Filariasis

Infectious diseases

Clinicals - History

Fact Explanation
Introduction Parasites are widespread throughout the developing world and are associated with a heavy burden of morbidity and mortality. Filariasis is a parasitic disease affecting humans and animals, and is caused by filariae (Wuchereria bancrofti which is a nematode parasite of the order Filariidae that is transmitted by arthropod vectors (Culex mosquito ) Disease is commonly seen in tropical and subtropical regions of the world. Introduction
Parasites are widespread throughout the developing world and are associated with a heavy burden of morbidity and mortality. Filariasis is a parasitic disease affecting humans and animals, and is caused by filariae (Wuchereria bancrofti which is a nematode parasite of the order Filariidae that is transmitted by arthropod vectors (Culex mosquito ) Disease is commonly seen in tropical and subtropical regions of the world.
Asymptomatic microfilaremia Filariasis causes a spectrum of diseases including the asymptomatic microfilaria. Culex mosquito is the vector for the transmission and the adult worms live in the lymphatic vessels of the definitive host. The microfilariae are released into the peripheral circulation. There are two catergories of microfilarimia, asymptomatic amicrofilaremia and patent infection (with or without microfilaremia).
Occasionally microfilaremia at the following sites is also reported: Bronchial aspirates, pericardial fluid, cervicovaginal smears, joint aspirates, and thyroid masses.
Asymptomatic microfilaremia
Filariasis causes a spectrum of diseases including the asymptomatic microfilaria. Culex mosquito is the vector for the transmission and the adult worms live in the lymphatic vessels of the definitive host. The microfilariae are released into the peripheral circulation. There are two catergories of microfilarimia, asymptomatic amicrofilaremia and patent infection (with or without microfilaremia).
Occasionally microfilaremia at the following sites is also reported: Bronchial aspirates, pericardial fluid, cervicovaginal smears, joint aspirates, and thyroid masses.
Fever Lymphatic filariasis is characterized by recurrent attacks of fever due to the inflammation of lymph nodes (lymphadenitis), lymphatics (lymphangitis) or due to recurrent infections associated with damaged lymphatics. Fever
Lymphatic filariasis is characterized by recurrent attacks of fever due to the inflammation of lymph nodes (lymphadenitis), lymphatics (lymphangitis) or due to recurrent infections associated with damaged lymphatics.
Pain in the Inguinal or axillary regions Inguinal, axillary and epitrochlear nodes lymph nodes are commonly involved. Pain in the Inguinal or axillary regions
Inguinal, axillary and epitrochlear nodes lymph nodes are commonly involved.
Testicular and/or inguinal pain Funiculitis, epididymitis and/or orchitis causing acute testis are seen among patients with filariasis. Testicular and/or inguinal pain
Funiculitis, epididymitis and/or orchitis causing acute testis are seen among patients with filariasis.
Skin exfoliation Acute dermatotolymphangitis, is the development of a plaque-like lesion of cutaneous or sub-cutaneous inflammation. It is accompanied by ascending lymphangitis and regional lymphadenitis. Skin exfoliation
Acute dermatotolymphangitis, is the development of a plaque-like lesion of cutaneous or sub-cutaneous inflammation. It is accompanied by ascending lymphangitis and regional lymphadenitis.
Limb or genital swelling The chronic sequelae of lymphatic filariasis develop years after initial infection. The manifestations are hydrocele and swelling of the testis and / or lymphedema of the entire lower limb, the scrotum, the entire arm, the vulva, and the breast . Limb or genital swelling
The chronic sequelae of lymphatic filariasis develop years after initial infection. The manifestations are hydrocele and swelling of the testis and / or lymphedema of the entire lower limb, the scrotum, the entire arm, the vulva, and the breast .
Milky urine Chyluria is a complication of filariasis. The chronic sequelae of lymphatic filariasis develop years after initial infection Milky urine
Chyluria is a complication of filariasis. The chronic sequelae of lymphatic filariasis develop years after initial infection
Paroxysmal cough and wheezing, weight loss, low-grade fever These are the features of Tropical pulmonary eosinophilia (TPE). Tropical pulmonary eosinophilia (TPE) is a distinct syndrome that develops in some individuals infected with W. bancrofti and B. malayi
-that are usually nocturnal (and probably related to the nocturnal periodicity of microfilariae)
Paroxysmal cough and wheezing, weight loss, low-grade fever
These are the features of Tropical pulmonary eosinophilia (TPE). Tropical pulmonary eosinophilia (TPE) is a distinct syndrome that develops in some individuals infected with W. bancrofti and B. malayi
-that are usually nocturnal (and probably related to the nocturnal periodicity of microfilariae)
Hematuria, froth in the urine (proteinuria) Renal abnormalities including proteinuria, haematuria, nephrotic syndrome and glomerulonephritis can occur with filariasis. Circulating immune complexes containing filarial antigens have been implicated in the renal damage Hematuria, froth in the urine (proteinuria)
Renal abnormalities including proteinuria, haematuria, nephrotic syndrome and glomerulonephritis can occur with filariasis. Circulating immune complexes containing filarial antigens have been implicated in the renal damage
Joint pain Lymphatic filariasis may also present as a mono-arthritis of the knee or ankle joint due to Circulating immune complexes containing filarial antigens. Joint pain
Lymphatic filariasis may also present as a mono-arthritis of the knee or ankle joint due to Circulating immune complexes containing filarial antigens.
Impaired vision, and blindness Causative factor for the Onchocerciasis is the filarial nematode Onchocerca volvulus, that is which is transmitted by Simulium. This particularly causes visual problems known as river blindness due to the invasion and death of microfilariae in the skin and eye. Loa loa infestation of the the eye may cause adult worms to be seen in the eye. Impaired vision, and blindness
Causative factor for the Onchocerciasis is the filarial nematode Onchocerca volvulus, that is which is transmitted by Simulium. This particularly causes visual problems known as river blindness due to the invasion and death of microfilariae in the skin and eye. Loa loa infestation of the the eye may cause adult worms to be seen in the eye.
Itching Onchocerciasis causes characteristic pruritic plaques. Loa loa infestation may also cause subcutaneous tissue lesions associated with itching. Itching
Onchocerciasis causes characteristic pruritic plaques. Loa loa infestation may also cause subcutaneous tissue lesions associated with itching.
Sense of adult worm migration under the skin Adults worms of Loa loa may migrate beneathe the skin. Sense of adult worm migration under the skin
Adults worms of Loa loa may migrate beneathe the skin.

Clinicals - Examination

Fact Explanation
Febrile Inflammation of lymph nodes (lymphadenitis) and lymphatics (lymphangitis) may release pyrogens that causes fever. Recurrent infections associated with damaged lymphatics may also cause the fever. Febrile
Inflammation of lymph nodes (lymphadenitis) and lymphatics (lymphangitis) may release pyrogens that causes fever. Recurrent infections associated with damaged lymphatics may also cause the fever.
Chronic swelling, and elephantiasis of the legs, arms, scrotum, vulva, and breasts. The chronic sequelae of lymphatic filariasis develop years after initial infection In lymphatic filariasis, repeated episodes of inflammation and lymphedema leads to lymphatic damage adding chronicity to the disease and graded as follows.
Pitting edema which is reversible with limb elevation (Grade1)
Nonpitting edema irreversible with the elevation of limb (Grade 2)
Severe swelling with sclerosis and skin changes (Grade 3).
Chronic swelling, and elephantiasis of the legs, arms, scrotum, vulva, and breasts.
The chronic sequelae of lymphatic filariasis develop years after initial infection In lymphatic filariasis, repeated episodes of inflammation and lymphedema leads to lymphatic damage adding chronicity to the disease and graded as follows.
Pitting edema which is reversible with limb elevation (Grade1)
Nonpitting edema irreversible with the elevation of limb (Grade 2)
Severe swelling with sclerosis and skin changes (Grade 3).
Features of hydrocele: enlarged scrotum, transilumination of the content In men, scrotal hydrocele is the most common chronic clinical manifestation of bancroftian filariasis due to accumulation of edematous fluid in the cavity of the tunica vaginalis testis. It is frequent in post-puberty. Mechanism of fluid accumulation is unknown. Features of hydrocele: enlarged scrotum, transilumination of the content
In men, scrotal hydrocele is the most common chronic clinical manifestation of bancroftian filariasis due to accumulation of edematous fluid in the cavity of the tunica vaginalis testis. It is frequent in post-puberty. Mechanism of fluid accumulation is unknown.
Skin changes: hyperpigmentation and hyperkeratosis with wart-like protuberances Endothelial and connective tissue proliferation with damaged or incompetent lymph valves will cause lymphatic dilatation, dysfunction leading to lymphedema. Early pitting edema and later brawny edema with hardening of tissues can be followed by hyper-pigmentation and hyper-keratosis. Skin changes: hyperpigmentation and hyperkeratosis with wart-like protuberances
Endothelial and connective tissue proliferation with damaged or incompetent lymph valves will cause lymphatic dilatation, dysfunction leading to lymphedema. Early pitting edema and later brawny edema with hardening of tissues can be followed by hyper-pigmentation and hyper-keratosis.
Lymphatic discharge Dilated lymphatics are ruptured leading to discharge of lymph fluid, later this will cause entry of microorganisms into the lymphatics. Lymphatic discharge
Dilated lymphatics are ruptured leading to discharge of lymph fluid, later this will cause entry of microorganisms into the lymphatics.
Respiratory System -Scattered wheezes and crackles are heard in both lung fields Tropical pulmonary eosinophilia (TPE) is a syndrome that is frequent in patients infected with W. bancrofti and B. malayi Respiratory System -Scattered wheezes and crackles are heard in both lung fields
Tropical pulmonary eosinophilia (TPE) is a syndrome that is frequent in patients infected with W. bancrofti and B. malayi
Joint tenderness Circulating immune complexes containing filarial antigens causes arthritis present as a mono-arthritis of the knee or ankle joint . Joint tenderness
Circulating immune complexes containing filarial antigens causes arthritis present as a mono-arthritis of the knee or ankle joint .
Periorbital swelling Lymphatic filariasis has been associated renal abnormalities including hematuria, proteinuria, nephrotic syndrome and glomerulonephritis. Circulating immune complexes containing filarial antigens have been implicated in the renal damage Periorbital swelling
Lymphatic filariasis has been associated renal abnormalities including hematuria, proteinuria, nephrotic syndrome and glomerulonephritis. Circulating immune complexes containing filarial antigens have been implicated in the renal damage
Visual impairment Ocular pathology is occur due to the invasion and death of microfilariae in the eye. This may be leading to blindness on certain occasions. Corneal pathology includes “fluffy” or “snow-flake” opacities (punctate keratitis), and hyperpigmented (sclerosing keratitis). Visual impairment
Ocular pathology is occur due to the invasion and death of microfilariae in the eye. This may be leading to blindness on certain occasions. Corneal pathology includes “fluffy” or “snow-flake” opacities (punctate keratitis), and hyperpigmented (sclerosing keratitis).
Pruritic plaques Pruritic hyperpigmented hyperkeratotic plaques, that are asymmetrically located are found as cutaneous manifestations in onchocerciasis. Pruritic plaques
Pruritic hyperpigmented hyperkeratotic plaques, that are asymmetrically located are found as cutaneous manifestations in onchocerciasis.
Features of loiasis Calabar swellings, eyeworms are seen in these patients. Features of loiasis
Calabar swellings, eyeworms are seen in these patients.
milky appearance of urine This is due to the chyluria occuring as a complication. milky appearance of urine
This is due to the chyluria occuring as a complication.

Investigations - Diagnosis

Fact Explanation
Thick Blood films Microfilariae of all species causing lymphatic filariasis are detected in blood. Thick Blood films
Microfilariae of all species causing lymphatic filariasis are detected in blood.
Urine examination and microscopy Microfilariae may also be detected in chylous urine and hydrocele fluid. Urine examination and microscopy
Microfilariae may also be detected in chylous urine and hydrocele fluid.
Full Blood count Marked Eosinophilia is seen in all forms of filarial infection. Full Blood count
Marked Eosinophilia is seen in all forms of filarial infection.
Serum immunoglobulin concentrations Elevated IgE and IgG4 levels will be observed in active disease. Serum immunoglobulin concentrations
Elevated IgE and IgG4 levels will be observed in active disease.
Antigen-detection assay This is done using serum,Urine and other body fluids. Antigen-detection assay
This is done using serum,Urine and other body fluids.
Antibody-detection assay The usual antibodies (IgG and IgE) lack specificity and usually cross react with antigens of Strongyloides. Also they do not differentiate past and recent infections. So the diagnosis based on recombinant antigens is only useful in expatriates while in persons in endemic regions which has no value. Antibody-detection assay
The usual antibodies (IgG and IgE) lack specificity and usually cross react with antigens of Strongyloides. Also they do not differentiate past and recent infections. So the diagnosis based on recombinant antigens is only useful in expatriates while in persons in endemic regions which has no value.
Chest X-ray Diffuse pulmonary infiltrates are visible on chest x-ray in patients with tropical pulmonary eosinophilia (TPE). Chest X-ray
Diffuse pulmonary infiltrates are visible on chest x-ray in patients with tropical pulmonary eosinophilia (TPE).
Ultrasound scan Rarely ultrasonography may be used. It can use to assess thickening of the tissues in the swollen limbs. Ultrasound scan
Rarely ultrasonography may be used. It can use to assess thickening of the tissues in the swollen limbs.
Lymphoscintigraphy Lymphoscintigraphy, is an radiological imaging study to use to assess the structural and functional changes in the lymphatics. Lymphatic dilatation, dermal back flow or obstruction to lymph flow in the edematous limbs can be demonstrated by this method. Lymphoscintigraphy
Lymphoscintigraphy, is an radiological imaging study to use to assess the structural and functional changes in the lymphatics. Lymphatic dilatation, dermal back flow or obstruction to lymph flow in the edematous limbs can be demonstrated by this method.
Biopsy and Histological examination Histological examination shows granulomatous reaction due to death of the adult worms. These granulomas are characterized by macrophages, plasma cells, eosinophils, neutrophils and lymphocytes. Macrophages later develop in to giant cells. There is endothelial and connective tissue proliferation with tortuosity of the lymphatics and damaged or incompetent lymph valves leading to lymphatic dilatation and subsequent lymphatic dysfunction.
Later skin changes like hyper-pigmentation and hyper-keratosis with wart-like protuberances appears and on histological examination, reveal dilated loops of lymphatic vessels within nodular lesions.
Biopsy and Histological examination
Histological examination shows granulomatous reaction due to death of the adult worms. These granulomas are characterized by macrophages, plasma cells, eosinophils, neutrophils and lymphocytes. Macrophages later develop in to giant cells. There is endothelial and connective tissue proliferation with tortuosity of the lymphatics and damaged or incompetent lymph valves leading to lymphatic dilatation and subsequent lymphatic dysfunction.
Later skin changes like hyper-pigmentation and hyper-keratosis with wart-like protuberances appears and on histological examination, reveal dilated loops of lymphatic vessels within nodular lesions.

Investigations - Management

Fact Explanation
Thick blood films Blood smears can be used to detect the microfilariae. After DEC therapy patients should follow up about 10-15 years in tropical countries and should undergo selective DEC therapy with microfilarial density. Thick blood films
Blood smears can be used to detect the microfilariae. After DEC therapy patients should follow up about 10-15 years in tropical countries and should undergo selective DEC therapy with microfilarial density.
Full blood count As a routine test before surgery to identify aneamia, as it should be corrected prior to surgery. Full blood count
As a routine test before surgery to identify aneamia, as it should be corrected prior to surgery.
Prothrombin time and International normalized ratio To detect any bleeding diathesis before surgery. Prothrombin time and International normalized ratio
To detect any bleeding diathesis before surgery.
Serum electrolytes and Creatinine These are particularly important in patients with co-morbities like diabetes mellitus or hypertension. Serum electrolytes and Creatinine
These are particularly important in patients with co-morbities like diabetes mellitus or hypertension.
Random blood sugar If patient is diabetic, blood sugar should be repeated on the day of surgery. Random blood sugar
If patient is diabetic, blood sugar should be repeated on the day of surgery.
Electrocardiogram Indicated prior to surgery particularly in patients who have a high risk for the cardiovascular problems such as diabetes mellitus, heart disease or hypertension. Electrocardiogram
Indicated prior to surgery particularly in patients who have a high risk for the cardiovascular problems such as diabetes mellitus, heart disease or hypertension.
Chest X-ray Indicated in filariasis as patient may have Tropical pulmonary eosinophiolia. Also generally it is indicated prior to surgery if patient having any pulmonary disease or malignancy. Chest X-ray
Indicated in filariasis as patient may have Tropical pulmonary eosinophiolia. Also generally it is indicated prior to surgery if patient having any pulmonary disease or malignancy.
Thick and thin blood smear Blood smears can be used to detect the microfilaria, but blood films may be innsensitive for monitoring microfilaremia on certain occasions. Thick and thin blood smear
Blood smears can be used to detect the microfilaria, but blood films may be innsensitive for monitoring microfilaremia on certain occasions.
Ultrasonography Hydroceles are due to accumulation of edematous fluid in the cavity of the tunica vaginalis testis. Mechanism of fluid accumulation is unknown. USS can be used to demonstrate and monitor lymphatic obstruction. Ultrasonography
Hydroceles are due to accumulation of edematous fluid in the cavity of the tunica vaginalis testis. Mechanism of fluid accumulation is unknown. USS can be used to demonstrate and monitor lymphatic obstruction.
Staging of oedema Staging of oedema can be done clinically as follows. Stage 1is lymphangitis with pitting edema and total dissapearance on treatment that may recur. Stage 2 is uniform persistent pitting edema wtih clinical history of filriasis. Stage 3 is uniform non pitting fibrous persistent lymphaedema, and stage 4 is non pitting with complications like ulcers warts etc of long duration.
Pitting edema can also be assesses as follows. 2mm or less = 1 + Edema. 2-4mm = 2 + Edema. 4-6mm = 3 + Edema. 6-8mm = 4 + Edema.
Staging of oedema
Staging of oedema can be done clinically as follows. Stage 1is lymphangitis with pitting edema and total dissapearance on treatment that may recur. Stage 2 is uniform persistent pitting edema wtih clinical history of filriasis. Stage 3 is uniform non pitting fibrous persistent lymphaedema, and stage 4 is non pitting with complications like ulcers warts etc of long duration.
Pitting edema can also be assesses as follows. 2mm or less = 1 + Edema. 2-4mm = 2 + Edema. 4-6mm = 3 + Edema. 6-8mm = 4 + Edema.

Management - Supportive

Fact Explanation
Minimize complications of lymphoedema -hygiene -skin care (early detection, treatment, and prevention of entry lesions), -exercise -elevation of the affected limb -appropriate footwear Recognition of the importance of Acute dermatolymphangioadenitis in the progression of lymphoedema has led to basic recommendations for the treatment of lymphoedema in filariasis-endemic areas. The cornerstones of this treatment include hygiene, skin care. Minimize complications of lymphoedema -hygiene -skin care (early detection, treatment, and prevention of entry lesions), -exercise -elevation of the affected limb -appropriate footwear
Recognition of the importance of Acute dermatolymphangioadenitis in the progression of lymphoedema has led to basic recommendations for the treatment of lymphoedema in filariasis-endemic areas. The cornerstones of this treatment include hygiene, skin care.
Prophylactic antibiotics To minimize acute dermatolymphangioadenitis in the progression of lymphoedema. Prophylactic antibiotics
To minimize acute dermatolymphangioadenitis in the progression of lymphoedema.
Diet control Meals rich in fats are restricted in those who with proven chyluria associated with lymphatic filariasis Diet control
Meals rich in fats are restricted in those who with proven chyluria associated with lymphatic filariasis
Bed rest in chyluria Medical management of chyluria with dietary modifications, anti-filarial drugs, bed rest and supportive measures gives reasonable success rate in excess of 70%, which is not affected by the disease duration, chronicity and primary versus recurrent nature of the disease Bed rest in chyluria
Medical management of chyluria with dietary modifications, anti-filarial drugs, bed rest and supportive measures gives reasonable success rate in excess of 70%, which is not affected by the disease duration, chronicity and primary versus recurrent nature of the disease
Prevention of the disease Transmission of filariasis can be controlled with annual mass treatment with drugs that target microfilariae. Prevention of the disease
Transmission of filariasis can be controlled with annual mass treatment with drugs that target microfilariae.
compressive bandaging To reduce leg volume or circumference in response to basic lymphoedema management. compressive bandaging
To reduce leg volume or circumference in response to basic lymphoedema management.

Management - Specific

Fact Explanation
Pharmacological management with Diethylcarbamazine (DEC) Diethylcarbamazine (DEC) is a microfilaricide.Data on the impact of treatment with antifilarial drugs on filarial morbidity are inconsistent.
For most of these studies, the primary outcome of interest was microfilaraemia rather than clinical morbidity.
Parasitemic patients should receive DEC(6 mg/kg/day). A 1-day course appears to be as effective as the traditional 12-day regimen
In Tropical pulmonary eosinophilia Treatment consists of diethylcarbamazine (DEC) for at least three weeks.
Pharmacological management with Diethylcarbamazine (DEC)
Diethylcarbamazine (DEC) is a microfilaricide.Data on the impact of treatment with antifilarial drugs on filarial morbidity are inconsistent.
For most of these studies, the primary outcome of interest was microfilaraemia rather than clinical morbidity.
Parasitemic patients should receive DEC(6 mg/kg/day). A 1-day course appears to be as effective as the traditional 12-day regimen
In Tropical pulmonary eosinophilia Treatment consists of diethylcarbamazine (DEC) for at least three weeks.
Pharmacological management with other anthelmintic drugs Ivermectin, mebendazole, abendazole are some other antihilmintics used fro the treatment. Ivermectin is a potent microfilaricide anthelminthic drug. Pharmacological management with other anthelmintic drugs
Ivermectin, mebendazole, abendazole are some other antihilmintics used fro the treatment. Ivermectin is a potent microfilaricide anthelminthic drug.
Steroid therapy Therapy for all filarial infections may be associated with allergic-like reactions resulting from degenerating filariae and Wolbachia, for which anti-histamines and corticosteroids may be useful.
These can also be used to soften and reduce the swelling of the lymphedematous tissues in mild to moderate filarial lymphedema.
Steroids also have shown to have a beneficial in Tropical pulmonary eosinophilia.
Steroid therapy
Therapy for all filarial infections may be associated with allergic-like reactions resulting from degenerating filariae and Wolbachia, for which anti-histamines and corticosteroids may be useful.
These can also be used to soften and reduce the swelling of the lymphedematous tissues in mild to moderate filarial lymphedema.
Steroids also have shown to have a beneficial in Tropical pulmonary eosinophilia.
Doxycycline Prolonged courses of doxycycline (which kills and sterilizes adult worms as a result of anti-Wolbachia activity) may have a role. Doxycycline
Prolonged courses of doxycycline (which kills and sterilizes adult worms as a result of anti-Wolbachia activity) may have a role.
Surgical management of lymphoedema Correction of gross limb elephantiasis via surgery proven to be less successful and sometimes necessitate multiple procedures with skin grafting. But during later stages together with other measurements, it will help in controlling the disease. Surgical management of lymphoedema
Correction of gross limb elephantiasis via surgery proven to be less successful and sometimes necessitate multiple procedures with skin grafting. But during later stages together with other measurements, it will help in controlling the disease.
surgical management of hydrocele Surgery is the recommended intervention for hydrocele, and if done properly, it is regarded as curative.
Bilateral Nodovenal shunt with reduction is the treatment of choice
surgical management of hydrocele
Surgery is the recommended intervention for hydrocele, and if done properly, it is regarded as curative.
Bilateral Nodovenal shunt with reduction is the treatment of choice
Management of onchocerciasis This is usually with doxycycline given as a dose of 200mg/day for 4-6 weeks. New treatments such as those with antibiotics are gaining popular now. Management of onchocerciasis
This is usually with doxycycline given as a dose of 200mg/day for 4-6 weeks. New treatments such as those with antibiotics are gaining popular now.
Management of chyluria Bed rest, use of abdominal binders to increase intra-abdominal pressure to stop lymph leakage, are initial steps in the management. Fat-restricted, high-protein diet with the addition of fats containing medium chain triglycerides (TGs) and high fluid intake are important dietary measures. Anti-filarial drugs may also improve the chyluria. Management of chyluria
Bed rest, use of abdominal binders to increase intra-abdominal pressure to stop lymph leakage, are initial steps in the management. Fat-restricted, high-protein diet with the addition of fats containing medium chain triglycerides (TGs) and high fluid intake are important dietary measures. Anti-filarial drugs may also improve the chyluria.

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