Surgical manifestations of filariasisM Subrahmanyam1, WK Belokar2, Sanjeevani Gole2
1 Department of Surgery, Medical College, Miraj., India
2 Department of Surgery, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha 442102 (M.S.), India
Surgical manifestations of filariasis as seen in 150 cases over a period of three years in the department of Surgery, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha are reviewed. The genital manifestations are more common than the elephantiasis in this endemic zone.
Filariasis is the term given to the various clinico-pathological phenomena caused by infestation with different varieties of Nematode worm-filaria. Of these Wuchereria bancrofti and Brugia malayi are responsible for elephantoid states. Wardha district in Maharashtra, Central India, is an endemic zone for filariasis and a number of afflicted cases seek hospital advice. We report below our experience of the past 3 years with such filarial cases.
One hundred and fifty cases of filarial disease encountered at The Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha, during a 3 year period (1974-1977) have been studied in detail with special reference to the mode of presentation of surgical manifestations.
[Table 1] depicts the surgical manifestations of filariasis encountered in the present study. The lesions were multiple in many cases. Out of the 150 cases of filariasis. 23 had elephantiasis, 35 had lymph gland enlargement, 15 had lymphangitis, 36 had epididymo-orchitis, 80 had hydroceles, 48 had filarial fever, 6 had lymph varix, 5 had hematuria and 5 had chyluria. Males suffered more frequently than the females in the ratio of 6:1. The maximum incidence occurred in 15-30 years of age group (98) followed by age group of 30-40 years (53) while in the 10-15 years of age group only 9 cases were detected.
[Figure 1] (see page 206A) reveals the clinical appearance. There were 15 cases of lymphangitis, out of which 13 occurred in the upper limb and 2 in the lower limb. Lymph vessels of affected extremity appeared as red streaks under the skin. The limb appeared red, hot, tender and swollen.
Epididymo-orchitis and Fitniculitis
Patients had tender, thickened epididymis and spermatic cord. Of the 35 cases recorded, one had associated arthritis of left knee, myositis of neck muscles and lymphangitis of right lower limb. 6 had hydroceles and 20 of them were having filarial fever. In 8 cases microfilariae could be demonstrated in the peripheral smear at night.
This usually followed lymphangitis and occurred in 10 cases-2 in the lower limb, 3 in the upper limb, 4 in the scrotum and one in the breast. In 3 cases adult worm could be demonstrated in the abscesses including one in the breast.
This is caused by varicosity of the lymphatics of the skin and subcutaneous tissues of scrotum. 6 cases of enlarged scrotum with rugosity and lymphatic vessels of variegated sizes were observed. 4 of these patients who were operated upon for hydroceles subsequently developed lymph scrotum, after varying intervals of 10 days to 30 days.
The lymphatics of spermatic cord are elongated, tortuous, elastic and characterised by bulkiness of the cord (6 cases). When such varices occur in groin, these are then designated as varicose groin glands (2 out of 6).
These patients had enlarged scrotum to such an extent that the penis was completely burried inside it. This is due to elephantiasis of scrotum. Bulkiness of the cord, edema of the tissues in the field of operation, presence of lymph varices in the cord, microfilariae in hydrocele fluid have been taken as evidence of lymphatic obstruction. 80 cases of hydrocele were recorded. Out of these 5 had elephantiasis of the scrotum. In 15 cases of hydrocele there was also thickening and tenderness of the spermatic cord and testis. In 2 of these cases microfilariae could be demonstrated in the hydrocele fluid. [Figure 2] (see page 206A) is a clinical photograph of hydrocele due to filaria origin.
Of the 23 cases recorded, 14 were in the lower limb, 4 in the upper limb, while the rest had their scrotum involved. 8 patients had hydrocele in addition. The limbs were swollen, skin was stretched and had nonpitting oedema. One case of elephantiasis of the glans penis was seen see [Figure 3] on page 206B. [Figure 4] see page 206B shows elephantiasis of the lower limb.
Chyle appears in the urine when varicose chyle laden lymph vessels rupture into the bladder, kidneys or ureters. Urine is opalescent, yellowish, milky white in colour due to regurgiated chyle from the intestinal lymphatics through retrograde channels. 5 such cases were seen.
In 2 cases of haematuria microfilariae could be demonstrated in the urine as well as in peripheral smear. One case had chyluria in addition.
There were 10 cases of pyocele. This started with fever, chills and rigors, funiculitis and orchitis and presented to us as pyoceie within 3-7 days.
Diagnosis of filariasis can be confirmed by demonstration of microfilariae in the peripheral smear at night. In 11 of our cases, microfilariae could be seen. In single sex infection prepatent or latent infection microfilaria cannot be seen in the peripheral smear. Eosinophilia, if present, may be a pointer but intestinal helminthic worm infestations should be excluded. Histopathological-confirmation can be obtained from the tissue biopsies wherever it is feasible. In the present study, adult worm was found on histopathology in 25 cases. Out of these, 8 were in the epididymis, 6 were in the tissue biopsies of chronic lymphangitis, 2 in the testis and the rest were detected in the inguinal lymph nodes. However, in cases of epididymo-orchitis, hydroceles and lymph varix, it is the clinical asumption.
Bancroftian filariasis is widely distributed but largely confined to tropical and subtropical countries. It is endemic in certain parts of India, Southern China, Japan, North Australia, West and Central Africa. In India it is distributed along the Eastern and Western coasts and some districts of West Bengal. It is estimated that at least 250 million people throughout the world are infected with Wuchereria Bancro fti and Brugia Malayi. Estimated population at risk in India has increased from 69.2 million in 1960 to 121.8 million in 1969 which is particularly marked in Urban areas.  A high incidence of filariasis has been quoted by Desai and Williams  in Kerala and Gujarat (Surat District). An increased incidence of filariasis around Lucknow has been reported by Chandra et al,  in 1973.
A lot of variation exists over the distribution of elephantiasis and hydrocele. Reported series in India show elephantiasis as common presentation,  but recently Dondero  reported that the genital manifestations are more common presentation in a suburb of Calcutta. In East Africa hydrocele is a more common presentation than elephantiasis, whereas in China, hydrocele, elephantiasis of leg and scrotum and chyluria are quite common.
The acute inflammatory manifestations are attributed to the helminthic toxins liberated by the worm which then by absorption produces the characteristic clinical manifestations-local and constitutional. Particularly the dead worms undergoing absorption, disintegration or calcification by causing toxicity produce lymphangitis and fever. Lymph oedema is due to narrowing and occlusion of lymph vessels following post-inflammatory and infective changes in addition to disintegration and fibrosis of lymph glands, draining the area.  In hydrocele the obstruction is located in para-aortic nodes and in elephantiasis of the leg, the site is in inguinal or iliac group of nodes.
Lymph scrotum developing after operation for hydroceie of filarial origin is explained on the basis of obliteration of potential space. Transudation from the dilated lymphaties of the cord and the sac, result in the fluid collections within the tunica in these hydroceles. Due to obliteration of the potential space after the operation and persistance of obstruction, transudation of lymph takes place into the subcutaneous tissues of the scrotum and the penis.
In cases of early hydroceles, acute epididymo-orchitis or lymph varix, the investigations are of help to confirm the diagnosis of filariasis. However, absence of microfilaria in the peripheral smear and inability to demonstrate the adult worm in the tissue biopsy make it difficult to confirm the diagnosis. Particularly in acute epididymo - orchitis, a therapeutic trial with diethyl carbimazine improves the condition. A need for serological tests, or use of antigen in the diagnosis of filariasis by skin test to show laboratory evidence arises when the other simpler investigations are not conclusive.
With the continued pervalence of the g disease and varied manifestations of filariasis it is imperative to make a prompt and early diagnosis and subject to adequate treatment.
We are thankful to Dr. M. L. Sharma, Principal and Medical Superintendent and to Dr. Sushila Nayar, Director Mahatma Gandhi institute of Medical Sciences for their kind permission to publish this paper.
Our thanks are due to Dr. S. N. Girnikar, of the Filarial Research-cum-Training Centre, Wardha for his constructive criticism. Thanks are due to Shri Shanmukha Rao for his secretarial assistance.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]