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Year : 2019  |  Volume : 9  |  Issue : 2  |  Page : 127-129  

Lymphatic filariasis presenting as a soft tissue swelling in midarm: A histopathological diagnosis at unusual site


Department of Pathology, IMS and SUM Hospital, Bhubaneswar, Odisha, India

Date of Acceptance06-Jun-2019
Date of Web Publication18-Sep-2019

Correspondence Address:
Nibedita Sahoo
Department of Pathology, IMS and SUM Hospital, Bhubaneswar - 751 003, Odisha
India
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DOI: 10.4103/tp.TP_67_18

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   Abstract 


Filariasis is a major social health problem in tropical countries like India. Wuchereria bancrofti accounts for 95% cases of lymphatic filariasis. The adult worm resides in the lymphatics and lymph nodes and causes little inflammatory response as long as it is alive, but granulomatous reaction is noted once the death of parasite occurs. In the present case, spectrum of inflammatory response is noted to the adult and larval form, which forms a soft tissue mass, masquerading as a soft tissue tumor clinically.

Keywords: Arm swelling, histopathology, microfilaria


How to cite this article:
Sahoo N, Mohanty P, Mohanty S, Naik S. Lymphatic filariasis presenting as a soft tissue swelling in midarm: A histopathological diagnosis at unusual site. Trop Parasitol 2019;9:127-9

How to cite this URL:
Sahoo N, Mohanty P, Mohanty S, Naik S. Lymphatic filariasis presenting as a soft tissue swelling in midarm: A histopathological diagnosis at unusual site. Trop Parasitol [serial online] 2019 [cited 2019 Oct 17];9:127-9. Available from: http://www.tropicalparasitology.org/text.asp?2019/9/2/127/267144




   Introduction Top


Filariasis is a chronic disabling parasitic disease and causes a major public health problem in tropical and subtropical countries such as India, China, Indonesia, and the Far East. It is caused mainly by nematode worms Wuchereria bancrofti, Brugia malayi, and Brugia timori, among which W. bancrofti is associated with almost 99.4% of cases and B. malayi with 0.6% cases of lymphatic filariasis in India.[1] Filariasis presenting as soft tissue swelling is very rare.[2],[3],[4],[5] Although there are cases describing the cytological aspect of this entity, only few cases describe the histopathology.[6] Herein, we report a rare case of filariasis presenting as subcutaneous soft tissue swelling which was diagnosed by histopathological examination as inflammatory granulomatous nodule formed due to adult and larval form of W. bancrofti.


   Case Report Top


An 18-year-old male residing eastern part of India came to the surgery outpatient department with a chief complaint of swelling over the right arm. On clinical examination, the swelling was of size 2 cm in maximum dimension, subcutaneous, mobile, and nontender. With a clinical diagnosis of lipoma, fine-needle aspiration cytology (FNAC) was suggested. The procedure was done twice and yielded a fluid-like scanty material. Smears were stained with Diff-Quik stain and hematoxylin and eosin stain. Microscopy revealed few lymphocytes, cyst macrophages, neutrophils, and histiocytes over a fluid-like background. With these findings, a diagnosis of benign cystic lesion with features of inflammation was suggested. Excision of the mass was done, and the gross received was two bits of nodular structures together measuring 2.5 cm × 2.0 cm, which was bisected and all embedded.

Microscopy revealed a circumscribed lesion surrounded by a fibrous capsule within which the stroma was myxoid and contained many dilated lymphatics [Figure 1]a. Many lymphatics showed fibrous obliteration of the lumen with proliferation of myofibroblasts within the lumen (inset). One focus revealed central necroinflammatory debris [Figure 1]b which on higher magnification showed a plenty of coiled microfilarial organisms of varying sizes at the periphery and few straight forms within the debris [Figure 1]c and [Figure 1]d. Other bit of tissue was a lymph node and showed central granulomatous reaction comprising palisaded histiocytes and foreign-body type giant cells surrounding many adult gravid form of female filarial organism and dead forms [Figure 2]a. On higher magnification, they had outer refractile cuticular layer and few of which contained the embryonated eggs and coiled to straight larvae within the body cavity [Figure 2]b and [Figure 2]c. Still, on higher magnification, microfilarial organism was slender, sheathed with multiple coarse discrete nuclei extending from head to tail, and the tip of the tail was free of nuclei which were consistent with W. bancrofti [Figure 2]b. The dead worms were fragmented and inflammatory cells were seen invading the body cavity [Figure 2]d. Surrounding soft tissue showed dense inflammation comprising plasma cells, eosinophils, neutrophils, and also mast cells. The routine hemogram showed hemoglobin: 14.2 gm%, total leukocyte count: 6850/cumm, with normal differential; absolute eosinophil count: 274/cmm; total platelet count: 220,000/cumm. Midnight peripheral smear was negative for microfilarial organism, but serum immunochromatography test for filarial antigen was positive. The patient was treated with diethylcarbamazine (150 mg) twice daily for 12 days with antihistaminic and single dose of albendazole + ivermectin.
Figure 1: (a) Many dilated lymphatics (arrow) with one focus depicting the necroinflammatory debris (asterisk), fibrous obliteration of the lumen by myofibroblastic proliferation (inset) (H and E × 40), (b) neutrophilic abscess (H and E, ×100), (c and d) Aggregates of curved form of microfilariae and some linear forms of microfilariae (H and E, ×400)

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Figure 2: (a) Live and dead adult worms with palisading arrangement of histiocytes (arrow) and foreign body-type giant cell reaction (H and E, ×100). Live adult parasite with larval forms within the body cavity (b) longitudinal section and (c) cross-section (H and E, ×400), (d) dead worm (arrow) with inflammatory infiltrate within the body cavity and fragmentation (H and E, ×400)

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   Discussion Top


Filarial adult worm resides in lymphatics and/or lymph nodes, while the larval form circulates in the peripheral smear which is taken by the mosquito and the disease is transmitted. Lymphedema due to lymphatic blockage and lymphadenitis are usual mode of presentation of filariasis; however, extralymphatic filariasis is rare and has been reported in uncommon sites, including skin and soft tissue swelling, breast, thyroid nodule, salivary gland, cervicovaginal smear, ovarian cyst, effusion fluids, and urine, bronchial, laryngeal, and pharyngeal brushings.[2],[7] The larval form possibly reaches the tissue space due to lymphovascular obstruction causing extravasation.[8]

Viable adult forms have intact outer cuticular layer with body cavity containing intestine, testis, or ovary. Female gravid worm contains an embryo coiled larval form. The dead parasites have fragmented outer membrane, body parts, or calcification.[9] They usually evoke the inflammatory reaction, which causes tissue injury, foreign body-type giant cell reaction, and fibrosis. The presence of dead and viable form in the same site is also described in the literature signifying that inflammation is probably caused due to dead parasites.[9] However, morphological details of viable and dead forms are not clearly evident in histopathology due to fixation artifact.[9],[10]

Peculiarity in our observation is that both larval forms and adult forms were seen in separate tissue with different immune response. The microfilarial form evokes a neutrophil response with the formation of microabscess, while adult form showed basically inflammation comprising histiocytes, multinucleated giant cells, lymphocytes, plasma cells, eosinophils, neutrophils, and good number of mast cells. The presence of eosinophils surrounding the pathological site highlights the presence of dead parasite, which was also noted in the present case.[8]

The disease presentation ranges from subclinical to acute and chronic manifestations such as lymphangitis, lymphadenitis, elephantiasis of genitals, legs, and arms or hypersensitive states such as pulmonary eosinophilia or sometimes filarial arthritis.[1]W. bancrofti and Brugia species cause lymphatic filariasis and presentation as subcutaneous nodule is very rare. The skin and subcutaneous filariasis are mainly caused by Onchocerca volvulus and Loa loa.[4]

Filariasis is usually diagnosed by the demonstration of microfilaria in stained or unstained blood films and detection of filarial antigen in the low level of microfilaremia. However, in endemic areas, a majority of the affected individuals remain asymptomatic with continued disease transmission.[7] Our case retrograde midnight sample did not reveal any microfilarial organism or eosinophilia.

FNAC is a well-known diagnostic procedure for the evaluation of subcutaneous soft tissue lesions. Different parasites such as filariasis, hydatid disease, and cysticercosis presenting as soft tissue lesion have been described in the literature.[11] Microfilaria is sometimes diagnosed in FNAC smears, but detection of adult form is very unusual.[5] But in our case, no filarial organisms were detected in the cytology slides. Although histopathology is not needed in all cases, it confirms the diagnosis when FNAC does not yield the organism.


   Conclusion Top


Filariasis is not uncommon in tropical countries like India, but presenting with a soft tissue nodule with heavy load of parasites, especially in histopathology sections, is extremely uncommon incident. This unique case will impart some awareness of diagnosing and subjecting proper therapy.

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.
Basavaraj K, Bharatesh SK, Murali D, Ramachandra K, Sowmya M. A study on morbidity management among lymphatic filariasis patients in Udupi district, Karnataka, India. Int J Med Public Health 2017;7:92-6.  Back to cited text no. 1
    
2.
Adhikari P, Upadhyaya P, Dhakal S, Dahal M, Bhattarai S. Filariasis presenting as an upper arm swelling – An unusual presentation. J Pathol Nep 2018;8:1317-9.  Back to cited text no. 2
    
3.
Pandey P, Dixit A, Chandra S, Tanwar A. Cytological diagnosis of bancroftian filariasis presented as a subcutaneous swelling in the cubital fossa: An unusual presentation. Oxf Med Case reports 2015;2015:251-3.  Back to cited text no. 3
    
4.
Oza H, Bhalodia J, Shah A, Modi P. Mid arm swelling- A rare presentation of filariasis. Natl J Med Res 2014;4:256-84.  Back to cited text no. 4
    
5.
Azad K, Arora R, Gupta K, Sharma U. Lymphatic filariasis: Aspiration of adult gravid female worm from a soft tissue swelling. J Cytol 2010;27:156-7.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Mahalingashetti PB, Subramanian RA, Jayker SS, Vijay A. Lymphatic filariasis: A view at pathological diversity. Trop Parasitol 2014;4:128-32.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Sahoo N, Saha A, Mishra P. Coexistence of microfilaria with metastatic adenocarcinomatous deposit from breast in axillary lymph node cytology: A rare association. J Cytol 2017;34:43-5.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Karumbaiah KP, Arshiya A, Subbannaiah, Kariappa TM. Cytodiagnosis of filariasis from a swelling in upper arm – A rare presentation. Sch J Appl Med Sci 2013;1:593-4.  Back to cited text no. 8
    
9.
Figueredo-Silva J, Norões J, Cedenho A, Dreyer G. The histopathology of bancroftian filariasis revisited: The role of the adult worm in the lymphatic-vessel disease. Ann Trop Med Parasitol 2002;96:531-41.  Back to cited text no. 9
    
10.
Dreyer G, Norões J, Figueredo-Silva J, Piessens WF. Pathogenesis of lymphatic disease in bancroftian filariasis: A clinical perspective. Parasitol Today 2000;16:544-8.  Back to cited text no. 10
    
11.
Yadav YK, Gupta O, Aggarwal R. Cytological diagnosis of parasites presenting as superficial nodular swelling: Report of 35 cases. J Parasit Dis 2012;36:106-11.  Back to cited text no. 11
    


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  [Figure 1], [Figure 2]



 

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