|Year : 2015 | Volume
| Issue : 4 | Page : 499-501
Incidental detection of filarial worm in metastatic axillary lymph node from ductal carcinoma breast
Ranjan Agrawal, Parbodh Kumar
Department of Pathology, Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh, India
|Date of Web Publication||14-Jul-2015|
Department of Pathology, Rohilkhand Medical College Hospital, Pilibhit Bypass Road, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Filariasis is a major disease of the tropics. Frequently, lymphatics of the lower limbs, retroperitoneal tissues, spermatic cord, epididymis, and mammary glands are involved. Simultaneous filariasis along with another underlying disease is rare. We present a rare case of filariasis of the axillary lymph node in a modified radical mastectomy specimen, which also showed metastatic deposits of ductal carcinoma breast. The case is presented due to its rarity.
Keywords: Axillary lymph nodes, breast, ductal carcinoma, filariasis, modified radical mastectomy
|How to cite this article:|
Agrawal R, Kumar P. Incidental detection of filarial worm in metastatic axillary lymph node from ductal carcinoma breast. Med J DY Patil Univ 2015;8:499-501
|How to cite this URL:|
Agrawal R, Kumar P. Incidental detection of filarial worm in metastatic axillary lymph node from ductal carcinoma breast. Med J DY Patil Univ [serial online] 2015 [cited 2019 Dec 9];8:499-501. Available from: http://www.mjdrdypu.org/text.asp?2015/8/4/499/160806
| Introduction|| |
Filariasis is a major health problem of the tropics and subtropics. The disease is endemic all over India with heavy infections reported from Uttar Pradesh, Bihar, Jharkhand, Andhra Pradesh, Orissa, Tamil Nadu, Kerala, and Gujarat.
Filariasis is an important cause of disability, because of its social stigma, psychosocial damage and economic losses. The disease is ranked by the World Health Organization as the second leading cause of permanent and long-term disability, and has been targeted for elimination by 2020. 
| Case Report|| |
A 40-year-old-female patient presented with a painful lump in the left breast along with lymphedema since 6 months. On examination, the lump was present in the upper outer quadrant of the left breast. The lump measured 1.5 cm × 1.0 cm in dimension, was hard, non-tender and was not fixed to the underlying structures. The skin above the lump was edematous and showed signs of inflammation. The patient was operated upon, and the lump with the surrounding tissue was resected. The present specimen received showed two lymph nodes, the larger measured 1 cm in diameter, while the other measured 0.5 cm in diameter. Sections from the larger lymph node showed metastatic deposits of adenocarcinoma [Figure 1], while the smaller one showed reactive hyperplasia with no evidence of metastasis. Outside the capsule of the larger lymph node adult filarial worms were noted in the lymphatics [Figure 2]. There was no tissue eosinophilia around the worm or within the lymph node. The total leucocyte count was 11,200 cells/mm 3 and the differential as P 61 L 30 E 8 M 1 . Extensive search in the peripheral blood smear collected under strict conditions as well as after induction therapy did not reveal any microfilariae. The patient was advised chest radiographs which was non-significant.
|Figure 1: Axillary lymph node showing metastatic deposits of ductal carcinoma (arrows) (H and E, ×100)|
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The history of the patient was significant. She developed a lump measuring 5 cm × 4 cm in dimension in the upper-outer quadrant of the left breast 2 years back. This lump grew in size along with puckering of the overlying skin. Fine-needle aspiration cytology of the lump was reported as colloid carcinoma following which the patient was subjected to modified radical mastectomy 1 year back. Sections from the resected breast tissue showed infiltrating ductal carcinoma-Bloom Richardson grading 8 with metastatic axillary lymphadenopathy.
| Discussion|| |
Lymphatic filariasis is caused by the worms Wuchereria bancrofti, Brugia malayi, and Brugia timori. W. bancrofti accounts for approximately 90% of all global filariasis followed by B. malayi and B. timori. Subcutaneous filariasis is caused by Loa loa (the eye worm), Mansonella streptocerca, and Onchocerca volvulus.
The most frequently involved lymphatics are those of lower limbs, retroperitoneal tissues, spermatic cord, epididymis, and mammary gland. , Filariasis causes a spectrum of diseases, including asymptomatic microfilaraemia, acute lymphangitis, and lymphadenitis, chronic lymphadenitis, edema of limbs and genitalia, and tropical pulmonary eosinophilia.  Microfilariae have been identified cytologically at unusual sites, such as lymph node, nipple secretions, pleural and pericardial fluids, ovarian cyst fluids, thyroid, soft tissue, bone marrow, epididymis, lung, bronchoalveolar fluid, breast, gastric brushings, cervicovaginal smears, and hydrocoele fluid.  They have also been reported in association with various benign and malignant tumors, such as tubercular pleural effusion/lymphadenitis, pregnancy, hemangioma of liver, meningioma, intracranial hemangioblastoma, squamous cell, and undifferentiated carcinoma of the uterine cervix, pharyngeal carcinoma, lymphangiosarcoma, urinary bladder carcinoma, prepucial carcinoma, metastatic carcinoma, melanoma, leukemia and non-Hodgkin's lymphoma. In some cases, it is associated with breast malignancy. ,,,, The presence of microfilariae along with neoplasms is generally regarded as a chance association, yet some authors suggest that such parasitic infestations may be a causative factor for tumourigenesis. 
Individuals infected by filarial worms may be described as either "microfilaremic" or "amicrofilaremic", depending on whether or not microfilariae can be found in their peripheral blood. Filariasis is diagnosed in microfilaremic cases primarily through direct observation of microfilariae in the peripheral blood. Occult filariasis is diagnosed in amicrofilaremic cases based on clinical observations or circulating antigens in the blood. Despite the high incidence of filariasis, microfilaria is not a very common finding.
In India, Asian countries and china they show nocturnal periodicity due to night biting habits of the vector, culex fatigans mosquito and sleeping habits of the host.  Man is the definitive host. Female mosquito is the intermediate host. Development or multplication of microfilaria never occurs in human blood.  Adult worms usually stay in one tissue and release early larval forms known as microfilariae into the host's bloodstream, which can be taken up with a blood meal by the arthropod vector where they develop into infective larvae ready to be transmitted to a new host. Few months after maturation they develop into white, thread-like adult worms and survive for several (10-18) years in the lymph nodes.
The laboratory tests to diagnose microfilariae include-demonstration in the peripheral blood; immuno chromatographic test; quantitative buffy coat; ultrasonography and lymphoscintigraphy. Histopathology can confirm the diagnosis by finding of an eosinophilic granulomatous reaction around the filarial parasites, which are in varying stages of degeneration. Some parasites can remain in the human body for varying periods of time without invoking any adverse host inflammatory response. The factors responsible for the initiation of host reaction are not known until now. Therefore, adult worms and microfilaria should be sought in all unexplained granulomas.
DEC is the drug of choice as it is effective against the adult worm and microfilaria. The other drug used is ivernectin in a single dose of 200-400 microgram per kg body weight. ,
| Conclusion|| |
Microfilariae at the site of the primary malignant tumor have been reported, but their coexistence with metastatic deposits has not been reported so far. Association of microfilariae with debilitating conditions suggests that it is an opportunistic infection and needs further study. In the present case, it is suggested that the presence of microfilariae was an incidental finding and that the patient was harboring subclinical filariasis. Furthermore, this also highlights the importance of screening for parasites even in the absence of clinical symptoms, especially in high endemic areas.
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[Figure 1], [Figure 2]