Journal of Cytology
Home About us Ahead of print Instructions Submission Subscribe Advertise Contact e-Alerts Login 
Users Online:460
  Print this page  Email this page Small font sizeDefault font sizeIncrease font size


 
CASE REPORT Table of Contents   
Year : 2009  |  Volume : 26  |  Issue : 4  |  Page : 151-152
Microfilaruria in a patient of intermittent chyluria


Department of Pathology, Kasturba Hospital, Daryaganj, Delhi, India

Click here for correspondence address and email

Date of Web Publication5-Apr-2010
 

   Abstract 

Besides peripheral blood smears, microfilariae have been described in aspirate smears from different sites. Identification of microfilariae in the chylous urine of otherwise asymptomatic filarial patients has been rarely described. One such case is presented.

Keywords: Mirofilaria; urine; chyluria

How to cite this article:
Seth A. Microfilaruria in a patient of intermittent chyluria. J Cytol 2009;26:151-2

How to cite this URL:
Seth A. Microfilaruria in a patient of intermittent chyluria. J Cytol [serial online] 2009 [cited 2020 Mar 30];26:151-2. Available from: http://www.jcytol.org/text.asp?2009/26/4/151/62186



   Introduction Top


Filariasis can have several manifestations, chyluria and tropical pulmonary eosinophilia being the unusual manifestations reported mainly from South Asian countries. Chyluria is a state of chronic lymphourinary reflux via fistulous communications secondary to lymphatic stasis caused by obstruction of the lymphatic flow. Detection of microfilariae in the sediment smears of urine has been described in the cystoscopically catheterized urine [1] but very rarely in the normally voided urine sample, [2] especially the chylous urine.


   Case Report Top


A 25-year-old man from the eastern part of India presented with complaints of passage of white urine intermittently since the last two months. He had no other complaint. His physical examination was within normal limits. On investigations, his hemoglobin was 11 g/dl, total leukocyte count (TLC) of 8600/cmm, and a differential of, polymorphs 70%, lymphocytes 25% and eosinophils 5%. Peripheral blood smears were unremarkable, with no parasites. He was asked to collect the urine sample when it was white. Examination of the urine was performed. Its color was milky-white and it did not clear on heating with 10% acetic acid, but cleared when mixed with equal parts of ether and on being shaken vigorously. Urinary protein was two plus (++) and no sugar was detected. Smears prepared from urinary deposits were fixed in 95% ethanol, stained with hematoxylin and eosin (H and E). The smears showed sheathed motile microfilariae having a uniformly tapering caudal end with no terminal nuclei. Occasional lymphocytes and rare red blood cells were also seen [Figure 1]. A diagnosis of chyluria with Wuchereria bancrofti microfilaruria was made.


   Discussion Top


Filariasis is a global problem. Numerically, the public health problem of lymphatic filariasis is greatest in India, China and Indonesia. These three countries account for approximately two-thirds of the estimated world total of persons infected. In the endemic areas, up to 10% may be afflicted by filariasis. [3] In India, lymphatic filariasis is mainly caused by Wuchereria bancrofti, the vector for which is the mosquito Culex quinquefasciatus (C. fatigans).

Besides peripheral blood smears, microfilariae have been reported in cervicovaginal smears, bronchial washings, ovarian cyst fluid, [2] hydrocele fluid, pericardial fluid, synovial fluid, nipple discharge, bone marrow smears [4] and aspirates from breast, lymph nodes, thyroid, [5] ovary, liver and spleen. [6] Microfilariae (MF) have also been rarely described in routine cytology smears of benign and malignant tumors. [7]

Chyluria occurs only in 2% of filarial afflicted patients in the filarial belt. The adult filarial worm causes lymphangitis, lymphatic hypertension and valvular incompetence. If the obstruction is between the intestinal lacteals and thoracic duct, the resulting cavernous malformation opens into the urinary system forming a lymphourinary fistula. The common sites of the fistula are renal fornix, pelvicalyceal system of the kidney, trigone of the bladder and prostatic urethra. Once such a fistula is formed, intermittent or continuous chyluria occurs. In addition to malnutrition caused by proteinuria, the patient may also present with renal colic due to chylous clots resulting in acute urinary retention, although this is rare.

Milky urine is also produced by urates, which clear on heating or phosphates, which clear on adding 10% acetic acid. Other causes of chyluria may be parasitic (Wuchereria bancrofti, Eustrongylus gigas, Tenia echinococcus, Tenia nana, malarial parasites, Cereonomas hominis) or nonparasitic (congenital lymphangiomas of the urinary tract, tuberculosis, reteroperitioneal abscess and neoplastic infiltration of retroperitional lymphatics, trauma and pregnancy). By far, the most important and the most common cause-effect relationship of chyluria is the one with Wuchereria bancrofti.

The most useful roentgenographic procedure in delineating lymphatic channels in patients of chyluria is lymphangiography, which is diagnostic to visualize the lymphourinary fistula, particularly when surgical intervention is planned. In some studies, radionuclide lymphoscintigraphy has been claimed to be a noninvasive technique in the diagnosis and management of chyluria.

In view of the rarity of detection of microfilariae in the urine as well as blood samples of even overt filariasis patients, serological markers have been developed to detect filarial infection. It is now known that patients with Wuchereria bancrofti infection mount an immune response of immunoglobulin of G4 subclass against Wuchereria bancrofti antigen, Wb-SXP-1. Rao et al.[8] used antibodies specific to the recombinant filarial antigen, Wb-SXP-1, to develop a sandwich enzyme-linked immunosorbent assay (ELISA) for the detection of circulating filarial antigen in sera from patients with lymphatic filariasis caused by Wuchereria bancrofti. This test was found to be 100% sensitive for the Wuchereria bancrofti infection. A similar ELISA that detects filaria-specific immunoglobulin G4 antibodies in unconcentrated urine has been developed by Itoh et al. [9] Similarly, estimation of urinary and serum immune complexes (ICs) are also potential serological markers for both the differential diagnosis of filarial infection and the therapeutic monitoring of MF carriers. In fact, occurrence of filaria-specific ICs in urine and their passage through the filtering structures of the kidney is suggestive of the focal or diffuse damage in those subjects. Detection of ICs in urine may provide a noninvasive means of assessing the extent of renal damage in patients with lymphatic filariasis. [10]

The management of cases of chyluria includes bed rest, high protein diet exclusive of all fats (except medium chain triglycerides, which enter the circulation through the portal system by-passing the thoracic duct), drug treatment (diethycarbamazine) and use of abdominal binders, which is claimed to prevent the lymphourinary reflux by increasing the intra-abdominal pressure. Surgical management is indicated in cases of recurrent clot-colic, retention of urine and progressive weight loss despite conservative treatment, especially in children. The cornerstone of management of chyluria is renal pelvic instillation sclerotherapy. Surgical alternatives include open or laparocopic chylolymphatic disconnection.

 
   References Top

1.Webber CA, Eveland LK. Cytologic detection of Wuchereria bancrofti microfilariae in urine collected during a routine workup for hematuria. Acta Cytol 1982;26:837-40.  Back to cited text no. 1  [PUBMED]    
2.Walter A, Krishnaswami H, Cariappa A. Microfilariae of Wuchereria bancrofti in cytologic smears. Acta Cytol 1983;27:432-6.  Back to cited text no. 2  [PUBMED]    
3.Diamond E, Schapira HE. Chyluria-a review of the literature. Urology 1985;26:427-31.   Back to cited text no. 3  [PUBMED]    
4.Sharma S, Rawat A, Chowhan A. Microfilariae in bone marrow aspiration smears, correlation with marrow hypoplasia: a report of six cases. Indian J Pathol Microbiol 2006;49:566-8.  Back to cited text no. 4  [PUBMED]    
5.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. 5  [PUBMED]    
6.Bhaskaran CS, Rao KV, Prasantha-Murthy D. Microfilarial granuloma of the spleen. Indian J Pathol Microbiol. 1975;18:80-3.  Back to cited text no. 6  [PUBMED]    
7.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. 7  [PUBMED]  [FULLTEXT]  
8.Rao KV, Eswaran M, Ravi V, Gnanasekhar B, Narayanan RB, Kaliraj P, et al. The Wuchereria bancrofti orthologue of brugia malayi SXP1 and the diagnosis of bancroftian filariasis. Mol Biochem Parasitol 2000;107:71-80.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]  
9.Itoh M, Weerasooriya MV, Qiu G, Gunawardena NK, Anantaphruti MT, Tesana S, et al. Sensitive and specific enzyme-linked immunosorbent assay for the diagnosis of Wuchereria bancrofti infection in urine samples. Am J Trop Med Hyg 2001;65:362-5.  Back to cited text no. 9  [PUBMED]  [FULLTEXT]  
10.Dixit V, Subhadra AV, Bisen PS, Harinath BC, Prasad GB. Antigen-specific immune complexes in urine of patients with lymphatic filariasis. J Clin Lab Anal 2007;21:46-8.  Back to cited text no. 10  [PUBMED]  [FULLTEXT]  

Top
Correspondence Address:
Ankit Seth
80, Thomson Road, New Delhi
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9371.62186

Rights and Permissions


    Figures

  [Figure 1]

This article has been cited by
1 HIFU, a noninvasive and effective treatment for chyluria: 15years of experience
Juhua Xiao,Ting Sun,Shouhua Zhang,Ming Ma,Xiaorong Yang,Jinshui Zhou,Jianfang Zhu,Fang Wang
Surgical Endoscopy. 2018; 32(7): 3064
[Pubmed] | [DOI]
2 Quiz: A middle-aged lady with intermittent turbid urine
HY Chan,F Ng,VWT Ho
Hong Kong Journal of Emergency Medicine. 2015; 22(5): 328
[Pubmed] | [DOI]
3 Chyluria in Pregnancy-A Decade of Experience in a Single Tertiary Care Hospital
Khalid Mahmood,Ahsan Ahmad,Kaushal Kumar,mahendra singh,sangeeta pankaj,Kalpana singh
Nephro-Urology Monthly. 2015; 7(2)
[Pubmed] | [DOI]
4 Filarial Chyluria as a Rare Cause of Urinary Retention
Hideharu Hagiya,Tomohiro Terasaka,Kosuke Kimura,Asuka Satou,Kikuko Asano,Koichi Waseda,Yoshihisa Hanayama,Takahide Takahashi,Michinori Aoe,Koji Iio,Toshiyuki Watanabe,Eisei Kondo,Fumio Otsuka
Internal Medicine. 2014; 53(17): 2001
[Pubmed] | [DOI]
5 Microfilaruria in a Patient of Chyluria
Arunansu Talukdar,Nikhil Sonthalia,Sayantan Ray
The American Journal of Tropical Medicine and Hygiene. 2013; 89(5): 817
[Pubmed] | [DOI]
6 Role of fine needle aspiration cytology in diagnosing filarial arm cysts
Tandon, N., Bansal, C., Sharma, R., Irfan, S.
BMJ Case Reports. 2013;
[Pubmed]
7 Microfilaruria with intermittent chyluria in pregnancy: An unusual association
Pujani, M., Agarwal, S., Jain, A.
Indian Journal of Medical Microbiology. 2013; 31(1): 100-101
[Pubmed]
8 A case report of chyluria with proteinuria - Filarial origin? An enigma
Saha, P., Sarkar, S., Sarkar, D., Sengupta, M.
Archives of Clinical Microbiology. 2012; 3(4)
[Pubmed]
9 Microfilaria in a patient of achylous hematuria: A rare finding in urine cytology
Ahuja, A., Das, P., Durgapal, P., Saini, A., Dogra, P., Mathur, S., Iyer, V.K.
Journal of Cytology. 2012; 29(2): 147-148
[Pubmed]
10 Microfilariae of Wuchereria bancrofti in urine: An uncommon finding
Verma, R., Vij, M.
Diagnostic Cytopathology. 2011; 39(11): 847-848
[Pubmed]
11 Microfilariae of Wuchereria bancrofti in urine: An uncommon finding
Ritu Verma,Mukul Vij
Diagnostic Cytopathology. 2011; 39(11): 847
[Pubmed] | [DOI]
12 Microfilaria in cytology smears from upper arm swelling
Pahwa, R., Arora, V.
Journal of Cytology. 2010; 27(4): 155
[Pubmed]



 

Top
 
  Search
 
  
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Email Alert *
    Add to My List *
* Registration required (free)  


    Abstract
    Introduction
    Case Report
    Discussion
    References
    Article Figures

 Article Access Statistics
    Viewed2997    
    Printed215    
    Emailed1    
    PDF Downloaded148    
    Comments [Add]    
    Cited by others 12    

Recommend this journal