A 42-Year-Old Woman Undergoing a Renal Transplant Evaluation

Heather Kesler DeVore, MD; Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR, LRCP; Sirhan Alvi, MBChB, MRCS(Ed), MRCS(Glasg)

Disclosures

May 12, 2016

Most cases involve worms appearing on the legs and feet, but the worms may occur anywhere on the body; cases involving the arms, breasts, head, and back have been well documented. Less commonly, patients with dracunculiasis can present with worms in other locations, such as the lungs, pancreas, testes, spinal cord, or periorbital tissue.[4,5]

A blister typically forms in the epidermis at the site chosen by the female worm to emerge, usually in the lower extremity. Just before blister formation, symptoms similar to an allergic reaction, such as mild respiratory distress with wheezing, urticaria, periorbital edema, and pruritus, may be noted. Affected individuals may also be febrile during this period. As the worm's head continues to emerge, the blister grows in size and becomes erythematous at its edges. The formation of edema around the site causes further pruritus and burning pain. The blister erupts (usually after a few days, although the eruption can occur after as long as 2 weeks), and the worm releases a milky fluid that is teeming with larvae. The swelling and pain will often decrease after the blister erupts. An ulcer forms around the blister site as the adult worm continues to emerge; the definitive diagnosis is often made at this stage, when the head of the worm is identifiable. No other commonly noted physical findings typically develop, although varying degrees of lymphadenopathy may be found at any stage of the illness.

The live Guinea worm cannot be identified radiologically, except in the rare instances when iodinated contrast medium is injected into the body of the worm to delineate its full extent; however, after it dies, the Guinea worm may become calcified from cell secretion or necrotic cellular debris. The female D medinensis worm appears as a long, stringlike, serpiginous calcification. The calcification is frequently segmented and beaded as muscle movements break up the body of the worm.

If the worm is in the breast, the calcifications may be intramammary, in and around the ducts, in the lobules, in the vascular structures, in interlobular connective tissue, or in the fat. They may also be found in the subcutaneous tissue of the skin. They can appear with or without an associated lesion, and their morphologies and distribution can provide clues to their etiology and to their association with benign or malignant processes. The incidence of breast calcification from Guinea worm infection is difficult to assess because dracunculiasis is rare outside of endemic areas. Cases of dracunculiasis are usually rural and not well documented; however, the breast is probably a relatively rare site of presentation.

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