Journal of Cytology
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CASE REPORT  
Year : 2017  |  Volume : 34  |  Issue : 1  |  Page : 66-68
Filarial abscess: Aspiration of adult gravid female worm from submandibular region, an unusual presentation


Department of Pathology, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India

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Date of Web Publication6-Jan-2017
 

   Abstract 

Microfilaria is a major public health problem in tropical and subtropical countries and is an endemic problem in India. Wuchereria bancrofti is the most common filarial infection. In some cases, microfilariae and adult filarial worm have been incidentally detected in fine-needle aspirates of various lesions; detection of microfilaria from subcutaneous site or from abscess site is even rarer. We here report an unusual case of Bancroftian microfilariasis in a 68-year-old female coming from endemic area presenting with right submandibular abscess. Our aim is to highlight the chances of finding microfilaria and adult worm in cytology of an unsuspected case at an unusual site.

Keywords: Adult female worm; filarial abscess; submadibular region

How to cite this article:
Afrose R, Alam MF, Ahmad SS, Naim M. Filarial abscess: Aspiration of adult gravid female worm from submandibular region, an unusual presentation. J Cytol 2017;34:66-8

How to cite this URL:
Afrose R, Alam MF, Ahmad SS, Naim M. Filarial abscess: Aspiration of adult gravid female worm from submandibular region, an unusual presentation. J Cytol [serial online] 2017 [cited 2017 Apr 30];34:66-8. Available from: http://www.jcytol.org/text.asp?2017/34/1/66/197626



   Introduction Top


Lymphatic filariasis is caused by the worms Wuchereria bancrofti, Brugia malayi, and Brugia timori. B. malayi is mostly confined to Southeast Asia. B. timori is restricted to Indonesian islands. In India, almost 99% of the cases are infected with W. bancrofti that is transmitted by the Culex mosquitoes. [1] It has predilection for lower limbs, spermatic cord, and epididymis. [2] Breast, thyroid, body fluids, [3],[4],[5] and skin [6] are unusual sites for filariasis. Despite the fact that large number of people are at risk and wide variety of tissues are affected, it is not common to find microfilariae or adult worm in fine-needle aspiration cytology (FNAC) smears. [4]

Submadibular or head and neck region involvement is an even rarer presentation. [7] Hereby, we report a case of filarial abscess in right submandibular region that is clinically presented as inflammatory pyogenic abscess.


   Case Report Top


A 68-year-old lady presented to surgery outpatient department with swelling and pain in the right submandibular region for the last 2 months. Local examination showed a soft and fluctuant swelling of 4 × 3 cm over right submandibular region. It was warm and tender on palpation. Clinical examination of the orofacial region did not revealed any odontogenic or nonodontogenic foci of infection.

All the hematological parameters were normal except for mild peripheral eosinophilia (12%) and a low hemoglobin level. A clinical diagnosis of submandibular pyogenic abscess was made and to exclude tuberculosis, FNAC was advised.

FNAC from the swelling yielded purulent material along with a creamy white thread. Smears showed adult gravid female filarial worm having an intact outer cuticle layer and body cavity filled with different stages of developing ova and microfilariae [Figure 1]. In addition, numerous embryos and coiled larvae and fully straightened larvae of W. bancrofti that were sheathed and had no nuclei in the tail end were also visualized. The background was composed of inflammatory cells including neutrophils, lymphocytes, macrophages, and eosinophils. Hence, a final diagnosis of filarial abscess was made.
Figure 1: An adult gravid female with sheathed microfilaria of Wuchereria bancrofti.
Note the tail tip is free from nuclei. (Giemsa stain, 400)


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   Discussion Top


In India, W. bancrofti is distributed chiefly along the seacoast and along the banks of big rivers (except Indus). But it has also been reported from Rajasthan, Punjab, Uttar Pradesh, and Delhi. [1] The life cycle of the filarial worms (bancroftian and brugian filariasis) can be divided in to the mosquito phase and human phase. Man is the definitive host and mosquito is the intermediate host. Adult worm resides in lymph node where gravid female worm release a large number of microfilariae. These larva pass through thoracic duct and pulmonary capillaries and ultimately come into the blood stream. Microfilariae are capable of living in the peripheral blood for a considerable time without undergoing any developmental metamorphosis. Subsequently, they are taken up by the female mosquitoes during their blood meal. Further development of microfilariae takes place in its intermediate host (mosquito) after which they become infective to man.

The microfilaria of both W. bancrofti and B. malayi display nocturnal periodicity as a part of the biological adaptation and thus correlating with the nocturnal biting habits of the mosquito. Adult female worms of the two abovementioned species cannot be distinguished though, adult male worms show minor differences. Species diagnosis thereby is made on the basis of morphology of the microfilaria. The microfilaria of W. bancrofti is larger in size and possesses smooth body curve, its body nuclei are more well defined, discrete, round, and uniform in size compared to that of B. malayi, which is smaller in size, possesses secondary kinks and blurred and intermingled nuclei. Tail tapers to a delicate point with absent terminal nucleus in W. bancrofti whereas later it is more bulbous and have two distinct terminal nuclei. [2] However, differentiation between these two nematodes is not clinically important as the mode of treatment remains same.

Filarial worm produces disease due to migration of adult parasite through the lymphatic system. [8] The adult W. bancrofti may involve the lymphatics of the lower limbs, spermatic cord, epididymis, testis, retroperitoneum, and female breast. [8] Its classical presentation are elephantiasis, chronic lymphedema, epididymitis, funiculitis, and lymphadenitis. [8] The diagnosis of filariasis is made either by demonstrating microfilariae, adult worm, or filarial antigen in blood or on ultrasound using B-mode and M-mode scan with or without color Doppler or pulsed wave Doppler by demonstrating filarial dance sign in dilated lymphatics. [9] In our case, radiological investigations were not performed as the patient was presenting as an inflammatory abscess in submandibular region and clinically filariasis was not suspected. Hence, FNAC was done where we found numerous microfilariae along with adult gravid worm. There are many case reports where the diagnosis of filariasis was made by demonstrating microfilariae in cytological smears, it is unusual to find adult filarial worms on aspiration smears. In the present case, the patient had a solitary swelling from which purulent exudates and fragment of adult worm was aspirated. There are a few reports in which adult filarial worms is aspirated from soft-tissue swellings, [8],[10] lymph node, [3],[11] and epididymal nodules. In all these cases, the swelling was painless and the patient was asymptomatic. This case was unusual and similar to the case reported by Kaur et al. [7] where the patient presented with an inflammatory abscess in the submandibular region, which is clinically suspected to be of pyogenic in origin and later on proved as a filarial abscess on FNAC.

[TAG:2]Conclusion [/TAG:2]

The main purpose of this case report is to raise the awareness that in tropical countries such as India where filariasis is endemic, it should always be considered as a differential diagnosis of swelling at any site. Our presentation revealed that adult female worm and microfilaria may even be present at rare sites such as submandibular region. Careful examination of cytological smears is very important in prompt recognition of the disease and institution of specific treatment especially in unsuspected and asymptomatic cases.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Park K. Epidemiology of communicable disease. In: Park K, editor. Textbook of Preventive and Social Medicine. 18 th ed. Jabalpur: Banarsidas Bhanot Publishers; 2005. p. 211-6.  Back to cited text no. 1
    
2.
Chatterjee KD. Phylum nemathelminthes: Class nematoda. In: Chatterjee KD, editor. Parasitology (Protozoology and Helminthology) in Relation to Clinical Medicine. 12 th ed. Kolkata: Chatterjee Medical Publishers; 1980. p. 184-99.  Back to cited text no. 2
    
3.
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. 3
[PUBMED]  Medknow Journal  
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.
Walter A, Krishnaswami H, Cariappa A. Microfilariae of Wuchereria bancrofti in cytologic smears. Acta Cytol 1983;27:432-6.   Back to cited text no. 5
    
6.
Valand AG, Pandya BS, Patil YV, Patil LG. Subcutaneous filariasis: An unusual case report. Indian J Dermatol 2007;52:48-9.   Back to cited text no. 6
  Medknow Journal  
7.
Kaur R, Philip KJ, Laxman KR, Masih K. Filarial abscess in the submandibular region. J Oral Maxillofac Pathol 2013;17:320.  Back to cited text no. 7
[PUBMED]  Medknow Journal  
8.
Kapila K, Verma K. Gravid adult female worms of Wuchereria bancrofti in fine needle aspirates of soft tissue swellings. Report of three cases. Acta Cytol 1989;33:390-2.  Back to cited text no. 8
    
9.
Norões J, Addiss D, Amaral F, Coutinho A, Medeiros Z, Dreyer G. Occurrence of living adult Wuchereria bancrofti in the scrotal area of men with microfilaraemia. Trans R Soc Trop Med Hyg 1996;90:55-6.  Back to cited text no. 9
    
10.
Pandit AA, Shah RK, Shenoy SG. Adult filarial worm in a fine needle aspirate of a soft tissue swelling. Acta Cytol 1997;41:944-6.  Back to cited text no. 10
    
11.
Arora VK, Sen B, Dev G, Bhatia A. Fine needle aspiration identification of the adult worm of Brugia malayi and its ovarian fragment from an epitrochlear lymph node. Acta Cytol 1993;37:437-8.  Back to cited text no. 11
    

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Correspondence Address:
Ruquiya Afrose
Department of Pathology, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh - 202 002, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9371.197626

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