Lymphadenovarix in the axilla – an unusual presentation of filariasis
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Clinical manifestations of lymphatic filariasis depend on the area of lymphatic involvement and the duration of infection. A 21 year old man, resident in a filariasis endemic region, presented with multiple matted lymph nodes with cystic areas forming a large mass in his left axilla. An ultrasound scan of the axilla using a 7.5 MHz transducer revealed grossly dilated lymphatics but no filarial dance sign. Fine needle (21 G) aspiration cytology (FNAC) from the dilated lymphatics and solid areas in the lymph node mass revealed multiple microfilariae in a background of reactive lymphoid cells. Peripheral blood smears revealed microfilaremia with significant eosinophilia. Diagnosis of left axillary Bancroftian lymphadenovarix was made. On the administration of oral diethylcarbamazine, the diameter of the lymphatic vessels in the lymphadenovarix reduced considerably in size and microfilaremia disappeared. We report this case because axillary lymphadenovarix is a rare presentation of filariasis. This case is also unique since microfilariae were demonstrated in the fluid aspirated from the dilated lymphatics of the lymphadenovarix in the absence of live adult worms.
KeywordsAdult Worm Fine Needle Aspiration Cytology Lymphatic Filariasis Filariasis Fine Needle Aspirate
Lymphatic filariasis is a major health problem in India especially in its southern provinces. A majority of the infected individuals in filariasis endemic communities are asymptomatic. Adult worms in the lymphatics cause progressive lymphatic vascular dilation and dysfunction . Progressive lymphatic dysfunction usually presents as lower limb lymphoedema, hydrocele, chyluria or rarely groin lymphadenovarix . Axillary lymphadenovarix is an extremely uncommon presentation of filariasis even in endemic communities. We thus present a case of filarial lymphadenovarix of the axilla which was successfully treated with diethylcarbamazine.
A chest x-ray was unremarkable. There was no evidence of leucocytosis, eosinophilia or parasites in his venous blood, sampled during the day. Routine and microscopic examination of the urine was within normal limits. Fine needle (21 G) aspiration cytology from the axillary mass revealed a scanty aspirate, smears from which showed features suggestive of reactive lymphoid hyperplasia.
Lymphatic filariasis is a major health problem in India with most infections caused by Wuchereria bancrofti. The presence of adult worms of Wuchereria bancrofti in the infected individuals is confirmed by detecting microfilariae or filarial antigens in the patient's blood . Ultrasound scans (B-mode and M-mode) with or without colour Doppler or pulse wave Doppler have been used to detect living adult W. bancrofti (filarial dance sign) in dilated intrascrotal juxtatesticular lymphatics (worm nests) of approximately 80% of microfilaremic but asymptomatic men residing in endemic areas . In individuals from endemic regions, with no sonologically detectable worms or microfilaremia, the presence of dilated lymphatics in the scrotum has been shown to be due to occult adult worms in those lymphatics . In these individuals treatment with diethylcarbamazine has led to the formation of scrotal nodules, histological examination revealing dead adult worms . Microscopic examination of fine needle aspirates from dilated lymphatics harboring adult worms in symptomatic patients has also revealed microfilariae . Similarly, microscopical examination of lymph node biopsies revealed microfilaria with an adult worm in the same lymphatic vessel in one case . However, to the best of our knowledge there are no reports of fine needle aspirates from dilated lymphatics without detectable adult worms revealing microfilariae on microscopy.
The diagnosis of a filarial infection can also been made by detecting microfilariae on microscopic examination of fine needle aspirates from lymph nodes [7, 8]. Fine needle aspiration cytology from breast mass, thyroid mass, hydrocoele fluid, pericardial fluid, pleural fluid, ascitic fluid, and cytology of cervicovaginal smears, bronchial aspirates, urine, nipple secretion, bone marrow and joint fluid aspirates have also been reported to yield microfilariae [9, 10]. Moreover, in these patients the peripheral smears rarely revealed microfilaremia or eosinophilia [9, 10].
Our case appears unique for a number of reasons. Firstly, filarial lymphangiectasia presenting as a visible lump (lymphadenovarix) in the axilla is rare. Secondly, the ultrasound scan of the lump did not identify any adult worm(s) in the axilla in spite of significant lymphangiectasia. The absence of worms in the lymphatics on the ultrasound does not, however, rule out their presence in the deeper lymphatics of the axilla. Interestingly, the filarial dance sign has not been detected in the axillary lymphatics of asymptomatic amicrofilaremic individuals residing in a filariasis endemic region of South India . Thirdly, ultrasound guided aspiration from the dilated lymphatics in the lymphadenovarix yielded microfilariae indicating the presence of adult gravid female worms in nearby lymphatics. Finally, the diameter of the lymphatic vessels reduced significantly and microfilariae disappeared from the blood following treatment with diethylcarbamazine. The effects of diethylcarbamazine on adult worms has been assessed by the absence of microfilaremia and the filarial dance sign on the scrotal ultrasound . Lymphatic vessel dilation however, is not reported to regress after death of the adult worms  but in this patient a dramatic reduction in the size of the lymphatics was observed following treatment.
In conclusion, although scrotal lymphatics are the preferred location for adult W. bancrofti, axillary lymphatics may also be affected. The host-parasite interaction in these lymphatics may be different from those in the scrotal lymphatics. This may explain the formation of a lymphadenovarix in the axilla and also the dramatic response to diethylcarbamazine in our patient. The authors recommend an ultrasound guided aspiration of fluid from dilated lymphatics of similar lesions in amicrofilaremic patients from filariasis endemic areas.
The authors would like to acknowledge Dr. G. Jayaraman, Department of Radiology, JIPMER for providing them with the ultrasound images.
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