| Abstract|| |
Lymphatic filariasis involving the female breast is unusual but not rare, especially where filariasis is endemic. In this report, we present a 38-year-old married woman presenting with a painless mass in the left breast of 4 months duration and slightly painful masses in both axillae for similar duration. Examination revealed a small, discrete, firm, non-tender mass in lower inner quadrant of left breast with associated bilateral, tender axillary lymphadenopathy. Mammography suggested a well-defined mass lesion in the left breast without any architectural distortion or micro calcifications. Ultrasonography (USG) of the breast suggested hypoechoic lesion in infero-medial quadrant of left breast and bilateral axillary lymphadenopathy. USG-guided fine needle aspiration cytology (FNAC) from the breast lump showed non-specific findings like eosinophilic infiltrate and occasional granuloma, while that from the enlarged lymph nodes in the axilla revealed inflammatory cells, giant cells, and epithelioid cells. Histopathological examination of the lumpectomy specimen revealed adult microfilaria with characteristic morphology of Wuchereria bancrofti.
Keywords: Breast lump, filariasis, fine needle aspiration cytology, wuchereria bancrofti
|How to cite this article:|
Bhattacharjee PK, Ray RP, Halder S. Filariasis of breast: An unusual presentation. Ann Trop Med Public Health 2012;5:376-8
| Introduction|| |
Filariasis is endemic in the tropics and in some portions of Africa. In India, it is commonly seen in Orissa, Uttar Pradesh, Bihar, Andhra Pradesh, Tamil Nadu, and Gujarat. The only known definitive host of these filarial parasites is man. Wuchereria bancrofti and Brugia malayi are the nematodes, which are primarily responsible for lymphatic filariasis. They are transmitted to man by the bite of mosquitoes (the intermediate vector), which have bitten an infected host previously.
The lymphatic filariasis, the commonest type of involvement in tropics where filarial is endemic, commonly involves the lower extremities, scrotum, and retroperitoneal tissue and presents as lymphedema, elephantiasis, and hydrocele. A less common manifestation of the infection is tropical pulmonary eosinophilia.
Involvement of the lymphatics of the breasts is much rare by comparison, and patients may present with breast lumps. 
| Case Report|| |
A 38-year-old married woman residing in West Bengal presented with a very slow growing painless mass in her left breast of 4 months duration and slightly painful masses in both axillae for similar duration. There was no history of pain, fever, cough, weight loss, or trauma. Neither was there any history of nipple discharge. There was no family history of breast carcinoma.
Examination revealed a firm, discrete, non-tender, 5 × 2 cm mass with smooth surface in the lower, inner quadrant of left breast. It showed limited mobility within breast tissue and was free from overlying skin and underlying muscle. There were palpable, mobile, and tender axillary lymph nodes on either side. The opposite breast appeared normal. Routine examination of blood showed eosinophilia.
Both mediolateral oblique and craniocaudal mammographic views, done as part of triple assessment, revealed a homogenous radio dense lesion with smooth regular outline in the infero-medial quadrant of left breast without any areas of micro or macro calcifications. The opposite breast appeared normal.
High resolution ultrasonography (USG) of the breast done to further evaluate and characterize the mass and for guiding fine needle aspiration cytology (FNAC) showed a well-circumscribed, oval, hypoechoic lesion with smooth contours at the site of the palpable mass and bilateral axillary lymphadenopathy. FNAC from the breast lump showed clear aspirate with intense eosinophilic infiltrate and occasional granuloma, while that from the enlarged lymph nodes in the axilla revealed inflammatory cells, giant cells, and epithelioid cells.
Lumpectomy was done in view of the indeterminate nature of the mass. Histopathological examination of the specimen revealed eosinophilic and chronic inflammatory infiltrates, section of adult microfilaria with characteristic morphology of Wuchereria bancrofti, its prominent somatic musculature and portion of its intestine, pointing towards the diagnosis of breast filariasis [Figure 1].
|Figure 1: Shows worm with prominent somatic musculature & section of intestine in the back ground of chronic inflammatory reaction; (H and E, ×40)|
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The patient received di-ethyl-carbamazine citrate, in the dose of 6 mg/kg/day for 4 weeks. Following treatment, there was complete resolution of enlarged axillary lymph nodes and peripheral blood eosinophilia.
| Discussion|| |
In lymphatic filariasis, the adult parasites live in the lymphatic vessels whilst their offspring, the microfilariae circulate in the peripheral blood and are available to the mosquito vectors when they feed on the human blood.
To start with, lymphatic filariasis presents with occasional febrile or inflammatory episodes. It is the initiation of the host's inflammatory immune reaction, which is responsible for the symptoms and signs associated with the filarial affliction of breast.  Intact worms produce minimal tissue reaction while degenerating parasites provoke inflammatory cell infiltration- mainly eosinophils and occasionally development of epitheloid granulomas. 1 The involved lymphatic vessels are eventually blocked and replaced by fibrous tissue, and the patient may present with a palpable breast mass i.e. a filarial granuloma. 
Filariasis of breast is occasionally seen in tropical areas where filariasis is endemic and usually presents as a unilateral painless solitary non-tender breast mass, commonly in the upper and outer quadrant.  Sometimes, skin over the nodule may be hyperemic with changes of peau d'orange, and the axillary nodes may be enlarged. 
Some other parasitic infections like cysticercosis, schistosomiasis may also present as lumps in the breast and are often clinically thought to be malignant. 
In this reported patient who presented with breast lump and enlarged axillary lymph nodes, filariasis was never thought of as a diagnostic possibility on clinical examination.
The classical mammographic picture of breast filariasis is those of benign appearing groups of elongated and serpiginous calcification with or without lucent centers, which are located in the connective tissue unrelated to the ducts (distinguishing them from the calcifications of intraductal carcinoma.)  Other parasitic diseases that can cause soft-tissue calcifications include cysticercosis, dracunculosis, and other filarial infections such as onchocerciasis and loiasis.  Our patient did not show any radio opacity on mammography.
Real time USG may sometimes show rigorous movement of the adult worm, an appearance labeled as "filarial dance." 
The presentation of our patient was unusual as she hailed from Bengal (not an endemic area for filariasis), had no history of having visited any known endemic areas recently, and had a deep-seated mass in the lower inner quadrant with none of the classical pictures on imaging. Literature search did not reveal any previous report of breast filariasis from this part of India.
Though it was not the case in this particular patient, Microfilariae may sometimes be detected in fine needle aspirates from the breast lump or lymph node, even though thick peripheral blood smear examination may not reveal them. Therefore, an excision biopsy, as was done in this case, may not always be necessary for the diagnosis of filariasis of the breast. 
Polymerase chain reaction-based immunological blood test for Wuchereria bancrofti can also be a helpful adjunct the diagnostic work-up. 
This case report underlines the fact that even in non-endemic areas, filariasis should be considered as one of the differential diagnosis of breast lumps especially when the presentations are atypical.
| References|| |
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Prosanta Kumar Bhattacharjee
Flat No 5, 4th Floor, "Suryatoran Apartment", 114/A, Barasat Road, Kolkata- 700110, West Bengal
Source of Support: None, Conflict of Interest: None