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Some Sequelae of Filariasis of Urological Interest
SOME SEQUELAE OF FILARIASIS OF UROLOGICAL INTEREST P. T. CHEN
AND
J. GRAY
From the Lester Hospital, Shanghai
While filariasis per se is of no special interest to the urologist the subsequent lymphatic obstruction does occasionally give rise to conditions which may concern him. Three types of such sequelae have come our way during the last 5 years. They are (1) filariasis of the spermatic cord and hydrocele; (2) elephantiasis of the scrotum and penis; and (3) chyluria. An illustrative example of the first two will be given. The second in particular is frequently met with in the out-patient department. The third condition will be dealt with at greater length. Filariasis of the cord. A Chinese policeman, age 46, was admitted with a hydrocele, some swelling of the spermatic cord and a history of frequency of micturition. No microfilariae were found in the blood. The blood film was in fact normal apart from a high eosinophilia. On performing the usual radical excision operation for the hydrocele a hard nodule was found in the cord. This was excised along with a number of veins. On section the nodule proved to be a filarial parasite probably Wuchereria bancrofti. Elephantiasis of the scrotum and penis. A Chinese farmer, aged 37, was admitted with the enormous scrotum depicted in figure 1. He had noticed symptoms referable to the external genitalia for at least 22 years. The first thing observed was a lump in the groin and a painful swelling of the left testis associated with recurrent febrile attacks. The scrotum began to enlarge and the skin desquamated and there was a troublesome serous discharge. From his description the condition appeared at this stage to be a lymph scrotum. Later he had a hydrocele which was tapped once. There was also a history of an abscess in the groin. His condition on admission was as in the photo and he was completely incapacitated from work owing to the weight of the scrotum. Micro:filariae were found in the blood. The scrotum was removed by means of the endothermy knife in several stages with a few days interval between each. The testes and cord were shelled out of the blubbery mass of subcutaneous tissue, the hydroceles were excised radically and a new scrotum formed out of healthy skin from the thigh with the aid of a skin graft. The whole procedure 68
69
SEQUELAE OF FILARIASIS
was attended with considerable sepsis and some shock but the final result was very satisfactory to the patient (fig. 2). Although we would have preferred to do something more of a plastic nature he refused this as he considered that the aesthetic appearance was not of great importance. The actual weight of the scrotum must have been about 60 pounds or about half the patient's entire body weight (weight on admission 181 pounds, on discharge 119 pounds). These 2 cases illustrate some points in the pathology. Ray, in an excellent description of the filarial affections of the male genital tracts,
FIG. l
FIG. 2
mentions lymphatic varix of the cord or varicocele, endemic funiculitis, chronic epididymo-orchitis, hydrocele, elephantiasis of the scrotum and lymph scrotum. It is easy to see how from its dependent and exposed position the scrotum is readily involved. Climatic conditions and poor hygiene account for repeated skin infection or irritation and this together with the lymphatic obstruction eventually give rise to the elephantoid condition which is the last stage of the vicious circle.
TABLE DATE
NO.
AGE
BLOOD PICTURE
1 TREATMENT
HISTORY
CYSTOSCOPIC FINDINGS
Microfil.+
Sudden haematuria followed by chyluria and frequency
Bladder normal. Both kidneys normal dye test and pyelograms. Chyle slight lll both ureteric specimens
Conservative (N.A.B.)
Improved while at rest
Conservative (N.A.B.)
Improved rest
RESULT
~~
1933
2753 29
1934
528 29
M.+
Old arthritis of hip healed. Chyluria noticed incidentally
Chyle pouring from left kidney. Right normal. Both renal functions and pyelograms normal. Bladder normal
1934
1405 20
M.-
Acute attack of chyluria, no haematuria. Frequency and loss of weight
Bladder normal. Chyle pouring Right nephrectomy Cured. Seen repeatedly since with no from right side. Function poor to dye and intravenous pyelogram, recurrence. Kidney also infection on this side. Left specimen showed diside normal lated in trarenal 1ym phatic spaces
1934
2980 34
M.-
Haematuria, frequency, chyluria 1½years
while
Bladder normal. Both kidney function normal. Left specimen.B. coli. Left pyelogram shows extra renal lymphatic fistula (?)
Conservative as chyle not obtained from either side. Left kidney in doubt
Improved at rest
-t 0
at
fi:I
:-'l
g M
z
>
8 :-'
~
1935
2347 36
M.+ in blood Abrupt onset. Frequency and urine and chyluria
Fistula seen near right ureter only with chyle exuding. Kidneys normal
Repeated cauterization with fulgurating electrode
Apparently cured. No recurrence
1935
3754 26
M.-
Haematuria recurrent followed by chyluria
Bladder normal. Chyle pouring from left ureter only. Pyelogram normal
Left nephrectomy
Cured
1937
5894 32
M.-
Chyluria, frequency 4 months, old gonorrhoea
Bladder normal. Chyle pouring Left nephrectomy from left ureter only. Pyelograms normal function both sides normal
Cured
SEQUELAE OF FILARIASIS
71
Macroscopically the thickness of the skin and the blubbery subcutaneous tissue produce a picture truly amazing the first time seen. The histological appearance of interlacing bands of fibrous tissue with a round celled exudate is also quite characteristic. These features are illustrated in the photo and it is unnecessary to say anything further about them. Turning to the last condition of chyluria this is of much greater interest. An abstract is given of the clinical histories of 7 cases seen and fully investigated during the last few years (table 1). There have been others which have not been completely investigated owing to refusal on the part of the patient. There are some features that may be discussed in further detail under (1) diagnosis and (2) treatment.
FIG.
3
Diagnosis. We believe that these cases were secondary to filariasis but only in 3 was the filaria discovered in the blood stream. The absence of the parasite in the blood is no conclusive evidence as may be seen from the case of filariasis of the cord described here where the adult parasite was found in the tissue although the microfilaria was not found in the blood. We do not think this is a question of great relevance; the important points are: (1) Does the chyle come from the bladder or (2) from the kidneys? If the latter, is the condition bilateral or umlateral? In determining these points we rely on the usual complete routine
72
P. T. CHEN AND
J.
GRAY
cystoscopic investigation but about ½hour prior to this a fatty meal is given. Under these conditions the appearance of chyle pouring like milk from the ureteric orifice is most striking. The examination of the separate specimen from each kidney for chyle, evidence of infection and for kidney function is carried out. Pyelography is then done. Only in 1 case (No. 2980) was there anything suggestive of a pyelo-lymphatic communication (fig. 3). This is not surprising in view of the findings at operation. In the first nephrectomy we per-
FIG.
4
formed for this condition (No. 1405) when the kidney was mobilised it looked so perfectly normal in every respect with no abnormal lymphatics visible that it was with some misgiving that we removed it. However, on making a histological examination by the "whole section" method (figs. 4 and 5) there were seen spaces believed to be dilated intra renal lymphatics communicating with the tubules which also showed evidence of pathological changes. In the last case (No. 5894) on mobilising the kidney a leash of dilated lymphatics was seen on the renal pedicle although the kidney itself appeared normal.
SEQUELAE OF FILARIASIS
73
Treatment. The case in which there was a fistula into the bladder (No. 2347) we treated with repeated fulguration. Under this treatment the fistula closed completely at all events during the period under which the patient was under observation. Unfortunately, it is practically impossible to follow up our patients over any length of time. The immediate result was certainly most satisfactory. With regard to the renal cases there were 4 in which the chyluria was proved to be unilateral and in 3 of these we did nephrectomy in every
FIG.
5
case with complete relief. One of the cases we have followed over a period of several years and there has been no recurrence. It is interesting to note in the histories how frequently there is a story of haematuria and this in itself, particularly if there is evidence of renal infection, may well be good grounds for nephrectomy, In the 4th case of unilateral chyluria we did not do nephrectomy as at that time we were somewhat hesitant about advising such drastic treatment, particularly as the blood film was positive for microfilaria. If we have been able to prove that the chyluria is unilateral, we have had no hesitation in recommending
74
P. T. CHEN AND
J.
GRAY
nephrectomy. One reason for this is that in surgical work here it is most desirable to produce successful results. It is practically impossible to explain the pathology of the disease in terms a simple country man can understand and he has no time to wait while we try experimental methods with drugs. Further any failure in treatment has a definitely harmful effect on surgical practice amongst people who are at best quite sceptical about our modern methods. For this reason we think it may not be without value to put on record the encouraging results that have followed nephrectomy for chyluria where the condition is proved to be unilateral and also to stress the value of complete urological investigation of all cases before giving the condition up as unamenable to treatment. REFERENCES ABESHOUSE, B.: Pyelo-lymphatic communications. Am. J. Surg., 25: 427, 1934. FAUST, E. C.: Human Helminthology, pp. 449-453. KrnD, FRANK: Chyluria. Brit. J. Urol., 2: 15, 1930. RAY, P. N.: Filarial affections of the male genital tract. Indian Med. Gaz., 69: 544, 1934.
AND
J. GRAY
From the Lester Hospital, Shanghai
While filariasis per se is of no special interest to the urologist the subsequent lymphatic obstruction does occasionally give rise to conditions which may concern him. Three types of such sequelae have come our way during the last 5 years. They are (1) filariasis of the spermatic cord and hydrocele; (2) elephantiasis of the scrotum and penis; and (3) chyluria. An illustrative example of the first two will be given. The second in particular is frequently met with in the out-patient department. The third condition will be dealt with at greater length. Filariasis of the cord. A Chinese policeman, age 46, was admitted with a hydrocele, some swelling of the spermatic cord and a history of frequency of micturition. No microfilariae were found in the blood. The blood film was in fact normal apart from a high eosinophilia. On performing the usual radical excision operation for the hydrocele a hard nodule was found in the cord. This was excised along with a number of veins. On section the nodule proved to be a filarial parasite probably Wuchereria bancrofti. Elephantiasis of the scrotum and penis. A Chinese farmer, aged 37, was admitted with the enormous scrotum depicted in figure 1. He had noticed symptoms referable to the external genitalia for at least 22 years. The first thing observed was a lump in the groin and a painful swelling of the left testis associated with recurrent febrile attacks. The scrotum began to enlarge and the skin desquamated and there was a troublesome serous discharge. From his description the condition appeared at this stage to be a lymph scrotum. Later he had a hydrocele which was tapped once. There was also a history of an abscess in the groin. His condition on admission was as in the photo and he was completely incapacitated from work owing to the weight of the scrotum. Micro:filariae were found in the blood. The scrotum was removed by means of the endothermy knife in several stages with a few days interval between each. The testes and cord were shelled out of the blubbery mass of subcutaneous tissue, the hydroceles were excised radically and a new scrotum formed out of healthy skin from the thigh with the aid of a skin graft. The whole procedure 68
69
SEQUELAE OF FILARIASIS
was attended with considerable sepsis and some shock but the final result was very satisfactory to the patient (fig. 2). Although we would have preferred to do something more of a plastic nature he refused this as he considered that the aesthetic appearance was not of great importance. The actual weight of the scrotum must have been about 60 pounds or about half the patient's entire body weight (weight on admission 181 pounds, on discharge 119 pounds). These 2 cases illustrate some points in the pathology. Ray, in an excellent description of the filarial affections of the male genital tracts,
FIG. l
FIG. 2
mentions lymphatic varix of the cord or varicocele, endemic funiculitis, chronic epididymo-orchitis, hydrocele, elephantiasis of the scrotum and lymph scrotum. It is easy to see how from its dependent and exposed position the scrotum is readily involved. Climatic conditions and poor hygiene account for repeated skin infection or irritation and this together with the lymphatic obstruction eventually give rise to the elephantoid condition which is the last stage of the vicious circle.
TABLE DATE
NO.
AGE
BLOOD PICTURE
1 TREATMENT
HISTORY
CYSTOSCOPIC FINDINGS
Microfil.+
Sudden haematuria followed by chyluria and frequency
Bladder normal. Both kidneys normal dye test and pyelograms. Chyle slight lll both ureteric specimens
Conservative (N.A.B.)
Improved while at rest
Conservative (N.A.B.)
Improved rest
RESULT
~~
1933
2753 29
1934
528 29
M.+
Old arthritis of hip healed. Chyluria noticed incidentally
Chyle pouring from left kidney. Right normal. Both renal functions and pyelograms normal. Bladder normal
1934
1405 20
M.-
Acute attack of chyluria, no haematuria. Frequency and loss of weight
Bladder normal. Chyle pouring Right nephrectomy Cured. Seen repeatedly since with no from right side. Function poor to dye and intravenous pyelogram, recurrence. Kidney also infection on this side. Left specimen showed diside normal lated in trarenal 1ym phatic spaces
1934
2980 34
M.-
Haematuria, frequency, chyluria 1½years
while
Bladder normal. Both kidney function normal. Left specimen.B. coli. Left pyelogram shows extra renal lymphatic fistula (?)
Conservative as chyle not obtained from either side. Left kidney in doubt
Improved at rest
-t 0
at
fi:I
:-'l
g M
z
>
8 :-'
~
1935
2347 36
M.+ in blood Abrupt onset. Frequency and urine and chyluria
Fistula seen near right ureter only with chyle exuding. Kidneys normal
Repeated cauterization with fulgurating electrode
Apparently cured. No recurrence
1935
3754 26
M.-
Haematuria recurrent followed by chyluria
Bladder normal. Chyle pouring from left ureter only. Pyelogram normal
Left nephrectomy
Cured
1937
5894 32
M.-
Chyluria, frequency 4 months, old gonorrhoea
Bladder normal. Chyle pouring Left nephrectomy from left ureter only. Pyelograms normal function both sides normal
Cured
SEQUELAE OF FILARIASIS
71
Macroscopically the thickness of the skin and the blubbery subcutaneous tissue produce a picture truly amazing the first time seen. The histological appearance of interlacing bands of fibrous tissue with a round celled exudate is also quite characteristic. These features are illustrated in the photo and it is unnecessary to say anything further about them. Turning to the last condition of chyluria this is of much greater interest. An abstract is given of the clinical histories of 7 cases seen and fully investigated during the last few years (table 1). There have been others which have not been completely investigated owing to refusal on the part of the patient. There are some features that may be discussed in further detail under (1) diagnosis and (2) treatment.
FIG.
3
Diagnosis. We believe that these cases were secondary to filariasis but only in 3 was the filaria discovered in the blood stream. The absence of the parasite in the blood is no conclusive evidence as may be seen from the case of filariasis of the cord described here where the adult parasite was found in the tissue although the microfilaria was not found in the blood. We do not think this is a question of great relevance; the important points are: (1) Does the chyle come from the bladder or (2) from the kidneys? If the latter, is the condition bilateral or umlateral? In determining these points we rely on the usual complete routine
72
P. T. CHEN AND
J.
GRAY
cystoscopic investigation but about ½hour prior to this a fatty meal is given. Under these conditions the appearance of chyle pouring like milk from the ureteric orifice is most striking. The examination of the separate specimen from each kidney for chyle, evidence of infection and for kidney function is carried out. Pyelography is then done. Only in 1 case (No. 2980) was there anything suggestive of a pyelo-lymphatic communication (fig. 3). This is not surprising in view of the findings at operation. In the first nephrectomy we per-
FIG.
4
formed for this condition (No. 1405) when the kidney was mobilised it looked so perfectly normal in every respect with no abnormal lymphatics visible that it was with some misgiving that we removed it. However, on making a histological examination by the "whole section" method (figs. 4 and 5) there were seen spaces believed to be dilated intra renal lymphatics communicating with the tubules which also showed evidence of pathological changes. In the last case (No. 5894) on mobilising the kidney a leash of dilated lymphatics was seen on the renal pedicle although the kidney itself appeared normal.
SEQUELAE OF FILARIASIS
73
Treatment. The case in which there was a fistula into the bladder (No. 2347) we treated with repeated fulguration. Under this treatment the fistula closed completely at all events during the period under which the patient was under observation. Unfortunately, it is practically impossible to follow up our patients over any length of time. The immediate result was certainly most satisfactory. With regard to the renal cases there were 4 in which the chyluria was proved to be unilateral and in 3 of these we did nephrectomy in every
FIG.
5
case with complete relief. One of the cases we have followed over a period of several years and there has been no recurrence. It is interesting to note in the histories how frequently there is a story of haematuria and this in itself, particularly if there is evidence of renal infection, may well be good grounds for nephrectomy, In the 4th case of unilateral chyluria we did not do nephrectomy as at that time we were somewhat hesitant about advising such drastic treatment, particularly as the blood film was positive for microfilaria. If we have been able to prove that the chyluria is unilateral, we have had no hesitation in recommending
74
P. T. CHEN AND
J.
GRAY
nephrectomy. One reason for this is that in surgical work here it is most desirable to produce successful results. It is practically impossible to explain the pathology of the disease in terms a simple country man can understand and he has no time to wait while we try experimental methods with drugs. Further any failure in treatment has a definitely harmful effect on surgical practice amongst people who are at best quite sceptical about our modern methods. For this reason we think it may not be without value to put on record the encouraging results that have followed nephrectomy for chyluria where the condition is proved to be unilateral and also to stress the value of complete urological investigation of all cases before giving the condition up as unamenable to treatment. REFERENCES ABESHOUSE, B.: Pyelo-lymphatic communications. Am. J. Surg., 25: 427, 1934. FAUST, E. C.: Human Helminthology, pp. 449-453. KrnD, FRANK: Chyluria. Brit. J. Urol., 2: 15, 1930. RAY, P. N.: Filarial affections of the male genital tract. Indian Med. Gaz., 69: 544, 1934.