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Table of Contents   
CASE REPORT  
Year : 2012  |  Volume : 5  |  Issue : 1  |  Page : 42-43
Orbital dirofilariasis


1 Department of Orbit, Oculoplasty, Reconstructive & Aesthetic Sevices, Medical Research Foundation, Sankara Nethralaya, Chennai, India
2 Department of Uvea and Ophthalmic Pathology (2), Medical Research Foundation, Sankara Nethralaya, Chennai, India
3 Department of Oculoplasty, Klinikum Nordstadt, Hannover, Germany
4 Department of Radiology, VRR Scan, Chennai, India

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Date of Web Publication13-Feb-2012
 

   Abstract 

Dirofilariasis is a zoonotic infestation with nematodes of the Dirofilaria species. Apart from pulmonary and cardiovascular manifestations; periocular, intraocular as well as orbital involvement have been described. Natural hosts to these parasites are domestic and wild carnivores like dogs, raccoons, foxes, and so on. Transmission occurs through a vector, namely Culex, Aedes or Anopheles mosquitoes. Humans can be accidental hosts and represent a dead end for the lifecycle of the worm.
We present the case of a 61-year-old male patient in Tamil Nadu, India, presenting with orbital dirofilariasis, whose computerized tomography characteristics mimicked lymphoproliferative disease.

Keywords: Computerized Tomography, dirofilariasis, orbit

How to cite this article:
Mukherjee B, Biswas J, Varde MA, Noronha V. Orbital dirofilariasis. Ann Trop Med Public Health 2012;5:42-3

How to cite this URL:
Mukherjee B, Biswas J, Varde MA, Noronha V. Orbital dirofilariasis. Ann Trop Med Public Health [serial online] 2012 [cited 2018 May 23];5:42-3. Available from: http://www.atmph.org/text.asp?2012/5/1/42/92880

   Introduction Top


Human beings are rare, accidental, dead-end hosts for the nematode dirofilaria, which may manifest as subcutaneous or retrobulbar nodules. The management involves excision followed by histological confirmation.


   Case Report Top


A 61-year-old Asian Indian male presented to us with a history of swelling above the right eye with drooping of the right upper lid since 15 days. There was no history of pain, trauma or any similar episode in the past. On examination, his best corrected visual acuity was 6/6; N6 in both eyes, extraocular motility was free, full, and painless. The pupils were normally reacting to light. Slit lamp examination revealed pseudophakia in both eyes, the retinal examination was within normal limits, and both eye intraocular pressures were 10 mmHg. There was a firm palpable mass over the right eye upper lid, which was mobile, not fixed to the skin or deeper structures, causing a mechanical ptosis of 5 mm [Figure 1]a.
Figure 1: a) Clinical picture of patient taken preoperatively showing swelling and mechanical ptosis of the right upper lid, b) Clinical picture of the same patient taken four weeks after excisional biopsy showing slight residual ptosis and complete resolution of the swelling, c) CT scan sagital cut showing a predominantly pre-septally located, ill-defined, soft tissue mass 'hugging' the globe, d) CT scan axial cut showing the same ill-defined soft tissue mass

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A thin sliced CT scan of the orbit showed a diffuse, ill-defined, homogenous, solid pre-septal lesion of the right orbit, enveloping the ocular surface, up to the insertion of the superior rectus / levator palpebrae superioris complex [Figure 1]c, d. An inflammatory or lymphoproliferative etiology was suspected. Routine hematological investigations were within normal limits. The patient was taken up for excisional biopsy of the lesion through a superior lid crease approach.

Intraoperatively, we found a rubbery, firm, well-circumscribed, spherical, grayish-yellow solid mass adherent to the superior orbital rim, which was dissected and removed in toto.

The pathological examination showed a gross specimen, 17 x 11 x 6 mm in size [Figure 2]a. Histological slides showed an abundance of eosinophilic granulocytes and chronic granulomatous inflammation [Figure 2]d. Multiple segments of a nematode with a thick, multilayered cuticle (5 - 15 μm), prominent body musculature, lateral chords, as well as, two internal and multiple external ridges were found. The worm was about 300 μm in diameter [Figure 2]b, c. An expert pathologist in the USA was consulted for further differentiation of the nematode. The findings were consistent with Dirofilaria. Screening of lungs and liver for other sites of infestation yielded negative results.
Figure 2: a) Photograph of the gross specimen with central cut surface facing up, b) Microphotograph of the cut section of the worm (H and E x 100) showing prominent musculature and internal ridges, c) Same section enlarged (H and E x200) showing the external ridges, d) Microphotograph of the surrounding tissue showing chronic granulomatous inflammation with abundance of eosinophilic granulocytes (H and E x 400)

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On his last follow-up visit after two months, the patient showed no signs of recurrence and a well-healing wound. There was mild residual ptosis [Figure 1]b.


   Discussion Top


Dirofilariasis is a very rare cause of orbital mass in India (Nadgir et al., [1] Mahesh et al., [2] Sathyan et al.. [3] ). To date only few cases, mostly of subconjunctival worm infestations, have been reported (Gautam et al.[4] ). The reports of human dirofilariasis in India come especially from the southern parts, namely Kerala (Ittyerah and Mallik [5] ). Our patient is from Tamil Nadu, also a southern Indian state. Dirofilariasis in humans has been well-described in Sri Lanka, so the geographical vicinity might play a role in the distribution of cases in India. Human dirofilariasis has been reported most frequently from southern Italy and Greece, but also in other European countries, as well as in USA and Australia (Pampiglione and Rivasi, [6] ).

The CT features of orbital dirofilariasis have been described by Smitha et al., [7] as a, 'well-defined, peripherally enhancing, heterogeneous, soft tissue lesion'. The differential diagnosis had included orbital abscess, sebaceous cyst, metastasis, and an inflammatory pseudotumor. In a retrospective study on 24 patients with pulmonary dirofilariasis in Brazil, the CT appearance has been described as 'well-circumscribed, solitary nodule, without calcification' (Rodrigues-Silva et al. [8] ).

Our case was unique in its presentation, as it was ill-defined and homogenous, as well as, enveloping the posterior ocular surface on orbital imaging, causing acquired mechanical ptosis.

Dirofilariasis should be considered as a differential diagnosis in orbital mass lesions, in endemic regions, enhancing the need for biopsy, to confirm the diagnosis.


   Acknowledgment Top


The authors would like to thank Dr. Narsing A Rao, Director, A Ray Irvine Ophthalmic Pathology Department Doheny Eye Institute, University of Southern California, Los Angeles, for confirmation of the histopathological diagnosis.

 
   References Top

1.Nadgir S, Tallur SS, Mangoli V, Halesh LH, Krishna BV. Subconjunctival dirofilariasis in India. Southeast Asian J Trop Med Public Health 2001;32:244-6.  Back to cited text no. 1
    
2.Mahesh G, Giridhar A, Biswas J, Saikumar SJ, Bhat A. A case of periocular dirofilariasis masquerading as a lid tumour. Indian J Ophthalmol 2005;53:63-4.  Back to cited text no. 2
    
3.Sathyan P, Manikandan P, Bhaskar M, Padma S, Singh G, Appalaraju B. Subtenons infection by Dirofilaria repens. Indian J Med Microbiol 2006;24:61-2.  Back to cited text no. 3
    
4.Gautam V, Rustagi IM, Singh S, Arora DR. Subconjunctival infection with Dirofilaria repens. Jpn J Infect Dis 2002;55:47-8.  Back to cited text no. 4
    
5.Ittyerah TP, Mallik D. A case of subcutaneous dirofilariasis of the eyelid in the South Indian state of Kerala. Indian J Ophthalmol 2004;52:235-6.  Back to cited text no. 5
    
6.Pampiglione S, Rivasi F. Human dirofilariasis due to Dirofilaria (Nochtiella) repens: An update of world literature from 1995 to 2000. Parassitologia 2000;42:231-54.  Back to cited text no. 6
    
7.Smitha M, Rajendran VR, Devarajan E, Anitha PM. Case report: Orbital dirofilariasis. Indian J Radiol Imaging 2008;18:60-2.  Back to cited text no. 7
  Medknow Journal  
8.Rodrigues-Silva R, Moura H, Dreyer G, Rey L. Human pulmonary dirofilariasis: A review. Rev Inst Med Trop Sao Paulo 1995;37:523-30.  Back to cited text no. 8
    

Top
Correspondence Address:
Bipasha Mukherjee
Medical Research Foundation, Sankara Nethralaya, 18, College Road, Chennai -600 006
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1755-6783.92880

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    Figures

  [Figure 1], [Figure 2]

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