Teaching Case

Asymptomatic 57 years old woman who referred a past history of filarial infection.

The patient was a 57 years old woman and had resided previously in an endemic area for filariasis (Africa). The patient referred a past history of filarial infection. At the moment of her visit to hospital she was asymptomatic. Routine screening mammograms of both breasts were obtained (Fig 1, Fig 2).

Filariasis is a major public health problem in tropical countries, with 120 million people carrying the infection. The global prevalence of lymphatic filariasis is currently estimated as 2% [1]. Disease manifestations affect epididymis and spermatic cord, breasts, limbs, pelvic inguinal and epitrochlear lymph nodes and other parts of the body (Fig 3). Filarial granulomas of the breast have been reported on several occasions though the breast is not a frequent site of infection [2]. Lymphatic filariasis, caused by the infection with parasites Wuchereria bancrofti and Brugia malayi, is rarely seen in nonendemic areas. In Spain, this disease is seen in immigrants or travelers from tropical countries. Adult worms live in lymphatic vessels, while their offspring, the microfilariae circulate in the peripheral blood. Microfilariae may appear in tissue fluids due to lymphatic or vascular obstruction and subsequent extravasation, so the finding of filariae in the breast may be explained this way. The acute manifestations usually relate to a painful lump with eritema, which may be confused with other entities, such as Paget´s disease [3]. Later phases of the infection may appear as lymphedema and fibrosis, as a calcified granuloma or as a calcified inactive parasite without an accompanying mass. In many of the reported filarial nodules of the breast, the definitive diagnosis was based on fine needle aspiration cytology or histopathology [2,3,4]. In our opinion, when wormlike calcifications are seen on mammograms of a patient from an endemic area of filariasis, the diagnosis should be suggested [5]. We consider that the previous history of filarial infection and the characteristic calcifications seen on mammograms make the diagnosis of calcified filariasis very likely. There is therefore, no need for histological confirmation, but follow-up mammography may be considered. However, in cases of uncommon clinical manifestations or suspicious calcifications it is necessary to obtain histological correlation of the lesion [3,4].