Dr. (Prof). Sachin Khanduri is a qualified and practising Radiologist based in Lucknow. He is currently Professor and Head of Department of Radiodiagnosis, Era’s Medical College, Lucknow. He is the Joint Secretary (Scientific)-UP IRIA (2018), Reviewer in Cureus Journal USA and JEMD India, and Faculty and MD Examiner at National and State Level. He has published more than 70 articles in various national and international journals, of which 35 research articles are PUBMED/ MEDLINE indexed. He has written a book titled “Textbook of Radiology for CT/MRI Technicians with MCQs” by Jaypee Publication (2017). He has presented paper and poster in RSNA and ELCC, Geneva and South Korea, and has been the guide of more than 50 thesis works.
Filariasis is parasitic disease with significant morbidity and socio-economic implications. Its uncommon presentation in female genital organs and rarer presentation in ovarian follicles pose a major diagnostic problem even in endemic regions.As in recent times, there is increase in travel and immigration ,physicians need to be familiar with cases not only endemic to their region but to non endemic diseases as well.Herein ,we report a case of a 26 year old female patient who presented with chronic pelvic pain and polymenorrhoea. Transvaginal ultrasonography revealed microfilariae in ovarian follicular fluid which led to correct diagnosis. This case report sheds light on uncommon presentation of filariasis which needs to be considered for correct diagnosis in endemic as well as non-endemic regions.
A 26-year-old female, married and having two children resident of Lucknow, Uttar Pradesh, presented with chronic pelvic pain and polymenorrhoea since 2 months. Clinical examination revealed right-sided pelvic tenderness. On per vaginal examination, uterus was normal in size with right forniceal tenderness. Patient was advised ultrasound whole abdomen for which she was referred to our department.
TUltrasound whole abdomen revealed bilateral bulky ovaries with 12–15 follicles measuring 4–5 mm arranged peripherally. Right ovary measured 42 × 30 × 28 mm (vol 19 cc) and left ovary measured 44 × 27 × 23 mm (vol 15 cc). Twirling motion was noted within one of the follicles in the right ovary. Transvaginal ultrasonography was performed for confirmation.
Transvaginal ultrasonography revealed bilateral bulky ovaries with multiple tiny follicles of varying sizes (Fig. 1). One of the follicles in the right ovary had a few echogenic foci within showing twirling movement on dynamic greyscale imaging (Video 1). Doppler signals that were non-rhythmic, non-pulsatile, and rapidly changed in size and position (Video 2) were seen on colour Doppler imaging (Fig. 2). Spectral Doppler trace showed the characteristic pattern of irregular worm (filarial dance) leading to provisional diagnosis of filarial oophritis.
Blood test revealed Hb—12.9 g, total count—6400/cm and on differential count—eosinophil 19%. Prolactin level was increased 44.24 ng/ml.
A finger prick test was performed at midnight, and thick blood smear with Giemsa staining showed microfilariae in haemorrhagic background suggesting the diagnosis of ovarian filariasis (Fig. 3). An immunochromatographic card test for filariasis detected circulating filarial antigens.
A combination of radiopathological investigations revealing circulating filarial antigen and filarial dance sign in ovarian follicles led us to the confirmation of diagnosis.
Wuchereria bancrofti causes lymphatic filariasis affecting large population in endemic areas. The socio-economic implications of this disease are significant as it causes severe disability. It is recognized as the second most disabling disease after malaria among the diseases transmitted by mosquitoes. There are eight species of filarial worms that can infect human. Out of them, four are responsible for dramatic filarial infection—(1) W. bancrofti, (2) Brugia malayi, (3) Onchocerca volvulus, and (4) Loa loa: former two causing lymphatic filariasis and latter two leading to non-lymphatic filariasis. Lymphatic filariasis has a predilection for lymphatics in the lower limbs and genital tract [3]. However, ovarian localization of lymphatic filariasis is rare, and only a few cases have been reported in the literature [4, 5]. In a case report by Sane and Patel, adult filarial worms were reported in a specimen of cystic teratoma [6]. In a case report by Sethi et al. [7], filarial worm was found in ovary and mesosalpinx and both patients presented with complaints related to gynaecological problems and not filariasis. The ovarian follicular involvement presented in this case report is rarer. Moreover, the literature shows that the reported cases have been based on histopathological reports of patients undergoing hysterectomy and oophorectomy, whereas we present a case which has been diagnosed on transvaginal ultrasonography showing a real-time filarial dance sign in follicular fluid. The illustrated case is the first case report to the best of our knowledge wherein microfilariae are present in ovarian follicular fluid demonstrating filarial dance.
Conflict of interest Dr. Sachin Khanduri, Dr. Namrata Nigam, Dr. Mazhar Khan, Dr. Anvisha Shukla, Dr. Ekta Tyagi, Dr. Tariq Ahmad Imam and Dr. Shobha Khanduri declare that they have no conflict of interest.
Ethical Standard All procedures were in accordance with the ethical standards of the responsible committee on human experimentation(institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008(5).
Human and Animal Rights This article does not contain any studies with human or animal subjects.
Informed consent Informed consent was obtained from the patient for being included in the study.
