Scientific Letter
Pulmonary Dirofilariasis: A Diagnostic Pitfall in Clinical Practice
Dirofilariasis pulmonar: un reto diagnóstico en la práctica clínica
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El nódulo parece ser maligno. B) Nódulo necrótico pulmonar bien delimitado que destruye parénquima pulmonar normal. Gusanos presentes dentro del tejido necrótico (flechas) (×20). 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(B) Well-defined necrotic pulmonary nodule invading normal lung parenchyma. Worms in necrotic tissue (arrows) (20×). (C and D) Typical dirofilariasis worms (<span class="elsevierStyleItalic">D. immitis</span>) embedded in necrotic material (C: hematoxylin and eosin staining 100×; D: hematoxylin and eosin staining 200×).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Human pulmonary dirofilariasis is an uncommon parasitosis caused by <span class="elsevierStyleItalic">Dirofilaria immitis</span>. The usual hosts and reservoirs are domestic and wild carnivores, while humans are inadvertent hosts through the vector by mosquito bites. Pulmonary infection is extremely rare, often asymptomatic and usually discovered on routine chest radiograph as a solitary lesion, commonly mislabeled as malignant tumor.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">A 45-year-old Caucasian female was referred to the family doctor complaining of influenza-like symptoms and chest pain. She was a smoker (1 pack-day over the last 15 years), but had no contact with dogs or other pets. She denied any travel outside Greece. Chest X-ray revealed a small peripheral solitary pulmonary nodule in the right upper lobe. Clinical examination was unremarkable. White blood cell count, erythrocyte sedimentation rate and C-reactive protein were normal. Tuberculin skin test was negative, as was sputum testing for common bacteria, and so empirical antibiotic therapy was initiated. One month later, symptoms were resolved but a new X-ray showed no radiological change, so lung cancer was suspected.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Computed tomography of the chest showed a well-defined 1.5<span class="elsevierStyleHsp" style=""></span>cm non-calcified nodule located peripherally on the right upper lobe abutting the parietal pleura with no lymphadenopathy. Fiberoptic bronchoscopy was normal. Microbiological and cytological analyses of bronchoalveolar lavage were negative. Immunological tests and screening for vasculitis were also negative.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Surgical resection was performed to rule out the tumor hypothesis. A 1.5<span class="elsevierStyleHsp" style=""></span>cm soft grayish yellow nodule was found on the upper lobe, not directly in contact with the pleura. A wedge resection of the nodule was performed. Frozen sections showed a benign lesion characterized by necrosis. Final microscopic examination documented a well-circumscribed necrotic nodule containing fragments of a non-viable parasite that had features of <span class="elsevierStyleItalic">D. immitis</span>, including a smooth surface and internal longitudinal ridges. The nodule was surrounded by a fibrous wall with inflammatory reaction composed of histiocytes and multinucleated giant cells. The patient had an uneventful postoperative course and did not require further medical treatment.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In Europe, human pulmonary dirofilariasis caused by the canine heartworm <span class="elsevierStyleItalic">D. immitis</span> is rare. Extra-pulmonary infection has also been reported.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> Humans become infected through mosquito bites but infection is not transmitted either from person-to-mosquito-to-person or from person-to-person, because humans are the “dead-end” hosts.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Differential diagnosis of a pulmonary coin lesion between malignant tumor and benign lesion is always a diagnostic challenge. Existing serologic assays lack sensitivity and specificity, and should be used to supplement other data.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> Histologic identification of the nematode through surgical biopsy is still considered the best diagnostic approach, despite the high iatrogenic risk. Since humans are the “dead-end hosts”, definitive therapy is surgical resection, and further medical treatment is not required.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Dirofilaria is endemic in the Mediterranean region, but the distribution of the disease is changing due to increasing environmental temperatures.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> However, knowledge regarding incidence is limited by the lack of registry and data are derived only from isolated reported cases. In Europe, fewer than 40 cases of pulmonary dirofilariasis have been reported, 3 of which were in Greece (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Sileli M, Tsagkaropoulos S, Madesis A. Dirofilariasis pulmonar: un escollo en el diagnóstico en la práctica clínica. Arch Bronconeumol. 2016;52:338–339.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1126 "Ancho" => 1499 "Tamanyo" => 404803 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Chest CT scan showing an apparently malignant solitary nodule in the right upper lobe abutting the pleura. (B) Well-defined necrotic pulmonary nodule invading normal lung parenchyma. Worms in necrotic tissue (arrows) (20×). (C and D) Typical dirofilariasis worms (<span class="elsevierStyleItalic">D. immitis</span>) embedded in necrotic material (C: hematoxylin and eosin staining 100×; D: hematoxylin and eosin staining 200×).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical aspects and diagnosis of human pulmonary dirofilariosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A. Muro" 1 => "M. 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Simón" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Parasitol Today" "fecha" => "1999" "volumen" => "15" "paginaInicial" => "386" "paginaFinal" => "389" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10461169" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Heartworm disease (<span class="elsevierStyleItalic">Dirofilaria immitis</span>) and their vectors in Europe – new distribution trends" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "R. Morchón" 1 => "E. Carretón" 2 => "J. González-Miguel" 3 => "I. Mellado-Hernández" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3389/fphys.2012.00196" "Revista" => array:5 [ "tituloSerie" => "Front Physiol" "fecha" => "2012" "volumen" => "3" "paginaInicial" => "196" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22701433" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/15792129/0000005200000006/v1_201605260126/S1579212915003304/v1_201605260126/en/main.assets" "Apartado" => array:4 [ "identificador" => "49861" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Scientific letters" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15792129/0000005200000006/v1_201605260126/S1579212915003304/v1_201605260126/en/main.pdf?idApp=UINPBA00003Z&text.app=https://archbronconeumol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1579212915003304?idApp=UINPBA00003Z" ]
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| 2024 August | 86 | 36 | 122 |
| 2024 July | 54 | 25 | 79 |
| 2024 June | 91 | 31 | 122 |
| 2024 May | 82 | 31 | 113 |
| 2024 April | 50 | 25 | 75 |
| 2024 March | 78 | 20 | 98 |
| 2024 February | 33 | 25 | 58 |
| 2023 March | 14 | 7 | 21 |
| 2023 February | 90 | 20 | 110 |
| 2023 January | 50 | 34 | 84 |
| 2022 December | 99 | 36 | 135 |
| 2022 November | 94 | 29 | 123 |
| 2022 October | 121 | 36 | 157 |
| 2022 September | 60 | 28 | 88 |
| 2022 August | 61 | 42 | 103 |
| 2022 July | 61 | 39 | 100 |
| 2022 June | 37 | 28 | 65 |
| 2022 May | 46 | 32 | 78 |
| 2022 April | 65 | 51 | 116 |
| 2022 March | 68 | 38 | 106 |
| 2022 February | 67 | 22 | 89 |
| 2022 January | 90 | 46 | 136 |
| 2021 December | 84 | 46 | 130 |
| 2021 November | 76 | 42 | 118 |
| 2021 October | 102 | 43 | 145 |
| 2021 September | 62 | 48 | 110 |
| 2021 August | 58 | 42 | 100 |
| 2021 July | 37 | 28 | 65 |
| 2021 June | 68 | 39 | 107 |
| 2021 May | 71 | 44 | 115 |
| 2021 April | 115 | 59 | 174 |
| 2021 March | 91 | 23 | 114 |
| 2021 February | 66 | 29 | 95 |
| 2021 January | 58 | 12 | 70 |
| 2020 December | 88 | 21 | 109 |
| 2020 November | 70 | 35 | 105 |
| 2020 October | 177 | 11 | 188 |
| 2020 September | 153 | 13 | 166 |
| 2020 August | 87 | 16 | 103 |
| 2020 July | 50 | 20 | 70 |
| 2020 June | 56 | 4 | 60 |
| 2020 May | 61 | 12 | 73 |
| 2020 April | 67 | 28 | 95 |
| 2020 March | 31 | 11 | 42 |
| 2020 February | 60 | 23 | 83 |
| 2020 January | 60 | 21 | 81 |
| 2019 December | 46 | 15 | 61 |
| 2019 November | 44 | 27 | 71 |
| 2019 October | 31 | 6 | 37 |
| 2019 September | 58 | 20 | 78 |
| 2019 August | 37 | 14 | 51 |
| 2019 July | 55 | 35 | 90 |
| 2019 June | 40 | 12 | 52 |
| 2019 May | 53 | 16 | 69 |
| 2019 April | 81 | 32 | 113 |
| 2019 March | 50 | 28 | 78 |
| 2019 February | 39 | 25 | 64 |
| 2019 January | 37 | 15 | 52 |
| 2018 December | 41 | 15 | 56 |
| 2018 November | 83 | 15 | 98 |
| 2018 October | 137 | 18 | 155 |
| 2018 September | 46 | 14 | 60 |
| 2018 May | 23 | 0 | 23 |
| 2018 April | 55 | 11 | 66 |
| 2018 March | 64 | 2 | 66 |
| 2018 February | 30 | 5 | 35 |
| 2018 January | 84 | 11 | 95 |
| 2017 December | 89 | 2 | 91 |
| 2017 November | 32 | 5 | 37 |
| 2017 October | 28 | 7 | 35 |
| 2017 September | 31 | 7 | 38 |
| 2017 August | 22 | 6 | 28 |
| 2017 July | 32 | 5 | 37 |
| 2017 June | 29 | 15 | 44 |
| 2017 May | 38 | 7 | 45 |
| 2017 April | 33 | 10 | 43 |
| 2017 March | 7 | 7 | 14 |
| 2017 February | 25 | 11 | 36 |
| 2017 January | 9 | 8 | 17 |
| 2016 December | 24 | 13 | 37 |
| 2016 November | 46 | 27 | 73 |
| 2016 October | 43 | 29 | 72 |
| 2016 September | 32 | 5 | 37 |
| 2016 August | 1 | 0 | 1 |
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