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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 16  |  Issue : 1  |  Page : 72-74

Incidental gravid adult filarial worm in the spermatic cord and the axillary tissue: Report of two cases


Department of Pathology, KGMU, Lucknow, UP, India

Date of Web Publication5-Jul-2017

Correspondence Address:
Preeti Agarwal
Assistant Professor, Department of Pathology, KGMU, Lucknow 226003, UP
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ajmhs.ajmhs_1_17

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  Abstract 

Gravid adult female worm of Wuchereria bancrofti was seen in the histology sections of axillary dissection of a radical mastectomy specimen in a patient with infiltrating ductal carcinoma and in sections from spermatic cord lesion in a 4-year-old boy. Careful observation and recognition of histologic features are important for the diagnosis in hematoxylin and eosin stained sections. In the present report, we highlight the salient morphologic features of the adult worm.

Keywords: Gravid adult female, histologic features, spermatic cord, wuchereria bancrofti


How to cite this article:
Agarwal P, Katiyar S, Sagar M, Rai A, Gupta B, Goel MM. Incidental gravid adult filarial worm in the spermatic cord and the axillary tissue: Report of two cases. Afr J Med Health Sci 2017;16:72-4

How to cite this URL:
Agarwal P, Katiyar S, Sagar M, Rai A, Gupta B, Goel MM. Incidental gravid adult filarial worm in the spermatic cord and the axillary tissue: Report of two cases. Afr J Med Health Sci [serial online] 2017 [cited 2020 Nov 28];16:72-4. Available from: http://www.ajmhs.org/text.asp?2017/16/1/72/209480


  Introduction Top


Filariasis is a well-known parasitic infestation involving the lymphatic system of humans. Clinical presentation may be misleading most of the times. Incidental finding of filarial worm at multiple sites is not an unusual finding.[1] It is endemic all over India with almost equal incidence in northern, central, and southern India. Ninety percent of the Indian Filariasis is caused by Wuchereria bancrofti.[2] Microfilariae present clinically as lymph edema, localized mass, or may be just observed as a coincidental finding with other neoplastic or non-neoplastic lesions.[3] It has been ranked as the second leading cause of permanent and long-term disability by the World Health Organization and has been targeted for elimination by 2020.[4]


  Case 1 Top


A 4-year-old boy presented with swelling in the inguinal region for 6 months. On clinical examination, it was a firm swelling with restricted mobility. Aspiration cytology was noncontributory and revealed occasional spindle cells only. A space-occupying lesion was visualized on ultrasound. The patient underwent surgical excision, and 5 cm × 2 cm × 3 cm soft-to-firm mass was deposited for histological examination. Initial sections revealed fibroblastic proliferation with atypia and lymphoplasmacytic inflammatory cell infiltrate. A mesenchymal lesion with differentials of inflammatory myofibroblastic lesion or Rhabdomyosarcoma was considered. Immunohistochemistry for Vimentin, Desmin, CD34, and Ki67 was applied, and the whole tissue was also processed to observe other areas. Vimentin was positive; however, no immunoexpression for desmin, CD34, or Ki67 was found in proliferating spindle cells.

To our surprise, a well-formed adult worm was found in the reprocessed sample. An eosinophilic oval structure was seen with calcific deposits inside and surrounded by necrosis and fibroblastic proliferation. Small nuclear bodies and microfilaria were identified in the body [[Figure 1], inset].
Figure 1: Section shows oval-shaped dead worm with dystrophic calcification (long arrow), a microfilaria (short arrow) (H&E 100×), and surrounding dense fibroblastic reaction. The outer layer is dense eosinophilic, and small, fine hematoxylin-stained nuclear bodies are seen (circled) in the inset (H&E 200×)

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  Case 2 Top


A 50-year-old female presented with the chief complaint of left breast lump since 2 years, which increased in size in the last 2 months and had developed into spontaneous ulceration. A modified radical mastectomy was performed without prior neoadjuvant chemotherapy.

The excised left breast specimen measured 16 cm × 10 cm × 4 cm. On serial sectioning, a gray white growth was identified in the upper outer quadrant measuring 3 cm × 3 cm × 2 cm. A total of 16 lymph nodes were dissected in the attached fibrofatty tissue and the axillary tail of the breast.

On microscopy, sections from the growth showed a malignant epithelial neoplasm disposed as tubules and nests and infiltrating the breast parenchyma [[Figure 2]a]. Out of the 16 lymph nodes, one was found to be positive for tumor invasion. An adult filarial worm was also evident with well-developed suckers in one lymph node [[Figure 2]b–[Figure 2]d].
Figure 2: Section shows infiltrative ductal carcinoma (A; H&E 200×) and low-power view of the gravid worm in one lymphatic channel (B; H&E 40×). The curved microfilaria can be easily recognized in the transverse section from the worm (C; H&E 200×), and the tailpiece with filaments is also seen (D; H&E 200×)

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  Discussion Top


W. bancrofti was named after the physician Otto Wucherer and the parasitologist Joseph Bancroft, both of whom extensively studied filarial infections.[5] Historically, ancient Greek and Romans have written about the similarities between the enlarged limbs and the cracked skin of infected individuals to that of elephants. Since then, this condition has been commonly known as elephantiasis, which is a misnomer, because elephantiasis literally translates to “a disease caused by elephants.”

Filariasis is transmitted by the Culex mosquito and is caused by the worms W. bancrofti, Brugia malayi, and Brugia timori, of which W. bancrofti is more common. Subcutaneous filariasis is caused by Loa loa (the eye worm), Mansonella streptocerca, and Onchocerca volvulus. Microfilaria is the infective larva that penetrates the feeding wound in the skin to enter the lymphatics and travel to the lymph nodes. After maturation in a few months, they develop into white, thread-like adult worms and survive for several (10–18) years in the lymph nodes. Once fertilized, several thousand microfilariae are discharged by the female, which dwell in the peripheral blood for 5–10 years.[2]

Both acute and chronic manifestations are seen. Multiple reports of its coexistence with varied lesions have been reported with co-existent breast carcinoma has also been known.[3],[6],[7] The presence of microfilariae along with neoplasms is generally regarded as a chance involvement, yet some authors suggest it may be a causative factor for tumorigenesis.[7]

Predominantly, authors have seen microfilaria in cell aspirates, peripheral blood, and even tissue sections. The current report describes the features of the adult worm.

The dead adult worm has a dense eosinophilic outer coat, which is followed by a thin layer of fine nuclear granules, which are stained by the hematoxylin dye of hematoxylin and eosin (H&E) stain. The gravid female has multiple curved microfilariae inside her body tube, which have an eosinophilic coat and a central nuclear material [[Figure 1]b and [Figure 2]c and [Figure 2]d]. No host response was identified around the adult worm present in the axillary tissue; however, the worm present in the spermatic cord of the child had undergone dystrophic calcification, and there was dense fibroblastic response so much so that it was mimicking malignancy. Identification of worm and processing of all tissue were vital in decision making in the first case.

Other methods of diagnosis other than the demonstration of microfilaria or adult worm are immunochromatographic test, quantitative buffy coat, ultrasonography, and lymphoscintigraphy.

Parasites may infest the human body for varying periods of time without invoking any adverse host inflammatory response. The factors responsible for the host reaction are not well established. Therefore, adult worms and microfilaria should be sought in all unexplained granulomas.

The drug of choice is diethylcarbamazine (DEC), because it is effective against the adult worm and microfilaria. The other drug used is ivernectin in a single dose of 200–400 μg per kg body weight.[8]


  Conclusion Top


The present cases highlight the histomorphology of gravid adult female filarial worm in cases harboring subclinical filariasis. Moreover, this also highlights the significance of screening for parasites even in the absence of clinical symptoms, especially in high-endemic areas.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Ottesen EA, Ramachandran CP. Lymphatic filariasis infection and disease: Control strategies. Trends Parasitol 1995;11:129-31.  Back to cited text no. 1
    
2.
Chowdhary M, Langer S, Aggarwal M, Agarwal C. Microfilaria in thyroid gland nodule. Indian J Pathol Microbiol 2008;51:94-6.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Gupta K, Sehgal A, Puri MM, Sidhwa HK. Microfilariae in association with other diseases. A report of six cases. Acta Cytol 2002;46:776-8.  Back to cited text no. 3
[PUBMED]    
4.
Gupta S, Sodhani P, Jain S, Kumar N. Microfilariae in association with neoplastic lesions: Report of five cases. Cytopathology 2001;12:120-6.  Back to cited text no. 4
[PUBMED]    
5.
Valand AG, Pandya BS, Patil YV, Patel LG. Subcutaneous filariasis: An unusual case report. Indian J Dermatol 2007;52:48-9.  Back to cited text no. 5
  [Full text]  
6.
Atal P, Choudhury M, Ashok S. Coexistence of carcinoma of the breast with microfilariasis. Diagn Cytopathol 2000;22:259-60.  Back to cited text no. 6
[PUBMED]    
7.
Kolte SS, Satarkar RN, Mane PM. Microfilaria concomitant with metastatic deposits of adenocarcinoma in lymph node fine needle aspiration cytology: A chance finding. J Cytol 2010;27:78-80.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Singh NG, Chatterjee L. Filariasis of the breast, diagnosed by fine needle aspiration cytology. Ann Saudi Med 2009;29:414-5.  Back to cited text no. 8
[PUBMED]  [Full text]  


    Figures

  [Figure 1], [Figure 2]



 

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   Abstract
  Introduction
  Case 1
  Case 2
  Discussion
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