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Crusted papule on forehead due to Dirofilaria repens

A 65-year-old woman presented with a thread-like structure coming out from the forehead. This was preceded by burning pain, swelling, and vague pinprick and crawling sensation of five months duration over the left lower eyelid. Fifteen days prior to the date of presentation to the outpatient department, she had a left-sided headache followed by a small swelling. Within a week, this swelling burst spontaneously with scanty pus discharge. On squeezing the lesion, the patient found a thread-like structure coming out. Examination revealed a single crusted papular lesion of 1 cm diameter on the glabellar region of the forehead with two thread-like structures extruding out (Figure 1). Bearing in mind the possibility that this might have been a worm, one end of the thread was rolled out on a plain steel rod. Soon it was realized that two ends of the same worm were presenting as two thread-like structures coming out from the forehead. The papular lesion was excised under local anaesthesia and sent for histopathological examination. Haematoxylin and eosin (H&E) sections showed neutrophilic infiltrate in the upper dermis with dense lymphocytic perivascular infiltrate in the mid and lower dermis. The entire worm was sent to the Center for Disease Control and Prevention, Atlanta, USA. It was identified as an infertile female Dirofilaria repens measuring 9.5 cm 380 mm (Figure 2). The oesophagus was thin, measured 847 mm long, and the vulva was located 1.3mm from the anterior end. Characteristic ridging of the cuticle was seen (Figure 3). The tail length was 55 mm.