Microfilariae coexisting with a follicular lesion in thyroid aspirate smears in an uncommon case of a retrosternal thyroid mass, clinically presenting as malignancy
Identifieur interne : 002545 ( Pmc/Corpus ); précédent : 002544; suivant : 002546Microfilariae coexisting with a follicular lesion in thyroid aspirate smears in an uncommon case of a retrosternal thyroid mass, clinically presenting as malignancy
Auteurs : Bharat Rekhi ; S. V. KaneSource :
- CytoJournal [ 0974-5963 ] ; 2011.
Url:
DOI: 10.4103/1742-6413.76732
PubMed: 21383959
PubMed Central: 3049240
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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Microfilariae coexisting with a follicular lesion in thyroid aspirate smears in an uncommon case of a retrosternal thyroid mass, clinically presenting as malignancy</title><author><name sortKey="Rekhi, Bharat" sort="Rekhi, Bharat" uniqKey="Rekhi B" first="Bharat" last="Rekhi">Bharat Rekhi</name><affiliation><nlm:aff id="AF0001">Department of Pathology, Department of Cytopathology, Tata Memorial Hospital, Parel, Mumbai, India</nlm:aff></affiliation></author><author><name sortKey="Kane, S V" sort="Kane, S V" uniqKey="Kane S" first="S. V." last="Kane">S. V. Kane</name><affiliation><nlm:aff id="AF0001">Department of Pathology, Department of Cytopathology, Tata Memorial Hospital, Parel, Mumbai, India</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">21383959</idno><idno type="pmc">3049240</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3049240</idno><idno type="RBID">PMC:3049240</idno><idno type="doi">10.4103/1742-6413.76732</idno><date when="2011">2011</date><idno type="wicri:Area/Pmc/Corpus">002545</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">002545</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Microfilariae coexisting with a follicular lesion in thyroid aspirate smears in an uncommon case of a retrosternal thyroid mass, clinically presenting as malignancy</title><author><name sortKey="Rekhi, Bharat" sort="Rekhi, Bharat" uniqKey="Rekhi B" first="Bharat" last="Rekhi">Bharat Rekhi</name><affiliation><nlm:aff id="AF0001">Department of Pathology, Department of Cytopathology, Tata Memorial Hospital, Parel, Mumbai, India</nlm:aff></affiliation></author><author><name sortKey="Kane, S V" sort="Kane, S V" uniqKey="Kane S" first="S. V." last="Kane">S. V. Kane</name><affiliation><nlm:aff id="AF0001">Department of Pathology, Department of Cytopathology, Tata Memorial Hospital, Parel, Mumbai, India</nlm:aff></affiliation></author></analytic><series><title level="j">CytoJournal</title><idno type="ISSN">0974-5963</idno><idno type="eISSN">1742-6413</idno><imprint><date when="2011">2011</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><back><div1 type="bibliography"><listBibl><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Park, K" uniqKey="Park K">K Park</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Jayram, G" uniqKey="Jayram G">G Jayram</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Roy, P" uniqKey="Roy P">P Roy</name></author><author><name sortKey="Rekhi, B" uniqKey="Rekhi B">B Rekhi</name></author><author><name sortKey="Chinoy, Rf" uniqKey="Chinoy R">RF Chinoy</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Avasthi, R" uniqKey="Avasthi R">R Avasthi</name></author><author><name sortKey="Jain, Ap" uniqKey="Jain A">AP Jain</name></author><author><name sortKey="Swaroop, K" uniqKey="Swaroop K">K Swaroop</name></author><author><name sortKey="Samal, N" uniqKey="Samal N">N Samal</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Sodhani, P" uniqKey="Sodhani P">P Sodhani</name></author><author><name sortKey="Nayar, M" uniqKey="Nayar M">M Nayar</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Pandit, A" uniqKey="Pandit A">A Pandit</name></author><author><name sortKey="Prayag, As" uniqKey="Prayag A">AS Prayag</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Varghese, R" uniqKey="Varghese R">R Varghese</name></author><author><name sortKey="Raghuveer, Cv" uniqKey="Raghuveer C">CV Raghuveer</name></author><author><name sortKey="Pai, Mr" uniqKey="Pai M">MR Pai</name></author><author><name sortKey="Bansal, R" uniqKey="Bansal R">R Bansal</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Kar, Dk" uniqKey="Kar D">DK Kar</name></author><author><name sortKey="Agarwal, G" uniqKey="Agarwal G">G Agarwal</name></author><author><name sortKey="Krishnani, N" uniqKey="Krishnani N">N Krishnani</name></author><author><name sortKey="Mishra, Sk" uniqKey="Mishra S">SK Mishra</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Mohanty, Sk" uniqKey="Mohanty S">SK Mohanty</name></author><author><name sortKey="Patnaik, D" uniqKey="Patnaik D">D Patnaik</name></author><author><name sortKey="Dey, P" uniqKey="Dey P">P Dey</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Yenkeshawar, Pn" uniqKey="Yenkeshawar P">PN Yenkeshawar</name></author><author><name sortKey="Kumbhalkar, Dt" uniqKey="Kumbhalkar D">DT Kumbhalkar</name></author><author><name sortKey="Bhopte, Sk" uniqKey="Bhopte S">SK Bhopte</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Chowdhary, M" uniqKey="Chowdhary M">M Chowdhary</name></author><author><name sortKey="Langer, S" uniqKey="Langer S">S Langer</name></author><author><name sortKey="Aggarwal, M" uniqKey="Aggarwal M">M Aggarwal</name></author><author><name sortKey="Agarwal, C" uniqKey="Agarwal C">C Agarwal</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Baloch, Zw" uniqKey="Baloch Z">ZW Baloch</name></author><author><name sortKey="Cibas, Es" uniqKey="Cibas E">ES Cibas</name></author><author><name sortKey="Clark, Dp" uniqKey="Clark D">DP Clark</name></author><author><name sortKey="Layfield, Lj" uniqKey="Layfield L">LJ Layfield</name></author><author><name sortKey="Ljung, Bm" uniqKey="Ljung B">BM Ljung</name></author><author><name sortKey="Pitman, Mb" uniqKey="Pitman M">MB Pitman</name></author></analytic></biblStruct></listBibl></div1></back></TEI><pmc article-type="letter"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">Cytojournal</journal-id><journal-id journal-id-type="publisher-id">CJ</journal-id><journal-title-group><journal-title>CytoJournal</journal-title></journal-title-group><issn pub-type="ppub">0974-5963</issn><issn pub-type="epub">1742-6413</issn><publisher><publisher-name>Medknow Publications & Media Pvt Ltd</publisher-name><publisher-loc>India</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">21383959</article-id><article-id pub-id-type="pmc">3049240</article-id><article-id pub-id-type="publisher-id">CJ-8-4</article-id><article-id pub-id-type="doi">10.4103/1742-6413.76732</article-id><article-categories><subj-group subj-group-type="heading"><subject>Letter to Editor</subject></subj-group></article-categories><title-group><article-title>Microfilariae coexisting with a follicular lesion in thyroid aspirate smears in an uncommon case of a retrosternal thyroid mass, clinically presenting as malignancy</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Rekhi</surname><given-names>Bharat</given-names></name><degrees>MD, DNB, MIAC</degrees><email xlink:href="rekhi.bharat@gmail.com">rekhi.bharat@gmail.com</email><xref ref-type="aff" rid="AF0001">*</xref><xref ref-type="corresp" rid="cor1"></xref></contrib><contrib contrib-type="author"><name><surname>Kane</surname><given-names>S. V.</given-names></name><degrees>MD</degrees><email xlink:href="drsvkane@rediffmail.com">drsvkane@rediffmail.com</email><xref ref-type="aff" rid="AF0001"></xref></contrib></contrib-group><aff id="AF0001">Department of Pathology, Department of Cytopathology, Tata Memorial Hospital, Parel, Mumbai, India</aff><author-notes><corresp id="cor1">*Corresponding author</corresp></author-notes><pub-date pub-type="collection"><year>2011</year></pub-date><pub-date pub-type="epub"><day>12</day><month>2</month><year>2011</year></pub-date><volume>8</volume><elocation-id>4</elocation-id><history><date date-type="received"><day>15</day><month>8</month><year>2010</year></date><date date-type="accepted"><day>20</day><month>9</month><year>2010</year></date></history><permissions><copyright-statement>© 2011 Rekhi and Kane; licensee Cytopathology Foundation Inc.</copyright-statement><copyright-year>2011</copyright-year><license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by/2.0/"><license-p>This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.</license-p></license></permissions><self-uri xlink:type="simple" xlink:href="http://www.cytojournal.com/content/8/1/4">This article is available from: http://www.cytojournal.com/content/8/1/4</self-uri></article-meta></front><body><p>To the Editor,</p><p>Filarial infection is a public health problem in the tropical regions of South-east Asia, including the Indian subcontinent that includes certain areas of heavy infestation, like Madhya Pradesh, Bihar, Jharkhand, along with others. It is caused by the nematodes <italic>Wuchereria bancrofti, Brugia malayi, Brugia tumori</italic> and others, transmitted through a mosquito <italic>Culex fastigens</italic>. Its disease manifestations include lymphoedema and superficial swellings.[<xref ref-type="bibr" rid="CIT1">1</xref>–<xref ref-type="bibr" rid="CIT3">3</xref>] Varied sites of involvement documented on aspirate smears include breast, epididymis, spermatic cord, lungs, etc.[<xref ref-type="bibr" rid="CIT4">4</xref>–<xref ref-type="bibr" rid="CIT6">6</xref>] Over the years, it has been uncommonly identified in the thyroid.[<xref ref-type="bibr" rid="CIT7">7</xref>–<xref ref-type="bibr" rid="CIT13">13</xref>] Herein, we present an uncommon case of a retrosternal thyroid mass that clinically presented as malignancy and on aspiration cytology disclosed a follicular lesion with coexisting microfilariae.</p><p>A 55-year-old gentleman from Ranchi (Jharkhand, India) was referred to our hospital with complaints of anterior neck swelling since 2 months, associated with dysphagia to solids and alteration of voice for a month. He had been a tobacco chewer for 30 years. He also disclosed history of aspiration a month ago, along with breathlessness. On clinical examination, his general condition was good. On local examination, a soft swelling was noted over his right thyroid and isthmus and a 10×7 cm hard swelling was noted over his left thyroid, extending into the retro sternum that did not move with deglutition. Left vocal cord palsy was noted. There was no stridor. Clinically, he was presumed with a diagnosis of stage IV carcinoma thyroid.</p><p>He underwent laboratory and radiological investigations, including an outside computed tomography (CT) scan, followed by fine-needle aspiration cytology (FNAC) on three occasions, including twice at our hospital.</p><p>His hemoglobin was normal i.e. 12 gm/dl (Normal: 13-17 gm/dl). Total leukocyte count was high i.e., 13.7×10e9/L (Normal: 4-10×10e9/L), including absolute neutrophilia. Percentage and absolute eosinophil counts were normal 4.73% and 0.65×10e9/L (Normal: 1-6% and 0.2-1×10e9/L). Basophil percentage was marginally high i.e., 0.33% (Normal: 0-0.2%). His thyroid function tests were within normal limits. There was no access for thyroid scan results.</p><p>Limited accessible imaging findings included a CT scan report that disclosed a left thyroid lobe lesion, eroding the thyroid cartilage, trachea and thoracic inlet. His chest X-ray was normal.</p><p>FNAC was performed by multiple passes in the thyroid using a 23-gauge needle. Smears were fixed in alcohol stained with Papanicolaou (Pap), while air-dried smears were stained with Giemsa stain. The initial smears were reported as papillary carcinoma thyroid. Repeat smears were hypercellular, comprising benign appearing follicular cells in focal acinar formations, flat monolayered sheets and focal papillaroid arrangements, lacking anatomical edge. Cells exhibited focal nuclear overlapping, focal grooves and fine chromatin clearing in rare cells. No nuclear elongation, uniform nucleomegaly or intranuclear inclusions were noted within the hypercellular smears. Besides, there were sheets of cystic macrophages and Hurthle cells in a background of thick and thin colloid. Diagnosis of an atypical follicular lesion of undetermined significance was considered. On critical examination, microfilariae of <italic>W. bancrofti</italic> were identified that displayed presence of sheath and were deficient in somatic nuclei at the posterior end of the body that was curved. A few rhomboid-shaped Charcot Leyden (CL) crystals were noted. There were no inflammatory cells. The previous smears were reviewed and a final diagnosis of microfilarial infestation, along with follicular lesion (of undetermined significance) was offered. [Figure <xref ref-type="fig" rid="F0001">1a</xref>–<xref ref-type="fig" rid="F0001">e</xref>]</p><fig id="F0001" position="float"><label>Figure 1</label><caption><p>a) Hypercellular smear showing clusters of follicular cells. Pap stain ×100; b) Follicular cells with surrounding macrophages. Pap stain ×400; c) Cells showing focal nuclear overlapping. Pap stain ×1000; d) Flat monolayered sheet of follicular cells with adjacent microfilaria. Pap stain ×400. Inset showing Charcot-Leyden crystals. Pap stain ×1000. Pap stain ×1000; e) A single microfilaria of <italic>Wuchereria bancrofti</italic> with sheath and somatic nuclei. The anterior end (thin arrow) and curved posterior end (thick arrow), lacking somatic nuclei seen. Pap stain ×1000</p></caption><graphic xlink:href="CJ-8-4-g001"></graphic></fig><p>Following, the patient succumbed to death within a week. However, post-mortem examination could not be performed.</p><sec sec-type="discussion" id="sec1-1"><title>DISCUSSION</title><p>The present case is a rare manifestation of filarial infection that has been uncommonly documented in the thyroid. Most of the reported cases revealed presence of colloid or nodular goitre, except for an occasional case of malignancy and another case of a follicular neoplasm.[<xref ref-type="bibr" rid="CIT7">7</xref>–<xref ref-type="bibr" rid="CIT13">13</xref>] In view of hypercellularity, papillaroid formations, along with presence of focal nuclear overlapping and grooves, the initial diagnosis in the present case was that of a papillary carcinoma. However, on detailed evaluation on review, only some of these features were noted in rare cells. The intranuclear inclusions were lacking within the hypercellular aspirate, along with presence of macrophages and Hurthle cells against a background of colloid. Hence, as per The Bethesda System for reporting thyroid cytopathology guidelines, the present case fitted in the category of follicular lesion of undetermined significance.[<xref ref-type="bibr" rid="CIT14">14</xref>] In addition to a follicular lesion, the second aspirate revealed microfilariae of <italic>W. bancrofti</italic>. Besides, CL crystals, as reported in our earlier documented case of breast filariasis, were also noted.[<xref ref-type="bibr" rid="CIT5">5</xref>] However, there was no accompanying inflammation. The peripheral blood smears did not exhibit eosinophilia as noted by others[<xref ref-type="bibr" rid="CIT7">7</xref><xref ref-type="bibr" rid="CIT10">10</xref><xref ref-type="bibr" rid="CIT12">12</xref><xref ref-type="bibr" rid="CIT13">13</xref>] in their case descriptions. However, some investigators[<xref ref-type="bibr" rid="CIT8">8</xref><xref ref-type="bibr" rid="CIT9">9</xref>] similar to our case, did not identify eosinophilia in their case reports on microfilaria in thyroid.</p><p>The present case was amicrofilaremic as there was lack of parasite in the blood smear that also ruled out contamination from blood. The possible explanation for this unusual occurrence is the lodgment of the parasite in the thyroid vasculature, including lymphatics. This patient hailed from an area with high endemicity, both for goiter and filariasis.[<xref ref-type="bibr" rid="CIT2">2</xref>] A similar observation was noted by Sodhani <italic>et al</italic>,[<xref ref-type="bibr" rid="CIT7">7</xref>] wherein the described case came from the area with high endemicity for both, goitre and filariasis.</p></sec><sec sec-type="conclusion" id="sec1-2"><title>CONCLUSION</title><p>FNAC is extremely useful in identifying filarial infection at uncommon sites like thyroid. An index of suspicion is necessary, especially in cases coming from high endemicity to tertiary cancer referral centre like ours’. A timely diagnosis that might be possible with FNAC could possibly help in obviating surgery in such cases that are treated with drugs, except in a case like the present one with a retrosternal mass, where surgery was required in order to relieve pressure symptoms. However, lymph node dissection would have been avoided, unlike in a case of thyroid carcinoma. The final histopathological examination could not be performed as the patient succumbed to death and autopsy was not performed. The possible reasons could have been related to pressure symptoms from the retrosternal mass, as filarial infection is rarely fatal. A coexisting hypercellular follicular lesion on thyroid aspirate smears in the present case created a diagnostic challenge.</p></sec><sec id="sec1-3"><title>COMPETING INTEREST STATEMENT BY ALL AUTHORS</title><p>We declare that we have no competing interests.</p></sec><sec id="sec1-4"><title>AUTHORSHIP STATEMENT BY ALL AUTHORS</title><p>Each author acknowledges that this final version was read and approved. All authors qualify for authorship as defined by ICMJE <ext-link ext-link-type="uri" xlink:href="http://www.icmje.org/#author">http://www.icmje.org/#author</ext-link>. Each author par-ticipated sufficiently in the work and takes public responsi-bility for appropriate portions of the content of this article.</p></sec><sec id="sec1-5"><title>ETHICS STATEMENT BY ALL AUTHORS</title><p>This manuscript is a case description in form of a letter. Therefore, IRB approval was not mandatory.</p></sec><sec id="sec1-6"><title>EDITORIAL / PEER-REVIEW STATEMENT</title><p>To ensure integrity and highest quality of CytoJournal publications, the review process of this manuscript was conducted under a double blind model(authors are blinded for reviewers and reviewers are blinded for authors)through automatic online system.</p></sec></body><back><fn-group><fn fn-type="other"><p>Available FREE in open access from: <ext-link ext-link-type="uri" xlink:href="http://www.cytojournal.com/text.asp?2011/8/1/4/">http://www.cytojournal.com/text.asp?2011/8/1/4/</ext-link></p></fn></fn-group><ref-list><title>REFERENCES</title><ref id="CIT1"><label>1</label><element-citation publication-type="book"><article-title>Reports of National Filaria control programme</article-title><source>National Institute of Communicable diseases</source><year>1955</year><publisher-loc>New Delhi</publisher-loc><fpage>80</fpage></element-citation></ref><ref id="CIT2"><label>2</label><element-citation publication-type="book"><person-group person-group-type="author"><name><surname>Park</surname><given-names>K</given-names></name></person-group><article-title>Park’s Textbook of Preventive and Social Medicine</article-title><year>2005</year><edition>18th ed</edition><publisher-loc>Jabalpur</publisher-loc><publisher-name>Bhanot Publishers</publisher-name><fpage>211</fpage><lpage>6</lpage></element-citation></ref><ref id="CIT3"><label>3</label><element-citation publication-type="other"><article-title>National Vector Borne Disease Control Programme</article-title><source>Lymphatic filariasis</source><comment>Available from: <ext-link ext-link-type="uri" xlink:href="http://www.namp.org">http://www.namp.org</ext-link> [last cited on 2010]</comment></element-citation></ref><ref id="CIT4"><label>4</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Jayram</surname><given-names>G</given-names></name></person-group><article-title>Microfilariae in fine needle aspirates from epididymal lesions</article-title><source>Acta Cytol</source><year>1987</year><volume>31</volume><fpage>59</fpage><lpage>62</lpage><pub-id pub-id-type="pmid">3468719</pub-id></element-citation></ref><ref id="CIT5"><label>5</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Roy</surname><given-names>P</given-names></name><name><surname>Rekhi</surname><given-names>B</given-names></name><name><surname>Chinoy</surname><given-names>RF</given-names></name></person-group><article-title>Panorama of cytomorphological findings of filariasis in the contralateral breast, clinically mimicking a carcinoma in a known case: a case report</article-title><source>Diagn Cytopathol</source><year>2008</year><volume>36</volume><fpage>794</fpage><lpage>6</lpage><pub-id pub-id-type="pmid">18831013</pub-id></element-citation></ref><ref id="CIT6"><label>6</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Avasthi</surname><given-names>R</given-names></name><name><surname>Jain</surname><given-names>AP</given-names></name><name><surname>Swaroop</surname><given-names>K</given-names></name><name><surname>Samal</surname><given-names>N</given-names></name></person-group><article-title>Bancroftian microfilariasis in association with pulmonary tuberculosis. 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