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An Interesting Case Of Breast Filariasis
V UPADHYAYA, DN UPADHYAYA, S SARKAR
Ind J Radiol Imag 2006 16:4:915-917
Key words : - Breast, Filariasis, Somomammography
INTRODUCTION
Lymphatic filariasis, also known as Elephantiasis, puts
at risk more than a billion people in more than 80
countries. Over 120 million have already been affected by
it and over 40 million of them are seriously incapacitated
or disfigured by the disease. One third of the people
infected with the disease live in India, one third are in
Africa and most of the remainder in South Asia, the Pacific
and the Americas [1].
Lymphatic filariasis in humans is commonly caused by
Wuchereria bancrofti and Brugia malayi. The breast is an
uncommon site of involvement. Breast filariasis has been
reported in the Indian subcontinent where the organism
is endemic.
CASE REPORT
A 55 year old woman presented with pain and swelling of
five months duration in her left breast. An ill defined lump
was palpable in the central part of the breast. No lymph
nodes were palpable in either axilla.
She was referred to us for X-Ray mammography and
ultrasound of the breast.
Mammography was done and standard craniocaudal and
mediolateral oblique views were obtained (GE Senographe
700 T, France). Tortuous band like opacity was noted in
the central and upper outer part of the left breast (Fig. 1 -
a and b). No calcifications were seen.
Ultrasound was done subsequently, using a high frequency
transducer of 11-14 MHz (GE Voluson 730 Expert,
Austria). It showed cystic lesions in the central and outer
part of the left breast (Fig. 2). Within these cysts,
vigorously moving clusters of small echogenic structures
were seen (Figs.3 and 4). These movements are
characteristic of live adult worms of W. bancrofti and a
provisional diagnosis of breast filariasis was made.
Fine needle aspiration was done and cytologic
examination confirmed the diagnosis by showing the
presence of adult worms of W. bancrofti.
Fig. 1 (a and b) - Mammography showing a tortuous band
like opacity in the central and upper outer part of left breast.
DISCUSSION
Filariasis is widespread in India. The disease, in India,
has a very ancient history since elephantiasis has been
reported in India from very early times by famous Hindu
physicians like Susruta and Madhavakara.
From the Sarkar Diagnostic Centre, C-1093, Sector-A, Mahanagar, Kucknow, India - 226006
Request for Reprints: Vaishali Upadhyaya, Sarkar Diagnostic Centre, C-1093, Sector A, Mahanagar, Lucknow, Uttar Pradesh
Received 25 November 2006; Accepted 30 November 2006
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916 V Upadhyaya et al
Fig. 2- Ultrasound image showing cystic lesions in left
breast.
Fig. 3 Ultrasound image showing clusters of small echogenic
structures within the cystic lesions. These were showing
vigorous movement during the scan known as the "Filarial
dance" sign.
Fig. 4 Ultrasound image showing clusters of small
echogenic structures within the cystic lesions. These were
showing vigorous movement during the scan known as the
"Filarial dance" sign.
It is a disease affecting humans and animals alike and is
caused by nematode parasites of the order Filariidae.
These parasites can be classified according to the habitat
of adult worms in the vertebral host. There are cutaneous,
body cavity and lymphatic groups. The latter includes
Wuchereria bancrofti, Brugia malayi and Brugia timori.
Most of the cases in humans are caused by W.bancrofti
and B.malayi. Man is the definitive host for these parasites.
The adult worms live in the lymphatics and produce
IJRI, 16:4, November 2006
approximately 50,000 microfilariae per day. Mosquitoes
serve as the intermediate vector and spread the disease.
When they feed from an infected person, they ingest the
microfilariae. These microfilariae undergo development in
the insect and then are inoculated back into the human
being during feeding for completion of the development
cycle. Some microfilariae have a unique circadian
periodicity in the peripheral circulation over a 24-hour
period. The arthropod vectors also have a circadian rhythm
in which they obtain blood meals.
The disease may be asymptomatic or there can be acute
episodes of local inflammation involving skin, lymph nodes
and lymphatic vessels. Chronic disease in endemic
communities can manifest in men in the form of genital
damage, especially hydrocele and elephantiasis of the
penis and scrotum. In women, the vulva or breast may be
involved. An entire arm or leg maybe affected in both [1].
Tests used for diagnosis include demonstration of
microfilariae in the peripheral blood or skin and detection
of filarial antigens and antibodies.
When the female breast is involved, the larvae enter the
lymphatic vessels causing lymphangitis, fibrosis and
disruption of lymphatic drainage [2]. The patient usually
presents with a unilateral painless solitary non tender
breast mass. The most common site is the upper outer
quadrant. Hyperemia in the overlying skin with changes
of peau d' orange and enlargement of axillary lymph nodes
has also been reported [3, 4].
Ultrasound is a valuable tool in the diagnosis of cases of
lymphatic filariasis. Amaral et al [5] had first reported the
use of ultrasound to visualize adult worms of W. bancrofti
in the scrotal area of infected men. They described a
continuous, distinctive and specific pattern of worm
movement called the "Filarial dance" sign. In patients who
exhibited this sign, nests of adult W. bancrofti were found
in the lymphatic vessels of the spermatic cord on surgery.
It has been reported that the location of the adult worm
nests within the lymphatic vessels remains remarkably
stable with time [6]. Suresh et al [7] have suggested that
this can be due to some kind of homing mechanism for
the parasite after its entry into the body of the host which
aids in ensuring reproducibility of the findings and
facilitates the performance of follow-up scans to assess
the response to chemotherapy. We were able to
demonstrate this sign in our patient which enabled us to
suggest the correct diagnosis.
These worms can later calcify and these calcifications
are well visualized on breast mammograms. They appear
elongated and serpiginous with no evidence of irregularity
or pleomorphism and are not oriented or adjacent to the
ducts. Due to their location in connective tissue unrelated
to the ducts, these can be differentiated from calcifications
of intraductal carcinoma [8]. A mass with serpiginous
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IJRI, 16:4, November 2006
calcifications may also be seen. No calcifications were,
however, noted in mammogram of our patient.
This case emphasizes the need to consider the possibility
of filariasis in patients presenting with a breast lump in
endemic areas and the utility of ultrasound in establishing
the diagnosis by demonstration of the characteristic filarial
dance sign.
REFERENCES
1. http://www.who.int/mediacentre/factsheets/fs102/en/
2. Alkadhi H, Garzoli E. Calcified filariasis of the breasts. N
Engl J Med 2005; 352(2) : e2.
An Interesting Case of Breast Filariasis 917
3. Lang AP, Luchsinger IS, Rawling EG. Filariasis of the
breast. Arch Pathol Lab Med 1987; 111: 757-9.
4. Lahiri VL. Microfilariae in nipple secretion. Acta Cytol 1975;
19: 154-5.
5. Amaral F, Dreyer G, Figueredo-Silva J, et al. Adult worms
detected by ultrasonography in human bancroftian
filariasis. Am J Trop Med Hyg 1994; 50: 753-7.
6. Dreyer G, Amaral F, Noroes J, Medeiros Z.
Ultrasonographic evidence for stability of adult worm
location in bancroftian filariasis. Trans R Soc Trop Med
Hyg 1994; 88: 558.
7. Seshadri S, Vasanthapuram K, Indrani S, et al.
Ultrasonographic diagnosis of subclinical filariasis. J
Ultrasound Med 1997; 16: 45-9.
8. Friedman PD, Kalisher L. Filariasis. Radiology 2002;
222: 515-17.
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