Indian Journal of Medical Microbiology IAMM  | About us |  Subscription |  e-Alerts  | Feedback |  Login   
  Print this page Email this page   Small font sizeDefault font sizeIncrease font size
 Home | Ahead of Print | Current Issue | Archives | Search | Instructions  
Users Online: 6976 Official Publication of Indian Association of Medical Microbiologists 
  Search
 
  
 ~  Similar in PUBMED
 ~  Search Pubmed for
 ~  Search in Google Scholar for
 ~  Article in PDF (735 KB)
 ~  Citation Manager
 ~  Access Statistics
 ~  Reader Comments
 ~  Email Alert *
 ~  Add to My List *
* Registration required (free)  

 
 ~  References
 ~  Article Figures

 Article Access Statistics
    Viewed1789    
    Printed33    
    Emailed0    
    PDF Downloaded96    
    Comments [Add]    
    Cited by others 1    

Recommend this journal

 


 
  Table of Contents  
CORRESPONDENCE
Year : 2013  |  Volume : 31  |  Issue : 1  |  Page : 100-101
 

Microfilaruria with intermittent chyluria in pregnancy: An unusual association


Department of Pathology, Lady Hardinge Medical College, New Delhi, India

Date of Submission18-Jun-2012
Date of Acceptance14-Oct-2012
Date of Web Publication15-Mar-2013

Correspondence Address:
M Pujani
Department of Pathology, Lady Hardinge Medical College, New Delhi
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0255-0857.108761

Rights and Permissions



How to cite this article:
Pujani M, Agarwal S, Jain A. Microfilaruria with intermittent chyluria in pregnancy: An unusual association. Indian J Med Microbiol 2013;31:100-1

How to cite this URL:
Pujani M, Agarwal S, Jain A. Microfilaruria with intermittent chyluria in pregnancy: An unusual association. Indian J Med Microbiol [serial online] 2013 [cited 2019 Nov 19];31:100-1. Available from: http://www.ijmm.org/text.asp?2013/31/1/100/108761


Dear Editor,

Lymphatic filariasis is one of the oldest and most debilitating diseases in the world, principally affecting the people in tropical and sub-tropical areas. One-third of the people infected live in India, one-third in Africa, and the rest in South Asia, Western Pacific and parts of Central and South America. Ninety percent of these infections are caused by Wuchereria bancrofti for which humans are the exclusive hosts and major vectors being culicine mosquitoes. Although the disease has no sex predilection, it mainly affects young adult males from poor socioeconomic background. [1] We report a rare case of microfilaruria in a pregnant female presenting with intermittent chyluria. Detection of microfilaria is described in centrifuged preparations of cystoscopically catheterised urine but very rarely in normally voided urine samples, especially the chylous samples. [2]

A 25-year-old 38 +3 weeks pregnant female admitted to the obstetrical emergency for the complaints of decreased foetal movements. She also gave history of off and on passage of milky urine for past 3 months. Emergency caesarian section was performed, a live healthy baby was delivered. The patient did not have any lymphedema, inguinal lymphadenopathy or cough. Urine sample on fifth postpartum day was sent for examination. Its colour was milky white and it did not clear on heating with dilute acetic acid ruling out phosphaturia, but cleared when mixed with equal parts of ether and shaken vigorously (Ether test). Urine protein was 4+ and sugar was nil (dipstick). Smears prepared from centrifuged sediment, as well as cytospin preparations were stained with papanicolaou and haematoxylin and eosin, revealed presence of sheathed microfilariae having tapering caudal end with no terminal nuclei in a background of numerous lymphocytes (40/hpf) and few epithelial cells [Figure 1]. However, no casts or crystals were seen. Ziehl-Neelsen-stained urine smears for acid fast bacilli were negative. Haematological investigations revealed haemoglobin of 10 g%, total leukocyte count 15,600/mm 3 , differential of 70% neutrophils, 11% eosinophils and 19% lymphocytes. Peripheral smear did not show any microfilaria or any other parasite. Stool sample was negative for any ova or cyst. A diagnosis of chyluria with W. bancrofti microfilaruria was rendered.
Figure 1: Cytospin smear showing single sheathed microfilaria with empty caudal end in a background of numerous lymphocytes (Pap, ×1000)

Click here to view


The filarial disease has protean manifestations in the form of chronic, acute and asymptomatic presentations, as well as a few syndromes associated with these infections that may/may not be directly caused by the parasite. Chronic manifestations include hydrocele and lymphedema, which in early stages may be associated with microfilaremia. Development of elephantiasis (limbs/genitalia) is most commonly associated with a history of recurrent inflammatory episodes. Chyluria, another form of chronic filarial syndrome, is caused by intermittent discharge of intestinal lymph (chyle) into the renal pelvis and finally into the urine. [1] Acute manifestations include acute inflammatory episodes of limbs/scrotum, termed as acute dermato-lymphangio-adenitis with features of cellulitis and drain towards central lymph nodes. Another form could be lymphadenitis especially of the inguinal lymph node due to immune-mediated response to an adult worm dying in the lymphatic tract. An acute filarial syndrome is tropical pulmonary eosinophilia caused by immunological hyper-responsiveness to filarial infection.

Chyluria occurs only in 2% of the filarial-infected patients. [3] The adult worm causes lymphangitis and valvular incompetence. If the obstruction is between intestinal lacteals and thoracic duct, the resulting cavernous malformation opens into the urinary system forming lymphourinary fistula. Once the fistula is formed, continuous or intermittent chyluria occurs. Causes of chyluria include parasitic (W. bancrofti, Tenia echinococcus, Tenia nana, malarial parasite, Cerconomas hominis) or non-parasitic (tuberculosis, congenital lymphangioma of urinary tract, trauma, pregnancy, malignant infiltration of lymphatics). [3]

The diagnosis of chyluria can be confirmed by evaluating a sample of postprandial urine for chylomicrons and triglycerides. The intermittent passage of milky cloudy urine should be differentiated from phosphaturia, which clears on addition of 10% acetic acid. Microscopic examination of urine sediment is of utmost value to look for pus cells (pyuria), microfilaria, acid fast bacilli (Ziehl-Neelsen-stained smears). Total leukocyte count, differential leukocyte count (eosinophilia) and peripheral smear for microfilaria may act as corroborative evidence. Intravenous urography, retrograde pyelography, lymphangiography and lymphoscintigraphy may be used to demonstrate abnormal lymphatic urinary fistula which in some cases may be therapeutic due to contrast dye-induced chemical pyelitis causing obliterative sclerosis of lymphatics leading to cessation of chyluria. [4],[5] Due to the rarity of the isolation of microfilaria in urine as well as blood samples, serological markers have been developed to detect infection. Patients with W. bancrofti infection mount an immune response of IgG4 antibody against W. bancrofti antigen WbSXP-1. Antibodies specific to recombinant filarial antigen, WbSXP-1, have been used to develop enzyme-linked immunosorbent assay (ELISA) for detecting circulating filarial antigen in sera of patients with filariasis. [6] A similar ELISA to detect filarial specific IgG4 antibodies in unconcentrated urine has been developed. [7]

Occasional case report of pregnant female with chyluria has been reported in literature; however, concomitant microfilaruria has not been demonstrated. [8] Medical management of chyluria includes bed rest, high protein diet with exclusion of fat (except medium-chain triglycerides), drug therapy with diethylcarbamazine and use of abdominal binders (to decrease lymphourinary reflex by increasing intra-abdominal pressure). Surgical management of refractory cases includes endoscopic sclerotherapy using silver nitrate, surgical lymphatic disconnection and microsurgical techniques.

 
 ~ References Top

1.De Vries CR. Basic science of lymphatic filariasis. Indian J Urol 2005;21:5-8.  Back to cited text no. 1
    
2.Seth A. Microfilaruria in a patient of intermittent chyluria. J Cytol 2009;26:151-2.  Back to cited text no. 2
[PUBMED]  Medknow Journal  
3.Diamond E, Schapira HE. Chyluria: A review of the literature. Urology 1985;26:427 31.  Back to cited text no. 3
[PUBMED]    
4.Singh I, Dargan P, Sharma N. Chyluria: A clinical and diagnostic stepladder algorithm with review of literature. Indian J Urol 2004;20:79-85.  Back to cited text no. 4
  Medknow Journal  
5.Núñez Mora C, Cárcamo Valor P, de Cabo Ripoll M, Kabani MH, Martínez-Piñeiro Caramés JA. Recurrent nonparasitic chyluria. Arch Esp Urol 1998;51:932-4.  Back to cited text no. 5
    
6.Rao KV, Eswaran M, Ravi V, Gnanasekhar B, Narayanan RB, Kaliraj P, et al. The Wuchereria bancrofti orthologue of Brugia malayi SXP1 and the diagnosis of bancroftian filariasis. Mol Biochem Parasitol 2000;107:71-80.  Back to cited text no. 6
    
7.Itoh M, Weerasooriya MV, Qiu G, Gunawardena NK, Anantaphruti MT, Tesana S, et al. Sensitive and specific enzyme-linked immunosorbent assay for the diagnosis of Wuchereria bancrofti infection in urine samples. Am J Trop Med Hyg 2001;65:362-5.  Back to cited text no. 7
    
8.Mount P, Thong M. Perirenal lymphatic filariasis presenting as chyluria during pregnancy. Kidney Int 2006;69:2115.  Back to cited text no. 8
    


    Figures

  [Figure 1]

This article has been cited by
1 Chyluria in Pregnancy-A Decade of Experience in a Single Tertiary Care Hospital
Khalid Mahmood,Ahsan Ahmad,Kaushal Kumar,mahendra singh,sangeeta pankaj,Kalpana singh
Nephro-Urology Monthly. 2015; 7(2)
[Pubmed] | [DOI]



 

Top
Print this article  Email this article
 

    

2004 - Indian Journal of Medical Microbiology
Published by Wolters Kluwer - Medknow

Online since April 2001, new site since 1st August '04