Pleural Effusion due to Lymphatic Filariasis. V.K. Arora and K. Gowrinath. Department of Tuberculosis and Chest Diseases, Jawaharlal Institute of Postgraduate ...
Case Report
Pleural Effusion due to Lymphatic Filariasis V.K. Arora and K. Gowrinath Department of Tuberculosis and Chest Diseases, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicheny
A case of pleural effusion is reported. Pleural biopsy showed microfilariae on histopathological examination. Treatment with diethyl carbamazine yielded excellent results. Filarial aetiology should be included in the differential diagnosis of idiopathic pleural effusions, especially in endemic areas.
[Indian J Chest Dis Allied Sci, 36, 3, 1994; pp 159-161]
The major clinical presentations of filariasis include fever, asymptomatic microfilariaemia, lymphatic obstruction and tropical pulmonary eosinophilia1. Acute manifestations are usually fever, adenolymphangitis, funiculitis, epididymitis or orchitis. Lymphoedema, hydrocele, elephantiasis, chyluria are the features of chronic filariasis. Pleural effusion as the sole manifestation of lymphatic filariasis (Wuchereria Bancrofti) has not been reported so far2. Case Report
A 60-year-old illiterate female with malaise, vague abdominal symptoms since 7 months and dry cough with low grade intermittent fever was referred to us by a primary health doctor who had treated her with INH + ethambutol for 9 months one year back, for similar complaints and again with antibiotics now. The patient had irregular bowel movements two months ago. She was married and attained menopause 13 years ago. All other members of the family were reported to be healthy. General examination was unremarkable. Chest examination revealed signs of effusion of left side. Other systems were normal. Blood counts were normal except for raised erythrocyte sedimentation rate (52 mmh1) and total eosinophil count of 500/mm3. Mantoux test reading with PPD (1 TU) was 20 x 22 mm. Chest x-ray revealed a moderate effusion on left side. Diagnostic pleurocentesis showed straw coloured fluid. Cytological examination showed lymphocytes and a few mesothelial cells. Culture for pathogenic organisms and tubercle bacilli was negative. The pleural biopsy showed presence of microfilariae suggestive of Wuchereria Bancrofti (Fig. 1). Peripheral blood smear was negative for microfilariae on three occasions. Serum showed elevated titre of antifilarial antibodies (1 : 262). Correspondence : Dr V.K. Arora, Director-Professor, Department of Tuberculosis and Chest Diseases, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry-605 006.
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Pleura/ effusion due to lymphatic filariasis
Fig. 1. Microphotograph showing microfilariae surrounded predominantly by lymphocytes (H & Ex 400).
The patient was treated with diethyl carbamazine citrate (DEC) in the dose of 6 mg/kg body weight for 12 days orally in divided doses after food, as recommended by WHO3. Repeat skiagram chest showed disappearance of pleural effusion on the subsequent visit. Follow up after 6 months did not show any recurrence of pleural effusion. Discussion Filariasis is a major public health problem in India. Wuchereria Bancrofti is the most widespread of the filarial organisms infecting man. The parasite is endemic in both urban and rural areas of India. It has been estimated that 374 million persons are living in endemic areas and 45 million are infected in India3. Diagnosis of filariasis is made on demonstrating microfilariae in the blood samples and body fluids, Adult parasites can be demonstrated only at autopsy. The host's immune response directed against the parasite lying in different lymphatic vessels appears to be the major factor in determining the clinical presentation. However, whether the immune response is due to the embryos, adult worm of larval antigens is not known4. Exuadative effusion observed in our patient appears to be due to lymphangitis5 and incomplete obstruction of lymphatics. However, the atypical hypersensitivity reaction which is known to occur in patients4 with lymphatic filariasis cannot be ruled out. At present, there is no substitute for DEC as the drug of choice in filariasis. However, ongoing trials with lvermectin with a single daily dose suggest that it may be an alternative to DEC6.
V.K. Arora and K. Gowrinath
References 1.
CIBA Foundation Symposium on Filariasis, No. 127, Singapore; Wiley, 1987.
2. Seth GP, Mukherjee S. Filarial pleurisy with effusion. Indian J Chest Dis 1969; 9:213-217. 3.
WHO Expert Committee on Filariasis. Lymphatic filariasis. 5th Report, WHO Tech Rep Series 1992; pp 3-45.
4.
Buck AA. Filariasis.. In : Strickland GT, ed Hunter's Tropical Medicine, 7th ed. Philadelphia : WB Saunders Company; 1991 : 713-722.
5.
Greene BM. Filariasis. In : Gorbach SL, Bartlett JG, Blacklow NR ed. Infectious Diseases. Philadelphia : WB Saunders Company; 1992 : 2008-2010.
6.
Kumaraswami V, Ottesen EA, Vijayasekaran V, et al. Ivermectin for the treatment of Wuchereria Bancrofti filariasis. JAMA 1988; 259 : 3150-3153.
