URINARY FILARIASIS PRESENTING AS BLADDER PSEUDOTUMORS

Abstract

Filariasis is a parasitic infection of the lymphatic channels due to vector borne tissue nematodes. Wuchereria bancrofti is the most commonly isolated species. The disease is endemic in tropical areas throughout the world, affecting approximately 100 million patients. The usual presentation involves inguinal lymphadenitis, and lymphedema of the lower extremities and external genitalia.' Urinary tract involvement may develop in the form of chyluria, which is thought to be due to stasis and hypertension within the retroperitoneal lymphatics that result in the reflux of lymph from the renal lymphatics into the renal fornix.1 We report a case of urinary filariasis presenting as gross hematuria and multiple exophytic bladder lesions. CASE REPORT A 27-year-old man presented with intermittent gross, painless hematuria 1 month in duration. The patient had been a resident of rural Indonesia before moving to Canada 3 years before the presentation. While in Indonesia the patient had had slowly progressive swelling of the right lower leg and knee since age 12 years. He noticed an occasional spontaneous discharge of milky white fluid through skin fissures around the ankle. Aspiration of the knee joint performed in Indonesia had revealed a similar white fluid. At age 20 years chylothorax developed, which was treated with chest tube drainage for 2 weeks. Chylothorax has not recurred. The patient also noticed the passage of white or cloudy urine on rare occasions. No specific diagnosis was made in Indonesia and no antimicrobial treatment was given. Physical examination demonstrated moderate to severe nonpitting lymphedema of the right thigh and lower leg. The external genitalia and left leg were normal. The remainder of the physical examination was normal. Urinalysis revealed whitish urine that was shown to contain chylomicrons aRer the removal of red blood cells by centrifugation. Excretory urography was normal. Computerized tomography of the abdomen and pelvis demonstrated dilated lymphatic glands around the distal right ureter and bladder (fig. 1). The lymphatic glands were not visualized around the kidneys, or in the para-aortic or para-caval regions. Cystoscopy showed multiple exophytic bladder lesions up to 1 cm. in diameter. These white or dark red lesions were on the trigone and around the right ureteral orifice. The surrounding urothelium appeared normal. The lesions were resected transurethrally and the surrounding areas were fulgurated. Histological evaluation revealed normal urothelium overlying a complex network of benign vascular channels. Most channels contained an eosinophilic material consistent with lymph but some contained numerous red blood cells (fig. 2). There was no evidence of cystitis or carcinoma in situ in the resected tissue. The patient underwent followup cystoscopy 3 months after transurethral resection. Small nodular lesions resembling the original tumors were noted on the trigone. Retrograde