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1) Four cases of lung abscess, presumably due to Endamoeba histolytica, without other signs or symptoms suggestive of amebiasis were admitted to one military hospital within 18 months. All had previously lived in the China-Burma-India or Philippine area, were unaware of amebic infestation, and had been in the United States for two or more years immediately preceding the present illness. 2) One case was treated with aureomycin with good results, all received emetine with dramatic effect upon the fever and quantity of sputum; the pulmonary cavities closed promptly with minimal scarring. 3) It is recommended that cases of pulmonary abscess in which the usual causative agents have been excluded, and which do not respond to penicillin, streptomycin or sulfadiazine be given a therapeutic trial of emetine before resort is had to surgery. Response to emetine is felt to be indicative of the amebic etiology.

SUMMARY 1.A review of the roentgenographic appearances of 12 cases of hepatopulmonary amebiasis treated in the Hospital for Diseases of Chest and Tuberculosis, Hyderabad, during the last three years has been presented. 2.The appearance of one or the other of the following three types of shadows in the postero-anterior chest films is helpful in the early diagnosis of hepato-pulmonary amebiasis: Type I: A homogeneous, soft, dome-shaped opacity with its base superimposed on and covering a variable extent of the right dome of the diaphragm and demarcated from it by the denser hepatic shadow below. Type II: A fluffy, irregular, opacity overlying the right dome of the diaphragm, indistinguishably merging with the hepatic shadow below. Type III: A small, dense, triangular shadow in the right costophrenic and/or cardiophrenic angle.

SUMMARY This report documents the authors' experience with pulmonary schistosomiasis due to Schistosoma japonicum . Ten cases are the subjects of this report consisting of five children and five adult Filipinos. In order to reach the lungs, the ova bypass the liver taking a direct course to the heart through porto-caval anastomoses created as a result of chronic portal hypertension. It appears that the initial pulmonary lesions are vascular, the ova embolized within the pulmonary arterioles. A later stage is the parenchymal, the ova migrating through the vessel wall as a consequence of toxic substances secreted by the ova which produce the characteristic necrosis. The healing of the vasculitis finalizes the completion of the luminal obliteration. The terminal stage, therefore, is one of pulmonary hypertension, a cardiovascular stage that eventually leads to cor pulmonale. Death is inescapable and is often due to congestive heart failure. Pulmonary schistosomiasis, or for that matter, the stage of embolization, is incurable.

Clinical analysis of nine cases of amebic pulmonary suppuration is presented. Except one case of primary pulmonary amebiasis, all the rest were secondary to hepatic involvement. Seven of nine cases were right basal in localization, one case was in the right middle lobe and one in the superior segment of the right lower lobe. In the absence of ease of demonstration of Entameba histolytica in the sputum, need for a suitable diagnostic tool for etiologic diagnosis is seriously felt. Complement fixation test could be considered a satisfactory diagnostic aid; further work in this line is desired. At present, therapeutic test with emetine continues to be the mainstay in the diagnosis of amebic pulmonary suppuration.

SUMMARY (1) Pleuropulmonary complications of amebic hepatitis or abscess are best treated by surgical measures, accompanied by specific chemotherapy. (2) Methods of diagnosis were as follows: (a) Clinical diagnosis of hepatitis or liver abscess with pleuropulmonary complications led to a correct diagnosis in most instances. Discharge which was “anchovy sauce” in nature was considered highly suspicious of amebic origin. (b) Scrapings for microscopic study of the wall of the abscess for E. histolytica. (c) Sinusograms to prove concomitant liver abscess communicating with a pleuropulmonary component. (d) Sputum examination for endameba and muscle fibers (Mason-Bahr). 4 (e) Stool or sigmoidoscopic examinations yielded positive results for amebic cysts in ten cases. (3) Surgical procedures were: simple aspiration of pleural effusions (ten cases), empyema drainage (one case), lobectomy (two cases), drainage of liver abscess (two cases), decortication of right lower lobe and drainage of abscess (one case). (4) All 16 patients have a followup of three months to five years.

Although diseases of the respiratory tract due to infection by protozoan and metazoan parasites are not common in the conventional practice of medicine they have been encountered with sufficient frequency to merit consideration. It is probable that such conditions will be recognized more frequently in the future since several million men and women have had overseas service in areas of the world where some of the more important parasites are heavily endemic. The increasing interest of American business in foreign countries implies a constant flow of personnel to these regions, and foreigners are coming to the United States in increasing numbers from many parts of the world. These individuals therefore constitute a very large number of persons who potentially at least may have been exposed to infections which are not endemic in this country. Investigation of clinical problems in such a group necessitates the application of geographical medicine—the interpretation of clinical data in the light of the travels of the particular patient and the geographic distribution of particular parasites. The infections, therefore, may be grouped from this point of view. Amebiasis, malaria, ascariasis, strongyloidiasis and cysticercosis may be acquired in the United States as well as in many other parts of the world. On the other hand paragonimiasis and schistosomiasis cannot be acquired on the North American continent, and endemic hydatid disease is so rare in this area as to be virtually nonexistent. In the consideration of future medical problems among veterans it is of the utmost importance that these implications of geographical medicine be given due consideration. It is equally important to recognize the fact that there may be a prolonged latent period, in some instances years in duration, between infection and the development of the resultant clinical syndrome.

Pleuro-pulmonary amebiasis complicates amebic hepatic abscesses in about 15 per cent of the reported cases, as indicated by Ochsner and DeBakey1 in their comprehensive review of the subject In 1936. The usual pulmonary complication consists either of a lower lobe abscess or a broncho-hepatic fistula, both of which arise by direct extension of an hepatic abscess through the diaphragm. Craig2 states that “the lower right lobe of the lung Is the site of the pulmonary amebic abscess almost invariably.” Amebic empyema arises in 17 to 33 per cent of the reported cases. Primary amebic broncho-pulmonary involvement has been reported, but in these cases it cannot be said with certainty that amebic colitis was not present. Ochsner and DeBakey’ found that “hematogenous” pulmonary abscesses with independent liver abscesses occurred in 10.4 per cent of 153 cases collected from the literature and in none of their own 13 cases. Craig2 refers to Girgis’ two fatal cases of multiple pulmonary and hepatic amebic abscesses in which Endamoeba histolytica could be demonstrated in emboli in the pulmonary arterial vessels, thus supporting the view that hematogenous dissemination of the parasite may occur, presumably from the liver through the right side of the heart to the lung. In the absence of demonstrable contiguity between hepatic and pulmonary lesions, one must assume that this type of blood-borne dissemination may occur. The following case report is of interest both because of the unusual location of the pulmonary lesion and the fact that Emetine alone failed to effect a clinical cure, while subsequent Chloroquine therapy caused a complete clearing of the pathological process.

SUMMARY Thirty-one cases of portopulmonary bilharziasis with hyperventilation at rest and dyspnea on effort were subjected to a study of lung mechanics in conjunction with the clinical, respiratory and hemodynamic variations at rest and exercise. The cases were subdivided into three groups, according to the pulmonary artery pressure at rest and on exercise. There was a mild restrictive lung disease in all cases from focal interstitial fibrosis secondary to oval deposition. The lung compliance was manifestly affected, and more so on exercise, as the pulmonary artery pressures were raised. This was reflected in an increased oxygen cost of breathing. A physiologic disturbance for the resting hyperventilation and the exercise dyspnea could therefore be revealed among other causes discussed for this and similar symptomatology in other diseases.