Case 283: Breast Filariasis.

History A 44-year-old woman who was a resident of Bihar, which is a state in eastern India, presented to the surgical outpatient department of our hospital with a history of gradually increasing swelling of the right breast associated with redness, pain, and itching over the past month. She reported a general sense of malaise and experienced episodes of chills over the past 6 months; however, she had no documented fever. There was no history of breast trauma. No history suggestive of a possible hypercoagulable state could be elicited (she was a nonsmoker, had undergone uncomplicated normal vaginal delivery 15 years earlier, was not taking oral contraceptives, and had no history to suggest past deep venous thrombosis). General physical examination findings were unremarkable. On local examination, she was found to have diffuse enlargement of the right breast. The skin over the lateral part of the breast was erythematous and showed the presence of prominent superficial veins. On palpation, few ill-defined firm mobile masses were found in the upper outer quadrant with overlying skin induration. No skin ulceration or nipple discharge was present. Few firm and discrete lymph nodes were palpable in the right axilla. Laboratory investigations showed mild anemia (hemoglobin level, 10 g/dL; normal range, 12-15 g/dL), a total leukocyte count of 14 000 cells per microliter (14 cells × 109/L) (normal range, 4500-11 000 cells per microliter [4.5-11 cells × 109/L]), a normal differential leukocyte count (74% neutrophils [normal range, 40%-80%], 24% lymphocytes [normal range, 20%-40%], and 2% eosinophils [normal range, 1%-4%]), and an erythrocyte sedimentation rate of 31 mm per hour (normal range, 0-29 mm per hour). She underwent both mammography and US. Real-time US showed mobile structures on the series of US images obtained seconds apart. On the basis of the imaging findings, US-guided fine-needle aspiration cytology was performed to confirm the diagnosis, and appropriate treatment was instituted.

"Filarial dance sign" real-time ultrasound diagnosis of filarial oophoritis.

Filariasis is a parasitic disease caused by Filarial nematodes (Wuchereria bancrofti, Brugia malayi, and Brugia timori) that commonly causes lymphatic obstruction resulting in edema and increase in the size of the affected organ. Filariasis is diagnosed by identifying microfilariae on Giemsa stain. The immunochromatographic card test is diagnostic. Ultrasound is the imaging modality of choice for detecting adult filarial worms/microfilaria in the lymphatic system, which are responsible for the classic "filarial dance sign" caused by twirling movements of the microfilariae. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 44:500-501, 2016.

[Serpiginous calcifications in breast filariasis: A descriptor not included in the BI-RADS classification system]. / Calcificaciones serpiginosas en la filariasis mamaria: un descriptor no incluido en el sistema BI-RADS.

Filariasis is a parasitic disease with a benign course caused by nematodes. Filariasis is endemic in some tropical regions, and immigration has made it increasingly common in some centers in Spain. The death of the parasites can lead to calcifications that are visible in mammograms; these calcifications have specific characteristics and should not be confused with those arising in other diseases. However, the appearance of calcifications due to filariasis is not included in the most common systems used for the classification of calcifications on mammograms (BI-RADS), and this can lead to confusion. In this article, we discuss the need to update classification systems and warn radiologists about the appearance of these calcifications to ensure their correct diagnosis and avoid confusion with other diseases.

The filarial dance sign in scrotal filarial infection: a case report.

We describe a case of the filarial dance sign (FDS) in the epididymal region of a 22-year-old migrant worker from India who presented with a tender right scrotal swelling. Sonographic examination revealed multiple cystic lesions in the paratesticular region. The FDS was visualized within one of the cystic lesions. FDS is diagnostic of lymphatic filariasis in the appropriate clinical context.

Real time ultrasound diagnosis of ovarian and pelvic filariasis by filarial dance sign.

Parasitic infestations of the ovary are quite rare with ovary being the least common site of infection in the female genital tract. Filariasis is a parasitic disease caused by filarial nematodes (Wuchereria bancrofti, Brugia malayai, Brugia timori). It causes lymphatic obstruction with resultant edema and increase in the size of the affected organ. We report a case of 24-year-old married female who presented to our radiology department for ultrasound evaluation with the main aim being to look for retained products of conception after the termination of early pregnancy. However on ultrasound examination ovarian filariasis was an incidental diagnosis with the classical twirling movement (filarial dance sign) seen in one of the follicles of the ovary. Ultrasound is the imaging modality of choice for detecting the adult filarial worm/microfilaria in the lymphatic system. Ovarian filariasis is a very rare diagnosis with only a handful of cases being reported in literature with most cases being diagnosed incidentally on histopathological examination of the post operative specimen.

Filarial dance--sonographic sign of filarial infection.

A 17-year-old boy presented with a 3-month history of swelling and vague pain in the scrotum. US revealed multiple anechoic cyst-like lesions in the body of left epididymis. These cysts showed tubular echogenic internal structures with peculiar twirling motion. This was recognised as the sonographic filarial dance-sign of live adult filarial worms. The boy subsequently underwent needle aspiration of the lesion, which microscopically demonstrated microfilaria of Wuchereria bancrofti. Our report includes an online video clip that will help familiarise readers with the filarial dance.

The "filarial dance" is not characteristic of filariasis: observations of "dancing megasperm" on high-resolution sonography in patients from nonendemic areas mimicking the filarial dance and a proposed mechanism for this phenomenon.

The objective of this series was to show that the sonographic appearance described as the "filarial dance" is not characteristic of filariasis but occurs in nonendemic areas as a manifestation of epididymal obstruction. An experienced observer documented cases after initial observation of the filarial dance in routine clinical practice using high-frequency linear array transducers. The filarial dance was described as excessive to-and-fro movement of echogenic particles within a prominent epididymis and graded 1 to 4 according to the extent and distribution of the abnormality. The country of birth, exposure to filarial infection or travel to a filarial-endemic area, previous scrotal surgery including vasectomy, any previous or current scrotal inflammatory disease, and any congenital testicular abnormalities were recorded. Over a 10-year period, sonographic appearances consistent with the filarial dance were observed in 18 patients (bilateral in 6). The mean patient age was 47.7 (range, 28-91) years. The abnormality was graded in the 24 affected testes as follows: grade 1, n = 3; grade 2, n = 8; grade 3, n = 8; and grade 4, n = 5. No patient had a history of filariasis or travel to an endemic area. Six of 18 patients (33.3%) had bilateral vasectomies; 5 (27.8%) had a history of epididymo-orchitis in the ipsilateral testis; 3 (16.7%) had previous scrotal surgery; and 4 (22.2%) had no relevant urologic history. We have described a sonographic appearance identical to the filarial dance in men with no history of filarial infection. Most had previous scrotal surgery or infection, suggesting that the filarial dance may not always be due to movement of filarial worms. The unifying condition in patients with filariasis and our patients is lymphatic obstruction, likely the underlying cause of the appearance in both groups.

Sensitivity of the immunochromatographic card test relative to detection of adult Wuchereria bancrofti worms by ultrasound.

The diagnosis of active infection in bancroftian filariasis continues to pose an important and continuously evolving challenge to filariasis-endemic countries and to health personnel. Sensitivity of the immunochromatographic card test (ICT) relative to detection of adult Wuchereria bancrofti worms by ultrasound was evaluated in a retrospective study conducted in the Center for Teaching, Research and Tertiary Referral Hospital for bancroftian filariasis (Federal University of Pernambuco) in Recife, Brazil. The results showed that among 408 persons tested, the overall sensitivity of the ICT was 84.5% and varied from 52% to 100% when patients were grouped by different criteria (age, sex, presence or absence of living adult worms by ultrasound, microfilaremia status/density). The present study provides evidence that a negative antigen result should be interpreted cautiously and may help to explain the different sensitivities of the antigen test found by different investigators in settings with different transmission intensities.

Validation of ultrasound bioimaging to predict worm burden and treatment efficacy in preclinical filariasis drug screening models.

Filariasis is a global health problem targeted for elimination. Curative drugs (macrofilaricides) are required to accelerate elimination. Candidate macrofilaricides require testing in preclinical models of filariasis. The incidence of infection failures and high intra-group variation means that large group sizes are required for drug testing. Further, a lack of accurate, quantitative adult biomarkers results in protracted timeframes or multiple groups for endpoint analyses. Here we evaluate intra-vital ultrasonography (USG) to identify B. malayi in the peritonea of gerbils and CB.17 SCID mice and assess prognostic value in determining drug efficacy. USG operators, blinded to infection status, could detect intra-peritoneal filarial dance sign (ipFDS) with 100% specificity and sensitivity, when >5 B. malayi worms were present in SCID mice. USG ipFDS was predictive of macrofilaricidal activity in randomized, blinded studies comparing flubendazole, albendazole and vehicle-treated SCID mice. Semi-quantification of ipFDS could predict worm burden >10 with 87-100% accuracy in SCID mice or gerbils. We estimate that pre-assessment of worm burden by USG could reduce intra-group variation, obviate the need for surgical implantations in gerbils, and reduce total SCID mouse use by 40%. Thus, implementation of USG may reduce animal use, refine endpoints and negate invasive techniques for assessing anti-filarial drug efficacy.

Filiarial chyluria with nephrotic-range proteinuria and associated hypoalbuminaemia and hypogammaglobulinaemia secondary to bilateral lymphorenal fistulae.

A 55-year-old man of Indian descent, presented to the emergency department with a 2-year history of passing 'milky' white urine, associated with dysuria, urinary retention, bilateral flank pain and 15 kg weight loss. He had migrated to Australia from India at the age of 16, with no overseas travel since, and denied having any fevers, rigours or chills. He was found to have chyluria and nephrotic-range proteinuria with marked hypoalbuminaemia and hypogammaglobulinaemia. Due to his ethnic origin and by diagnostic exclusion, a presumptive diagnosis of filariasis was made. With bilateral lymphorenal disconnection, as definitive management, the patient's chyluria and proteinuria resolved with restoration of normal plasma protein and immunoglobulin levels.

Efficacy of co-administered diethylcarbamazine and albendazole against adult Wuchereria bancrofti.

Although diethylcarbamazine (DEC) and albendazole are recommended to interrupt transmission of Wuchereria bancrofti, little is known about the macrofilaricidal effect of this drug combination. Forty-seven men with W. bancrofti infection were randomly assigned to receive a single dose of either DEC alone (6 mg/kg) (n=25) or a combination of DEC (6 mg/kg) and albendazole (400 mg) (n=22). Physical examinations for scrotal nodules (resulting from worm death) and ultrasound examinations (to detect living adult worms) were performed before treatment and 7, 14, 30, 45, 60, 90, 180, 270 and 360 days after treatment. Blood was examined for microfilariae before and 30 days and 360 days after treatment. Seven days post treatment, intrascrotal nodules were detected at the site of 21 (46.7%) adult worm nests in men who received DEC alone compared with 2 (6.1%) sites in men who received DEC and albendazole (P=0.002). One year after treatment, 10 (22.2%) original adult worm nests remained detectable by ultrasound among men who received DEC alone compared with 18/32 (56.3%) nests among men who received both drugs (P=0.016). Microfilaraemia prevalence and density decreased to a similar extent in both groups. Addition of albendazole appeared to decrease the macrofilaricidal effect of DEC against W. bancrofti, with no detectable enhancement in microfilarial suppression.

Lymphoscintigraphy as a diagnostic tool in patients with lymphedema of filarial origin--an Indian study.

Lymphedema is a common clinical problem. Filariasis is the commonest cause of lymphedema in India and is a chronic debilitating disease. The purpose of this study is to highlight the role of lymphoscintigraphy in the evaluation of lymphedema. Our study population consisted of 418 patients diagnosed with filarial lymphedema of different clinical stages referred for lymphoscintigraphy of the limbs by the lymphologist at our institution. An analysis of the various studies was done to determine how lymphoscintigraphy can be useful in documentation of the diagnosis, evaluation, as a screening procedure to prevent progression, and to enhance management of filarial lymphedema.

A rare presentation of hydropneumothorax in tropical pulmonary eosinophilia: cavitation and pneumonic consolidation in a child.

Tropical pulmonary eosinophilia (TPE) is a syndrome of wheezing, fever and eosinophilia seen predominantly in the Indian subcontinent and other tropical areas. The pathogenesis is due to an exaggerated immune response to the filarial antigens which includes type I, type III and type IV reactions with eosinophils playing a pivotal role. Leucocytosis with an absolute increase in eosinophils in the peripheral blood is the hallmark of TPE. Other criteria for the diagnosis of TPE include high titres of antifilarial antibodies, raised serum total IgE > 1000 ku/L and a favourable response to the antifilarial agent, diethyl-carbamazine. Although TPE runs a benign course, if left untreated, it could result in a fair degree of respiratory morbidity.

Who Is Doing the Dance in Epididymis: The Principle of Moblile Echogenicities Without Filarial Infection: Case Report.

The aim of this study was to explore the principle of moblile echogenicities in epididymis in patients with a history of postvasectomy or infertility, which were reported as the characteristic sonographic sign of filarial infection.We reported a 38-year-old man presented with a 3-year history of infertility after marriage. Ultrasound imaging revealed an enlarged body in the inner left epididymis along with innumerable punctate mobile echogenicities, which showed random to-and-fro movements in the left epididymis. This had previously been recognized as the sonographic filarial dance sign of live filarial worms or microfilaria. The patient subsequently underwent needle aspiration of the left epididymis.Histopathological examination confirmed that the mobile echogenicities were a large number of macrophages with phagocytized sperm or clumps of agglutinated sperm. Our report includes a video clip that will help familiarize readers with this phenomenon.Our case highlighted that moblile echogenicities should be an important sign for epididymal obstruction to initiate corresponding treatment.