Role of Fine Needle Aspiration
Cytology in Diagnosis of Filarial
Infestation
1* 1
Bipin Kumar, M.D., Smriti Karki, M.D., and Sanjay Kumar Yadava, M.B.B.S.2
Filariasis is a tropical disease transmitted by the Culex mosqui-
toes. The diagnosis of it is conventionally made by demonstrat-
ing microlariae in the peripheral blood smear. However;
microlariae and adult larial worm have been incidentally
detected in ne needle aspirates of various lesions in clinically
unsuspected cases. The cases of lariasis diagnosed by ne nee-
dle aspiration cytology (FNAC) were retrieved from the archives
of the Cytopathology laboratory between the periods of January
1998 to February 2009. Both Papanicolaou- and MayGrun-
waldGiemsa-stained smears were available in all the cases. A
total of 26 diagnosed cases of lariasis were found, of which 19
were related to funiculo-epididymitis, four presented with breast
lump, and three cases with lymphadenopathy. Smears revealed
fragments of adult worm in 12 cases including 10 gravid female
worm containing eggs and microlariae and two male adult
worm; whereas in remaining 14 cases only microlariae or eggs
were seen. Unfertilized eggs were seen in three cases and fertil-
ized eggs were seen in ve cases. Tissue response in the form of
eosinophils in 16 cases, acute inammatory exudate in ve
cases, macrophages in 22 cases, epitheloid cell granulomas in
ve cases, giant cells in four cases, lymphocytes in 10 cases,
and plasma cells in three cases were seen. Adherence of poly-
morphonuclear leukocytes, eosinophils, and epithelioid cells
were observed in four cases. On conclusion, laria may affect
the epididymis, spermatic cord, breast, and lymph node, and the
accurate diagnosis can be easily and conveniently achieved by
FNAC without any requirement of biopsy. Diagn. Cytopathol.
2011;39:812. ' 2010 Wiley-Liss, Inc.
Key Words: lariasis; microlariae; gravid female worm; ne
needle aspiration cytology; tissue response
Filariasis is a disease transmitted by the Culex mosquitoes.
The chief sites of infection are lymphatic trunks of the
lower limbs, spermatic cord, epididymis and the pelvic,
1
Department of Pathology, B P Koirala Institute of Health Sciences,
Dharan, Nepal
2
Department of Internal Medicine, B P Koirala Institute of Health
Sciences, Dharan, Nepal
*Correspondence to: Bipin Kumar, M.D., Associate Professor, Depart-
ment of Pathology, B P Koirala Institute of Health Sciences, Dharan,
Nepal. E-mail: bipinkumar31@yahoo.co.in
Received 9 July 2009; Accepted 1 December 2009
DOI 10.1002/dc.21314
Published online 20 January 2010 in Wiley Online Library
(wileyonlinelibrary.com).
8 Diagnostic Cytopathology, Vol 39, No 1
inguinal and epitrochlear lymph nodes. It can rarely affect
lungs, breast, eyeball, thyroid, and body cavities.112 Most
of those infected remain asymptomatic or present with fea-
tures of acute or chronic disease.1,2,8 The diagnosis is usu-
ally made by identifying the microlariae in the peripheral
blood smear.1,2,7,8 However, microlariae and adult larial
worm have been incidentally detected in ne needle aspi-
rates of various lesions in clinically unsuspected cases of
lariasis with absence of microlariae in the peripheral
blood.1,9,12
Methods
The cases of lariasis diagnosed by ne needle aspiration
cytology (FNAC) were retrieved from the archives of the
cytopathology laboratory between the period of January
1998 to February 2009. Free-handed or ultrasound-guided
FNAC was done by using 23G needle and 10 ml dispos-
able plastic syringe. Both Papanicolaou (PAP) and May
GrunwaldGiemsa (MGG)-stained smears were available
in all the cases.
Results
A total of 26 cases of lariasis diagnosed on routine
FNAC from various sites were found. Thirteen cases were
related to epididymitis, out of which two have associated
epididymal cysts; six were related to funiculitis; three
cases were related to lymphadenopathy; and four pre-
sented with breast lump. Out of these 26 cases, only one
case was clinically suspected as larial infestation.
Cytological Findings
Smears revealed fragments of adult worm in 12 cases
including 10 gravid female worm containing eggs and
microlariae, and two adult male worm; whereas in
remaining 14 cases, only microlariae or eggs were seen.
Unfertilized eggs without sheath were seen in three cases
and fertilized eggs having sheath along with microlariae
were seen in ve cases. Microlariae were sheathed, cau-
dal nuclei were absent and number varied from 3 to 500
' 2010 WILEY-LISS, INC.
 Table I. Showing Clinical Details and Cytological Features
Clinical features Cytological features
Age (years)/sex/
S/No address Complaints Dn Local examination Clinical diagnosis Site of FNAC Aspirate mf/AW/egg Associated cytological ndings
1 18/M/Dharan Sw, rt side scr 6d 2c r, dis, up pole, tes Epididymal cyst epidy uidy mf+unf/fer egg Epididymal cells, E, L, Mp
2 28/M/Sunsari Sw, rt side scr 1m 1c, r, dis, spm cor Enc hydr Spm cor hem mf+AW E, Mp, L, P
3 20/M/Dharan Sw, rt side tes 3m 1c, r, beaded, epidy Tb epididymitis epidy hem mf+AW granul, Mp, G, N, E
4 26/M/Dharan Sw, rt side tes 2m 2c r nodule, epidy Tb epididymitis epidy purul mf+AW AIE, granul, Mp, G, gr ti
5 22/M/Jhapa Sw, rt side tes, pn 2m 1c r, tender nodule, epidy Tb epididymitis epidy hem M AW Mp, N, E, L, P
6 30/M/Sunsari Sw, rt side tes, pn 3m 2c r, tender nodule, epidy Paratesticular mass epidy hem mf E, gr ti, N
7 9/F/Dharan Sw lt axilla 2m 2c solitary, r, LN RLN, TbLN Lt ax, LN hem mf N, E, Mp, nec material
8 29/M/Dharan Sw lt side tes 1w 1c cystic, up pole tes Epididymal cyst epidy uidy mf+AW N, Mp, L, gr tis
9 19/M/Sunsari Sw, lt arm, F, C 2y 1c r, mob, Epitr LN RLN Epitr LN uidy mf+unf/fer egg L, germinal centre cells, E
10 22/M/Jhapa Sw b/l tes 2w 1c, Lt r beaded, rt thickened, epidy epididymitis Lt epidy hem mf E, L, Mp, epididymal cells
11 26/M/Bihar Pn lt groin 2m 2c, r, nodular lt spm cor Tb funiculitis Spm cor uidy mf+AW+unf/fer egg Mp, L, P, granul
12 25/M/Dharan Sw lt side tes 3w 1c r, nodule epididymitis epidy hem mf N, E, Mp
13 32/F/Sunsari Lt breast lump 2m 1c r nodule broadenoma breast hem mf Mp, E, N
14 24/M/Sunsari Sw, rt scr 2w 1c, r nodule, spm cor lariasis Spm cor uidy mf N, E, Mp
15 21/M/Dharan Sw, lt scr 2w 1c, r nodule, low pole tes Epidi-orch epidy hem M AW L, Mp, epididymal cells
16 19/M/Dharan Sw, rt side scr 4m 3c, r rt spm cor spermatocele Spm cor uidy mf Mp, E, N
17 23/F/Dharan Lt breast lump 1w 1c r, mobile nodular broadenoma breast wht thr mf Ductal cells
18 40/F/Jhapa Lt breast lump, pn 6m 3c, tender r mastitis breast wht str mf+AW +fer egg N, E, Mp, G, gr tis, granul
19 18/M/Dharan Sw, lt scr 3m 1c, r nodule, spm cor Tb funiculitis Spm cor purul mf+AW AIE, granul, Mp, G, gr ti
20 36/M/Morang Sw, lt tes 2m 1c, pnl nodule, low pole tes Epidi-orch epidy hem mf+fer egg N, Mp, L, E
21 31/M/Sunsari Sw, rt scr 3m 1c, r, mobile, pnl, spm cor funiculitis Spm cor uidy mf L, Mp, E, N
22 28/F/Dharan Sw, rt axilla 4w 2c, dis, rt ax LN TbLN Rt ax LN uidy mf+AW Mp, E, N
23 32/M/Panchathar Sw rt tes, pn, infer 1y 0.8c, r nodule low pol tes Tb epididymitis epidy pur mf+AW AIE, Mp
24 27/F/Dharan Rt breast lump 2w 1c, r, linear nodule broadenoma breast wht thr mf N, E, Mp
25 35/M/Bihar Sw rt scr 3m 1.5c, r, tender nodule Tb epididymitis epidy purul mf AIE, Mp
26 40/M/Sunsari Sw lt scr 4w 1c, r, tender nodule Tb epididymitis epidy purul mf+AW AIE
S/No, serial number; Dn, duration; FNAC, ne needle aspiration cytology; mf, microlaria; A, adult; W, worm; unf, unfertilized; fer, fertilized; M, male; F, female; Sw, swelling; rt, right; lt, left;
scr, scrotum; d, day; w, week; m, month; y, year; c, centimeter in diameter; r, rm; dis, discrete; up, upper; low, lower; tes, testis; epidy, epididymis; E, eosinophils, L, lymphocytes; P, plasma
cell; N, neutrophils; Mp, macrophages; G, giant cells; granul, granuloma; AIE, acute inammatory exudate; gr, granulation; tis, tissue; Spm, spermatic; cor, cord; Epidi-orch, epididymo-orchitis;
Enc, encysted ; Hydr, hydrocele; hem, hemorrhagic; purul, purulent; F, fever; pn, pain; pnl, painless; C, cough; Tb, tuberculosis; ax, axillary; LN, lymph node; RLN, reactive lymphadenopathy;
TbLN, tuberculous lymphadenitis; mob, mobile; Epitr, epitrochlear; nec, necrotic; b/l, bilateral; wht, white; thr, thread; str, strands.

Diagnostic Cytopathology, Vol 39, No 1

FILARIASIS DIAGNOSED BY FNAC

9
Diagnostic Cytopathology DOI 10.1002/dc
Diagnostic Cytopathology DOI 10.1002/dc
KUMAR ET AL.
Table II. Distribution of Cases According to the Place
Dharan Sunsari disrict
Home/District/State (Disrict Sunsari) (other than Dharan)
Number of cases 12 7 3
Table III. Age Distribution of the Cases
Age (years) 0005 0610 1115 1620
Number of cases 0 1 0 5
Fig. 1. Fragment of adult gravid female worm with unfertilized eggs
(Papanicolaou, 310). [Color gure can be viewed in the online issue,
which is available at wileyonlinelibrary.com.]
per slide at various stages of development. These ndings
suggest identifying the species as Wuchereria bancrofti.
Many were curved, coiled and had crisscross arrangement
with other microlariae. Tissue response with the pres-
ence of eosinophils in 16 cases, acute inammatory exu-
date in ve cases, macrophages in 22 cases, epitheloid
cell granulomas in ve cases, giant cells in four cases,
lymphocytes in 10 cases, and plasma cells in three cases
were seen. Adherence of polymorphonuclear leukocytes,
eosinophils, and epithelioid cells were seen in four cases.
The clinical details and cytological ndings are shown in
Tables IIII and Figures 18.
Discussion
Filariasis is a common health problem in South-East
Asia.7,9 India and South-East part of Nepal is endemic
zone for it.6,9 Human beings are the denitive host.2
Wuchereria bancrofti account for more than 90% fol-
lowed by Brugia malayi and Brugia timori.6 Most of the
infection encountered in India and Nepal are by Wuchere-
ria bancrofti.9 This study showed Wuchereria bancrofti
infection in all of the cases. Filarial worm can localize
anywhere in the body but scrotal, inguinal, and abdominal
lymphatics are common sites.1 The microlariae released
10 Diagnostic Cytopathology, Vol 39, No 1
Jhapa Panchthar Morang Bihar
district district district (India)
1 1 2
2125 2630 3135 3640 >40
6 7 4 3 0
Fig. 2. Fragment of adult gravid female worm with coiled and elongated
form of larva (Papanicolaou, 310). [Color gure can be viewed in the
online issue, which is available at wileyonlinelibrary.com.]
and circulate in peripheral blood.7 In endemic area, peo-
ple become infected early in life and develop microlare-
mia, reaching a peak between 15 to 20 years of age.8 The
age ranged between 9 and 40 years in this study and the
peak age was found between 21 and 30 years. Most peo-
ple with microlaremia do not show signs or symptoms
of the disease but remain an important source of infection
in the society.1,8 Few present with acute or chronic dis-
ease.1 Symptomatic lymphatic lariasis has very low
microlaremia and is prone for further reinfection.8 The
diagnosis is conventionally made by demonstrating micro-
lariae in the peripheral blood smear.1,2,7,8 However,
microlaria, adult worm, and eggs have been incidentally
detected in ne needle aspirates of various lesions in clin-
ically unsuspected cases of lariasis.1,8,9,12
Case reports and studies highlighting microlariae and
adult larial worm in cytology smears from various sites
can be found in the English literature.112 In a country
such as Nepal and India, where the incidence of lariasis
is high, nding laria in ne needle aspirate is not so
uncommon and is usually due to larval form of parasite.8
In this study, 26 cases presented as scrotal swelling,
lymphadenopathy, or breast lump. Out of which only one
had fever and other three had pain. Only one case had
 Diagnostic Cytopathology DOI 10.1002/dc
FILARIASIS DIAGNOSED BY FNAC

Fig. 3. Fragment of adult male worm with sperms in the background Fig. 6. Lymph node aspirate showing microlariae with crisscross
(Papanicolaou, 310). [Color gure can be viewed in the online issue, arrangement in the background of lymphocytes, germinal centre cells,
which is available at wileyonlinelibrary.com.] and eosinophils (Papanicolaou, 310). [Color gure can be viewed in the
online issue, which is available at wileyonlinelibrary.com.]

Fig. 4. Sheathed microlaria lacking caudal nuclei suggesting the spe-

cies Wuchereria bancrofti (MGG, 320). [Color gure can be viewed in Fig. 7. Smear showing adherence of epithelioid cells to coiled micro-
the online issue, which is available at wileyonlinelibrary.com.] lariae (MGG, 320). [Color gure can be viewed in the online issue,
which is available at wileyonlinelibrary.com.]

Fig. 5. Microlaria and sheathed fertilized egg (Papanicolaou, 320). Fig. 8. Smear showing granuloma and foreign body giant cells (Papani-
[Color gure can be viewed in the online issue, which is available at colaou, 310). [Color gure can be viewed in the online issue, which is
wileyonlinelibrary.com.] available at wileyonlinelibrary.com.]
Diagnostic Cytopathology DOI 10.1002/dc
KUMAR ET AL.
clinical suspicion of lariasis. In this study, 12 cases pre-
sented in the hospital from local town Dharan, and 13
cases from the neighboring area belonging within 100 km
of distance. Only one person came to the hospital from a
distance of 200 km. This indicates the presence of large
number of cases of lariasis affecting epididymis, sper-
matic cord, lymph node, breast, and other organs. In our
views, the number of cases in this study signies only the
tip of iceberg. In our studies, smears revealed fragments
of adult worm in 12 cases including 10 gravid female
worm containing eggs and microlariae, and two adult
male worm; whereas in remaining 14 cases only micro-
lariae or eggs were seen. Unfertilized eggs without sheath
were seen in three cases and fertilized eggs having sheath
along with microlariae were seen in ve cases.
Host tissue response on cytological smear is well docu-
mented.10,12 Cytologic smears in our study showed presence
of eosinophils in 16 cases, granuloma was noted in ve
cases, giant cells in four cases, and ve cases showed acute
inammatory exudate. Neutrophils, lymphocytes, and mac-
rophages were seen as predominant nding in seven cases.
One case aspirated from axillary lymph node showed case-
ous-like necrotic material with microlariae but Acid Fast
Bacilli was not seen. Cell adherence to microlaria is evi-
denced and reasoned by the presence of larial antibodies
(Ig E) in the sera of the patient and the role of complement
is also found.3,8 In this study, four cases showed cell adher-
ence of neutrophils, eosinophils, macrophages, epithelioid
cells, or lymphocytes to elongated and coiled forms of larva.
Filaria causing lymph edema of a lower limb lator on
developing into lymphangiosarcoma is reported.8 Chance
association of inltrating duct carcinoma of breast, follic-
ular carcinoma of thyroid, multiple myeloma of eye, sec-
ondary deposits of adenocarcinoma in subcutaneous nod-
ule, ascites and pleural effusion are also found.8 In this
study, no such association was found.
Diagnostic methods include night blood examination,
immunoassay, polymerase chain reaction, ultrasound, and
lymphoscintigraphy.13 Demonstration of microlariae in
peripheral blood smear is usual method in clinically sus-
pected cases. Absence of microlariae in the peripheral
blood does not exclude larial infection. Antibody detec-
tion tests are not specic and demonstration of parasitic
antigen in the blood is a sophisticated method.2 Ultrasound
and lymphoscintigraphy is not available at all places. Bi-
opsy is inconvenient for the patient, expensive and tissue
removal further compromises lymph drainage.2 FNAC is
cheap, easy, and simple outdoor procedure and its value in
asymptomatic and clinically unsuspected cases is well
documented.2,5,12 It provides denite diagnosis of lariasis
and exclude the clinical possibilities of other inammatory,
cystic, and neoplastic lesions. The demonstration and iden-
tication of the parasites in the cytologic smear plays sig-
nicant role in recognition of the disease and hence, no fur-
ther investigation is required. Institution of specic treat-
12 Diagnostic Cytopathology, Vol 39, No 1
ment can be started earlier after the diagnosis, so that
severe manifestation of lariasis can be prevented.8
Diethylcarbamazine with albendazole is used to treat
lymphatic lariasis as well as other helminths, particularly
intestinal worms, which are commonly found to coinfect
individual with lariasis in larial-endemic region.14 In-
testinal helminths could play a role in the survival and
persistence of lymphatic-dwelling larial parasite and that
effective elimination of intestinal helminths by albenda-
zole could adversely inuence survival of adult larial
worm, thus indirectly displaying its antilarial activity.14
Thus in tropical country like Nepal and India, the diag-
nosis of lariasis should be considered as one of the dif-
ferential diagnosis of a swelling and all such cases should
be subjected for FNAC for denitive diagnosis and fur-
ther treatment.
Conclusions
Filaria may affect the epididymis, spermatic cord,
lymphnodes, and breast, and the accurate diagnosis can
be easily and conveniently achieved by FNAC without
any requirement of biopsy.
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