AAMJ, Vol. 8, N. 2, April, 2010, Suppl. ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ BREAST FILARIASIS; DIAGNOSIS AND TREATMENT A REPORT OF (2) CASES Morsy Rateb Genedy Parasitology Department, Faculty of Medicine – Al-Azhar University ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ INTRODUCTION Filariasis has a worldwide distribution with disease prevalence in Africa, Asia including southest Asia, china, India, central and south Americe (3). The filarial worms that parasitize man include Wucheria bancrofit; which causes elephantiasis, and loa loa; which causes calabar swellings. Filariai are transmitted by insect intermediate hosts, which acquire the organism by feeding on the blood of an infected person and taeking in microfilarial larvae (5). These then develop in the thorax of the insect into much larger infective larvae , migrate to the proboscis , and in turn are injected back into the next person on whom the insect feeda. further development takes place, propaply in the lymphatic system , and the adult worms mature , mate and produce eggs which turn into the microfilariae; these develop a cycle of entry into bloodstream and migratie into the tissues. They probably spend part of this time lodged in pulmonary vessels, where they give rise to symptoms and allergic reactions. Parasitic infestations are associated with peripheral cosinphalia. In addition, symptoms may be associated with intestinal malabsorption, blood loss, malnutrition, skin rashes and local hypersensitivity. 109 Morsy Rateb Genedy ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ A REPORT OF TWO CASES The first case : A 22 year old farmer Indian female patient came to surgical outpatient clinic complaining of a mass in the left breast for 6 months duration by papaltion, a small subcuanous nodule of approximately 7mm in the diameter was identified in the areola, the nodule was non tender and firm.There was no nipple discharge and the nipple has no any discharge. By lymph node examination, no any cervical lymphadenopathy. Other medical or physical signs were unremarkable. After surgical consultation, fine needle aspiration (FNA) of the breast nodule was performed using a 23- gauge needle attached to a 10 ml disposable syringe. The aspirate was smeared on a slide, air dried and stained with Giemsa stain. Histopathological examination showed a gravid female adult worm long with numerous MF were sheathed with elongated terminal nuclei and a caudal space at the posterior end. Also there was numerous inflammatory cells in the form of lymphocytes, histocytes and polymorphs. No ductal cells were included in the morphologically consistent with the wuchererid bancrofti was entertained. Blood films were taken at 10 AM and 10 PM, microscopic examination showed positive results to microfilaride, patient received Diethyl car bomazine 3Mg/Kg for 3 weeks. After one month patient was improved. The second case: A 45 years old Bengladishian female patient, her main occupation in Bengladish was a farmer, but she came to kingdom of Saudi Arabia to work as a house servant, by medical history . She has a family history of filariasis and one of her brothers has a history of elephentiasis, she came to Medical outpatient clinic complaining of chest pain since 3 months with swelling in lower qudrant of right breast, vital signs showed: B:P=130/80, pulse= 75/ minute, respiratory rate= 20/m, Temperature: 36 110 AAMJ, Vol. 8, N. 2, April, 2010, Suppl. ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ c, no congested neck veins, chest and heart were clinically free, by breast examination; we palpated a small subcutaneous nodule approximately 11 mm in diameter was identified in the areola . The nodule was non tender and firm, There was no nipple discharge, Lymph node examination showed no any lymphodenopathy , other medical or physical signs were unremarkable. All routine investigations were done included: complete blood picture, urine and stool examination, renal and liver function tests, fasting blood sugur, serum uric acid , brucela ESR, x ray chest (PA) view, E.C.G, Abdominal ultrasonography, and mammography were done . In addition, Blood films were taken, two samples at 10 AM and 10 PM. Results of these laboratory investigations were within normal limits, E.C.G was normal. X- ray chest and Abdominal sonography showed no any abnormal findings, blood films revealed negative results. After surgical consulltation, fine needle aspiration (FNA) of the breast nodule was performed using a 23-gauge needle attached to a 10 ml disposable syringe. The aspirate was smeared on a slide, air dried, and stained with Giemsa stain . Histopathological examination showed a gravid female adult worm with many microfilariae were sheated with elongated terminal nuclei and a caudal space at the posterior end, surrounded by lymphocytes , microphages, histocytes and eosinophils . No ductal cells were included in the aspirate. A diagnosis of microfilaria of the breast morphologically consistent with the wuchereria bancrofti was entertained. Blood films were taken divrenaly and nocturnaly; microscopic examination showed negative results to microfilariae. Patients received treatment for 21 days, after one month breast swellings subsided, chest pain started to disappear, patient still coming to (O.P.D) clinic for follow up. 111 Morsy Rateb Genedy ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ DISCUSSION Bancrofian filariasis has a worldwide distribution, particularly mosquitoes which serve as the intermediate host while taking a blood meal, the insect ingests MF. Over 14 to 21 days, the MF develop within the insect into infective third- stage larvae. They re-enter the definitive human host when the insect feeds again. The larvae mature into adult worm which lives for 10 to15 years and produces MF . Clinically, patients usually come to outpatient clinics or hospitals present with a solitary painless nodule in the upper outer quadrant of the breast in our report, multiple lesions were not present in other cases reported by others, central and periareolar regions were also involved. Filariasis may be diagnosed by demonstration of microfilariae in blood taken at an appropriate time or by detection of filarial antibodies. Treatment is usually by diethylc arbamazine 3mg/kg three times dialy for 3 weeks. This can kills the microfilariae and results in relief of pulmonary symptoms, it may therefor be used as a theraputic trial in patients with appropriate clinical features and travel history. The adult worm may not be eliminated or killed by this treatment, so prevention of infection by elimination of insect vectors and avoidance of bites is particulary important. In developing countries, filarias still a big challenge and dificult problem because of many causes such as poverity ignorance, lack of healthy services, bad housing, delayed diagnosis, expensive prevention programs and high cost management. At the present, two cases, an FNA smear yielded a fragment of gravid female adult worm along with numerous MF. Cytologic diagnosis of filariasis by FNA from 112 AAMJ, Vol. 8, N. 2, April, 2010, Suppl. ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ other sites other than the breast, skin, thyroid gland, lymph nodes, testicles, lung and epididymitis . A review of these cases by kaya and colleagues revealed that, the positivity for the MF in blood exminations in these patients was approximately 12% . Therefore, because of the low yield and stringent sampling, requirement of blood examination (FNA) cytology appears to be more convenient and effective diagnostic method in patient with breast mass lesions. Conclusion Filariasis of the breast, thyroid gland, testis, lymph nodes or lung can be demondtrated and identified by taking a smear or biopsy using (FNA) for proper recognition of the disease and treatment . Most of the designs manifest as subcutaneous hard nodule with cutaneous attachement. More recently, in endemic areas, FNA has been employed to diagnose cases of breast involvement 113 Morsy Rateb Genedy ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ Fine needle aspiration (FNA) showing female adult filarial worm along with discharged numerous coiled form of larvae outside the adult worm (Giemsa stain X100) Fine needle aspirate (FNA) showing Microfilarial larvae which have sheathed, terminal nuclei and a caudal space at the posterior end (Giemsa X400) 114 AAMJ, Vol. 8, N. 2, April, 2010, Suppl. ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ REFERRENCES 1) Walter A , Krishnaswani H , Cariappa microfilariae of wucheria bancrofti in cytology swears acta cytol 1982 ,27:432-6 . 2) Webb JKG ,job CK , Gault EW (1960) Tropical eosinophilia