Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 19  |  Issue : 2  |  Page : 136-138

Giant scrotal lymphatic filariasis


1 Department of Surgery, Madamfo Specialist Hospital Sekondi, Western Region ; Department of Surgery, School of Medical Sciences, University of Cape Coast, Cape Coast, Ghana
2 Department of Microbiology and Immunology, School of Medicine, University of Health and Allied Sciences, Ho Volta Region, Ghana

Date of Web Publication15-Nov-2017

Correspondence Address:
Verner N Orish
Department of Microbiology and Immunology, School of Medicine, University of Health and Allied Sciences, Ho Volta Region
Ghana
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jomt.jomt_20_17

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  Abstract 


Wuchereria bancrofti, transmitted by mosquito, is endemic in Ghana and scrotal elephantiasis is a rare manifestation. Scrotal elephantiasis can assume a large size impacting negatively on the quality of life of patients. We present a case of a 47-year-old male, living in lymphatic filariasis endemic area of Ghana, with a 10-year history of giant scrotal swelling. The patient had subtotal scrotectomy done with preservation of both testes and penis. Surgery had satisfactory outcome, marking the end of the patient’s 10-year ordeal with the huge scrotal mass.

Keywords: Lymphatic filariasis, scrotal elephantiasis, subtotal scrotectomy, Wuchereria bancrofti


How to cite this article:
Atawurah H, Orish VN. Giant scrotal lymphatic filariasis. J Med Trop 2017;19:136-8

How to cite this URL:
Atawurah H, Orish VN. Giant scrotal lymphatic filariasis. J Med Trop [serial online] 2017 [cited 2019 Sep 15];19:136-8. Available from: http://www.jmedtropics.org/text.asp?2017/19/2/136/218401




  Introduction Top


Scrotal elephantiasis is a rare manifestation of Wuchereria bancrofti infection even in endemic areas where 70% of infected individuals are asymptomatic.[1] This condition occurs when adult worms of W. bancrofti reside and obstruct the lymphatic vessels draining the scrotum. Although other conditions can cause the obstruction of the lymphatic drainage such as congenital or acquired aplasia or hypoplasia of the lymphatic vessels, infective obstruction of the lymphatic drainage by W. bancrofti is the most common cause.[2] Scrotal elephantiasis is a chronic debilitating disease with immense emotional and physical strain with adverse impact on the quality of life of the men affected.[3],[4] These chronic, huge scrotal swellings are usually associated with chronic, irreversible lymphedema with extensive fibrosis which can only be corrected by surgery in most cases.[2],[5] We report a rare case of giant scrotal lymphedema in a middle-aged man.


  Case Report Top


A 47-year-old man presented to Madamfo Specialist Hospital, Sekondi, Ghana, with a 10-year history of gradually increasing scrotal swelling. The swelling was so huge that for the past 6 years; the patient has been confined to wheelchair and required assistance by relatives in lifting the mass before he lies on bed. There was no history of difficulty in passing urine, no change in bowel habit, and no weight loss. The patient is a fisherman who lives in a fishing community in the Western Region of Ghana. There was nothing of interest in the medical history and the patient had no surgery in the past. Examination showed a middle-aged man with difficulty in walking due to a huge scrotal swelling. He was afebrile, not pale, not jaundiced, not cyanosed, and no difficulty in breathing. There was no generalized lymphadenopathy and no pedal edema. The chest was clear and abdomen was without any abnormalities with no evidence of external hernia. Scrotal examination revealed a firm, nontender mass measuring 62 cm × 48 cm × 30 cm [Figure 1]. Scrotal skin was thick, slightly pitting and the penis was buried in the scrotal mass. The patient was negative for HIV 1 and 2 and testicular tumor markers were normal. Blood smear and skin snip for microfilaria were not done; however, all other laboratory investigations were normal. A diagnosis of scrotal elephantiasis was made based on the size of the swelling and the endemicity of filariasis in the community where he resides. The patient was prepared for the surgery.
Figure 1: Huge scrotal mass

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Under spinal anesthesia, the patient was placed in the supine position. With the help of two assistants, scrotum was thoroughly washed with antiseptic solution and draped. Spinal anesthesia was used during surgery with intraoperative infiltration of incision sites with 1% adrenaline solution loaded in a 10cc syringe. Subtotal scrotectomy was done with preservation of both testes and penis [Figure 2]. Lateral flaps were used to reconstruct the scrotum [Figure 3]. The excised specimen weighed 25 kg. It contained numerous fluid-filled cystic structures.
Figure 2: Penis exposure after excision of scrotal mass

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Figure 3: Wound closed, scrotum reconstructed and catheter in the bladder

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Histopathological examination showed nonspecific chronic inflammation with epidermal thickening and dermal fibrosis. Wound healed completely after 3 weeks. Examination 3 months after surgery showed an acceptable cosmetic result [Figure 4].
Figure 4: Three months after surgery

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  Discussion Top


W. bancrofti infection is endemic in rural and urban areas in Ghana, transmitted mainly by anopheles mosquitoes.[6],[7] Scrotal and limb elephantiasis are relatively rare clinical manifestations of those infected with W. bancrofti.[7] The diagnosis of scrotal elephantiasis, in this case, was made based on the reported endemicity of W. bancrofti in the Western Region, especially in the coastal community where the patient resides.[6],[7] Although microfilaremia was not established in this patient, the histopathological findings were consistent with lymphatic filariasis.[8],[9] Being in an endemic area does not mean that all scrotal lymphedema is caused by W. bancrofti infection. Other acquired causes such as postsurgical complications have been implicated.[9] There was no history of past abdominal or inguinal surgeries in this patient, ruling out the possibility of any postsurgical causes of scrotal lymphedema.[9]

The patient had to endure 10 years of giant scrotal mass, which obviously affected his quality of life. It is not clear why the patient waited this long to get the much needed surgical management. However, it is not an uncommon finding in Sub-Saharan Africa to see patients with chronic debilitating conditions failing to avail themselves the opportunity to get proper management for their condition.[10] This is probably due to poverty, ignorance, stigmatization, or unavailability of health-care facilities.[10]

Surgery was necessary for this patient as there are no effective nonsurgical means of managing patient’s conditions.[11],[12] The patient had the recommended surgical procedure of complete removal of elephantoid tissue with preservation of the testes and penis.[9],[13] The surgery yielded a cosmetically satisfactory result, a finding which is a fairly common outcome of the surgical procedure employed.[9],[13]


  Conclusion Top


This was a case of a clinical diagnosis of giant scrotal elephantiasis in a middle-aged man, confirmed by histological findings following a successful surgical procedure. The subtotal scrotectomy procedure was very beneficial to the patient as the outcome was very satisfactory.

This case also shows the unnecessary emotional and physical trauma some patients have to endure in resource-limited settings. It is important that the public is educated on the various chronic debilitating diseases and their available management. More so, health-care workers, working in rural areas, should be educated to identify these chronic diseases, especially at the early stages, so that they can refer to the appropriate health-care facilities for further definitive management.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kazura JW, Bockarie M, Alexander N, Perry R, Bockarie F, Dagoro H et al. Transmission intensity and its relationship to infection and disease due to Wuchereria bancrofti in Papua New Guinea. J Infect Dis 1997;176:242-6.  Back to cited text no. 1
    
2.
Thejeswi P, Prabhu S, Augustine AJ, Ram S. Giant scrotal lymphoedema − A case report. Int J Surg Case Rep 2012;3:269-71.  Back to cited text no. 2
    
3.
Viehoff PB, Gielink PD, Damstra RJ, Heerkens YF, van Ravensberg DC, Neumann MH et al. Functioning in lymphedema from the patients’ perspective using the international classification of functioning, disability and health (ICF) as a reference. Acta Oncol 2015;54:411-21.  Back to cited text no. 3
    
4.
Singh V, Sinha RJ, Sankhwar SN, Kumar V. Reconstructive surgery for penoscrotal filarial lymphedema: A decade of experience and follow-up. Urology 2011;77:1228-31.  Back to cited text no. 4
    
5.
Shah KG, Choksi DB, Vohra AS, Barad J. Giant scrotal and penile elephantiasis of idiopathic etiology. A case report. Internet J Urol 2007;5:1-4.  Back to cited text no. 5
    
6.
Gyapong JO, Adjei S, Sackey SO. Descriptive epidemiology of lymphatic filariasis in Ghana. Trans R Soc Trop Med Hyg 1996;90:26–30.  Back to cited text no. 6
    
7.
Dunyo SK, Appawu M, Nkrumah FK, Baffoe-Wilmot A, Pedersen EM, Simonsen PE et al. Lymphatic filariasis on the coast of Ghana. Trans R Soc Trop Med Hyg 1996;90:634-8.  Back to cited text no. 7
    
8.
Shenoy RK. Clinical and pathological aspects of filarial lymphedema and its management. Korean J Parasitol 2008;46:119-25.  Back to cited text no. 8
    
9.
Rahman GA, Adigun IA, Yusuf IF, Aderibigbe AB, Etonyeaku AC. Giant scrotal lymphedema of unclear etiology: A case report. J Med Case Rep 2009;3:7295.  Back to cited text no. 9
    
10.
Molyneux DH, Hotez PJ, Fenwick A. “Rapid-impact interventions”: How a policy of integrated control for Africa’s neglected tropical diseases could benefit the poor. PLoS Med 2005;2:e336.  Back to cited text no. 10
    
11.
Farina R, Farina G. Pemescrotal elephantiasis (osqueofaloplasty). Rev Bras Cir 1995;85:205-12.  Back to cited text no. 11
    
12.
Apesos J, Anigian G. Reconstruction of penile and scrotal lymphedema. Ann Plast Surg 1991;27:570-3.  Back to cited text no. 12
    
13.
Kuepper D. Giant scrotal elephantiasis. Urology 2005;65:389.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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