Unexpected Guest

Dr C Jayakumar , Dr Gigo karimattim George, Gigo scan Kottayam ,DrVenkat ,DrVishnu B Menon ,Community medicine 

Eleven year old girl otherwise normal attending school presented to the office room for a swelling in the in the medical aspect of the right upper arm of size 2 into 1 cm. No history of weight loss nights Fever or flexibility or bleeding tendency for the girl

No history of having contact with pets or with people having pets

No history of kissing parents or siblings or sleeping in over crowded room

The child’s vitals were normal

PICCLE normal

No neuro cutaneous markers noted

All auxogical parameters were normal

Systemic examination normal

The swelling situated 4cm above medical aspects of right elbow has no focus infection in the drainage area and it was not tender or erythematous

Differentials

Secondary, bacterial lymphadenitis

Infectious mononucleosis

neurofibromatosis

Labs CBC 12,000/cmm

CRP 8

P40%L56%E4%

Peripheral smear normal

EBV IgM negative

At this point USG of the skin nodule was done to rule out neuro fibroma

USG report was a big surprise

Moving worm was isolated

Dirofilaria

Treatment

Most of the cases it can be left alone

Definitive treatment is surgical removal

Medical management is ivermectin 200micrigram /kg maximum 6mg as single dose along with 6mg /kg /day Diethyl carbamazine as BD for a period of 14to 21 days

Dirofilaria immitis most often causes pulmonary disease in the human host, but can also uncommonly cause nodules in other tissues. Humans are suboptimal hosts and larvae that migrate to the heart usually die. Dead worms produce infarcts when they lodge in pulmonary vessels; these infarcts are usually referred to as “coin lesions” on chest radiography, which may be mistaken for malignancy. Following embolization, patients may present with vague systemic symptoms (e.g. malaise, fever, chills) and respiratory distress. There is often a mild eosinophilia.

Species of Dirofilaria in the subgenus Nochtiella usually (but not always) manifest as subcutaneous nodules. These nodules are often tender, and may be fixed or migratory. D. repens-associated lesions can occur in a variety of locations, the most typical being in exposed sites (e.g. scalp, arms, legs, eyelids, chest), but occasionally have been found in deeper tissue such as the breast, epididymis, spermatic cord, and subconjunctiva. Many reports of D. tenuis involve the facial region (e.g. ocular and periocular sites, oral mucosa, cheek) and breast nodules. Unlike D. immitis, some of these species may achieve a degree of development beyond the larval stage in the human host, as adult-stage D. repens and D. tenuis are often discovered in human infections. However, most do not develop to sexual maturity. There are very rare reports of patent D. repens infections in humans with detectable microfilariae in the blood.

Dancing sign

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