Introduction: Pleuropulmonary paragonimiasis does not show any specific symptoms and radiologic findings, thereby leading to the possibility of misdiagnosis. We aimed to evaluate the specific clinical and pleural fluid features of pleuropulmonary paragonimiasis masquerading as tuberculous pleurisy. Methods: We retrospectively analyzed the clinical and radiologic characteristics of 20 patients found to have pleuropulmonary paragonimiasis masquerading as tuberculous pleurisy between January 2001 and September 2011. 17 patients (85%) presented with respiratory symptoms, including dyspnea (n=6, 30%), hemoptysis (n=5, 20%), cough (n=5, 20%) and pleuritic chest pain (n=4, 15%). Chest radiographs revealed intrapulmonary parenchymal lesions, such as air-space consolidation (n=6, 30%), nodular opacity (n=4, 20%), cystic lesion (n=3, 15%), ground glass opacity (n=2, 10%), and pneumothorax (n=1, 5%). Results: Pleural fluid examination revealed eosinophilia, very low glucose levels, and high LDH levels in 87%, 76%, and 88% of the patients, respectively. Despite the increased ADA level (46.6 IU/L), this analysis helped distinguish pleuropulmonary paragonimiasis from tuberculous pleurisy. Conclusions: Pleuropulmonary paragonimiasis is often initially misdiagnosed as tuberculous pleurisy. In patients with unexplained pleural effusion living in paragonimiasis-endemic areas, pleural fluid should be examined through thoracentesis to distinguish between pleuropulmonary paragonimiasis and tuberculous.