14 December 2017 - Case of the Week #446

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Thanks to Dr. Sajna VM Kutty, Aster MIMS, Kerala (India) for contributing this case. The discussion was edited by Dr. Nat Pernick. To contribute a Case of the Week, first make sure that we are currently accepting cases, then follow the guidelines on our main Case of the Week page.




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Case of the Week #446

Clinical history:
An 8 year old child presented with an enlarged, 2 x 2 cm posterior cervical lymph node with restricted mobility. FNAC was performed.


Histopathology images:



What is your diagnosis?


































Diagnosis:
Granulomatous lymphadenitis with microfilaria



Test question (answer at the end):

Which statement regarding microfilarial infection is true:

A. Infections are associated with exposure to animals.
B. Most patients have nonspecific symptoms.
C. Diagnosis is made by culture.
D. Mosquito control is an important part of treatment.
E. Quarantine is an important component of treatment.

Discussion:

Filariasis is due to infection by threadlike nematodes of the family Filarioidea. It is a major public health problem in India, China, Indonesia, Africa and the Far East. Wuchereria bancrofti accounts for up to 90% of cases. Filarial infection can cause lymphedema of the limbs (elephantiasis), genital disease (hydrocele, chylocele and swelling of the scrotum and penis) and recurrent painful acute attacks (World Health Organization > Lymphatic Filariasis, retrieved 13 December 2017). Most infected people are asymptomatic but virtually all have subclinical lymphatic damage and up to 40% have kidney damage with proteinuria and hematuria.

Diagnosis is typically made by identifying microfilariae in peripheral blood smears. Rarely microfilariae are coincidentally detected in FNAC in association with various inflammatory and neoplastic lesions (J Cytol 2010;27:78, J Cytol 2017;34:43).

Humans are the exclusive host of infection with W. bancrofti. Many infected individuals remain asymptomatic and serve as potential sources of infection. Adult worms lodge in the lymphatics, where females release larvae (microfilaria), which periodically circulate in the blood, and are occasionally ingested by feeding mosquitoes. Microfilaria mature in the mosquitoes before becoming infective and are spread to new humans during mosquito feeding.

Finding microfilaria in cytosmears is rare. Wuchereria bancrofti can be identified by its sheath and multiple, coarse, discrete nuclei extending from head to tail except in the small terminal portion of the caudal end. Treatment consists of multiple doses of albendazole and ivermectin to the entire at risk population, in addition to mosquito control.


Test Question Answer:

D. Mosquito control is an important part of treatment.