Saudi Journal for Health Sciences

ORIGINAL ARTICLE
Year
: 2020  |  Volume : 9  |  Issue : 2  |  Page : 109--113

Cytopathological diagnosis of filariasis by fine-needle aspiration cytology in different body locations: A retrospective study of 5 years in central India


Abhay Vilas Deshmukh, Shubhangi Natthuji Mangam, Pravinkumar Vijaykumar Ghongade, Vitaladevuni Balasubramanyam Shivkumar 
 Department of Pathology, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha, Maharashtra, India

Correspondence Address:
Vitaladevuni Balasubramanyam Shivkumar
Department of Pathology, Mahatma Gandhi Institute of Medical Sciences, Sevagram - 442 102, Wardha, Maharashtra
India

Abstract

Background: Filariasis is one of the common health problems in tropical countries. The parasite causing the disease primarily resides in lymphatic channels or lymph nodes. It can remain viable in these places for decades. The clinical presentation may vary from superficial palpable swelling to pain and erythema. The cytopathological diagnosis of microfilaria on fine-needle aspiration cytology (FNAC) helps in prompt recognition of the disease. Aim: The aim of the study was to analyze the presence of microfilariae (MF) diagnosed on FNAC from different body locations based on clinicopathological data and cytopatholgical features. Methods: It was a retrospective observational study in which cases of MF over last 5 years which were diagnosed on FNAC were analyzed. Results: Of 34069 cases of FNAC and 45623 cases of fluid cytology, 27 cases (0.033%) of filariasis were diagnosed on cytopathology smears. The various sites included the skin and soft tissue (8 cases), lymph node (6 cases), breast (5 cases), pleural fluid (4 cases), scrotal swelling (3 cases), and thyroid gland (1 case). Eosinophilia was found in 18 cases (66.67%). The background showed inflammatory infiltrate in 17 cases (62.96%), while florid reactive mesothelial hyperplasia was seen in 2 cases (7.4%). We found 4 cases (14.81%) of incidental malignancies along with MF (3 breast and 1 pleural fluid). Conclusion: Although rare, filariasis should always be suspected as a differential diagnosis of FNAC in different body location swellings. A careful attitude while screening cytopathological smears helps to diagnose MF even in asymptomatic cases.



How to cite this article:
Deshmukh AV, Mangam SN, Ghongade PV, Shivkumar VB. Cytopathological diagnosis of filariasis by fine-needle aspiration cytology in different body locations: A retrospective study of 5 years in central India.Saudi J Health Sci 2020;9:109-113


How to cite this URL:
Deshmukh AV, Mangam SN, Ghongade PV, Shivkumar VB. Cytopathological diagnosis of filariasis by fine-needle aspiration cytology in different body locations: A retrospective study of 5 years in central India. Saudi J Health Sci [serial online] 2020 [cited 2020 Oct 24 ];9:109-113
Available from: https://www.saudijhealthsci.org/text.asp?2020/9/2/109/292648


Full Text



 Introduction



Filariasis is one of the common parasitic diseases in tropical and subtropical countries in the world.[1] It is also a major health problem in India, usually found in the states of Bihar, Uttar Pradesh, Jharkhand, Kerala, Orissa, Gujarat, and Maharashtra.[1],[2] There are over 553.7 million people at risk of lymphatic filariasis in India itself.[3] The parasite causing the disease primarily resides in lymphatic channels or lymph nodes. It can remain viable in these places for decades. The clinical presentation may vary from superficial palpable swelling to pain and erythema.[4] Microfilariae (MF) are diagnosed with peripheral blood smears conventionally.[3] MF are also found rarely in different body locations such as effusion fluids, aspirates of the breast, thyroid, lymph node, salivary gland, and soft tissue and can be diagnosed on fine-needle aspiration cytology (FNAC) incidentally.[1],[2],[3],[4] There are few studies published in the literature on the diagnosis of MF on FNAC.[2],[5] The present study was conducted to assess the diagnosis of MF diagnosed on FNAC from different body locations along with their clinicopathological and cytopathological features at a rural tertiary care hospital in central India.

 Methods



It was a retrospective observational study conducted in the Department of Pathology at Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha, Maharashtra, a rural tertiary care hospital in central India over a period of 5 years from November 2014 to October 2019. Routinely, informed consent is obtained before performing FNAC or pleural tap from patients/relatives. All the cases of body swelling FNAC and fluid cytology were collected and analyzed retrospectively. During this period, 34,069 cases of FNAC and 45,623 cases of body fluid cytology were done in the cytopathology section. FNAC was done using 22–26 gauge needle and 10 mL syringe under aseptic precautions. The material aspirated was spread on glass slides. Both wet and dry smears were prepared. In case of cystic lesions and body fluids, repeat FNAC was carried out. The fluids were centrifuged in Shandon Cytospin 4 machine at 3000 rpm for 3 min. The final required amount of material 0.1–0.5 ml was spread uniformly on the glass slide attached to the cytofunnel of the machine. Smears fixed in 95% alcohol were stained with Papanicolaou stain, while air-dried smears were stained with Giemsa stain. We found 27 cases of MF in aspirates of different parts of the body and fluids. The slides of these cases were retrieved, and clinicopathological and cytopathological features were reviewed to reaffirm the diagnosis of filariasis.

 Results



Microscopically, of five cases of the breast, two cases showed the presence of MF along with clusters of benign breast epithelial cells of fibroadenoma [Figure 1]a, while three cases were associated with infiltrating duct carcinoma breast [Figure 1]b. The smears from soft tissue showed rare spindle cells in the presence of MF [Figure 1]c. The smears from pleural effusion showed MF in the background of red blood cells, eosinophils, and lymphocytes [Figure 1]d. The aspirate from the axillary lymph node showed the presence of lymphocytes along with fat cells [Figure 1]e, while smears from thyroid showed follicular cells in small clusters [Figure 1]f.{Figure 1}

The incidental finding of MF was found in 27 cases which accounts for 0.033% of all FNACs and body fluid cytology cases done at our Institute. The age of patients ranged from 26 to 68 years, with a mean age of 44.66 years. The most common age group involved in our study was 31–50 years (n = 15; 55.55%).

The disease was more prevalent in males as compared to females (male-to-female ratio of 1.2:1). Skin and soft tissues were the most common sites of involvement (n = 8; 29.62%). The various other sites involved includes the lymph node (n = 6; 22.22%), breast (n = 5, 18.5%), pleural fluid (n = 4; 14.8%), scrotal swelling (n = 3, 11.11%), and thyroid gland (n = 1, 3.7%). The palpable swelling was the most common presentation (85.18%), followed by fever (55.55%), pain (40.74%), erythema (29.62%), and associated complaints like hydrocele (7.4%). We found four cases (14.81%) of malignancy which were associated with filariasis in our study. Of four cases, three cases were associated with infiltrating duct carcinoma breast [Figure 1]b, while one case was associated with adenocarcinoma lung. Eosinophilia was observed in 18 cases (66.66%) on peripheral blood smear examination [Table 1].{Table 1}

The aspiration yielded clear fluid in 13 cases (48.14%), pus-like aspirate in 10 cases (37.03%), and hemorrhagic in 4 cases (14.81%). The cytology smears showed the presence of abundant MF of Wuchereria Bancrofti in both coiled and uncoiled forms. The MF was sheathed with elongated terminal nuclei and a central caudal space at the posterior end. The cytology smears showed the presence of inflammatory cells including lymphocytes, eosinophils, and neutrophils in majority of cases (n = 17, 62.96%) [Figure 1]. 3 cases showed presence of granuloma (11.11%) (two cases from soft tissue and one case from lymph node) while florid reactive mesothelial hyperplasia was observed in 2 pleural fluid cases (7.4%). Of five cases of breast cytology, MF was associated with fibroadenosis in two cases, and duct carcinoma cells in rest three cases [Table 2] [Figure 1]a and [Figure 1]b.{Table 2}

 Discussion



Filariasis is one of the common health problems in tropical countries including India. It is caused by nematodes Brugia malayi, W. bancrofti, Loa loa, Brugia timori, Onchocerca volvulus, Mansonella ozzardi, and Mansonella perstans.[6] The most common species in India includes W. bancrofti (95%) and B. malayi (5%).[3],[4] The parasite causing the disease primarily resides in lymphatic channels or lymph nodes. The other commonly affected organ includes epididymis, spermatic cord, breast, and retroperitoneal tissues.[3] It can remain viable in these places for decades. The clinical presentation may vary from superficial palpable swelling to pain and erythema. The diagnosis of MF on cytology smears is usually incidental.

MF in our study was diagnosed on Giemsa- and Papanicolaou-stained smears. All cases were diagnosed as an incidental finding where none of the case was referred to us with clinical suspicion of MF. The incidental finding of MF was found in 27 cases out of 79,692 which accounts for 0.033% of all FNACs and body fluid cytology cases done at our Institute. Similar findings were documented in the literature by Mitra et al.[1] and Pal et al.[3] Khare et al.[4] documented an incidence of 0.078%, while Subrata Pal et al.[3] found it to be 0.125%. A large number of cases belonged to 31–50 years' age group, with a mean age of 44.66 years (n = 15; 55.55%). Similar findings were observed by Khare et al.[4] Our study showed male preponderance similar to that of Pal et al.[3]

Our study showed incidental finding of MF in the skin and soft tissue as the most common site of involvement (n = 8; 29.62%). Similar findings have been documented by Yenkeshwar et al.[5] (7 cases, 31.81%) in central India. While Mitra et al.[1] found the breast as the most common site of involvement, Pal et al.[3] and Khare et al.[4] found lymph nodes as the most common sites of involvement. The cause for discrepancy in different sites is not properly ascertained, it may be probably related to less number of cases in all documented literature. The palpable swelling was the most common presentation (85.18%) in our study. Our findings are consistent with Andola and Naik[2] (18 cases, 72%), and Yenkeshwar et al.[5] (16 cases, 72.7%), while Pal et al.[3] found it only in 13 cases (59.09%). Eosinophilia is usually associated with the presence of MF in the body. We found eosinophilia in 18 cases (66.66%) on peripheral blood smear examination. Similar findings were documented by Mitra et al.[1] (15 cases, 62.5%) and Yenkeshwar et al.[5] (7 cases, 62.5%) while Andola SK et al.[2] found it in only (4 cases, 16%). Thus, eosinophilia does suggest the presence of MF in the body. The other associated complaint includes hydrocele in 2 cases (7.4%). Khare et al.[4] also reported hydrocele and primary infertility as associated complaints in two cases in their study. The lymphatic vessels of the spermatic cord and scrotal sac perhaps appear to be the principal site of adult W. Bancrofti in men presented with asymptomatic microfilaremia.[1],[7]

The demonstration of MF in soft tissue is rare. We found eight cases in which MF were present in the skin and soft tissues. Similar findings were also reported in the literature.[4],[5],[7],[8],[9] We found six cases of MF in the lymph nodes. Smears showed the presence of MF in the background of reactive lymphocytes and eosinophils which are similar to findings observed by few authors.[3],[4],[5],[7] Three cases from the inguinal scrotal region showed the presence of MF in our study which is the most common site for complications documented in the Indian literature.[9,10] The MF cause blockage of lymphatic vessels of spermatic cord even in asymptomatic filariasis patients,[9] and thus patients usually present with epididymo-orchitis. This is the most common presentation of filariasis in India. Various studies in literature showed the presence of adult filarial worm in testiculoscrotal swelling.[4],[11]

Few authors have described the incidental finding of MF along with malignancy. We found four cases (14.81%) of malignancy which were associated with filariasis in our study. Of four cases, three cases were associated with breast carcinoma, while one case was associated with adenocarcinoma lung. Andola and Naik[2] found 1 case of breast duct carcinoma and 3 cases of adenocarcinoma in 25 patients, while Yenkeshwar et al.[5] found 6 cases of malignancy of 22 cases. The breast is relatively uncommon site for MF.[1],[12],[13] Pal et al.[3] described the incidental finding of gallbladder carcinoma and mucoepidermoid carcinoma parotid gland along with MF in their study. The association of MF along with malignancy is accidental. The probable reason may include the presence of marked increased vascularity in malignancy, leading to increased concentration of MF. These are then released due to the rupture of vessels at the local site.[2],[3] The pathogenesis may be attributed to lymphatic blockage as well as damage to vessel walls by inflammation, stasis, and trauma.[2],[3],[5] Similar to the breast, the thyroid gland is also one of the uncommon sites for the presence of MF. We found a case of incidental finding with the presence of thyroid follicular cells. Similar findings were also observed in the literature.[5],[14],[15],[16]

Our study aspiration yielded clear fluid in 48.14% of the cases. Our findings are consistent with Andola and Naik[2] who found in 64% of the cases, while Mitra et al.[1] found in 255 cases and Yenkeshwar et al.[5] found in 40.9% of the cases. In our study, hemorrhagic aspirate was found in 14.18% of the cases, all of which were pleural fluid cytology, in which one case showed malignancy.

We found the presence of MF of W. Bancrofti in both coiled and uncoiled forms in almost all cases. The MF was sheathed with elongated terminal nuclei and a central caudal space at the posterior end. The cytology smears showed the presence of inflammatory cells including lymphocytes, eosinophils, and neutrophils in majority of cases (n = 17, 62.96%). Similar findings have also been documented by Mitra et al.[1] and Khare et al.[4] in their studies.

All of the patients in our study responded well to the diethylcarbamazine therapy and in case where patients presented with superficial swellings, it reduced on completion of treatment, thus avoiding the surgical management.

 Conclusion



Although rare, filariasis should always be suspected as a differential diagnosis of FNAC in different body location swellings, even in asymptomatic patients. A careful screening attitude should always be developed in cases of FNACs of superficial body swellings, especially in tropical country like India. The prompt identification and specific medical treatment avoids unnecessary surgical interventions in such cases.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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