Microfilariae of Wuchereriabancrofti in Urine:An Uncommon FindingRitu Verma, M.D.* and Mukul Vij, M.D.

Filariasis is a global health problem commonly seen in tropicsand subtropics. Microfilariae has been reported in cytologicalspecimens from various sites but is an unusual finding from sedi-ments of centrifuged normally voided urine samples. This high-lights the presence of adult worms in the lymphatics and thushelping in prompt decision to start antihelminthic treatmentbesides providing surgical treatment for chyluria. Diagn. Cyto-pathol. 2011;39:847–848. ' 2011 Wiley Periodicals, Inc.

Key Words: microfilariae; chyluria; urine cytology

Filariasis is a global health problem commonly seen in

tropics and subtropics. It is caused by three closely related

filarids—Wuchereria bancrofti, Brugia malayi, and Brugiatimori. In India B timori infection does not occur.1 Filaria-

sis has been reported in cytologic smears from thyroid,2

breast,3 lymphnode,4,5 male genital organs,6 soft tissue

swellings,7 bone marrow,8 gynaecologic smears,9 body

fluids,10 and other sites.11,12 Detection of microfilariae in

the sediment smears of urine has been described in the cys-

toscopically catheterized urine13 but very rarely in the nor-

mally voided urine samples especially in the chylous urine.

Case Reports

A 55-year-old female presented with chief complaint of

milky urine for six months and gross painless hematuria

associated with clots for five months. There was no

history of associated fever. The patient underwent ultra-

sonograpghy, intravenous pyelography and contrast-

enhanced computed tomography of the abdomen which

revealed a small simple cyst in the right kidney and spas-

ticity of pelvicalyceal system on left side with enlarged

retroperitoneal lymph node. Patient underwent left ureteric

catheterization three months prior to the admission when

on cystouretheroscopy her bladder was found to be full of

chyle with glue blood clots. She responded partially and

again started having hematuria after one month.

Laboratory investigations showed normal peripheral

leukocytic and eosinophil count. Hemoglobin and platelet

counts were normal. Three consecutive morning samples

of urine were submitted for exfoliative cytology. Grossly

urine was brownish-red. The sediment smears were

stained with May–Grunwald–Giemsa and hematoxylin-

eosin stains. Smears revealed degenerated urothelial cells

along with neutrophils, lympyocytes, red blood cells, and

few microfilariae (Fig. 1). No malignant cells were seen.

The microfilariae were identified as those of W. bancroftiby the presence of structure-less, sac-like hyaline sheath

present throughout the length, a cephalic space and nuclei,

extending from the head and ending abruptly, leaving the

tip of tail free of nuclei, and the pointed terminal end.

Subsequently, the patient was treated with 21 days course

of diethylcarbazine after which she became asymptom-

atic.

Discussion

Chyluria has been described in patients with lymphoma,

carcinoma, trauma, abscess, tuberculosis, filariasis, preg-

nancy, and stenoses of the thoracic duct. However filaria-

sis and congenital malformation of the lymphatic systems

remained the most common causes of the disorder espe-

cially in patients from south east Asia. Chyluria is a

known complication of filariasis, whereas achylous hema-

turia is documented as an occasional finding. Chyluria

usually occurs in *2% of filarial afflicted patients in the

filarial belt. In the life cycle of W bancrofti, adult para-sites are usually localized to the lymphatic system and

microfilaria are seen circulating in the peripheral blood.

During their transport in blood, they can get lodged in

various organs. The adult filarial worm causes lymphangi-

tis, lymphatic hypertension, and valvular incompetence. If

Department of Pathology, Sanjay Gandhi Postgraduate Institute ofMedical Sciences, Raebareli Road, Lucknow, India

*Correspondence to: Ritu Verma, M.D., Department of Pathology,Sanjay Gandhi Postgraduate Institute of Medical Sciences, RaebareliRoad, Lucknow 226014, India. E-mail: dr_rituverma@rediffmail.com

Received 7 July 2010; Accepted 2 September 2010DOI 10.1002/dc.21562Published online 9 February 2011 in Wiley Online Library

(wileyonlinelibrary.com).

' 2011 WILEY PERIODICALS, INC. Diagnostic Cytopathology, Vol 39, No 11 847

the obstruction is between the intestinal lacteals and tho-

racic duct, the resulting cavernous malformation opens

into the urinary system forming a lymphourinary fistula.

Once a fistula is formed intermittent or continuous chylu-

ria occurs.14 Thus shedding of microfilaria in urine is

probably determined by local factors, such as lymphatic

blockage by scars or tumors and damage to vessel walls

by inflammation, trauma or stasis.15

In cases of chyluria where microfilariae are never found,

the adult filariae are presumably dead and possibly calci-

fied, and thus the obstruction of the thoracic duct persists.

In view of rarity of detection of microfilariae in the

urine, serological markers have been developed to detect

filarial infection. The patients have IgG4 antibody against

W. bancrofti antigen Wb-SXP-1. Similarly estimation of

urinary and serum immune complexes are also potential

serological markers for both the differential diagnosis of

filarial infection and the therapeutic monitoring of micro-

filariae carriers. Detection of immune complexes in urine

may provide a noninvasive means of assessing the extent

of renal damage in patients with lymphatic filariasis.16

The management of cases of chyluria includes bed rest,

high protein diet exclusive of fats, diethylcarbamazine

and use of abdominal binders. Surgical management is

indicated in cases of recurrent clot-colic and retention of

urine. The cornerstone of management of chyluria is renal

pelvic instillation sclerotherapy.

Conclusion

Filariasis is common in the south-east Asia but detection of

microfilaria in the urine is rare. Filariasis as a cause of chy-

luria is diagnosed only on the basis of immunological tests

in the absence of cyto-pathological evidence of microfilaria

in urine, blood or lymph nodes. Often, these cases have

dead and calcified adult worms involving the lymphatics.

Presence of microfilaria in the urine is a more direct evi-

dence of filariasis and it suggests the presence of live adult

worms in the lymphatics that requires definite anti filarial

treatment. Though generally a harmless condition in a ma-

jority, chyluria should not be ignored, instead all cases

must be aggressively investigated to arrive at a cause.

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Fig. 1. Microfilaria of W. bancrofti from centrifuged smears of urinepresent on a background of degenerated urothelial cells and lymphocytes.

VERMA AND VIJ

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Diagnostic Cytopathology DOI 10.1002/dc