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Year : 2019  |  Volume : 9  |  Issue : 2  |  Page : 124-126  

Filariasis presenting as a solitary testicular mass


Department of Pathology, Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Dehradun, Uttarakhand, India

Date of Acceptance25-Jun-2019
Date of Web Publication18-Sep-2019

Correspondence Address:
Sushil Kumar Shukla
Department of Pathology, Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Doiwala, Dehradun - 248 140, Uttarakhand
India
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DOI: 10.4103/tp.TP_15_19

PMID: 31579667

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   Abstract 


In an endemic country like India, the occurrence of filariasis is very common, especially in the states of Uttar Pradesh, Bihar, Jharkhand, Odisha, Andhra Pradesh, and Tamil Nadu. The present study describes the case of a male from a nonendemic state who presented with a testicular lump. Fine-needle aspiration cytology (FNAC) of the lump revealed many adult filarial worms. The appearance of adult filarial worms in different sites, other than lymph nodes and lymphatic vessels, are relatively rarer and should always be reported. Filariasis remains asymptomatic for a long time and responds very well to treatment if diagnosed early. Despite the availability of multiple diagnostic options, FNAC holds a great importance in diagnosing filariasis, especially in cases where there are normal eosinophil counts and no peripheral filarial parasite. Finally, careful examination of cytological smear for the parasite in high-risk groups is helpful in labeling the disease in early asymptomatic states.

Keywords: Filariasis, testicular fine-needle aspiration cytology, testis


How to cite this article:
Shukla SK, Kusum A, Sharma S, Kandari D. Filariasis presenting as a solitary testicular mass. Trop Parasitol 2019;9:124-6

How to cite this URL:
Shukla SK, Kusum A, Sharma S, Kandari D. Filariasis presenting as a solitary testicular mass. Trop Parasitol [serial online] 2019 [cited 2019 Dec 11];9:124-6. Available from: http://www.tropicalparasitology.org/text.asp?2019/9/2/124/267132




   Introduction Top


In an endemic country like India, the occurrence of filariasis is very common, especially in the states of Uttar Pradesh (UP), Bihar, Jharkhand, Odisha, Andhra Pradesh, and Tamil Nadu.[1] Classically, filarial parasite is diagnosed on a peripheral blood film of a suspected patient, preferably in the night time. Although there are various case reports regarding the demonstration of microfilaria on cytological smears, still, it is very challenging to isolate the parasite on a cytology. Emphasis should always be given on careful examination of cytological smears, to look for the presence of the parasite, more so in the high-risk groups. We report one such case of a young male from a nonendemic state who presented with a testicular swelling with no previous history of travel from any endemic state of India. Fine-needle aspiration cytology (FNAC) from the swelling revealed many adult filarial worms. Commonly, these worms are limited to the lymph nodes and lymphatic vessels. The appearance of adult filarial worms in different sites, other than lymph nodes and lymphatic vessels, are relatively rarer and should always be reported.


   Case Report Top


A 37-year-old male from Uttarakhand presented with a left, mildly painful, solitary, persistent testicular swelling for 2 months. The swelling gradually increased in size during the course, and there were no associated symptoms or history of any coexisting illness. His general physical examination was unremarkable, and the urine analysis was well within normal limits. A provisional diagnosis of orchitis was made. The patient was put on empirical antibiotics and antiinflammatory medications which shows poor response. Owing to the poor antibiotic response, FNAC of the swelling was advised. His local examination showed a 4 cm × 3 cm, nontender, slightly mobile lump in the left testis. On FNAC, cytological smear of the testicular lump revealed a large number of viable and dead microfilarial worms.[1] It was also associated with a giant cell reaction and inflammatory cells [Figure 1]. The patient was put on diethylcarbamazine for 3 weeks. The patient responded dramatically well to the treatment. The swelling absolutely disappeared following the full course of therapy.
Figure 1: Cytological smear of testicular FNAC showing microfilaria (May-Grünwald-Giemsa stain, 2000)

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   Discussion Top


Filariasis is a major health issue in tropical countries like India; somewhat because the illness is asymptomatic and to some extent due to the fact that many parts of the country are still devoid of basic sanitation facilities. The disease is endemic to the eastern part of the country, mainly UP, Bihar, Jharkhand, Odisha, etc., Filariasis is caused by the infection from nematode worms such as Wuchereria bancrofti, Brugia malayi, and Brugia timori. It is transmitted by mosquito bite. Humans are definitive hosts, whereas mosquitos play as intermediate hosts. Microfilarial worms can reside in the lymphatic system for as long as 15 years, from where adult filarial worm releases microfilarial larvae. These larvae migrate through the thoracic duct to the pulmonary capillaries and then to peripheral circulation.[2] Definitive diagnosis of filariasis is made by demonstrating the adult filarial worm on a peripheral blood smear. Peripheral eosinophilia also serves a clue to the parasitic infestation. In the present case, we did not find any increase in eosinophil count or parasitemia on the blood smear examination. The same has been reported earlier by many authors.[3],[4] This reflects the variability of host response to the parasite. The disease can also be diagnosed by filarial antigen detection. However, such a method is only helpful in high-risk groups and endemic zones. Moreover, antigenic detection is expensive and has a very limited availability. Other diagnostic modalities such as fluorescence in situ hybridization and polymerase chain reaction are helpful but are all limited to research laboratories only.[5] More often, filarial worms are not usually picked up by FNAC. However, adult filarial worms have been demonstrated at various sites including lymph nodes from various locations, arm nodules, salivary glands, and epididymis.[6] Filariasis is mostly an incidental finding on cytology, frequently missed on FNAC. A careful examination of cytological smear, especially in high-risk groups and endemic regions, is a must for early detection and treatment. On cytological smear, presence of eosinophils, neutrophils, and giant cell reaction due to restriction of movement of adult filarial worms has been noted in most of the reported cases.[4] In the present case, we did not find any peripheral eosinophilia or parasites on the peripheral blood smear examination. However, a symptomatic testicular swelling directed us to go for an FNAC, which, later on, was found out to be the only evidence of filariasis in this patient.


   Conclusion Top


Filariasis remains asymptomatic for a long time and responds very well to treatment if diagnosed early. The variability of host response to the filarial worm results in an uncommon clinical picture (such as in our case). Despite the availability of multiple diagnostic options, FNAC holds a great importance in diagnosing filariasis, especially in cases where there are normal eosinophil counts and no peripheral filarial parasite. Careful examination of cytological smear for the parasite in high-risk groups is helpful in labeling the disease in early asymptomatic states.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Mitra SK, Mishra RK, Verma P. Cytological diagnosis of microfilariae in filariasis endemic areas of Eastern Uttar Pradesh. J Cytol 2009;26:11-4.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Park K, editor. Lymphatic filariasis. In: Park's Textbook of Preventive and Social Medicine. 22nd ed. Jabalpur: Banarasidas Bhano; 2013. p. 245-50.  Back to cited text no. 2
    
3.
Rawat V, Rizvi G, Sharma N, Pandey H. An unusual presentation of Wuchereria bancrofti infection. Indian J Med Microbiol 2009;27:382-3.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Varghese R, Raghuveer CV, Pai MR, Bansal R. Microfilariae in cytologic smears: A report of six cases. Acta Cytol 1996;40:299-301.  Back to cited text no. 4
    
5.
Ahuja M, Pruthi SK, Gupta R, Khare P. Unusual presentation of filariasis as an abscess: A case report. J Cytol 2016;33:46-8.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Tummidi S, Kothari K, Patil R, Singhal SS, Keshan P. Incidental detection of two adult gravid filarial worms in breast: A case report. BMC Res Notes 2017;10:412.  Back to cited text no. 6
    


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