TK

8/22/2013

Lymphatic Filariasis
Infection - 3 closely related Nematodes Wuchereria bancrofti

Brugia malayi
Brugia timori * Transmitted by the bite of infected mosquito responsible for considerable sufferings/deformity and disability * All the parasites have similar life cycle in man * Adults seen in Lymphatic vessels * Offsprings seen in peripheral blood during night

8/22/2013

Filarial worms
Tissue dwelling parasites

Possess a unique life cycle stage the microfilaria - between the egg and J1
Egg microfilaria J1 J2 J3 J4 Adult

these are present in the bloodstream or skin of the definitive host. Filarial worms utilize arthropods as vectors

TK

8/22/2013

Epidemiology

95% cases due to Wuchereria bancrofti, other species include Brugia malayi and Brugia timori

120m people infected in >80 countries in Africa, Asia, the Pacific

islands and South and Central America

40m of those infected are disfigured or severely incapacitated

W. bancrofti usually resides in deeper lymphatic system besides

in lower lymphatic system, with no natural or reservoir host

B.malayi usually resides in lower lymphatic system of limb, can be transmitted to cats and rhesus monkeys

TK

8/22/2013

 W. bancrofti- broad equatorial belt particularly

Africa, Middle East, Southeast Asia, Indo-Pacific islands, Parts of Australia and South America Brugia malayi - Orient, South Pacific, and Southern Asia to India overlaps with W. bancrofti - but does not occur in Africa or South America

TK

8/22/2013

TK

8/22/2013

Man Natural Host Age All age (6 months) Max: 20-30 years Sex Higher in men Migration leading to extension of infection to non-endemic areas

Immunity may develop after long year of exposure (Basis of

immunity-not known)

8/22/2013

Associated with Urbanization, Poverty, Industrialization,

Illiteracy and Poor sanitation.

1. 2.

Climate: is an important factor which influences: The breeding of mosquito Longevity (Optimum temperature 20-300C & Humidity 70%)

3. 4.

The development of parasite in the vector

Sanitation, Town planning, Sewage & Drainage.
8/22/2013 8

Adults: Thread-like, smooth cuticle, filariform oesophagus. Female: 10 cm x 0.2 mm. (2 sets of genitalia, vulva 1mm from anterior end) Male: 4 cm x 0.1 mm. (one set of genitalia, posterior end curved with2 spicules)
Takes

6-12 months for females to release microfilariae

Produce

for 5-10 years

TK

8/22/2013

Micrifilariae:

Embryos laid by the female

250 X 8m, with graceful curves with

rounded anterior & posterior ends

Have loose redundant sheath No alimentary canal The body contains columns of nuclei

The tail is free of nuclei

Life span about 2~3 months
8/22/2013 10

TK

Anopheles Vector:

Wuchereria bancrofti is mainly

Aedes

transmitted by
Culex in India, Anopheline & Aedes mosquitoes in Africa

Culex

B. malayi and B. timori are

transmitted mainly by Mansonia and Anopheles Mansonia

TK

8/22/2013

11

TK

8/22/2013

12

W. bancrofti -10 PM to 2 AM B. malayi - 8 PM to 4 AM Theories: Adaptation between biting & microfilariae +ve chemotaxis between mosquito

saliva & microfilariae

CO2 in blood stimulates microfilariae to migrate to peripheral blood Khalils theory: Blockage theory
Nocturnal periodicity of microfilariae
TK
8/22/2013 13

Pathology

Adult worms live in the afferent lymphatic vessels and cause

severe disruption to the lymphatic system Scrotal damage and massive swelling may occur when adult Wuchereria bancrofti lodge in the lymphatics of the spermatic cord

Late stage disease is typified by elephantiasis painful and

disfiguring swelling of the limbs Trauma and secondary bacterial infection of affected tissues is common Incubation period: 1 year.
TK
8/22/2013 14

Manifestations are 2 types

1. Lymphatic Filariasis (Presence of Adult worms) 2. Occult Filariasis (Immuno hyper responsiveness)

Clinical Spectrum

None

Asymptomatic microfilaremia

Filarial fever

Chronic pathology

TPE

8/22/2013

15

There are 4 stages :

1. Asymptomatic amicrofilariaemic stage 2. Asymptomatic microfilariaemic stage 3. Stage of Acute manifestation 4. Stage of Obstructive (Chronic) lesions

8/22/2013

16

In endemic areas, a proportion of population does not show mf

or clinical manifestation even though they have some degree of exposure to infective larva similar to those who become infected.
Laboratory diagnostic techniques are not able to determine whether they are infected or free.

8/22/2013

17

Considerable proportions are asymptomatic for months and

years they have circulating microfilariae important source of infection can be detected by Night Blood Survey and other suitable

procedures

8/22/2013

18

During initial months and years, there are recurrent episodes of Acute inflammation in the lymph vessel/node of the limb & scrotum that are related to bacterial & fungal super infections of the tissue that are already compromised lymphatic function.

Clinical manifestations are consisting of: 1. Filarial fever 2. Lymphangitis

3. Lymphadinitis
4. Epididimo orchitis
8/22/2013 19

Occult or Cryptic filariasis, in classical clinical manifestation

mf will be absent. Occult filariasis is believed to be the result of hyper responsiveness to filarial antigens derived from mf. Seen more in males.
Patients present with paroxysmal cough and wheezing, low grade fever, scanty sputum with occasional haemoptysis, adenopathy and increased eosinophilia. X-ray shows diffused nodular mottling and interstial thickening

8/22/2013

20

8/22/2013

21

8/22/2013

22

8/22/2013

23

8/22/2013

24

8/22/2013

25

8/22/2013

26

8/22/2013

27

Lymphoedema is classified into 7 stages on the basis of the presence

& absence of the following: 1. Oedema 2. Folds 3. Knobs

4. Mossy foot
5. Disability

8/22/2013

28

Swelling reverses at night

Skin folds-Absent Appearance of Skin-Smooth, Normal

8/22/2013

29

Swelling not reversible at

night

Skin folds-Absent Appearance of skinSmooth, Normal

8/22/2013

30

Swelling not reversible at

night

Skin folds-Shallow Appearance of skinSmooth, Normal

8/22/2013

31

Swelling not reversible at night

Skin folds-Shallow Appearance of skin - Irregular,

* Knobs, Nodules

8/22/2013

32

Swelling not reversible at

night

Skin folds-Deep Appearance of skin Smooth or Irregular

8/22/2013

33

Swelling not reversible

at night

Skin folds-Absent, Shallow, Deep

Appearance of skin

*Wart-like lesions on
foot or top of the toes

8/22/2013

34

Swelling not reversible at night

Skin folds-Deep Appearance of skin-Irregular Needs help for daily activities Walking, bathing, using

bathrooms, dependent on
family or health care systems

8/22/2013

35

b) Chronic phase: Hydrocele:

TK

8/22/2013

36

Obstruction of lymphatics: Distension & varicosities of l.v. distal to obstruction.

Lymphatic edema. Rupture of distended lymphatics. Elephantiasis.

TK

8/22/2013

37

TK

8/22/2013

38

Obstructive phase photos

TK
8/22/2013 39

Clinical.
Microscopy
Microfilariae in Giemsa stained thick blood films

Knotts technique
Microfilariae in chylous urine or hydrocele

Adults in lymph nodes High eosinophilia Serology - ICT

DEC Provocative test

Molecular techniques
8/22/2013 40

TK

Imaging techniques:
1-Ultrasonography 2- Lymphoscintography

Calcification of inguinal lymph nodes

Obstruction of Cisterna chyli or its tributeries

TK

8/22/2013

41

Diethyl carbamazine (DEC): 6 mg/kg/day/12 days (affects adults & mf). Repeated /6 months: till no mfmia.

Antihistaminics & corticosteroids.

Ivermectin: 150g/kg body weight (Single oral dose).

Repeated /6 or 12 months (affects mf)

Other treatment options are ivermectin combination of DEC and albendazole

TK

8/22/2013

42

 Diethylcarbamazine (DEC) rapidly kills microfilariae and will kill adult worms if given in full dosage over 3 weeks Release of antigens from dying microfilaria causes allergic-type reactions add an antihistamine and aspirin to treatment regimen Symptomatic treatment. Surgical management.

TK

8/22/2013

43

Prevention and control Rapid diagnosis and treatment of infected individuals Mass drug administration to at risk communities

Vector control:
eliminate mosquito breeding sites through improved sanitation and enviromental management Personal protection against mosquito bites by insecticides, Bed nets and repellants

TK

8/22/2013

44

Heartworms (Dirofilaria immitis)

TK

8/22/2013

45

Heartworms (Dirofilaria immitis):

TK

8/22/2013

46

Adult male: 6-12 inches long

Adult female: 12-16 inches long

Adults coiled in right side of dog heart

Unsheathed microfilaria in dog blood DIAGNOSTIC

TK

8/22/2013

47

HUMAN INFECTIONS of Dirofilaria immitis are rare (~70 cases). Larvae are killed by the host reaction and scar tissue nodules form in lungs around worms Symptoms are coughing and chest pain. In only 4 cases were adult worms recovered from the human heart.

These were found incidentally at autopsy and were not related to

the death of the patient.

TK

8/22/2013

48