Breast
Infectious
Filariasis

Editorial Board Member: Gary Tozbikian, M.D.
Andrii Puzyrenko, M.D., Ph.D.
Julie M. Jorns, M.D.

Topic Completed: 8 March 2021

Minor changes: 8 March 2021

Copyright: 2002-2021, PathologyOutlines.com, Inc.

PubMed Search: Filariasis [title] breast

Andrii Puzyrenko, M.D., Ph.D.
Julie M. Jorns, M.D.
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Cite this page: Puzyrenko A, Jorns JM. Filariasis. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/breastfilariasis.html. Accessed August 4th, 2021.
Definition / general
  • Lymphatic filariasis is caused by a chronic mosquito borne parasitic infection that involves the lymphatic vessels and lymph nodes of a human host (Trends Parasitol 2017;33:83)
Essential features
  • Lymphatic filariasis is transmitted by mosquito bite
  • Infection is caused by the migration of filaria larvae into lymph nodes and lymphatic obstruction
Terminology
  • Elephantiasis
  • Bancroftian filariasis
ICD coding
  • ICD-10:
    • B74 - filariasis
      • B74.0 - filariasis due to Wuchereria bancrofti
      • B74.1 - filariasis due to Brugia malayi
      • B74.2 - filariasis due to Brugia timori
  • ICD-11:
    • 1F66 - filariasis
      • 1F66.2 - filariasis due to Brugia species
      • 1F66.3 - lymphatic filariasis
        • 1F66.30 - filariasis due to Wuchereria bancrofti
        • 1F66.31 - filariasis due to Brugia malayi
        • 1F66.32 - filariasis due to Brugia timori
        • 1F66.3Z - lymphatic filariasis, unspecified
Epidemiology
Sites
  • Inguinal (femoral) lymph nodes and lower extremities are most commonly involved (Clin Microbiol Rev 1998;11:366)
  • Can affect arms, breast and genitalia
Pathophysiology
  • Mosquito deposits larvae into the bloodstream, which migrate to host lymph nodes and grow into adult worms
  • Adult females give birth to numerous microfilariae (Asian Pac J Trop Med 2011;4:581)
  • Intact adult worms produce minimal tissue reaction but can cause lymphatic obstruction leading to lymphedema (peau d'orange skin - mimics malignancy)
  • Disrupted lymphatic drainage increases the susceptibility to repeated infections, most commonly streptococcal and fungal infections
  • Acute and chronic inflammation lead to fibrosis, hyperpigmentation and hyperkeratosis (Microcirculation 2013;20:349)
  • Degenerating / dying worms provoke an inflammatory reaction in the tissue, forming a mass with eosinophilic and granulomatous inflammation
Etiology
  • 3 species of nematode parasites cause lymphatic filariasis in humans (Trends Parasitol 2017;33:83):
    • Wuchereria bancrofti is the most common cause of infections worldwide (accounting for > 90% of cases)
    • Brugia malayi and Brugia timori can be the causative organisms in Asia
  • Infection is transmitted by mosquito vectors (Culex, Anopheles, Aedes and Mansonia species)
  • Humans are the definitive host
Diagrams / tables

Images hosted on other servers:
Life cycle of filarial worms

Life cycle of filarial worms

Clinical features
  • Incubation period is variable and can be 8 - 16 months
  • Breast (local) (Asian Pac J Trop Med 2011;4:581)
    • Unilateral, nontender swelling, commonly in the upper outer quadrant
    • May be mobile from quadrant to quadrant and mimic fibroadenoma
    • May be filarial abscess
    • May be associated with enlarged lymph nodes and simulate breast carcinoma
    • Overlying skin has induration, hyperpigmentation, dilated veins
  • Systemic (filariatic fever) (Korean J Parasitol 2008;46:119)
    • Headache, fever, chills and general malaise
Diagnosis
  • Peripheral blood smear (preferably taken after 8 p.m. and stained with either Giemsa or H&E stain) (Asian Pac J Trop Med 2011;4:581)
  • PCR (detection parasite antigen)
  • Serologic enzyme immunoassay test (detection of antifilarial IgG1 and IgG4)
  • Imaging with CT, MRI and ultrasonography (Filaria J 2003;2:3)
  • Histologic evaluation of surgically removed tissue
Laboratory
Radiology description
  • Real time ultrasound may show the movement of echogenic particles ("filarial dance") (Filaria J 2003;2:3)
Radiology images

Images hosted on other servers:
Unusual groupings of benign appearing calcifications

Unusual
groupings of
benign appearing
calcifications

Linear, tortuous, noncalcified opacities (right); serpiginous, linear and discontinuous calcifications (calcified worms, left)

Noncalcified opacities (left); calcified worms (right)

Caption

Linear, tortuous,
noncalcified
opacities

Oval shaped isodense lesion (arrow)

Oval shaped isodense lesion (arrow)

Cyst with few linear echogenic foci (arrow)

Cyst with few linear echogenic foci (arrow)

Dilated tubular channels; filarial worm (white arrows)

Dilated tubular
channels; filarial
worm (white arrows)

Prognostic factors
Case reports
Treatment
  • Medical treatments
    • Diethylcarbamazine (DEC) is recommended as potential monotherapy (Trends Parasitol 2017;33:83)
    • Single combined dose of ivermectin, albendazole and DEC resulted in clearance of microfilaria in 96% of affected patients for up to 3 years (currently recommended by the WHO as triple therapy) (Clin Infect Dis 2020;71:e68)
  • Surgical treatment may be an option (J Cutan Med Surg 2018;22:611)
  • Chronic management
    • Skin hygiene, regular washing with soap and water, using compressive bandages, cold / heat therapy, antibiotic and antifungal creams to prevent flares of lymphangitis (PLoS Negl Trop Dis 2015;9:e0004171)
Clinical images

Images hosted on other servers:
Right breast lump with pigmentation

Right breast lump with pigmentation

Lump in the right breast

Lump in the right breast

Resolved infection after DEC therapy

Resolved infection after DEC therapy

Gross description
Microscopic (histologic) description
  • Intact adult filariae in lymph nodes (pathognomonic) (Clin Microbiol Rev 1998;11:366)
  • Dead filariae with surrounding granulomatous inflammation and calcifications
  • Chronic lymphangitis with lymphatic vessel dilatation and fibrosis
  • Eosinophilic lymphadenitis
Microscopic (histologic) images

Contributed by Bobbi Pritt, M.D.
Adult female worm Adult female worm Adult female worm Adult female worm

Adult female worm


AFIP images
Gravid female worm of<br><i>Wucheria bancrofti</i><br>surrounded by fibrosis

Gravid female worm of
Wucheria bancrofti
surrounded by fibrosis

Cytology description
  • Microfilaria may appear as coiled structures with visible nuclei (Diagn Cytopathol 2011;39:8)
  • Fragments of adult worms may be present
Positive stains
  • Filaria are visible on Giemsa stain
Videos
Sample pathology report
  • Left breast, excisional biopsy:
    • Foreign body reaction to larval organisms showing a granulomatous inflammation with longitudinal calcified corpuscles, consistent with filariasis
Differential diagnosis
  • Granulomatous mastitis:
    • Shows well formed granulomas within lobules or adjacent to ducts
    • May show giant cells and chronic inflammation
    • Microabscesses may be present with lipid vacuoles
  • Bacterial or fungal lymphadenitis:
  • Cysticercosis:
    • Caused by larval cysts of the tapeworm Taenia solium
    • Larvae with similar stroma but contain a scolex, hooks and surrounding fluid filled "bladder"
    • Clinically presents with multiple lesions
  • Breast carcinoma:
    • Poorly defined palpable mass or area of thickening
    • Neoplastic epithelial proliferation with variable architecture, including glandular, cribriform, cords, trabeculae, papillae or solid growth
  • Fibroadenoma:
    • Painless, slowly growing, mobile, well defined, palpable mass
    • Calcifications may be present and appear as a cluster
    • Admixed benign glandular and stromal elements
Board review style question #1

A 37 year old woman presents with a nodule in her left breast associated with enlarged axillary lymph nodes. The nodule is surgically removed and shows the image above on review. What histological finding is most specific for lymphatic filariasis of the breast?

  1. Adult worm with eggs in lymph node
  2. Chronic lymphangitis with fibrosis
  3. Eosinophilic lymphadenitis
  4. Granulomatous lymphadenitis with calcifications
  5. Lymphatic vessel dilatation
Board review style answer #1
A. Adult worm with eggs in lymph node

Lymphatic filariasis of the breast due to Wuchereria and Brugia can show chronic lymphangitis with lymphatic vessel dilatation, eosinophilic lymphadenitis and granulomatous inflammation; however, these are not specific for filariasis and can be often seen due to other conditions. A key histologic feature supportive of filariasis is the presence of adult worms in lymph nodes.

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Reference: Filariasis
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