FILARIASIS

Filariasis is a group of parasitic (nematode) infections caused by biting flies

They share similar life cycles but differ in:
(1) their vector, (2) the final dwelling place of the adult worms, (3) the circadian
periodicity of the microfilariae, and (4) the pathological syndromes they cause.
Adult stage reside in the lymphatics or in connective tissue

Worm species Adult worm Microfilariae

Wuchereria bancrofti Lymphatic vessels Blood
Brugia malayi Lymphatic vessels Blood
Oncocercus valvulus Subcutaneous Skin
Loa loa Subcutaneous Blood
Mansonella perstans Retroperitoneal Blood

Filariasis produces a spectrum of illness ranging from:

1. asymptomatic form with circulating microfilaria
2. acute form - lymphatic inflammation with streaky tender lymphangitis and tender
lymph nodes
3.. chronic form - lymphatic obstruction leading to lymphoedema, hydrocoele,
elephantiasis of the limbs, and episodic adenolymphangitis with filarial fever
4. cryptic form causing lymphatic and renal pathology, and tropical pulmonary
eosinophilia (TPE).

Life cycle
Infection is introduced by the bite of the mosquito. Enter the lymphatics and travel
to the lymph nodes.
After maturation in a few months they develop into white, thread-like adult worms
and survive for several (10-18) years in the lymph nodes.
Once fertilised, the female discharges several thousand microfilariae, which dwell
in the peripheral blood for 5-10 years.
There is a nocturnal periodicity between 11 pm and 3 am of microfilariae in the
blood stream.
If circulating microfilariae are ingested by a mosquito during feeding, the
organisms develop into infective larvae.
Repeat the cycle when the mosquito bites.
 Lymphatic Filariasis
Lymphatic filariasis is caused by W. bancrofti, B. malayi, or B. timori

Pathology
The principal pathologic changes result from inflammatory damage to the
lymphatics, which is typically caused by adult worms and not by microfilariae
These consequences of filariasis are due both to direct effects of the worms and to
the inflammatory response of the host to the parasite
Inflammatory responses are believed to cause the granulomatous and proliferative
processes that precede total lymphatic obstruction

Clinical Features
The most common presentations of the lymphatic filariases are
1) Asymptomatic (or subclinical) microfilaremia
These patients have very few clinical symptoms
Few patients have microscopic hematuria and/or proteinuria, dilated (and tortuous)
lymphatics (visualized by imaging).
These patients remain clinically asymptomatic for years.
2) Hydrocele
3) Acute adenolymphangitis (ADL)
Characterized by high fever, lymphatic inflammation (lymphangitis and
lymphadenitis), and transient local edema
Regional lymph nodes are often enlarged, and the entire lymphatic channel can
become indurated and inflamed.
The lymphangitis is retrograde, extending peripherally from the lymph node
draining the area where the adult parasites reside
4) Chronic lymphatic disease
This stage results from permanent damage of lymphatics. The permanent changes
associated with elephantiasis
Brawny edema follows early pitting edema, and thickening of the subcutaneous
tissues and hyperkeratosis occur
Superinfection of these poorly vascularized tissues becomes a problem
Genital involvement is common, hydroceles may develop
If there is obstruction of the retroperitoneal lymphatics, the increased renal
lymphatic pressure leads to rupture of the renal lymphatics and the development of
chyluria

Diagnosis
microscopy
Thick-smear blood film is drawn using blood drawn in the night between 11 pm
and 2 am
Adult worms localized in lymphatic vessels or nodes are largely inaccessible
Microfilariae can be found in blood, in hydrocele fluid
The differentiation between the various filarial species is based on the morphology
of the sheaths
Serology
Assays for circulating antigens of W. bancrofti permit the diagnosis of
microfilaremic and cryptic (amicrofilaremic) infection

Polymerase chain reaction (PCR)based assays for DNA of W. bancrofti and B.

malayi in blood have been developed
Ultrasound
Ultrasound in conjunction with Doppler techniques may result in the identification
of motile adult worms within dilated lymphatics
Eosinophilia and elevated serum concentrations of IgE and antifilarial antibody
support the diagnosis of lymphatic filariasis

Treatment
Diethylcarbamazine (DEC, 6 mg/kg daily for 12 days), which has both macro- and
microfilaricidal properties, remains the treatment of choice for the individual with
active lymphatic filariasis
An alternative treatment is ivermectin, albendazole, doxycycline
Early treatment of asymptomatic persons is recommended to prevent further
lymphatic damage.
Supportive treatment-antipyretics and analgesics, antibiotic therapy if secondary
bacterial infection
Side effects of DEC treatment include fever, chills, arthralgias, headaches, nausea,
and vomiting.
Lymph edema can be reduced intialy elevation of limbs and elastocrepe bandages
may help in improving the circulation and prevent worsening.
Later stages only surgery will be usefull

Prevention
Ancillary measures include prevention of secondary infection by good foot care
cleaning the affected limb every night with soap and water, keeping the interdigital
areas dry, and clipping the nails
In endemic areas emphasis is to be made on vector control

Tropical Pulmonary Eosinophilia

Tropical pulmonary eosinophilia (TPE) is a distinct syndrome that develops in
some individuals infected with lymphatic filarial species
Pathology
Microfilaria and parasite antigens are rapidly cleared from the bloodstream by the
lungs
Clinical symptoms result from allergic and inflammatory reactions elicited by the
cleared parasites
Clinical Features
The main features include a history of residence in filarial-endemic regions,
paroxysmal cough and wheezing esp in night.

Investigations
Pronounced blood eosinophilia (>3000 eosinophils/microl)
Chest x-rays or CT scans can be normal or can show diffuse miliary lesions or
mottled opacities may be present in the middle and lower lung fields
Pulmonary function show restrictive abnormalities
Total serum IgE levels (10,000100,000 ng/mL) and antifilarial antibody titers are
markedly elevated.
Differential Diagnosis
Asthma,
Lffler's syndrome,
Allergic bronchopulmonary aspergillosis.

Treatment
DEC is used at a daily dosage of 46 mg/kg for 14 days
Ivermectin is not useful for tropical pulmonary eosinophilia