specimen,
received steroid therapy and developed sepsis with acute respiratory
distress syndrome (hyperinfection syndrome).
• Chest X-ray shows diffuse ground-glass opacity and consolidation in the
lung, as well as a chest drainage tube in the lower left thoracic cavity. CT
shows diffuse ground-glass opacity and obvious inter-lobular septal
thickening (arrowhead), so-called crazy-paving, and pleural fluid
Pulmonary
Strongyloidiasis

8. Dirofilariasis
• Dirofilariasis is arthropod born disease caused by the filarial
nematode “Dirofilaria immitis”.
• Adults often reside in the pulmonary arterial system (lung arteries)
as well as the heart.
• The parasite is commonly called “heartworm“.
• Dogs and cats are the main host, but human is an accidental host .
• Infection is transmitted by mosquitoes from dogs to humans.
• When man gets infection, the infective stages (L3) travel in the bloodstream until it lodges in
a small pulmonary arterial branch in which further development of the parasite is not
possible and dies.
• Pulmonary lesion is generally nodular and characterized by a central necrotic area surrounded
by a granulomatous inflammation and a fibrous wall.
• Chest x-ray examination will usually reveal a noncalcified, well-circumscribed, pulmonary nodule
(coin lesion) in the periphery of the lungs.
• The nodule will usually be less than 4 centimeters in diameter, although it may be as large as 4.5
centimeters in diameter.
Human Pulmonary Dirofilariasis

9. A: Plain chest radiographic showing pulmonary coin lesion in right lung.
B: CT showing a pulmonary nodule of 1.5 cm in the sub-pleural parenchyma of the right middle lobe, with
sharp outlines and a rounded small protuberance.
Pulmonary Dirofilariasis
Definitive diagnosis is usually made at histopathology of the excised nodule and demonstration of
fragments of the parasite.

10. • The condition of marked eosinophilia with pulmonary
involvement was first termed tropical pulmonary eosinophilia
• Tropical pulmonary eosinophilia is an occult form of human
filariasis.
• The gamma-glutaryl transpeptidase found in the infective L3 stage
larvae of Filaria has been found to have similarities with the
gamma-glutaryl transpeptidase present on the surface of human
pulmonary epithelium. It has, therefore, been proposed that
filarial gamma-glutaryl transpeptidase may play an important role
in the pathogenesis of tropical eosinophilia.
• Airway hyperresponsiveness, manifesting as asthma-like
syndrome, has been reported in tropical pulmonary
eosinophilia and it has been suggested that interleukin-4 induces
and interferon-γ suppresses filarial-induced airway
hyperresponsiveness.
• The intense eosinophilic alveolitis seen in acute tropical
pulmonary eosinophilia is suppressed by 3 weeks of treatment
with diethylcarbamazine citrate.
• A mild eosinophilic alveolitis along with radiological, physiological
and hematological abnormalities, though with reduced intensity,
persists in some patients.
Tropical Pulmonary Eosinophilia

11. Tropical Pulmonary
Eosinophilia
Chest radiographs showing bilateral diffuse
bronchopneumonia that is asymmetrical and
greater in the left lung.
The eosinophil count was over 6,000 cells/mm.
The lungs cleared with anti-filarial drugs.
CT scan of the thorax show reticulonodular
pulmonary opacities, bronchiectasis, air
trapping and mediastinal lymphadenopathy

12. Schistosomiasis
There are three important Schistosoma species: S. hematobium, S.
mansoni, and S. japonicum.
Although all three species can cause pulmonary disease, S mansoni and S
japonicum are the ones most frequently observed.
Pulmonary schistosomiasis is divided into:
a) Early (acute) pulmonary schistosomiasis.
b) Late (chronic) pulmonary schistosomiasis
Acute pulmonary schistosomiasis
Early-stage pulmonary involvement is unique to non-immune patients.
Occurs 3–8 weeks after post-infection.
In some cases, the pulmonary symptoms coincided with febrile illness (Katayama fever), but the
pulmonary symptoms continued for weeks after the fever subsided.
Pulmonary involvement cannot be attributed to schistosomula migration through the lungs, which
occurs typically 5 to 7 days after penetration, nor can they be attributed to granuloma formation
around schistosoma eggs, because this process starts before oviposition is expected to take place
Pulmonary pathogenesis is immunologically mediated and similar to that seen in other forms of
eosinophilic pneumonias, such as Loeffler’s syndrome, in which the initiating agent exists
elsewhere in the body (eg, intestine), but the eosinophils are sequestered in the pulmonary
capillaries

13. Radiological findings are nonspecific for diagnosis of early pulmonary schistosomiasis, and
examining stool and urine for parasite eggs may be negative, but the following may be useful
indication for diagnosis:
 History of exposure to freshwater in endemic areas.
 The high eosinophilic counts that occur during the acute stage of the disease
 Serologic testing is potentially much more sensitive.
Chest radiography reveals diffuse infiltrates and
prominent hilum with ill-defined small nodules
scattered throughout both lungs, in acute
schistosomiasis.
CT scan at the level of the bronchial
bifurcation showing nodules surrounded by
ground-glass halos. The arrows indicate the
largest nodules.
Schistosomiasis

14. Late (chronic) pulmonary schistosomiasis
Ectopic migration of schistosome eggs to the pulmonary beds:
• In the case of S haematobium infection, the final station of the adult flukes is in the perivesical
plexus. From there the eggs laid by the mature flukes can be swept by the systemic venous
system that drains the vesical plexus to reach the lungs.
• As for S mansoni, their ova are swept with the portal blood flow and become lodged in the
venules of the liver. There, the host immune system creates a granuloma around the eggs, which
eventually can cause periportal hepatic fibrosis and portal hypertension.
• Portal hypertension opens the collateral circulation leading to portocaval shunts, which enables
the schistosome eggs to be swept along until they become lodged in the lungs
• Chronic pulmonary disease results from granulomatous reaction to eggs deposited in the
pulmonary vasculature, which leads to intimal fibrosis, pulmonary hypertension, and cor-
pulmonale.
Radiography
o Generalized interstitial fibrosis, distributed equally throughout both lungs.
o Pulmonary arterial enlargement.
o Cardiomegaly.

15. Chronic Pulmonary Schistosomiasis
“Bilharzial” cor pulmonale. Chest X-ray showing signs of
pulmonary hypertension (prominent fourth arc – arrow).
(A) CT scan through the bifurcation of the trachea
that shows multiple lesions of different sizes in both
lungs.
(B) CT scan through a point just above the
diaphragm that shows diffuse ground-glass areas
with some nodularity. The findings are mainly at the
lung periphery.

16. Development:
Esophageal varices are dilated submucosal veins of the esophagus due to the
development of collateral drainage vessels
Schistosomal hepatic fibrosis (occurring in chronic schistosomiasis mansoni &
japonicum)  Portal hypertension  Portosystemic collateral formation which
connect to the esophageal plexus  esophageal varices.
Esophageal varices
Esophageal varices appear as multiple tortuous
filling defects in right X ray view during barium
swallowing
CT scan sagittal view, showing large esophageal varices
(black arrows and white arrows), diameter 6 mm.

17. Radiologic findings correlate well with the stage of the disease and include:
1) The penetration of juvenile worms through the diaphragm into the pleural cavity can cause
pleural effusion or pneumothorax.
2) Once the parasites get to the lung, patchy consolidations can occur due to exudative or
hemorrhagic pneumonia which appear as Ground glass opacity.
3) Linear areas of increased opacity or hyper-attenuation indicate peripheral atelectasis or
worm migration.
4) Worm cysts, whose diameters range from 0.5 to 1.5 cm, are visualized after the
consolidation resolves and manifest as either solitary or multiple nodules or gas-filled cysts.
5) Fibrous track: The presence of a track between a pulmonary nodule and the pleura that may
correspond to the worm's burrow tunnel.
6) Complications of cysts include pleural effusion, empyema, pneumothorax and pericardial
effusion .
Paragonimiasis
• Food-borne parasitic disease caused by the lung fluke Paragonimus
westermani.
• It is endemic in southeast Asia, the Far East, and is also relatively
common in Latin America and Africa .
• The disease can affect both the lung and pleura, although lung
parenchymal involvement is thought to be commoner than pleural
involvement

18. A 38-year-old man with pleural effusion who was diagnosed with pleural paragonimiasis. (A)
Chest radiography showed pleural effusion. (B) Chest computed tomography showed pleural
thickening with pleural effusion. (C) Subpleural consolidation.
Pleural Paragonimiasis

19. Chest radiograph shows nodular, and
cavitation lesions.
Pulmonary
paragonimiasis
High resolution CT image showing the "solar eclipse"
effect indicating worm cysts (arrow). A right-sided
pneumothorax and worm cyst appear in the posterior
right lung.

20. (A, B) Chest radiograph and computed tomography (CT) on admission.
(A) Multiple mass-like opacities are shown in the right lung (arrow).
(B) Multiple nodules with adjacent areas of ground glass opacity, suggestive of hemorrhagic
metastasis, are observed in both lungs (arrows).
(C) Fluorodeoxyglucose-positron emission tomography (FDG-PET) CT showing increased FDG uptake
(arrows).
Pulmonary paragonimiasis

21. Pulmonary
hydatid disease
• The lung is the second most common site of
involvement with hydatid cysts in adults after
the liver, and the most common site in
children. The coexistence of liver and lung
disease is present in only 6% of patients.
• When pulmonary hydatid cysts rupture and
communicate with bronchioles, patients are
described to cough up 'grape skin' like material .
• Other less common thoracic hydatid
manifestations include invasion of the
mediastinum 4, pericardium, pleural, chest
wall 5, cardiovascular system, or inferior vena
cava
• Thoracic involvement may occur via:
• transdiaphragmatic route (0.6-16% of cases
of hepatic disease)
• hematogenous spread

22.  Primary diagnostic method in pulmonary hydatid disease is
the plain radiograph.
 Air contrast allows intact pulmonary hydatid cyst to be seen
as solitary or multiple circumscribed or oval masses on
radiography.
 Calcification of pulmonary hydatid cyst is uncommon.
 Generally, chest Radiographic scan features include multiple
or solitary cystic lesion, unilateral or bilateral, and with
diameter of 1-20 cm.
 Radiographic and CT features may differ in complicated and
uncomplicated cysts.
o Uncomplicated cysts are characterized by:
• Round or oval masses with well-defined borders
• Enhancement after contrast injection
• Hypodense content relative to the capsule
o Complicated cysts may show:
• Meniscus sign or air crescent sign
• Cumbo sign or onion peel sign
• Water-lily sign
• Consolidation adjacent to ruptured cyst
Radiographic and CT features

23. Intact hydatid cysts
Postero-anterior(a) and lateral (b) chest radiography showing well-defined rounded
opacities (Red arrows) in the right lung of a patient with unruptured hydatid cysts

24. Chest radiography showing:
(A) Well-defined single rounded opacity in the left lung of a patient with
unruptured hydatid cyst.
(B) Well-defined left and right rounded opacities in both lungs of a patient with
unruptured hydatid cysts.
Intact hydatid cysts

25. Chest radiograph shows a huge hydatid
cyst located in the upper and mid-zone
of the left lung causes displacement of
the mediastinum to the right.
Intact hydatid
cysts
Giant intact hydatid cyst in the right lung.

26. Intact simple cyst: (A) Chest radiograph shows a well-defined opacity located in
the upper and middle zone of the right lung. (B) CT image shows that the mass has
water attenuation
Intact hydatid cysts

27. Chest X-ray revealed two large intact hydatid cysts in the right lung and ruptured
hydatid cyst in the left lung.
Intact and ruptured hydatid cysts

28. Ruptured Hydatid Cysts
Expanding pulmonary hydatid cysts PHCs sooner or later reach a
bronchioles and after erosion of the bronchioles, a communication
between the pericyst and bronchial tree is established.
This condition causes a variety of characteristic radiographic signs
of ruptured PHCs, which may raise suspicion about the presence of
hydatid cyst(s) or even allow a specific diagnosis of the disease:
1) Air meniscus (or air crescent) sign of detachment: a slight amount of air to enter between the
pericyst and endocyst
2) Double-arch or cumbo sign: If more air is introduced to the parasitic membranes,
3) Water lily or Camelot sign: If more air is introduced to the parasitic membranes, the endocyst
collapses and an air-fluid level is seen with parasitic membranes floating on the fluid surface
4) Empty cyst sign: If all the parasitic contents are evacuated and only the pericyst produced by
the host remains, it may even be filled with air.

29. Plan X ray chest; classical air meniscus in the
superior aspect of the lesion as a result of the
enlarging cyst communicating with an adjacent
bronchiole. This allowed a slight amount of air
to enter between the pericyst and endocyst,
producing the air meniscus or air crescent (sign
of detachment)
CT appearance of meniscus sign: A crescent
shaped air is seen in the potential space
between the pericyst and ectocyst of the
cystic lesion.
Air meniscus or Air crescent sign

30. With further entry of air, the cyst ruptures, and fluid is coming out from endocyst with entry of
some air. So, the endocyst contains air with fluid level is capped by a crescent.
Cumbo sign: Double air arc is seen in (a) chest radiography and (b) CT scan.
Double arch’ sign or Cumbo’s sign

31. Water lily or Camelot sign: (a) chest radiography shows a cavitary lesion with a
germinative layer in the left lung. (b) On CT scan (mediastinal window), a cystic cavitary
lesion with dependent wavy contour created by floated parasitic membranes is seen.
Water lily or Camelot sign:

32. Chest radiograph showing a large ruptured
hydatid cyst occupying most of the right lower
lung. There is a thickened pericyst around this
old hydatid.
The diaphragm and lower lateral chest wall are
obscured by pleural reaction and fluid.
Empty or Dry
cyst sign
Dry cyst sign. The empty and air-filled cyst is
seen after expectoration of cyst content in
ruptured hydatid cyst in left upper lobe of 9-
year-old girl.

33. Chest X-ray showing left hydropneumothorax
CT thorax showing left hydropneumothorax, pleural thickening and hydatid membranes floating in the
pleural fluid "serpent sign"
Ruptured pleural hydatid cyst (Serpent sign)
(Serpent sign)

34. Mediastinal calcified hydatid cyst
(a) Chest radiograph shows a well defined opacity in the right cardio-phrenic angle (arrow).
(b) Contrast enhanced CT shows a cystic lesion with segmental ring formed calcification that
connects to the pericardium (arrow).
At surgery calcified hydatid cyst was removed.
Mediastinal hydatid cyst

35. Soft Tissue and
Bone Parasites
The commonest parasitic infections with
radiologic manifestations in these sites include:
o Cysticercosis.
o Hydatid disease
o Guinea worm
o Filariasis
o Sparganum
• Bone provides suitable contrast for
radiological detection of these parasites.
• But in soft tissues, they can be detected
only after its calcification.
Semester for Doctorate
degree (9004)
D. Ibrahim Abouelasaad

36. Plain radiographs of lower limbs:
showed multiple “rice-grain” calcified lesions in
the muscles and subcutaneous tissues due to
disseminated cysticercosis
Patient with multiple “rice-grain” calcifications in
thigh muscles due to disseminated cysticercosis.
Cysticercosis

37. Plain radiograph of chest and abdomen showing multiple “rice-grain”
calcifications in the muscles and subcutaneous due to disseminated
cysticercosis
Cysticercosis

38. A case of hydatid cyst of the fibula, which is an
uncommon site for the occurrence of this disease
Nondisplaced pathological fracture in
the left upper tibia due to hydatid cyst
Bone hydatid cyst

39. Complicated Hydatid Cyst of Ulna
X-Ray right forearm showing expansile lytic lesion of ulna with thinned out cortex (arrow) and
pathological fracture proximally with similar features (arrow) in proximal radius and calcinosis of
subcutaneous tissue.
Histopathological examination parts of a cyst wall composed of acellular eosinophilic lamellated material
surrounded by fibrosis and dense chronic inflammation with few protoscolices of Echinococcus granulosus

40. Bone
hydatid
cyst
X-ray of left femur: Antero-posterior and Lateral view - Cortical thickening and sclerosis
(arrows) with intervening cystic lucencies in the diaphysis (arrow heads). There is contour
deformity of the bone.
Histopathological examination parts of a cyst wall composed of acellular eosinophilic lamellated material
surrounded by fibrosis and dense chronic inflammation with few protoscolices of Echinococcus granulosus

41. Hydatid
cyst in
muscle
• MRI showed multi-cystic lesion involving vastus lateralis of
quadriceps femoris muscle.
• On both T1(Axil) and T2(Coronal)-weighted images, the
daughter cysts are hypointense to the mother cyst. Daughter
cyst membrane detachment seen between two of the daughter
cysts (water lily sign).

42. Plain radiograph of the foot showed calcified
fragment of Guinea worm at the back of his
ankle.
Dracunculiasis
Guinea worm

43. Plain radiograph showing Convoluted, serpiginous
calcification in a necrotic adult guinea worm in the soft
tissues of thighs and calf
Guinea
worm

44. Serpiginous, beaded calcification in a
dead guinea worm in the soft tissues of
the abdominal wall (A) and the pelvis
overlying the bladder (B).
Guinea worm

45. Dracunculiasis. a and b Plain radiographs of the left knee and leg of a patient coming from Mali
shows “worm-like” calcifications in the soft tissues caused by dead calcified worms.
c. CT image of the left leg of the same patient as in a and b, confirms the dead calcified worms in
the subcutaneous tissue and muscles of the left lower limb
Guinea worm
(Dracunculiasis)

46. (B), Lateral X-ray chest reveal irregular nodular calcified shadows in left breast
(A), PA X-ray chest revealed irregular nodular calcified shadows in the both breast tissues
(calcification in a dead guinea worm).
Guinea worm (Dracunculiasis)

47. Breast
Filariasis
• Bilateral (A) mammograms show trabecular thickening and multiple tortuous
tubular channels, particularly in the upper lateral quadrant of the breast (arrow
in a) not conforming to ductal distribution. A few separate discrete well-
circumscribed lobulated masses are also seen. (B) The same findings (arrows) are
seen in more detail in this zoomed image.
Demonstration of the filarial dance on real-time US images
Fine-needle aspiration cytology shows microfilaria larvae

48. Mammograms of a female right breast
mass reveal spiral-shaped calcification
(arrow) due to calcified Loa loa worm.
X ray of the left hand shows thread-
like and punctate calcification of Loa
loa that have died while migrating
through the soft tissues.
Filarial infections -Loa loa

49. Subcutaneous
Sparganosis in
the Leg
The patient was a 60-year-old woman, and she was admitted to a hospital due to
ankle pain that was aggravated on dorsiflexion. She had noticed a mass on her knee
some 20 years ago, but she received no medical management for it. The mass moved
into the ankle joint 3 months before the current admission. A living sparganum was
recovered by surgery, and the calcified tract near the knee was proved to be the
pathway along which the larva had passed.

50. Soft Tissue
Sparganosis
• MRI showing a 1.8 cm-sized, well-
circumscribed, round mass arising at
the right distal sciatic nerve.
• The lesion showed heterogeneous
high signal intensity on T2-weighted
images (arrows) (A, B) and
intermediate signal intensity on T1-
weighted images (arrows) (C, D) with
a target sign or a fascicular sign.

51. Intramuscular
Sparganosis

52. A 53-year-old female patient with
cervical sparganosis. D.
Craniocaudal (left) and
mediolateral oblique (right) views
on mammography show multiple
tubular or linear calcifications,
which could be the previous
migration tracts of the sparganum,
scattered in the subcutaneous layer
of the left breast.
Breast
Sparganosis

53. Breast
Sparganosis
• Mammogram of
the present breast
sparganosis case. A:
Mediolateral oblique
view, B: Craniocaudal
view.
• Well defined,
isodense, lobular,
and continuous cord-
like structures
(arrows) were
characteristically
observed in the
upper outer
quadrant of the left
breast.

54. D. Ibrahim Abouelasaad