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\begin{document}

\title{A case Report on rare finding of Microfilaria in Pus sample of an ulcer
over Elephantiasis Leg}



\author[1]{Manoj  Adhikary}%
\author[1]{Kshitiz  Pandey}%
\author[1]{Sadikchya  Lamichhane}%
\author[1]{Patrik Pandey}%
\affil[1]{Bakulahar Ratnanagar Hospital}%


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  \date{May 19, 2024}


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\textbf{Authors}

\textbf{1.Manoj Adhikary}

Department of Dermatology,~Bakulahar Ratnanagar Hospital,~Chitwan,~Nepal

adhikary332@gmail.com

\textbf{2.Kshitiz Pandey} ~ ~~Corresponding Author

Department of Internal Medicine,~Bakulahar Ratnanagar
Hospital,~Chitwan,~Nepal

osialfeca1234@gmail.com

\textbf{Sadikchya Lamichhane}Department of Dermatology, Bakulahar
Ratnanagar Hospital, Chitwan, Nepal
sadikchya41@gmail.com\textbf{4.Pratik Pandey}

Department of Internal Medicine,~Bakulahar Ratnanagar
Hospital,~Chitwan,~Nepal

pandeypatrick293@gmail.com

\emph{Title:}

\emph{A Rare finding of Microfilaria in Pus sample of an ulcer over
Elephantiasis Leg}

Abstract:

Skin ulcerations are a significant cause of morbidity and can be
challenging to manage. Among the various causes of chronic non-healing
ulcers, lymphedema is also considered a possible diagnosis in countries
such as Nepal. Lymphatic filariasis has been a significant public health
issue in endemic areas. Wuchereria bancrofti is a common nematode
parasite that causes lymphatic filariasis. Excessive retention of
lymphatic fluid in the interstitial compartment can cause localized
tissue swelling, known as lymphedema, which is caused by impaired
lymphatic drainage. Microfilariae can be detected in peripheral blood,
body fluids, and needle aspirates. Microfilaria is not commonly found in
ulcers on elephantiasis legs. We discuss here a case of 73 year old
women with elephantiasis legs with pus discharging ulcers in the thighs.
Microscopic examination of pus discharge revealed microfilaria which
highlights the importance of pus examination as diagnostic modality in
endemic countries.~ ~ ~

Introduction:

~{Chronic non-healing ulcers pose a significant challenge for
healthcare~~~~ professionals in the Departments of Dermatology and
Surgery.} ~{While venous disorders account for the majority of cases,
approximately 30\% of chronic ulcers result from various vascular
disorders, including diabetes, malignant ulcers, traumatic~~~~~ ulcers,
and chronic lymphedema (2)}.{ Lymphatic filariasis remains a public
health concern in several regions of South-East Asia.} ~{While a decline
in prevalence is notable, isolated cases of lymphedema and elephantiasis
persist (3). ~}Nearly 63\% of 1.34 billion people worldwide are at risk
of LF, and about 50\% of the 120 million infected people live in the
South-East Asia Region. This region bears approximately 57\% of the
total global burden of an estimated 5.1 million disability-adjusted life
years (DALYs) lost due to LF. (4){ ~}
~{Lymphatic~filariasis~is~a~progressive~condition~that significantly
impacts both the physical and psychological well-being of affected
patients, resulting in a considerable reduction in their quality of life
(5). It remains a debilitating parasitic disease (6).}

Apart from the blood and lymph node aspirate, microfilaria can also be
isolated in fine needle aspirates from various samples, as well as from
chyluria, chylous ascites, and hydrocele fluid (6).

Case report:

{A 73-year-old female patient was admitted with complaints of bilateral
leg swelling persisting for the past 53 years.} (Figure 1)\selectlanguage{english}
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\emph{Figure.1 Clinical photo of patient showing elephantiasis leg.}
\selectlanguage{ngerman}
~{There were three ulcers, each measuring on average 2 × 3 cm, and
exhibiting pus discharge.} There was an associated fever with chills.
She also reported a history of recurring swelling in both legs, along
with intermittent episodes of ulceration. On examination, non-pitting
edema was observed in both the feet, legs, and thighs, and three ulcers
were observed in the right groin. Each ulcer had an irregular margin,
sloping edge, and a yellowish overlying slough, with a discharge of pus.
The base was indurated and fixed with underlying structure. The skin of
both legs had a blackish pigmentation and rough scaling. There was an
incision mark with fibrosis present on the right thigh, indicating a
similar past history. Bilateral inguinal lymph nodes were palpable. They
were discreet, smooth, and firm in consistency. All other systems were
within normal limits. Blood parameters were in normal parameters except
slightly raised eosinophils (5\%) and ESR (45).

{Due to the presence of infection and pus discharge in the}

{ulcer,~a~pus~sample~was~collected~for~microscopic~examination~and~culture~sensitivity.
~}

(Figure 2)\selectlanguage{english}
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\emph{Figure 2.Pus collection on sterile syringe without needles}

Microscopic findings:

Gram staining revealed the presence of multiple microfilariae when{}

observed~under~a~binocular~microscope.

(Figure 3)\selectlanguage{english}
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\emph{Figure.3 Gram staining of pus showing microfilaria}

The patient underwent incision and drainage (I\&D) for a right inguinal
abscess located under the ulcer. In addition, medical management was
provided using steroids (Prednisolone) and Diethylcarbamazine (6mg/kg)
(7).{ There was dramatic improvement in ulcer healing within 3 weeks
with minimal~ scar. Patient was followed up in 4 months without
recurrance and~ healed ulcers.}

Discussion:

Filariasis is the most common cause of lymphedema worldwide. Around 120
million people are infected, and approximately 40 million have lymphatic
problems. The disease is seen in Africa, Southeast Asia, the Western
Pacific, the Americas, and the Middle East (8).{ Transmission and
morbidity rates are highest in Southeast Asia and Sub-Saharan Africa.}
It is caused by Wuchereria bancrofti, Brugia Malayi, and Brugia Timori,
and is transmitted by female mosquitoes (Culex, Anopheles, and
Aedes).~{Nearly 90\% of microfilariae are of W. bancrofti (6,9).}
Usually, people residing in endemic zones and being exposed to repeated
mosquito bites over several months are required in order to acquire
lymphatic filariasis. The majority of infected patients are
asymptomatic, while others present with acute symptoms such as fever,
headache, malaise, inguinal and axillary lymphadenitis, lymphangitis,
cellulitis, abscess formation, and funiculoepididymo-orchitis. In the
chronic form, it can lead to the formation of elephantiasis in the legs,
arms, scrotum, vulva, penis, and breasts. Chyluria and lymphovarix are
rare conditions. Eosinophilia and microfilaremia are common during the
acute phase.

{Peripheral blood smears stained with~~ Gram stain, Ziemsa stain, or
H\&E are crucial for diagnosing microfilaria, as they enable detection
in the blood.} Differential diagnosis of filariasis should be considered
for any lymphedema in an endemic zone, even in the absence of
circulating antigens or parasites on laboratory examination.

Conclusion

This case report highlights rare finding of the presence of microfilaria
in the pus sample of an ulcer over an elephantiasis leg. Lymphatic
filariasis, caused by Wuchereria bancrofti, is a common public health
issue in endemic areas. The patient presented with chronic leg swelling,
recurrent ulceration, and lymphadenopathy. Microscopic examination of
the pus sample revealed the presence of microfilariae. The patient was
managed with incision and drainage for abscess, along with medical
treatment involving steroids and diethylcarbamazine. This case
emphasizes the importance of considering filariasis as a differential
diagnosis in chronic non-healing ulcers, particularly in endemic
regions, even in the absence of circulating antigens or parasites on
laboratory examination. Early detection and appropriate management can
be crucial in reducing the morbidity associated with lymphatic
filariasis.

Acknowledgements:

Author wants to thank all teaching staff of Department of Dermatology
and staffs of Department of Microbiology, Bakulahar Ratnanagar Hospital
for their suggestions and constant support to make this work successful.

References

1. Grada, A. A., \& Phillips, T. J. (2017). Lymphedema: Pathophysiology
and clinical manifestations.~\emph{Journal of the American Academy of
Dermatology} ,~\emph{77} (6), 1009--1020.
https://doi.org/10.1016/j.jaad.2017.03.022

Karnasula, V. M. (2012). Management of ulcers in lymphoedematous
limbs.~\emph{Indian Journal of Plastic Surgery: Official Publication of
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https://doi.org/10.4103/0970-0358.101291

Shenoy, R. K. (2008). Clinical and pathological aspects of filarial
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\url{https://doi.org/10.3347/kjp.2008.46.3.119}

Bizhani, N., Hashemi Hafshejani, S., Mohammadi, N.~\emph{et
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Panuncialman, J., \& Falanga, V. (2010). Unusual causes of cutaneous
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G., \& Urhekar, A. D. (n.d.).~\emph{Microfilaria in pus sample of an
ulcer over Elephantiasis leg: an unusual case presentation} .
Ijcmas.com. Retrieved July 17, 2023, from
https://www.ijcmas.com/vol-2-7/Harapriya\%20Kar,\%20et\%20al.pdf

CDC-Centers for Disease Control, \& Prevention. (2010).~\emph{CDC -
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https://www.cdc.gov/parasites/lymphaticfilariasis/health\_professionals/dxtx.html

Pathak, B., \& Maimoon, S. (2022). Incidental finding of microfilaria in
lymph node cytology: A case report.~\emph{Cureus},~\emph{14}(11),
e31275. \url{https://doi.org/10.7759/cureus.31275}

Hasan Khalaf, Noor Alhalabi and Basim Almothafar. 2020. An Unusual
Presentation of Lymphatic Filariasis in Non-Endemic Country.
Int.J.Curr.Microbiol.App.Sci. 9(06): 3112- 3115. doi:
\url{https://doi.org/10.20546/ijcmas.2020.906.372}

\textbf{Declaration of Conflicting Interests:} ~The author(s) declared
no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.

\textbf{Funding:} ~The author(s) received no financial support for the
research, authorship, and/or publication of this article.

\textbf{Patient consent:} Written informed consent was obtained from the
patient to publish this report in accordance with the journal's patient
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