Microfilaria in Malignant Pleural Effusion: An Unusual Presentation

CME INDIA Case Presentation by Dr. Nishith Kumar, MD, FAPSR, Consultant Department of Pulmonary Medicine, OMC, Ranchi.

CME INDIA Case Study

How Presented?

52 years-old-male /Non-smoker who presented with c/o chest discomfort, chest pain and breathlessness of two weeks duration.

Pleural fluid examination

Revealed Exudative Effusion with lymphocytes predominance, Low ADA & normal glucose level.

Cytological examination

Revealed presence of Atypical cells with enlarged pleomorphic nuclei with granular chromatin & moderate to abundant cytoplasm suggestive of Adenocarcinoma.

Microscopy

(Checkout the video. Zoom in to see the Microfilaria of wuchereria bancrofti in pleural fluid wet mount)

What was done?

Patient have been put on 3 weeks course of DEC.
Pleural fluid sample have also been sent for Cell block preparation so that IHC (Immunohistochemistry) can be performed.

Plans

To start anti-cancer therapy after IHC results.
Repeat Pleural fluid examination after 3 weeks to confirm negative microscopy for Microfilaria in Pleural fluid.
Bronchoscopy to rule out Endobronchial obstruction followed by ICD placement followed by Chemical Pleurodesis.

Points to Ponder

I have previously come across two more similar cases (Adenocarcinoma + Microfilaria in Pleural Fluid)
Basically these types of findings certainly provide food for thought whether concomitant Microfilaria + atypical cells in pleural fluid is an unusual incidental finding or causative association?
Lymphatic filariasis is endemic in India. Filaria has a wide spectrum of presentation. Filarial lung involvement is usually in the form of tropical pulmonary eosinophilia with pulmonary infiltrates and peripheral eosinophilia.
Filariasis presenting with pleural effusion is an unusual presentation. Malignancy in association with filarial pleural effusion is extremely rare & there are only few case reports of the same.

Filariasis is a major health problem in India
Filarial lung involvement is usually present in form of tropical pulmonary eosinophilia with pulmonary infiltrates and eosinophilia in peripheral blood.
Filariasis presenting with pleural effusion is an unusual presentation.
It is very rare to find malignancy in association with filarial pleural effusion.
The role of filariasis in such scenarios is not established. As filariasis is endemic in India, the coexistence of filariasis with pleural effusion is more likely to be coincidental rather than aetiological.
It is likely that coexistent debilitating condition lowers the host immunity, leading to manifestations of symptoms secondary to microfilaria infestation or microfilaria maybe an opportunistic in such patients
The rarity of present case is all the more unique due to its association with concomitant Adenocarcinoma.
All cases with filarial effusions should also be worked up to rule out malignancy.

References

Gupta K, Sehgal A, Puri MM, Sidhwa HK. Microfilariae in association with other diseases. A report of six cases. Acta Cytol. 2002;46:776-78
Chaturvedi A, Kumar A. Malignant pleural effusion with filariasis. Journal of The Association of Physicians of India. 2017;65(5):106-07.
Kolte SS, Satarkar RN, Mane PM. Microfilaria concomitant with metastatic deposits of adenocarcinoma in lymph node fine needle aspiration cytology: A chance finding. J Cytol. 2010;27(2):78-80
Chordiya AP, Datar S, Agrawal AK, Gadkari RU, Shrikhande AV. Microfilaria in malignant pleural effusion: An unusual incidental finding or causative association? Int J Res Med Sci. 2015;3(10):2889-991.
Agarwal, Kiran & Chhikara, Aruna. (2019). Case Report Pathology Section Filarial Pleural Effusion with Lymphoma: A Rare Association CASE REPORT. Journal of Clinical and Diagnostic Research. 13. 10.7860/JCDR/2019/38114.12423.