Medical Journal of Dr. D.Y. Patil Vidyapeeth

CASE REPORT
Year
: 2016  |  Volume : 9  |  Issue : 3  |  Page : 382--384

Microfilaria in pleural effusion: An unusual association


Rehena Sarkar, Tapashi Ghosh, Rupali Dey, Jayanta Bikash Dey 
 Department of Microbiology, Bankura Sammilani Medical College and Hospital, Bankura, West Bengal, India

Correspondence Address:
Rupali Dey
Department of Microbiology, Bankura Sammilani Medical College and Hospital, Bankura, West Bengal
India

Abstract

Lymphatic filariasis is a major public health problem in tropical countries and India is endemic for it. However, lymphatic filariasis presenting as pleural effusion is an unusual manifestation and finding microfilaria in pleural effusion without any lung pathology is rare. We report a case of pleural effusion without any underlying lung pathology and normal blood picture. Clinical cure occurred after treatment with diethyl-carbamazepine. Filariasis should be kept in view while considering the differential diagnosis of idiopathic pleural effusion, especially in endemic countries.



How to cite this article:
Sarkar R, Ghosh T, Dey R, Dey JB. Microfilaria in pleural effusion: An unusual association.Med J DY Patil Univ 2016;9:382-384


How to cite this URL:
Sarkar R, Ghosh T, Dey R, Dey JB. Microfilaria in pleural effusion: An unusual association. Med J DY Patil Univ [serial online] 2016 [cited 2019 Dec 14 ];9:382-384
Available from: http://www.mjdrdypu.org/text.asp?2016/9/3/382/182513


Full Text

 Introduction



Lymphatic filariasis is a public health problem in India. The disease is endemic in India with 600 million people in 250 districts are at risk of developing lymphatic filariasis. About 95% of the cases of lymphatic filariasis are caused by infection with Wuchereria bancrofti. [1]

Lymphatic filariasis is characterized by a wide range of clinical presentations from asymptomatic microfilaremia to common clinical manifestations such as acute adeno-lymphangitis, hydrocele, lymphedema, and elephantiasis.

Manifestations of acute filarial disease are fever, adenolymphangitis, funiculitis, or epididymo-orchitis. Hydrocele, lymphedema and elephantiasis, chyluria, and tropical pulmonary eosinophilia are the chronic manifestation.

The adult worms reside in the lymphatics of the human host whereas microfilariae, the larval forms circulate in peripheral blood. [2] Filariasis coexistent with pleural effusion is rare but has been reported on several occasions. [3],[4],[5] To the best of our knowledge, until date, most of the reported cases of pleural effusion associated with microfilaria have some evidence of lung pathology or tropical pulmonary eosinophilia.

 Case Report



A 26-year-old male smoker, resident of southern part of West Bengal, was admitted to a tertiary care hospital with history of 10 days fever, productive cough, and progressively increasing breathlessness with provisional diagnosis of tubercular pleural effusion.

On physical examination, he had reduced chest expansion, stony dull percussion, and reduced breath sounds on the left side. Vital signs were within normal limits.

His hemoglobin was 107 g/L, total lymphocyte count-8.2 × 10 9 /L, with polymorphs-217.4 × 10 9 /L (0.76), lymphocytes-42.9 × 10 9 /L (0.15), eosinophils-22.9 × 10 9 /L (0.08), monocytes-2.8 × 10 9 /L (0.01), platelet-286 × 10 9 /L, and erythrocyte sedimentation rate-18 mm/first hour. His packed cell volume was 0.33, mean cell volume-82 fl, mean corpuscular hemoglobin - 26.8 pg/cell, and mean corpuscular hemoglobin concentration-314 g/L. The chest X-ray showed left-sided pleural effusion [Figure 1]. Sputum examination for acid-fast bacilli on three occasions was negative.{Figure 1}

Pleural fluid aspiration done and pleural fluid was straw colored. Pleural fluid cytology revealed specific gravity-1.018, cell count-5800/cmm with neutrophil 0.3 × 10 9 /L (0.05), lymphocytes-4.6 × 10 9 /L (0.80), mesothelial cells-0.9 × 10 9 /L (0.15), protein-45 g/L, and sugar-3.3 mmol/L. Mesothelial cells showed reactive changes.

Microscopic examination of pleural fluid from centrifuged sediments showed many microfilaria of W. bancrofti with adjacent mesothelial cells, lymphocytes, and few reactive mesothelial cells [Figure 2], [Figure 3]. Microscopic view of microfilaria showed that the tail tip was free of nuclei, and the length and breadth of the cephalic space were equal. These two features distinguish these as microfilaria of W. bancrofti [Figure 4]. No malignant cells and acid-fast bacilli were seen in pleural fluid cytology.{Figure 2}{Figure 3}{Figure 4}

Pleural fluid cytology was reported as primary filarial effusion with reactive mesothelial cells. Peripheral blood was negative for microfilaria after diethyl carbamazepine provocation test.

Culture of the pleural fluid for M. tuberculosis was negative. Adenosine deaminase level in pleural fluid was within normal limit.

The patient was prescribed diethyl-carbamazine (100 mg thrice daily for 3 weeks). He improved clinically, and a repeat chest radiograph showed resolution of pleural effusion. The subsequent hemogram was also normal. In follow-up visit at 3 months, patient was advised repeat chest X-ray, which showed no further recurrence of pleural effusion.

 Discussion



Filariasis is mainly distributed along the sea-coast and banks of big rivers in India. [6] Pleural effusion as a result of filariasis is an uncommon manifestation. Exudative effusion may develop due to lymphangitis resulting from incomplete obstruction of lymphatic channels. It may be chylous in nature as because of occlusion of thoracic duct leading to leakage of chyle. [4] Transudative pleural effusion is very rare. Only one case of tropical pulmonary eosinophilia with bilateral transudative pleural effusion had been reported by Aggarwal et al. [7] Arora et al. reported a case of pleural effusion with microfilaria of W. bancrofti in pleural biopsy, elevated anti-filarial antibodies, and no microfilaria in peripheral blood. [8] Singh et al. reported a case of pleural effusion with microfilaria of W. bancrofti associated with malignancy. [3] Akhtar et al. reported a case of 60-year-old male with Bancroftian filarial effusion along with hoarseness of voice and right axillary lymph node swelling, but the case could not be followed up. [9] Rajender et al. reported a case of pleural effusion with microfilaria of W. bancrofti associated with the same finding in nocturnal peripheral blood. [10]

So, from all the above-reported cases, we can conclude that majority of the pleural effusion with microfilaria were associated with lung pathology or tropical pulmonary eosinophilia.

Our case had exudative pleural effusion with microfilaria of W. bancrofti with no microfilaria in peripheral blood and tropical pulmonary eosinophilia. Pleural effusion subsided after treatment with diethyl-carbamazepine without any further recurrence.

To conclude, filarial etiology should be searched in idiopathic pleural effusion after ruling out tuberculosis and malignancies, especially in a resident of the endemic area.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Park K. Textbook of Preventive and Social Medicine. 23 rd ed. Jabalpur: Bhanot; 2015. p. 270.
2Simonsen PE. Filariasis. In: Cook GC, Zumla AI, editors. Manson's Tropical Diseases. 22 nd ed. London: Elsevier; 2009. p. 1477-508.
3Singh SK, Pujani M, Pujani M. Microfilaria in malignant pleural effusion: An unusual association. Indian J Med Microbiol 2010;28:392-4.
4Menon B, Garg A, Kalra H, Sharma R. Microfilarial pleural effusion in a case of tropical pulmonary eosinophilia. Indian J Chest Dis Allied Sci 2008;50:241-3.
5Yelikar BR, Potekar RM, Kumar UM, Patil VS. Filariasis presenting as non resolving pleural effusion. Int J Biol Med Res 2012;3:2284-6.
6Chatterjee KD. Parasitology (Protozoology and Helminthology). 13 th ed. New Delhi: CBS Publisher; 2009. p. 238-9.
7Aggarwal J, Kapila K, Gaur A, Wali JP. Bancroftian filarial pleural effusion. Postgrad Med J 1993;69:869-70.
8Arora VK, Gowrinath K. Pleural effusion due to lymphatic filariasis. Indian J Chest Dis Allied Sci 1994;36:159-61.
9Akhtar S, Gumashta R, Gumashta J. Delayed diagnosis bancroftian filarial pleural effusion. Prog Health Sci 2012;2:207-10.
10Rajender M, Aruna T, Reddy AS, Lokesh G, Raghukanth A, Goli G. A Rare Case Report of Filarial Pleural Effusion. J Chalmeda Anand Rao Inst Med Sci 2014;7:57-60.