Citation: Brody MB, Tuite C and Evers KA. What’s the Worm? Breast Calcications in a Patient from Cameroon.
Austin J Clin Case Rep. 2016; 3(6): 1108.
Austin J Clin Case Rep - Volume 3 Issue 6 - 2016
ISSN : 2381-912X | www.austinpublishinggroup.com
Brody et al. © All rights are reserved
Austin Journal of Clinical Case Reports
Open Access
Abstract
Determining the signicance of calcications seen on mammogram can be
a vexing problem for radiologists. Identifying benign morphologies can avoid
unnecessary work-ups and procedures. We describe breast calcications
typical for larial infection seen on screening mammogram in a patient who is a
native of Cameroon. Filariasis is the most common parasitic infection affecting
the breast, and is transmitted by insect vectors. It is most prevalent in parts of
Africa, Asia, and India. In general, breast calcications due to larial infection
in Westernized countries are seen in asymptomatic patients from endemic
areas, and are the result of treated, chronic, or “burned out” infection. The
epidemiologic, mammographic, and clinical and features of larial infection are
discussed.
Keywords: Filariasis; Breast calcications; Mammogram
Case Presentation
A 68 year old female was referred by her primary care physician
for routine screening mammography on our mobile mammography
unit. e patient is a native of West Africa. She reported that her prior
mammograms were performed in Cameroon and were not obtainable
for comparison. At the time of screening, she was asymptomatic.
She denied a family history of breast cancer, or a personal history of
hormone use, prior breast procedures, or reduction surgery. Routine
mammographic views show calcications bilaterally. In the lower
inner le breast (Figure 1a), there are thick linear calcications with
lucent centers. In the subareolar right breast (Figures 1b & 1c), there
are thick linear calcications arranged in a serpiginous conguration.
In the upper inner right breast and central outer le breast (Figures
1d &1e), there are ne linear calcications arranged in a coiled
conguration. In the upper outer right breast, there are more tightly
grouped thick linear calcications, for which the patient was called
back for additional imaging. On magnication imaging (Figure 2),
this group is comprised of monomorphic thick linear calcications,
representing fragments of similar-appearing calcications in other
areas of the breasts.
Based on the characteristic appearance of the breast calcications,
and appropriate epidemiologic history, the patient was given a BI-
RADS Category 2 assessment and advised to return in one year for
routine screening. e ndings were reported by telephone to the
referring Nurse Practitioner.
Discussion/Conclusion
Breast calcications seen on this patient’s mammogram are
consistent with lariasis infection.
Filariasis is the most common parasitic infection aecting
the breast [1], occurring mainly in sub-Saharan Africa; Southeast
Asia; the Indian subcontinent; several Pacic islands; Northern
Australia [2]; areas of Central and South America; and small areas of
Caribbean, especially Haiti [3]. It is caused by roundworms that infect
Case Report
What’s the Worm? Breast Calcications in a Patient from
Cameroon
Brody MB*, Tuite C and Evers KA
Department of Diagnostic Imaging, Fox Chase Cancer
Center, USA
*Corresponding author: Marion B Brody, Department
of Diagnostic Imaging, Fox Chase Cancer Center,
Philadelphia, PA, USA
Received: November 08, 2016; Accepted: December
28, 2016; Published: December 30, 2016
the lymphatics and subcutaneous tissues. e majority of larial
lymphatic infections are caused by the W. Bancroi species [3],
which is transmitted to humans by mosquito vectors. Similar breast
calcications may also be seen from cutaneous infection with Loa, a
nematode endemic to west and central Africa [4,5]. Co-infection with
more than one helminthic species is not uncommon.
Filarial disease starts with a bite from an infected mosquito,
which introduces larvae into the patient’s bloodstream. e larvae
migrate to local lymphatic vessels, where they mature into adult
worms over a period of almost a year. At this time, the adult worms
mate, producing microlaria, which migrates through lymphatic’s
into the bloodstream. In most geographic areas, the concentration of
circulating microlaria is highest in the evening [3]. If a mosquito bites
the infected individual during this time, it will ingest the organisms
and then may infect other humans. e circulating microlarias do
not mature into adult worms; additional adult worms may only be
introduced into a human host through subsequent bites by infected
mosquitoes. Adult worms survive in the human lymphatics for ve
years or more.
Most individuals infected with larial organisms are
asymptomatic. However, the worms may incite a brisk inammatory
reaction. When the inammation occurs around lymphatic vessels,
it causes brosis, and over a period of time, lymphatic obstruction.
is obstruction leads to the clinical syndrome of elephantiasis -
swelling and skin thickening of the extremities. An elephantiasis-type
presentation, however, is uncommon in the breast.
Acute symptomatic larial infections involving the breast are
unusual, and occur almost exclusively in endemic regions. ey
may present as rm, non-tender or painful subcutaneous breast
nodules [6-9], with overlying skin hyperemia, peau d’orange, and/
or nipple discharge [8]. On mammography, the nodules appear as
dense ovoid masses [1], and may be associated with calcications
[1,9,10]. In this setting, the ndings may appear alarming and prompt
recommendation for biopsy. Rarely, ultrasound of the nodules show
Austin J Clin Case Rep 3(6): id1108 (2016) - Page - 02
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Austin Publishing Group
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rhythmic movements of the organisms in dilated cystic lymphatics, a
nding described as “larial dance” [1,9].
Most breast calcications from larial infection, like those
seen in our patient, are the result of treated, chronic, or “burned
out” infection. eir presence is attributed to calcication of the
dead parasites in perilymphatic so tissue [1,2,5,9]. Although they
are rarely encountered in Western countries, they are not unusual
in other parts of the world. For example, Adeniji-Sofoluwe et al.
[9] found them present in 7.4% of mammograms in Nigeria. As
noted, their morphology does not readily conform to the BI-RADS
lexicon. ey have been described as serpiginous [1,2,5-7]; tortuous
and ring-like [9]; wormlike [1,2,5]; meandering [5]; vermiform [4];
lamentous [5,6]; and tubular with lucent centers [7]. ey have
also been described as “continuous or beaded ne calcications” and
coiled, “hair-like whorls of calcications” [9]. Several authors have
described them as typically bilateral, while one author notes them to
be bilateral in only 12% of cases [4,5,9]. e calcications may be seen
in any area of the breast, including the subareolar region, but they
most are most commonly found in the lower inner and upper outer
quadrants [9,11]. Adeniji-Sofoluwe [9] reports that they occur more
oen in the le breast. In cases where only small fragments of the
calcied worm are present, the ndings may raise concern for breast
malignancy and result in additional imaging, biopsy, and/or surgery.
Calcications due to chronic larial infection tend to remain stable
on follow up examinations [1,2,5].
In asymptomatic immigrants with larial calcications on
mammogram, a CBC to exclude peripheral eosinophilia is sucient
to rule out active infection. In rare instances in which acute or active
infection is suspected, assays for Circulating Filarial Antigen (CFA)
and examination of peripheral blood smears for microlaria may help
conrm the diagnosis. Polymerase chain reaction assays have been
used as research tools but are not commercially available [3].
In our case, the patient reported no palpable abnormalities, skin
changes or nipple discharge in either breast at the time of screening
or prior. e patient’s peripheral eosinophil level was normal. Most
of the calcications have the typical whirled, lucent-centered, or
serpiginous, morphology described in other reports; however, some
of the calcications are located in the upper inner quadrant, an area of
the breast less commonly involved. As is sometimes the case, a group
of calcications in the upper outer right breast comprised of only
fragments of worms prompted additional imaging.
In summary, when characteristic calcications are seen on
mammograms in women from endemic areas, the diagnosis of larial
infection can be made. Knowledge of these unusual imaging ndings
may prevent unnecessary additional imaging or biopsy, especially
when the patient is asymptomatic.
A
B
C
D
E
Figure 1: Screening mammogram of a 68 year old female from Cameroon shows calcications characteristic of larial infection. In the lower inner left breast,
a left MLO view (a) shows thick linear calcications with lucent centers. In the subareaolar right breast, right CC (b) and right MLO (c) views show thick linear
calcications arranged in a serpiginous conguration. In the upper inner right breast and central outer left breast, right (d) and left (e) MLO views show ne linear
calcications arranged in a coiled conguration.
Figure 2: Magnication ML view of the upper outer right breast show a group
of monomorphic thick linear calcications, resembling fragments of similar-
appearing forms in other areas of the breasts.
Austin J Clin Case Rep 3(6): id1108 (2016) - Page - 03
Brody MB
Austin Publishing Group
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Citation: Brody MB, Tuite C and Evers KA. What’s the Worm? Breast Calcications in a Patient from Cameroon.
Austin J Clin Case Rep. 2016; 3(6): 1108.
Austin J Clin Case Rep - Volume 3 Issue 6 - 2016
ISSN : 2381-912X | www.austinpublishinggroup.com
Brody et al. © All rights are reserved
