EpistemisChocolate nummular sputum
Specialty: Respiratory.
Why it occurs
- Advanced chronic pulmonary paragonimiasis (infection by the fluke Paragonimus westermani that forms fibrous cysts in the lung parenchyma; the parasites deposit eggs and blood debris that are expectorated in the form of rounded dark brown or chocolate-colored globular masses that resemble coins)
- Cavitary tuberculosis colonized by Aspergillus with concomitant anaerobic superinfection
- Cavitated fungal mycetoma with old localized recurrent encapsulated hemorrhages
- Chronic lung abscess of amoebic origin with narrow bronchial fistula that intermittently drains dense, round-shaped debris.
Initial workup
Direct microscopic examination of sputum in search of capped eggs of Paragonimus; Ziehl-Neelsen stain for acid-fast bacilli (tuberculosis); Stool culture and examination for parasites in feces; High-resolution chest computed tomography (CT); Specific serology (ELISA) for Paragonimus or Entamoeba histolytica.
red flags
Abundant frank hemoptysis concomitant with expectoration of nummular sputum, dyspnea at rest, persistent hectic fever with profuse night sweats, significant cachexia, or massive eosinophilia in peripheral blood associated with neurological symptoms (suggestive of ectopic migration of the parasite to the brain).
Standard management
- Praziquantel — 25 mg/kg orally three times a day for 3 consecutive days, as the antiparasitic treatment of choice for paragonimiasis
- Triclabendazole — 10 mg/kg orally in a single dose or two doses separated by 12 hours as an effective alternative
- Clindamycin (300 mg orally every 8 hours if there is associated anaerobic bacterial superinfection).
Educational guidance for study. It is NOT a prescription recommendation. The actual choice depends on the cause, the patient, and current guidelines.
- Area
- Respiratory
- Listed causes
- 4
- Treatment options
- 3