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BREAST IMAGING Table of Contents   
Year : 2006  |  Volume : 16  |  Issue : 4  |  Page : 915-917
An interesting case of breast filariasis


Sarkar Diagnostic Centre, C-1093, Sector-A, Mahanagar, Lucknow-226006, India

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Date of Submission25-Nov-2006
Date of Acceptance30-Nov-2006
 

Keywords: Breast, Filariasis, Somomammography

How to cite this article:
Upadhyaya V, Upadhyaya D N, Sarkar S. An interesting case of breast filariasis. Indian J Radiol Imaging 2006;16:915-7

How to cite this URL:
Upadhyaya V, Upadhyaya D N, Sarkar S. An interesting case of breast filariasis. Indian J Radiol Imaging [serial online] 2006 [cited 2019 Aug 24];16:915-7. Available from: http://www.ijri.org/text.asp?2006/16/4/915/32383

   Introduction Top


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 Top


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 [Figure - 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 (Figure 2). Within these cysts, vigorously moving clusters of small echogenic structures were seen [Figure - 3],[Figure - 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.


   Discussion Top


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.

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 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 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 Top

1.http://www.who.int/mediacentre/factsheets/fs102/en/  Back to cited text no. 1    
2.Alkadhi H, Garzoli E. Calcified filariasis of the breasts. N Engl J Med 2005; 352(2) : e2.  Back to cited text no. 2    
3.Lang AP, Luchsinger IS, Rawling EG. Filariasis of the breast. Arch Pathol Lab Med 1987; 111: 757-9.  Back to cited text no. 3  [PUBMED]  
4.Lahiri VL. Microfilariae in nipple secretion. Acta Cytol 1975; 19: 154-5.  Back to cited text no. 4  [PUBMED]  
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.  Back to cited text no. 5  [PUBMED]  
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.  Back to cited text no. 6  [PUBMED]  
7.Seshadri S, Vasanthapuram K, Indrani S, et al. Ultrasonographic diagnosis of subclinical filariasis. J Ultrasound Med 1997; 16: 45-9.  Back to cited text no. 7    
8.Friedman PD, Kalisher L. Filariasis. Radiology 2002; 222: 515-17.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]

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Correspondence Address:
V Upadhyaya
Sarkar Diagnostic Centre, C-1093, Sector A, Mahanagar, Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-3026.32383

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    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]

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