Pankaj Kumar Garg, Shuchi Bhatt, Bineeta Kashyap, Ashish George & Bhupendra Kumar Jain

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J Vector Borne Dis 48, June 2011, pp. 119–121Case ReportsGenital filariasis masquerading as testicular torsionPankaj Kumar Garg1, Shuchi Bhatt2, Bineeta Kashyap3, Ashish George1 & Bhupendra Kumar Jain11Departments of Surgery, 2Radiodiagnosis and 3Microbiology; University College of Medical Sciences and GTB Hospital, University ofDelhi, Delhi, IndiaKey words  Genital filariasis; masquerading; testicular torsion; Wuchereria bancroftiGenital filariasis in India presents commonly as sec-ondary vaginal hydroceles with an associated epididymo-orchitis1. Wuchereria bancrofti is the major species ac-counting for >98% of filarial cases in India. Acute scrotumis rarely seen in genital filariasis. It is usually caused bysecondary bacterial infection of obstructed lymphatic chan-nels2. Presence of linear echogenic structures with persis-tent, random, almost tireless twirling movements on highresolution ultrasonography is considered diagnostic of adultfilarial worms3. Ultrasonography is the only modality avail-able currently to assess the response to antifilarial drugs.We present an unusual case of genital filariasis who pre-sented with acute scrotum.Case report: An 18-year-old male presented with severepain in left scrotum of 6 h duration. He denied any historyof trauma. He was a resident of eastern Uttar Pradesh,India.  On physical examination, there was a tender swell-ing in the left scrotum. Elevation of scrotum provided norelief in pain. There was no palpable inguinal lymphaden-opathy. Clinical diagnosis of acute testicular torsion wasmade. High resolution ultrasonography of scrotum revealedintensely congested testes (left > right). There were mul-tiple anechoic cystic lesions in both the testes (mainly inthe region of rete testes) and epididymis. Multiple elon-gated tubular structures (50–100 microns) could be visu-alized within these cystic lesions (Fig. 1). Peculiar ran-dom movements of these tubular structures were similarto movements demonstrated by microfilariae. Ultrasoundguided aspiration was carried out from one of the cysticlesion in the rete testis. Microscopic examination donewithin 30 min of aspiration, showed multiple microfilariae.Presence of sheath and absence of nuclei from tip-tail ofmicrofilariae confirmed the diagnosis of W. bancrofti (Fig.2). His total leukocyte count was 6600/mm3. Microscopicexamination of urine showed 1–2 pus cells/high powerfields. Patient was prescribed diethycarbamazine (6mg/kg/day) for 14 days and diclofenac sodium (100mg/day in two divided doses) for three days. Though pa-tient was completely asymptomatic after three weeks ofFig. 1: (a) Magnified high resolution grey scale image showing enlarged epididymis tail with evidence of multipledilated anechoic channels; and (b)Transverse section of scrotal sac showing the testes (T) and epididymis (E)in cross-section with associated hydrocele (H). Epididymis is enlarged and demonstrating multiple dilatedchannels. J Vector Borne Dis 48, June 2011 120therapy, however, repeat ultrasonography of scrotum yetrevealed a few motile microfilariae. Thereafter, a singledose of Ivermectin (0.4 mg/kg) was prescribed. Six weeksafter resolution of symptoms, patient’s sperm count was15 millions/mm3.DISCUSSION The filarial infection is prevalent in both the urbanand rural areas. Adult worms are found in the lymphaticvessels and lymph nodes of humans only; there is no ani-mal reservoir3. Adult worms in the lymphatic channelsproduce clinical manifestations of the disease due to lym-phatic dysfunction, obstruction and inflammation. Geni-tal bancroftian filariasis may manifest in several ways in-cluding hydrocoele, lymph varix, lymph scrotum, filarialpenis or elephantiasis of the genitalia and chyluria.Hydrocoele accounts for 90% of the morbidity due to geni-tal filariasis. Acute presentation of genital filariasis is rarelyseen and includes acute funiculitis, orchitis and epididymi-tis2. These acute manifestations are caused by secondarybacterial infection of obstructed lymphatic channels. Sys-temic antibiotics are invariably required for the resolutionof acute genital filariasis.Diagnosis of genital filariasis can be confirmed bydirect demonstration of microfilaria in blood or aspiratedfluid unequivocally. The tools available for the detectionof active infection in an amicrofilaremic patient are circu-lating filarial antigen (CFA) tests and the ultrasound withhigh frequency probe showing filaria dance sign (FDS).The CFA detection tests are now regarded as the ‘goldstandard’ for diagnosing W. bancrofti infections4. Thespecificity of these assays is near complete, and the sensi-tivity is greater than that achievable by the night wet bloodsmears for microfilariae. Two commercial configurationsof this assay are available, one based on enzyme-linkedimmunosorbent assay (ELISA) methodology that yieldssemi-quantitative results, and the other based on a simpleimmunochromatographic card test, yielding only qualita-tive (positive/negative) answers. The FDS represents liv-ing adult worms in their natural habitat (lymphatic ves-sels and lymph nodes) visualized by ultrasonography. Thiswas first described by Amaral and coworkers5 in 1994 as“peculiar, random-appearing movements of objects insidea vessel-like structure”. Various studies have establishedthe role of high-frequency, high-resolution scrotal ultra-sonography for diagnosing scrotal filarial infection insymptomatic patients6.Our case highlights an unusual manifestation of geni-tal filariasis, acute scrotum caused by severe congestionof testis and epididymis by a large number of microfi-laria. Our patient responded to antifilarial drugs and anal-gesics and did not require antibiotics. This is unlike acutephase usually seen in genital filariasis where secondarybacterial infection of obstructed lymphatic channels is thecause of acute clinical manifestations. Suppuration usu-ally takes place if systemic antibiotics are not instituted inthese patients.This case underlines the importance of ultrasound asa diagnostic tool in genital filariasis as it could give us aspecific diagnosis in this patient. Though patient was inacute pain on the left side, peculiar filarial dance sign couldbe better perceived on the right rete testis. Possible rea-sons for this disparity may be manyfolds. The rete testis isa complex anastomosis of seminiferous tubules located inthe mediastinum testis. Their drainage is via several effer-ent ductules which open to form the head of the epididy-mis. In our patient, there were more dilated channels alongwith lesser number of microfilaria on the right side as com-pared to left side. This provided enough room for the mi-crofilarial motility which could be appreciated on USGwith ease.This case also questions the previous reports of fi-larial dance sign being a feature of adult worms. Micro-scopic examination of aspirate from the cystic lesion fromthe region of rete testis in our case, where filarial dancesign was appreciated on high resolution USG, revealedpresence of microfilaria and not adult worm. We feel thatthese microfilariae, which were of the size of 50–100 mi-crons, could be picked up on high resolution USG due toFig. 2: Wuchereria bancrofti microfilaria seen on microscopicexamination of USG guided testicular aspirate (Giemsastained×1000). 121  Garg et al: Genital filariasis and testicular torsiontheir rapid movements within an ideal acoustic mediumand turbulence within the surrounding fluid created by theirmovements. Shyamkumar et al7 presented the same find-ings and stressed renaming of this sign to “microfilarialdance sign” instead of filarial dance sign.This case report highlights an unusual presentation ofgenital filariasis where intense congestion of testis andepididymis with microfilaria resulted in acute scrotummasquerading testicular torsion. High resolution ultra-sonography is an invaluable tool for the diagnosis of geni-tal filariasis and to assess the response of antifilarial drugs.REFERENCES1. Barreto SG, Rodrigues J, Pinto RGW. Filarial granuloma of thetesticular tunic mimicking a testicular neoplasm: a case report.J Med Case Reports 2008; 2: 321.2. Iturregui-Pagán JR, Fortuno RF, Noy MA. Genital manifesta-tion of filariasis. Urology 1976; 8: 207–9.3. Chaubal NG, Pradhan GM, J Chaubal JN, Ramani SK. Danceof live adult filarial worms is a reliable sign of scrotal filarialinfection. J Ultrasound Med 2003; 22: 765–9.4. Weil GJ, Lammie PJ, Weiss N. The ICT filariasis test: a rapidformat antigen test of diagnosis of Bancroftian filariasis.Parasitol Today 1997; 13: 401–4.5. Amaral F, Dreyer G, Figueredo-Silva J, Noroes J, Cavalcanti A,Samico SC, et al. Live adult worms detected by ultrasonogra-phy in human Bancroftian filariasis. Am J Trop Med Hyg 1994;50: 753–7.6. Bhaskar C, Harinath, Reddy MVR. Filariasis in India. J InternatlMed Sci Acad 2000; 13: 8–12.7. Shyamkumar N,  Mehrotra S,  Athyal RP, Taranath A, Nair S,Govil S, Chacko NK. Can we see microfilaria on ultrasound? Areal-time ultrasound and wet smear demonstration of dancingmicrofilaria. The Internet J Urol 2004; 2(1). Available from:http://www.ispub.com/ostia/index.php?xmlFilePath=journals/iju/vol2n1/filaria.xml.Correspondence to: Bhupendra Kumar Jain, Director, Professor and Head, Department of Surgery, University College of Medical Sciences,Guru Teg Bahadur Hospital, Dilshad Garden, Delhi-110 095, India.E-mail: bhupendrakjain@gmail.comReceived: 24 October 2010 Accepted in revised form: 20 May 2011

Genital filariasis masquerading as testicular torsion

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