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Indian Journal of Medical Microbiology, Vol. 28, No. 4, October-December, 2010, pp. 392-394 Case Report Microfilaria in malignant pleural effusion: An unusual association SK Singh1, Mukta Pujani2, Meenu Pujani2 1 Ganesh Diagnostic and Imaging Centre Pvt. Ltd, New Delhi, India Date of Submission: 27-Jun-2009 Code Number: mb10115 PMID: 20966579 Abstract Lymphatic filariasis is common in tropical countries and is endemic in India. Filariasis presenting with pleural effusion is an unusual presentation. Malignancy in association of filarial pleural effusion is extremely rare. We report a case of a 60-year-old female who presented with chest pain, loss of weight and breathlessness for a few months. Pleural fluid examination revealed malignant cells, along with microfilaria of Wuchereria bancrofti.Keywords: Malignancy, microfilaria, pleural effusion, Wuchereria bancrofti Introduction Filariasis is a major health problem in India. Pleural effusion as a presentation of filariasis is unusual. Microfilaria coexistent with malignancy is rare but has been reported on several occasions. [1],[2],[3],[4],[5],[6] To the best of our knowledge, till date only a few cases of adenocarcinoma in association with microfilarial pleural effusion have been reported. [2],[5],[6] Case Report A 60-year-old female resident of Bihar presented with right-sided pleuritic chest pain, progressively increasing dyspnoea, dry cough, generalized malaise and loss of weight for two months. There was no past or family history of tuberculosis. Clinical examination revealed moderate fever, normal pulse rate and blood pressure and signs of right-sided pleural effusion with decrease in vocal resonance, increased vocal fremitus and dull on percussion. There was no organomegaly. Her hemoglobin was 9.3 gms%, TLC-10500/mm 3 , with polymorphs - 59%, lymphocytes - 27%, eosinophils - 9%, monocytes - 5% and ESR - 18 mm at the end of one hour. The Mantoux test was negative and chest X-ray showed right-sided pleural effusion. Sputum examination for AFB on three occasions was negative. Diagnostic USG-guided pleural tap was performed and haemorrhagic fluid obtained. On examination it showed glucose - 65 mg/dl, protein - 3.2 g/dl and LDH - 286 IU/l. Acid-fast bacilli were not detected in the direct smears made from the fluid and the culture for Mycobacterium tuberculosis was negative. Microscopic examination of pleural fluid from centrifuged sediments showed lymphocytes and reactive mesothelial cells, along with small clusters and dispersed tumour cells. These tumour cells had increased nucleocytoplasmic ratio with moderate amount of vacuolated cytoplasm, central to eccentrically placed hyperchromatic, pleomorphic nuclei with coarse chromatin and irregular nuclear membrane. Few bi- and multi-nucleated tumour giant cells and occasional signet ring cells were also seen. Microfilarial forms of W. bancrofti were also seen [Figure - 1]. A diagnosis of metastatic deposits from adenocarcinoma from occult primary along with coexistent microfilaria was made. However, no microfilaria was detected in the buffy coat preparation from nocturnal peripheral blood. Albendazole and diethylcarbazine therapy showed clearance of parasite from the pleural fluid in a week. However, the patient refused further investigation and went home with symptomatic improvement after therapeutic thoracocentesis. Discussion Filariasis is common in tropical countries and is a major public health problem in India. Microfilaria have been identified in samples submitted for cytological examination, such as aspirated material from lymph node, breast lump, cutaneous swellings and also from bone marrow, bronchial aspirate, nipple discharge, ascitic, pleural and pericardial fluid, ovarian cyst fluid and cervicovaginal smears. [2],[3] However, pleural effusion is an uncommon manifestation. Wuchereria bancrofti is the most widespread of filarial organism infecting humans. The usual clinical presentations include fever, asymptomatic microfilariaemia, lymphatic obstruction and tropical pulmonary eosinophilia. The development of pleural effusion is an uncommon manifestation of filariasis and such effusions tend to be chylous in nature due to leakage of chyle from the occluded thoracic duct. Non-chylous effusions caused by microfilariae are rare. Exudative effusion may be due to lymphangitis resulting in incomplete obstruction of lymphatics. Diagnosis of filariasis is made by demonstrating microfilaria in the peripheral blood samples and body fluids. Filariasis is endemic in India and, therefore, the coexistence of filariasis with pleural effusion was thought to be coincidental rather than etiological. Gupta et al. reported six cases where microfilariae were found in body fluid cytology and fine needle aspiration smears in association with tubercular pleural effusion/lymphadenitis, pregnancy, non-Hodgkin's lymphoma, malnutrition and young age. Although the finding of microfilariae in cytologic smears is considered incidental, the association of microfilariae with debilitating conditions suggests that it is an opportunistic infection. [4] In India, the most common cause of pleural effusion is tuberculosis and therefore this was the first diagnosis considered. Malignancy is the commonest cause of haemorrhagic pleural effusion seen with malignancy of lung, breast, lymphoma or as adenocarcinoma from occult primary. [5] Ultrasound or CT-guided thoracocentesis with cytological examination of the fluid aspirated or pleural biopsy improves the cytological yield greatly. Filarial etiology should be considered in the differential diagnosis of idiopathic cases of pleural effusion from endemic (as well as non-endemic) areas. In cases of recurrent effusion, tuberculosis and malignancy should be considered first, but a careful search for microfilaria in centrifuged sediments of pleural fluid may be quite rewarding. References
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