MEDICAL ILLUSTRATION Unilateral Leg Swelling Umar Zein1, Hadiki Habib2 1 Dr. Umar Zein Tropical and Infectious Diseases Clinic, Medan, Indonesia. 2 Departement of Internal Medicine, Faculty of Medicine Universitas Indonesia - Cipto Mangunkusumo Hospital, Jakarta, Indonesia Correspondence mail: Dr. Umar Zein. Jl.Denai 269 Medan, Indonesia. email: uzein_2000@yahoo.com, salinahhabib@gmail.com. Figure 1. Lymphatic filariasis of right leg before treatment Figure 2. Microfilariae of W. bancrofti Figure 3. After 2 weeks treatment of DEC A 50-year old man was consulted due to right leg swelling concomitant with redness and pain since two months between admission. The patient experienced fever and dull pain in right inguinal region before the leg became swollen. Antibiotic and antipyretic had been given but gave unsatisfaction response. No history of bedridden, hospitalization, or malignancy. He worked as a palm oil farmer in Geragas Village, langkat District, North Sumatera, Indonesia, an endemic region of Bancroftian filariasis. Physical examination revealed normal vital signs, there was non pitting oedema and redness in right gastrocnemius region (Figure 1). Laboratory results of routine blood count and haemostasis were within normal limit, except leucocytosis (12000/m3) and eosinophilia (15%). Peripheral blood sample was drawn between 10 66 Acta Medica Indonesiana - The Indonesian Journal of Internal Medicine Vol 46 • Number 1 • January 2014 Unilateral leg swelling pm and 2 am and showed positive microfilariae with gently curved body, a tail that is tapered to a point, and the nuclear column is loosely packed, appropriate for Wuchereria bancrofti (Figure 2). Patient’s diagnosis was acute lymphangitis due to filariasis of W. bancrofti. Treatment was based on protocol in Cunha (2010).1 Albendazole 1 x 400 mg po single dose plus Diethylcarbamazine (DEC): • Day 1 : 50 mg PO • Day 2 : 50 mg PO q8h • Day 3 : 100 mg PO q8h • Day 4-14 : 2 mg/kg PO q8h Doxicycline 100 mg PO q12h for 6 weeks is optional (doxyciclin was not given for this case) . Paracetamol 3x 500 mg and cetirizine 10 mg daily for five days was given for symptomatic purposed. The diagnosis was reported to health department of North Sumatera Province for epidemiological input and preparation of mass drug administration. There were no serious side effect of DEC treatment. After 2 weeks, the swelling was resolved (Figure 3). The patient use compressive stocking to reduced puffiness of the right leg after long distance walking. This temporer swelling was mild sequel of the filariasis. Lymphatic filariasis is one of neglected tropical diseases in Indonesia. It is a mosquito- transmitted, helminth infection, transmitted predominantly by Anopheles mosquitoes. There are 8 type of filarial worms but only 4 of them are that most causing human disease and complication, there are Wuchereria bancrofti, Brugia malayi, Oncocherca volvulus, and Loa- loa.2 World Health Organization (WHO) in 2009 reported there were 120 milions people in 81 countries infected with filariasis, 40 milion people suffer from permanent damage because of these diseases, such as elephanthiasis, or urogenital swelling.3 Almost all regions in Indonesia are endemic with filariasis, espesciallly in the East Indonesia Region. From 2000 to 2009 chronic cases of filariasis there were 11.914 patients in 401 city/districts.4 Wuchereria bancrofti is one of the most widely distributed not just in tropic region, but also in sub tropic. Humans are the only definite hosts. The parasite has nocturnal periodicity, which mean that microfilariae density in human blood will increase and night, but the microfilaria will hardly be found.2 Early clinical manifestation of filariasis are lymphangitis, lymphadenitis, epidydimitis or orchitis, due to adult worm activities in lymphatic drainage. People in endemic regions sometimes do not show symptoms of acute clinical manifestation. Inappropiate or delayed treatment will cause chronic lymphatic obstruction (extremity elephantiasis, hydrocele, chyiluria).2,5 REFERENCES 1. Cunha BA, ed. Antibiotic essentials. 9th edition. New York: Physician’s Press; 2010. p. 251. 2. Pohan HT. Filariasis. In: Sudoyo AW, Setiati S, Alwi I, eds. Buku ajar ilmu penyakit dalam. 3rd volume. 4th edition. Jakarta: Pusat Penerbitan Ilmu Penyakit Dalam FKUI/RSCM; 2006. p. 1789-92. 3. WHO. Lymphatic filariasis. Switzerland: World Health Organization; 2010. p. 1. 4. Subdit Filariasis & Schistosomiasis. Rencana nasional program akselerasi eliminasi Filariasis di Indonesia 2010-2014. Jakarta: Direktorat P2B2, Ditjen PP & PL Kementrian Kesehatan Republik Indonesia; 2010. 5. Mak J. Pathology of lymphatic filariasis. IeJSME. 2012;6:80-6. 67