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A 60 year old woman with axillary mass

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Q1: What is the diagnosis?

The slide (fig 1, see p 510) shows a microfilaria ofWuchereria bancrofti present within the lymph node, which was subjected to fine needle aspiration cytology. The microfilariae (embryos) usually found in the blood of the infected patient are sheathed, transparent bodies measuring about 290 μm in length and 6–7 μm in breadth. The microfilariae are surrounded by a hyaline sheath and have a central column of nuclei. The nuclei do not extend up to the tail in W bancrofti and serve as a distinguishing feature of the species. Hence the diagnosis is filarial lymphadenitis.

Q2: How will you treat this patient?

The treatment of lymphatic filariasis is currently limited to diethylcarbamazine administered in a daily dose of 6 mg/kg given in either single or three divided doses for 2–3 weeks. The drug exerts no direct lethal action on the microfilariae but modifies them so that they are engulfed by the phagocytes of the endothelial system and thereby removed from circulation. Ivermectin, a drug effective in the treatment of onchocerciasis has been used for lymphatic filariasis. However, currently available evidence is against its use in lymphatic filariasis, where the treatment of choice continues to be diethylcarbamazine. Treatment of chronic lymphatic obstruction is difficult. Elevation of the affected limb, use of elastic stockings, and local foot care are advisable and may be of help. Surgical decompression with nodovenous shunts may provide relief to severely affected limbs. Filarial hydrocele should be drained or managed surgically. Our patient was treated with diethylcarbamazine given in a dose of 100 mg three times a day for three weeks. Her lymphadenopathy and fever subsided within one week of treatment. The patient is currently on follow up and continues to be symptom free.

Q3: What is Weingarten's syndrome?

Weingarten's syndrome or tropical pulmonary eosinophilia is a condition characterised by cough, lassitude, dyspnoea on exertion and asthmatic attacks especially at night, occasionally with haemoptysis. The most striking feature is severe peripheral eosinophilia, which may rise to values as high as 60%. Chest radiography shows disseminated pulmonary mottling in about 20% cases. Lung function tests show a restrictive abnormality in 70% and an obstructive one in 30% of patients. One form presents as axillary lymphadenopathy. Total serum IgE concentrations and antifilarial antibody titres are characteristically raised. Diethylcarbamazine is used in a daily dose of 4–6 mg/kg for 14 days. Relapse may occur in up to 25% of patient and requires retreatment.

Discussion

Filariasis is a morbid condition produced by a nematode (filariae). The adults of both sexes live in the lymphatics, skin, connective tissues or serous membranes, producing live embryos (microfilariae) which find their way into the blood stream and skin where they are capable of living. In the endemic areas, people become infected early in life and develop microfilaraemia. The disease may result in early filariasis or chronic obstructive filariasis. Early filariasis may manifest as filarial fever, filarial lymphadenitis and lymphangitis, filarial funiculitis and epididymitis, filarial orchitis or abscesses. Chronic obstructive filariasis may manifest as lymph gland enlargement, thickened lymphatic trunks, lymph scrotum, hydrocele, chyluria and lymphuria, chylocele, chylous ascites, or chylous diarrhoea. Gradually, chronic filariasis may lead to lymphoedema and the dramatic elephantiasis. Rarely, there may be filarial arthritis, ocular filariasis presenting as unilateral proptosis. Raised intracranial tension1 and psychoneurotic disturbances have been seen. Unusually, haemorrhagic pericardial effusion2 and glomerulonephritis3 have been described. Our patient manifested the disease as lymphadenitis and lymphangitis of the axillary lymph nodes. Filariasis is an unusual cause of axillary lymphadenopathy, more so, manifestingonly as axillary lymphadenopathy. Our patient was started on diethylcarbamazine and her fever and lymph nodes subsided within a week of starting treatment.

Final diagnosis

Axillary lymphadenitis: filarial.

Learning points

  • Filariasis, an endemic disease of the tropics can cause fever, lymphadenitis, funiculitis, epididymitis, orchitis, or abscesses.

  • Chronic obstructive filariasis may manifest as lymphadenopathy, lymph varices, lymph scrotum, hydrocele, chyluria, chylocele, and elephantiasis.

  • Tropical pulmonary eosinophilia may manifest as cough, dyspnoea and asthmatic attacks. Hypereosinophilia is striking and IgE concentrations are characteristically raised.

  • Treatment is with diethylcarbamazine in 6 mg/kg/day in three divided doses.

References

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