Filariasis of the buccal mucosa: A diagnostic dilemma
A 54-year-old female school teacher reported with a complaint of intermittent swelling inside the mouth on the left side. Repeated exacerbations of the swelling occurred 4-5 times in a span of 8 months. Itching of the cheek always preceded the swelling, which got resolved within 1-2 days. There was no change in sensation over the affected area. She had consulted many clinicians prior to reporting to our hospital and had taken medications. However, the patient's symptoms had persisted. The detail of past consultations or medications regarding presenting complaint was obscure. She gave a medical history of hypertension and dyslipidemia for which she was on medication since 5 years. General physical examination did not show any relevant findings. No cervical or generalized lymphadenopathy was found.\nExtra-orally, diffuse swelling of left cheek was noted with no color changes. Intra-orally, examination of the left buccal mucosa revealed a hard movable mass of 1 cm × 0.5 cm anterior to the anterior border of ramus almost at the level of 27 []. Slight tenderness was present on palpation of the mass. Although the parotid papilla was prominent, it was not tender on palpation. Blood investigations were unremarkable. The erythrocyte sedimentation rates were mildly raised, Mantoux test was normal. Blood smear for staining malarial and filarial parasites were negative.\nAn occlusal radiograph placed vertically in the upper gingival sulcus in contact with the buccal mucosa to check for any soft-tissue calcifications did not reveal any findings.\nDifferential diagnoses of a parotid sialolith, minor salivary gland tumor, cysticercosis, calcified facial node, and lipoma were made.\nUltrasound scan of the cheek revealed a well-defined round hypo-echoic lesion in the muscular layer of the left cheek measuring 0.8 cm × 0.5 cm, with small specks of calcification. There were no obvious vascularity within the lesion and no perilesional edema []. The parotids appeared normal bilaterally. The probability of inflammatory pathology was considered.\nExcisional biopsy of the nodule was carried out. Histological examination revealed a dense fibrous capsule showing infiltrate of mixed inflammatory cells consisting of lymphocytes, macrophages, eosinophils, and neutrophils. Within the capsule, a single female filarial worm showing “double uterus” appearance containing numerous larval forms was seen []. Further, magnification revealed a thick layed cuticle with multiple longitudinal ridges and centrally placed intestinal tubule within the well-developed musculature [Figures and ]. A definitive diagnosis of Dirofilariasis repens was arrived at.\nPatient was treated with diethylcarbamazine (DEC) 100 mg tid for 3 weeks, albendazole 400 mg hs and cetrizine 5 mg Once daily for 5 days.\nFollowing medication, patient was reviewed regularly for 8 months and found to be completely asymptomatic.