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Dracunculiasis of the Breast: Radiological Manifestations of a Rare Disease

Case Report

Shannon K. Barry1*, William Gregory Schucany1

Radiology Case. 2012 Nov; 6(11):29-33 :: DOI: 10.3941/jrcr.v6i11.1137

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1. Department of Radiology, Baylor University Medical Center at Dallas, Dallas, TX, USA

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  ABSTRACT
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Dracunculiasis of the breast is a rare manifestation of prior infection with the parasite dracunculus medinensis (guinea worm). We describe a case of a 60-year-old woman, who had recently emigrated from Cameroon. She presented for an annual screening mammogram and was found to have coarse linear or coiled serpiginous calcifications. These findings were recognized as calcified guinea worms within the breast tissue. This case report aims to highlight the mammographic findings of this rare infectious disease.








  CASE REPORT
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A 60-year-old woman who had moved to the United States from Cameroon presented for an annual screening mammogram. The patient had no signs or symptoms of breast disease. Her past medical history was positive for remote dracunculus medinensis infection.

Bilateral screening mammogram was performed with craniocaudal and mediolateral oblique views of both breasts. Both breasts demonstrated calcifications. The left breast demonstrated two linear serpiginous focal calcifications. The right breast demonstrated calcifications along the 10 o`clock axis, 7-8 cm from the nipple. Although benign calcifications were suspected, further evaluation with magnification views was recommended.

A diagnostic mammogram of both breasts was performed (Fig. 1 Preview this figure

Figure 1: Conventional Radiography
60-year-old female with dracunculiasis of the breast. Craniocaudal mammogram demonstrates bilateral linear serpiginous focal calcifications.
and Fig. 2 Preview this figure
Figure 2: Conventional Radiography
60-year-old female with dracunculiasis of the breast. Mediolateral oblique mammogram demonstrates bilateral linear serpiginous focal calcifications.
). Focal spot magnification views (Fig. 3 Preview this figure
Figure 3: Conventional Radiography
60-year-old female with dracunculiasis of the breast. Craniocaudal magnification view of the left breast demonstrates two linear serpiginous focal calcifications.
and Fig. 4 Preview this figure
Figure 4: Conventional Radiography
60-year-old female with dracunculiasis of the breast. Magnification view of the right breast demonstrates two linear serpiginous focal calcifications.
) demonstrated calcifications in the upper outer quadrant of the right breast, consistent with dermal calcifications. In addition, coarse linear calcifications of both breasts were also demonstrated which had a coiled or serpiginous linear appearance. Given the patient`s past medical history of prior infection with dracunculus medinensis, these findings were recognized as being characteristic for dracunculiasis of the breast. Routine annual mammogram was recommended, as the findings are a sequela of prior infection, and do not indicate active infection.

  DISCUSSION
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Dracunculiasis is a parasitic infection caused by dracunculus medinensis, also known as the guinea worm [1]. The infection is contracted by drinking water from ponds contaminated by copepods (water fleas) that contain immature forms of the parasite. After ingestion, the larvae penetrate the intestinal mucosa and migrate into the subcutaneous tissues. Female worms emerge through skin lesions, usually on the lower limbs [2]. Larvae are released into the water by the emerging worm to continue the life cycle. There is no known treatment for dracunculiasis and preventive measures have been applied in attempts for eradication.

There are several historical references to this infection including the Old Testament of the Bible, and ancient Greek texts. Historically, once the worm emerged from the wound, it would be pulled out a few centimeters each day with gentle pressure, while wrapping the worm around a stick. One of the symbols of modern medicine depicts this form of treatment, known as the Rod of Asclepius. If the infection is identified before an ulcer forms, the worm can be surgically removed [3]. Immature female worms can die in transit and calcify. The migration of the worm to the breast tissue remains very rare [2].

Once prevalent in 20 nations in Asia and Africa, the disease, according to a recent article in the Journal of the American Medical Association, remains endemic only in 3 countries: Sudan, Mali, and Ethiopia, which have limited or no access to clean water [4]. Distribution of the disease remains isolated to sub-Saharan Africa. Eradication measures recommended by World Health Organization include mapping of all endemic villages and establishing community-based surveillance systems in every known endemic village, implementing effective case containment measures in all endemic villages, implementing specific interventions such as ensuring access to safe water, health education, community mobilization, filters and providing vector control of potential unsafe water sources with temephos insecticide (Abate®). To measure the effectiveness of the eradication measures the World Health Organization also recommends reporting on a regular basis, even if zero cases, maintaining global and national dracunculiasis databases to monitor the epidemiological situation, and managing the certification process for global eradication country by country. In 1989, Cameroon began hosting events, today known as National Guinea Worm Days, promoting interventions consisting of active surveillance, social mobilization, health education, distribution of filters, construction of new water sources, chemical treatment of unsafe water sources, and case containment [5]. In 2007, the World Health Organization certified Cameroon as free of Guinea worm disease.

There are no cases of dracunculiasis of the breast diagnosed in the United States described in the literature. There are two cases described in the United Kingdom. Hamilton and Evans describe a patient with breast calcifications detected on screening mammogram in a Nigerian woman who moved to the UK. The patient had calcified worms within both breasts and no symptoms attributable to these calcifications; however, the patient did have a history of prior dracunculiasis infection and removal 10 years previously in Nigeria [6]. Bin Saleem and Ahmed describe a case of dracunculiasis of the breast in a Kenyan woman who presented to a surgical outpatient clinic with a painless lump in the right breast. On clinical examination she was found to have an irregular lump under her right nipple. Mammogram showed a calcified Guinea worm under the right nipple without any suspicion of malignancy [2]. The condition requires no treatment, as the calcified worms are no longer viable and do not indicate active disease. However, they may be mistaken for another etiology, which would lead to unnecessary intervention, such as biopsy.

Our case of dracunculiasis of the breast is the first case described in the United States. A pertinent clinical history of emigration from Cameroon, a country where dracunculiasis was once endemic, proved to be of great value in the correct diagnosis in this case. Dracunculiasis is a rare disease that has specific radiological manifestations and should be a consideration in patients who have recently emigrated from countries where dracunculiasis infection is endemic, or from countries where eradication occurred after the patient immigrated to the United States. The radiological significance of this condition is in recognizing that is a sequela of a prior infection and does not represent an entity that would require further evaluation, which may lead to an unnecessary invasive procedure, such as biopsy. The differential diagnosis includes other entities that cause calcifications of the breast, such as arterial or vascular calcifications, intraductal calcifications, prior mastitis, remote trauma, fibroadenoma, and calcified sutures. These various diagnoses have specific imaging characteristics that allow them to be differentiated from one another. In this patient, the most pertinent finding was the patient`s positive history of prior dracunculiasis infection and negative history of any prior surgical intervention.

  TEACHING POINT
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Dracunculiasis of the breast is a rare disease that manifests as coarse linear calcifications that have a coiled or serpiginous linear appearance on mammogram. This diagnosis should be a consideration in patients who have recently emigrated from countries where dracunculus medinensis infection is endemic, or from countries where eradication occurred after the patient immigrated to a non-endemic country.








  FIGURES
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Display figure 1 in original size

Figure 1: 60-year-old female with dracunculiasis of the breast. Craniocaudal mammogram demonstrates bilateral linear serpiginous focal calcifications.

Figure 1: Conventional Radiography (Open in original size)
60-year-old female with dracunculiasis of the breast. Craniocaudal mammogram demonstrates bilateral linear serpiginous focal calcifications.

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Display figure 2 in original size
Figure 2: 60-year-old female with dracunculiasis of the breast. Mediolateral oblique mammogram demonstrates bilateral linear serpiginous focal calcifications.

Figure 2: Conventional Radiography (Open in original size)
60-year-old female with dracunculiasis of the breast. Mediolateral oblique mammogram demonstrates bilateral linear serpiginous focal calcifications.

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Display figure 3 in original size
Figure 3: 60-year-old female with dracunculiasis of the breast. Craniocaudal magnification view of the left breast demonstrates two linear serpiginous focal calcifications.

Figure 3: Conventional Radiography (Open in original size)
60-year-old female with dracunculiasis of the breast. Craniocaudal magnification view of the left breast demonstrates two linear serpiginous focal calcifications.

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Display figure 4 in original size
Figure 4: 60-year-old female with dracunculiasis of the breast. Magnification view of the right breast demonstrates two linear serpiginous focal calcifications.

Figure 4: Conventional Radiography (Open in original size)
60-year-old female with dracunculiasis of the breast. Magnification view of the right breast demonstrates two linear serpiginous focal calcifications.

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Display figure 5 in original size
Figure 5: Summary Table of Dracunculiasis of the Breast

Figure 5: Table (Open in original size)
Summary Table of Dracunculiasis of the Breast

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Display figure 6 in original size
Figure 6: Differential Table for Dracunculiasis of the Breast

Figure 6: Table (Open in original size)
Differential Table for Dracunculiasis of the Breast

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  REFERENCES
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1. James, WD, Berger TG. Andrews` Disease of the Skin: Clinical Dermatology. Saunders Elsevier 2006; 437 Get full text
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2. Bin Saleem, T. & Ahmed, I. J Ayub Med CollAbbottabad 2006; 18(4) Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

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3. Stelling C. Dracunculiasis Presenting as Sterile Abscess. AJR 1982; 138:1159-1161 Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

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4. Voelker R. Global Partners Take Two Steps Closer to Eradication of Guinea Worm Disease. JAMA 2011; 305(16): 1642 Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

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5. Sam-Abbenyi A, Dama M, Graham S, and Obate Z. International Journal of Epidemiology. 1999;28:163-168 Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

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6. Hamilton L.J. & Evans A.J. Dracunculiasis: a rare cause of breast calcification detected on screening mammography Clinical Radiology Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

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