1 From the Department of Radiology, Saint Barnabas Medical Center, Old Short Hills Rd, Livingston, NJ 07039. Received October 13, 1999; revision requested June 5, 2000; revision received July 28; accepted August 30.
The patient was a 69-year-old Nigerian woman who was visiting her daughter in the United States. She presented for baseline mammography, and the patient had no palpable breast abnormality, pain, or nipple discharge. She had not undergone mammography or breast biopsy previously, and there was no family history of breast cancer. Her medical history included weight loss and vague shoulder and hip pain. Physical examination of the breasts revealed no abnormalities.
Figure 1 shows minimal fibroglandular tissue. There are unusual
groupings of benign-appearing calcifications in the retroareolar
and posterior central aspects of the left breast. Some of the
calcifications, particularly the group in the retroareolar region,
appear elongated and serpiginous. There are no signs of irregularity
or pleomorphism. The calcifications are not oriented or adjacent
to the ducts.
| fig.ommitted |
Figure 1. Craniocaudal mammogram of the left breast shows minimal fibroglandular tissue. There are unusual groupings of benign-appearing calcifications in the retroareolar and posterior central (curved arrow) aspects of the breast. The group of calcifications (straight arrow) in the retroareolar region appear elongated and serpiginous.
| |
A photographic magnification of a true lateral mammogram of
the left breast shows that several of the calcifications have
lucent centers (
Fig 2).
| fig.ommitted |
Figure 2. Photographic magnification of a true lateral mammogram of the left breast. Several calcifications (arrow) have lucent centers.
| |
The right craniocaudal mammogram (
Fig 3) also demonstrates multiple
groupings of benign-appearing calcifications in the retroareolar,
posterior central, and posterior lateral aspects of the breast.
The groups of calcifications are similar to those seen in the
opposite breast.
| fig.ommitted |
Figure 3. Craniocaudal mammogram of the right breast shows multiple groupings of benign-appearing calcifications in the retroareolar (short arrow), posterior central (curved arrow), and posterior lateral (long arrow) aspects of the breast. The calcifications appear serpiginous.
| |
On a photographic magnification of a true lateral mammogram
of the right breast, the group of retroareolar calcifications
demonstrates a wavy and tortuous appearance (
Fig 4). Some of
these calcifications have lucent centers, although others do
not. They are similar to those in the opposite breast.
fig.ommitted
|
Figure 4. Photographic magnification of a true lateral mammogram of the right breast. The group of calcifications (arrow) in the retroareolar aspect of the right breast demonstrates the wavy and tortuous nature of some of the calcifications. Some of these calcifications have lucent centers, although others do not.
| |
A detailed history revealed that as a teenager in Nigeria the
patient had undergone routine screening in her community for
filarial infection. Her condition was misdiagnosed, which resulted
in a treatment that addressed symptoms but did not treat the
underlying infection. For decades, the patient’s infection
remained dormant. However, results of blood tests demonstrated
an abnormal titer for the filarial antigen
Wuchereria bancrofti. On the basis of findings of classic serpiginous calcifications
demonstrated on mammograms of both breasts, confirmatory laboratory
data, and a history of being from a part of the world where
filariasis is endemic, the diagnosis of filariasis was established.
The tortuous calcifications with wavy and elongated attributes
(
Figs 1–
4) were clearly distinguished from the calcifications
of intraductal carcinoma owing to their location in the connective
tissue unrelated to the ducts (
1). The lucent-centered appearance
and characteristic locations of the calcifications in the breast
parenchyma were essential in excluding malignancy.
Given the mammographic findings and associated history, a differential diagnosis of various parasitic diseases, including filarial infections, can be determined, and malignancy and benign dystrophic calcifications can be excluded. The filarial infection, caused by W bancrofti, demonstrated in this patient has mammographic features different from the nematodal infections caused by Onchocerca volvulus (onchocerciasis), Loa loa (loiasis), and Trichinella spiralis (trichinosis) (2). The filarial infections of O volvulus and L loa are distinguished from the infection of W bancrofti on the basis of the location and appearance of the organisms. O volvulus organisms are often found in spaces just beneath the skin epithelium and, occasionally, in lymphatic vessels and lymph nodes. They are often distinguishable because their calcifications form intricate tangles (3). The calcifications of loiasis can be distinguished from those of W bancrofti on the basis of their appearance as either short or long continuous or beaded fine calcifications when the worm is extended. Loiasis may also appear as hairlike whorls of calcifications. Trichinosis calcifications are located only in the pectoral muscles, whereas those of filariasis are located primarily in the breast parenchyma. Trichinosis calcifications are much smaller, more numerous, and not serpiginous when compared with those of filariasis (4). Benign dystrophic calcifications can also be differentiated from those of parasitic diseases on the basis of their coarse, dense, irregular appearance.
Lymphatic filariasis is endemic in the Tropics and portions of Africa. In Nigeria, as much as 25% of the population is infected (5). The disease is equally distributed in both sexes (3) and affects an estimated 120 million people worldwide (6). The two nematode parasites, W bancrofti and Brugia malayi (3), cause the major types of lymphatic filariasis. The adult worms of these parasites inhabit lymph vessels and lymph nodes. The only known definitive host of the nematode parasites is man (7). The infection is transmitted by means of the bite of a mosquito that has previously bitten an infected host. The larvae then migrate into the puncture wound and reach the subcutaneous lymphatic vessels (3).
The onset of lymphatic filariasis often is slow, and patients may have occasional febrile or inflammatory episodes. Granulomatous lymphangitis often develops in the tissue adjacent to the lymphatic vessel or groups of vessels affected (8). Eventually, the blocked vessels are replaced with fibrous tissue (3), and the patient may present with a palpable breast mass, which represents the filarial granuloma. The skin over the filarial granuloma of the breast may be hyperemic with peau d’orange changes (6).
A tentative diagnosis can be determined with results of specific immunologic techniques, such as gel diffusion, latex hemagglutination, indirect immunofluorescence, polymerase chain reaction, and enzyme-linked immunosorbent assay. Observation and identification of the adult worm or the larvae in the blood of an infected patient can help in establishing a definitive diagnosis of filarial infection. The characteristic appearance and distinct body nuclei of the microfilariae can be distinguished on a wet-slide preparation (3). Identification of the adult larvae in lymph nodes during biopsy can also help in the determination of an accurate diagnosis.
The treatment of filariasis often is based on symptomatic control. The best known and most common medication for treatment is diethylcarbamazine citrate. Treatment with this agent is known to cause a rapid decrease in the severity of the infection within a few days. However, the rapid release of antigen from the larvae in response to diethylcarbamazine often leads to serious side effects. The patient may develop sudden breast erythema, which may mimic mastitis, as well as skin thickening, chills, fever, dizziness, and malaise. This rapid serious response from the medical treatment is termed the Mazzotti reaction (3).
Given the large number of people from the Tropics, eastern China, and central and western Africa with lymphatic filariasis and the increasing travel and mobility of people from all countries, one may expect the numbers of patients with filariasis who present themselves in local hospitals to increase. To that end, increased diagnostic vigilance with regard to the symptoms and characteristics of filariasis will be necessary.
Our congratulations to the 55 individuals who submitted the most likely diagnosis (filariasis) for Diagnosis Please, Case 43. The names and locations of the individuals, as submitted, are as follows:
- Pablo Jose Abbona, MD, Mar Del Plata, Argentina
- Kimberly Amrami, MD, Rochester, Minn
- Pr. Michel Blery, Le Kremlin Bicêtre Cedex, France
- Brigitte Bolner, MD, Paris, France
- Eric L. Bressler, MD, Minnetonka, Minn
- Andrea Bruscagnin, MD, Venezia, Italy
- Sinan Cakirer, Atesehir, Istanbul, Turkey
- Dr. Tirso Cascajares Murillo, Los Mochis, Sin., Mexico
- Daniel M. Chernoff, MD, Saratoga Springs, NY
- Ricky Cooper, MD, Maywood, Ill
- Flavio Corti, MD, Mar del Plata, Argentina
- M. G. de Baets, MD, Lugano, Switzerland
- Dra. Estela Di Nella, Mar del Plata, Argentina
- Mark T. DiMarcangelo, DO, MSc, FACR, Cherry Hill, NJ
- Arie Franco, MD, PhD, Livingston, NJ
- Milton R. Fuentealba, MD, General Roca, Rio Negro, Argentina
- Roberto García-Valtuille, MD, Santander, Spain
- Douglas Gardner, MD, Windsor, Ontario, Canada
- Yves Goël, MD, Lausanne, Switzerland
- Burton M. Gold, MD, Mineola, NY
- W. Zev Goldstein, MD, Poughkeepsie, NY
- Daniel S. Gordon, MD, Fayetteville, NC
- Henry C. Gorman, MD, Martinez, Ga
- John Grizzard, MD, Midlothian, Va
- Flavius Guglielmo, MD, Basking Ridge, NJ
- Ferris M. Hall, MD, Boston, Mass
- Marc J. Homer, MD, Boston, Mass
- Douglas S. Katz, MD, Mineola, NY
- Young A. Kim, Kyonggi-do, Korea
- Mitchell A. Klein, MD, Milwaukee, Wis
- Albert Kujas, MD, Paris, France
- S. Lachanis, MD, Athens, Greece
- Abelardo Lemus
- Richard B. Levine, MD, Metairie, La
- Paul Madsen, Greendale, Wis
- Antonio J. Madureira, MD, Porto, Portugal
- N. B. S. Mani, MD, Chandigarh, India
- Dr. Eduardo Mondello, Buenos Aires, Argentina
- Harish Panicker, MD, Madison Heights, Mich
- Frank Paolantonio, DO, York, Pa
- Jean R. Paquelet, MD, Columbus, Ohio
- Víctor Pérez-Candela, MD, Las Palmas de Gran Canaria, Spain
- Enrique Remartinez Escobar, MD, Melilla, Spain
- Bonna Rogers-Neufeld, MD, Fresno, Calif
- Luis Antonio Rossi, São Paulo, Brazil
- Mourad Said, MD, Monastir, Tunisia
- Manuel T. Salvador, Barcelona, Spain
- Taro Shimono, MD, Osaka, Japan
- Dr. Franz Sulzer, Kapfenberg, Austria
- Arlene Sussman, MD, Mineola, NY
- William H. Sutro, MD, Roslyn Heights, NY
- Alejandro Tempra, MD, Mar del Plata, Argentina
- Herminia Tyminski Al-Saffar, MD, Manama, Bahrain
- Stanko Yovichevich, MD, Sydney, New South Wales, Australia
- Valentin Zambrana, MD, Mazatlan, Sinaloa, Mexico
- Lanyi M. Diagnosis and differential diagnosis of breast calcifications New York, NY: Springer-Verlag, 1988; 179.
- Suneja SK, Olopoenia L, Teal JS, Grigsby ME, Debruhl N. Mammographic calcifications due to filarial disease. Trop Doct 1990; 20:143-144.
- Maegraith BG. Adams and Maegraith clinical tropical diseases 9th ed. Boston, Mass: Blackwell Science, 1989; 64-102.
- Ikeda D, Sickles E. Mammographic demonstration of pectoral muscle microcalcifications. AJR Am J Roentgenol 1988; 151:475-476.
- Brown HW. Basic clinical parasitology New York, NY: Appleton-Century-Crofts, 1975; 142-151.
- Chow CK, McCarthy JS, Neafie R, et al. Mammography of lymphatic filariasis. AJR Am J Roentgenol 1996; 167:1425-1426.
- Reeder MM, Palmer PES. The radiology of tropical diseases Baltimore, Md: Williams & Wilkins, 1981; 665-662.
- Chen Y, Xie Q. Filarial granuloma of the female breast: a histopathological study of 131 cases. Am J Trop Med Hyg 1981; 30:1206-1210.
作者：
Paul D. Friedman DO and Lester Kalisher MD 2007-5-12