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Double-trouble: filariasis presenting as monoarticular effusion in an adolescent with Ewing’s sarcoma Parikshaa Gupta1, Gargi Kapatia1, Amal Basnet2, Sanjay Jain2, Aman Sharma2, Arvind Rajwanshi1

Departments of 1Cytology & Gynaecologic Pathology & 2Internal Medicine, PGIMER, Chandigarh, India

Dr Parikshaa Gupta Postgraduate Institute of Medical Education & Research Sector 12, Chandigarh. India. 160012 parikshaa@gmail.com +91 9914204124

Contact Details: 1.  Khare P, Kala P, Jha A, Chauhan N, Chand P. Incidental diagnosis of filariasis in superficial location by FNAC: A retrospective study of 10 years. J Clin Diagn Res.

2014;8:FC05-8. 2. Chatterjee KD. Phylum Nemathelminthes: Class Nematoda. In: Chatterjee KD, editor. Parasitology in relation to clinical medicine. 13. Calcutta: CBS Publishers and

distributors; 1980. pp. 237–238. 3. Shulan A, Rana G, Wilson A, Shulania NK. Incidental diagnosis of Filariasis in an aspirate from a knee joint in a tertiary care hospital – An unusual case report.,

JIPBS. 2016;3:78-79. 4. Dreyer G, Dreyer P, Piessens WF. Extralymphatic disease due to bancroftian filariasis. Braz J Med Biol Res. 1999;32:1467-1472.

References

•  An 18-year-old male presented with high-grade fever, pain and swelling in left knee joint and significant weight loss since 3 months.

•  The pain was subacute in onset, moderate to severe in intensity and interfering with ambulation.

•  A month later, he developed pain in right knee joint, bilateral ankle joints and small joints of feet; there was no swelling.

•  There were no skin lesions or significant lymphadenopathy.

Clinical Presentation

•  Hemogram revealed bicytopenia. •  Rheumatoid factor was within normal limits •  Lactate dehydrogenase levels were raised. •  Radiographs: showed an irregular, permeative, lytic lesion in the lower meta-

diaphysis of femur without any periosteal reaction (Figure 1) •  MRI: the lesion was found to be iso to hypointense on T1W and hyperintense on

T2W images •  Core needle biopsy from this lesion revealed Ewing’s sarcoma. •  Knee Aspiration: was done in view of the atypical findings. Synovial fluid was sent

for microbial culture and cytologic examination. Cultures were sterile

Investigations

•  Cytological examination from the synovial fluid revealed the presence of many microfilariae along with few polymorphs, lymphocytes and degenerated cells.

•  The microfilariae were ensheathed, having delicate curves with nuclei not extending up to the tail-tip, conforming to the morphology of Wuchereria bancrofti. (Figure 2)

Cytological Findings

•  The present case highlights the importance of synovial fluid cytology in patients who have a knee effusion in the setting of a bone malignancy.

•  Although such effusions can be reactive, it is imperative to consider aspiration whenever there are atypical clinical findings.

•  The finding of microfilariae in synovial fluid is exceedingly rare, as the parasite is known to home mainly in lymphatics, spermatic cord and epididymis while breast, thyroid, body fluids and skin are unusual sites.

•  Articular filariasis is an uncommon but treatable condition; diethlycarbazine is the drug of choice.

•  A high index of suspicion needs to be maintained, especially in patients from endemic areas

Discussion

•  Maintain a high index of suspicion of filariasis in patients from endemic areas; filariasis can co-exist with other pathologies and may be overlooked.

•  Synovial fluid examination is a must in patients with atypical joint effusions.

Take Home Message

Figure 1: AP radiographs of both knees, showing an irregular, permeative, lytic lesion in the lower meta-diaphysis of left femur without any periosteal reaction.

Figure 2: a) SurePathTM preparation showing ensheathed microfilaria with few neutrophils and lymphocytes in the background (Papanicolaou, 20x); b) Sediment smear showing similar microfilariae (MGG, 10X); c & d)  SurePathTM preparation showing ensheathed microfilariae with the nuclei not reaching up to the tip of the tail (Papanicolaou, 40x)