Chyluria is an uncommon late stage finding in bancroftian filariasis and is often associated with gross hematuria. Lymph node obstruction below the cisterna chyli leads to reflux of intestinal lymph into renal lymphatics which may then rupture, allowing chyle to flow into the urinary collecting system. Urine is often white in the morning and progressively turns red later in the day. The onset of chyluria may be abrupt or gradual, with the findings most pronounced after eating a fatty meal. Transient urinary retention can result from blood or chylous clots. Although painless, it may result in significant loss of dietary proteins, lipids, and other nutrients, leading to anemia, hypoproteinemia, and weight loss. Chylous diarrhea can also have the same detrimental nutritional consequences.

In India there is a group of patients who present with chyluria but without lymphedema. Many will have hydroceles or lymphoceles in the scrotum or groin but no elephantiasis. Their clinical history is the same, with fevers, chills, and occasionally painful lymphangitis in the legs or groins. Laboratory investigations for filariasis are always positive. The urine may be so thick that it sets like a jelly. There is no diarrhea or other gastrointestinal symptoms, nor is chyle or protein lost in the stools. No patients have a chylothorax or chylopericardium, but all have pyelonephritis.

The female breast may be a site of chronic fibrosis with nodules (inflammatory lesions containing degenerating adult worms) simulating malignancy. Breast lymphedema and even elephantiasis from lymphadenitis and lymphatic obstruction affect some women (Fig. 26.9).

Fig. 26.9. Unilateral filarial elephantiasis of the breast. Filarial infection by W. bancrofti not uncommonly involves the breast (West Africa).

There are two other clinical conditions which are important. The first is filarial monoarthritis, which occurs particularly in regions in which W. bancrofti is endemic. The knee, followed by the ankle, are the most often involved joints. A rapid cure follows treatment with diethylcarbamazine. The other condition is tropical pulmonary eosinophilia, in which patients present with paroxysmal coughing and wheezing that is generally nocturnal (see later). Nonimmune travelers will have different disease manifestations than people native to endemic regions, while people treated with drug chemotherapy show a further altered course of disease, because for them it is the death of the adult worms which causes the distinctive pathological changes.