Filariasis: Making an Early diagnosis

1:5 Uday Sankar Ghosh, Kolkata

OVERVIEW
Filariasis is, a disease group affecting humans, caused by nematode parasites of the order Filariidae,
and transmitted by mosquitoes - Culex quinquefasciatus is globally the most important vector.1,2 The
adult worms have different habitat in humans like the lymphatic group (Wuchereria bancrofti, Brugia
malayi, Brugia timori); cutaneous group (Loa loa, Onchocerca volvulus, Mansonella streptocerca)
and body-cavity group (Mansonella perstans and ozzardi).3,4 Parasites of the lymphatic group are
clinically most significant in our country.5, 6
The bulk infection is due to Wuchereria bancrofti (92-98%) and a small percentage is Brugia. Filarial
life cycle consists of five larval stages.7, 8 The third stage larvae (microfilaria) enter the human skin
from a mosquito bite, migrate into bloodstream, and eventually reach lymphatic channels where
they finally settle down (predominantly in inguinal, scrotal, and abdominal lymphatics) and begin
to grow into adult, sexually mature forms that lead to production of abundant amounts of first stage
larvae to be taken up by the mosquito again.8, 9 This may take 6–12 months for a traveller and 2-3
years for an indigenous individual – this is known as pre-patency; the adult worms can live for 5-18
years. Infection usually occurs at very young age (less than 8years) and has a spectrum of clinical
manifestations, however, most often it is asymptomatic (~70%).5, 6, 8, 9.
Prevalence of microfilaremia increases with age, as adult worms are gradually acquired over years;
it stabilizes over the second to third decade. Infected individuals cannot sustain higher levels of
parasitemia once they leave the endemic area because the mosquito vector is inefficient.1, 2 The
manifestation of acute and chronic filariasis usually occurs only after years of repeated and intense
exposure to infected vectors in endemic areas- mostly late second to fourth decade of life. 5, 6, 7 Most
of the asymptomatic infections can ultimately present as chronic complication for which there is
no radical cure or any chemoprophylaxis. Filarial diseases are rarely fatal, but the consequences of
infection can cause significant disfigurement, impairment of working capacity, personal misery and
social stigmatization.1-6 WHO has identified lymphatic filariasis (LF) as the second leading cause of
permanent and long-term disability after leprosy.3, 4, 8
LF is one of the most debilitating neglected tropical diseases and is one of seven diseases worldwide
that the WHO has targeted for eradication. In 2000 WHO established the Global Programme to
Eliminate Lymphatic Filariasis.1, 2, 8 The goal of the program is to eliminate LF as a public health
problem by 2020 through consecutive annual rounds of mass drug administration (MDA) until
interruption of transmission is achieved, and provide care for those who suffer the devastating clinical
consequences.3, 9
India is one of the five countries with the highest estimated disease burden worldwide (~38%). LF is
endemic in 257 districts in 21 states (and union territories); the at-risk population is 600 million with
about 31 million having microfilaria and 23 million suffering from disease conditions.3, 8 Economic
losses per year in India are estimated to be around one billion US dollars (~$842) and around 8%
of potential male labor force is lost per day per year. 10 The National Filaria Control Program was
launched in India in 1955 and now has a goal of elimination of LF by 2015. To ensure success of
these ambitions, diagnostic tools, especially early and rapid acting, will play an important role in
mapping of endemic areas, monitoring effectiveness of MDA and surveillance for resurgence.10, 11
20
 Filariasis: Making an Early Diagnosis
Manifestations can be protean and classified as: 1) Acute - Fever
with chills and rigors, lymphedema with pain, lymphadenopathy
(cervical, axillary, inguinal and generalised – Acute Filarial
Lymphangitis/Acute Dermatolymphangioadenitis), chyluria,
hematuria, inflammatory granuloma or abscesses, pain in
testes, funiculitis, epididymoorchitis. 2) Chronic - funiculitis,
epididymoorchitis, hydrocele, breast edema, elephantiasis.
3) Occult- Pulmonary eosinophilia, mono and polyarthritis,
tenosynovitis, glomerulonephropathy, retroperitoneal
lymphangitis (acute abdomen), central serous retinopathy,
iridocyclitis, recurrent scleritis and macular oedema,
endomyocardial fibrosis, urticaria, recurrent upper respiratory
infections, asthmatic bronchitis. Any lymph node or any body
part can be affected but commonly genital lymphatics are
involved in males. 4) Asymptomatic - Endemic normals-
negative for Mf but positive for antigens (pre-patency)
and asymptomatic microfilaremic - is characterised by the
presence of microfilaria in peripheral blood during night but
without any overt clinical manifestations of filariasis with or
without antigens – also known as Mf carriers (patency).1-3,6,8
Factors affecting pathogenesis of filarial manifestations include
the cumulative exposure to bites, quantity of accumulating
adults , number of secondary infections, the degree and type
of host immune response (Th1/Th2) and possibly genetic
predisposition.11-13 Hydrocele is less common in microfilaria
carriers than endemic normals. Lymphatic filarial parasites
also harbor an endosymbiont – Wolbachia - that contributes
to inflammation.14 Commonly, the diagnosis of lymphatic
filariasis relies upon suggestive clinical and epidemiologic
clues and supportive laboratory findings. The morbidity of
human filariasis results mainly from the host reaction to
microfilaria and adult worms in different areas of the body
which increases with duration.14-16 So, early diagnosis and
treatment are the best options. The patients of acute and
chronic manifestations usually come for medical attention
while the very big pool of asymptomatic and occult infections
are usually inaccessible individually, their coming to medical
attention is primarily by mass community screening or as a
chance finding.
DIAGNOSIS
Most of the clinicians rely on their clinical acumen in the
diagnosis of clinical filariasis (low specificity and sensitivity
for acute or asymptomatic active infections).15, 16 Laboratory
tests can be divided into nonspecific and specific tests. Specific
tests include - direct detection of microfilaria on blood smears,
serologic tests, DNA PCR and radiology. Nonspecific tests are
eosinophilia, high IgE levels and lymphoscintigraphy (that
reveal dilated lymph channels or backflow even in the early
stage of infection).
The direct methods include visualization of microfilaria (or
the adult worm) - is made by microscopic examination of thick
film of blood collected between 10:00 PM and 2:00 AM, with or
21
without DEC provocation, stained by Geimsa or hematoxylin-
eosin for the presence of microfilaria. Adult worm may be
found in fluids drawn from swollen areas or serous collections.
X-ray tests can show calcified adult worms in lymphatics;
ultrasonography can show the ’filarial dance’.1, 2, 7 Lymph node
aspirate and chylus fluid may also yield microfilaria or worm.
Direct diagnosis, though definitive, is difficult, because of
timing inconvenience of blood collection, long pre-patency,
low patency (<60%) and inadequate sensitivity.Reliance on
microfilaria testing may lead to late as well as under diagnosis;
it is necessary to develop diagnostics for early detection of
the disease.16-18
Early diagnosis of filarial infections is best possible with
seromarkers. With the entry of the microfilaria there is
a natural IgM response within a few weeks which slowly
changes to an IgG response – initially IgG1 and IgG2 – which
changes to IgG4 after some more time.11-13 Antigens appear
with development of adult worms from microfilaria. This
appearance of antigenemia from both adults and the larvae
leads to increased easily detectable levels of IgG4. Antibody
detection has served as the basis for diagnostic assays for
filariasis for many decades, especially with the native antigens.
The best of these assays were sensitive for infection but cannot
distinguish current infection from past infection or exposure
to other parasite and there was significant degree of cross-
reactivity with other helminth infections – leading to poor
specificity (~40%).15-17
With the advent of recombinant antigens antibody tests have
become refined.19, 20, 21 Antibody-based diagnostic assays
using four recombinant antigens, Bm14, WbSXP, BmSXP
and BmR1 have become commercially available.22-26 They
are based on the detection of antifilarial IgG4 antibodies.
The BmR1 ELISA as well as dipstick (Brugia Rapid
immunochromatography based) antibody tests have very
high sensitivity for Brugia malayi (~100%), Bm14 ELISA
is sensitive for both Wuchereria bancrofti and Brugia malayi
(~91%-96%), and WbSXP was predominantly sensitive for
Wuchereria bancrofti (91%) and somewhat less for Brugia
malayi (40%). BmSXP is another recombinant antigen having
high sensitivity for Wuchereria bancrofti (95%).25, 26 Both
WbSXP and BmSXP(WB Rapid) have high specificity for
Wuchereria bancrofti (96-99%). A combined test format using
BmR1 and BmSXP has been advocated by some as a more
comprehensive test of pan filariasis.26,27,28.
‘Seva Filachek’ is a dipstick based ELISA system which
has been permitted by government of India (Signal MF) for
microfilarial antigen(IC-Ag) as well as filarial antibodies
(IgG4) in diagnosis of filarial infection in different clinical
groups. The detection of IgG4 antibody titre of 1:300 and
above against specific microfilarial antigen was found to be
useful. Free as well as immune- complexed antigen could
also be detected. Overall the test system has a sensitivity and
specificity of around 80% for antibody detection and 88%
 Medicine Update 2012  Vol. 22
for antigen detection.27-30. There was no interference from
non-filarial helminths or other immune activation states
like positive rheumatoid factor, ANF or high levels of IgE.
However the problem of specificity especially in the form of
distinguishing past from present infection and rarely other
helminths remains.30 The rapid format assays, though more
convenient can give indeterminate result in upto 30% cases,
which is unusual in ELISA.27-30. The ‘OnSite’ Filariasis
IgG/IgM Rapid Test uses conserved recombinant antigens
to simultaneously detect IgG and IgM to the Wuchereria
bancrofti and Brugia malayi parasites without the restriction
on specimen collection. Recombinant multiple beaded
antigens including Bm14 and Bm33 from Brugia malayi
has been used to follow therapy response by determining
IgG4 levels. Bronchoalveolar lavage fluid of patients with
tropical pulmonary eosinophilia contains IgE antibodies that
recognize Brugia malayi antigen, Bm 23-25.30, 27
Filarial Antigen tests, available commercially, are probably
better than antibody tests. They show little 24 hour variation in
their positivity can detect active infection (better specificity)
and have a significantly wider user experience and evidence
base for monitoring therapy.31-33 This antigen test is available
only for infection caused by Wuchereria bancrofti but not for
Brugia. Immunochromatographic test (ICT) is a highly sensitive
and specific circulating filarial antigen (CFA) detection assay,
both as card test (AD-12.1 antibody) and in ELISA based
format (Og4C3 antibody– ‘Tropbio’) are now available for
the diagnosis of Wuchereria bancrofti infection.32-37 This test
is positive in early stages of the disease when the adult worms
are alive and becomes negative once they are dead. The Card
test is a qualitative test with possibility of indeterminate results
but very rapid; the Elisa format is a semi quantitative test
that provides definite results.36-38 Filarial antigen detection has
been found to be more useful in epididymoorchitis and allergic
state such as tropical eosinophilia and in lymphedema. ‘Binax
Filariasis Now Test’ is a variety of commercial card test for
Wuchereria bancrofti antigen.37
DNA probes using Real-Time Polymerase Chain Reaction
(RT-PCR) are of high specificity and sensitivity, but are not
cost effective.39 Assays for circulating immune complex of
filarial antigen and antibodies are also used for serodiagnosis
in microfilaria negative cases.40
CONCLUSION
With the knowledge of filarial endemicity, its associated
morbidities and the national and international intervention
strategies for its elimination, it nearly becomes obligatory
for any practising doctor to have some working ideas on this
disease. Serological tests are the tests of choice for early
markers of infection, but they can be hardly used in individuals
as the disease is most often asymptomatic - all age group
mass screening is the preferred option.41,42 Antibody detection
provides an early means to detect filarial parasite infection.
22
Presence of IgM antibody to the parasite antigens suggest
current infection, whereas, IgG corresponds to late stage or
past infection. Utilization of recombinant proteins eliminates
cross-reaction. 43, 44 Furthermore, identification of conserved
antigens allows ‘pan-filaria’ test to be applicable. However
antibody testing is probably better in children. Antigen
positivity indicates active disease and it can be used both
in sera and body fluids and also in urine and it is the better
test considering its specificity. In nearly all antigens positive
cases the antibody will be positive and both will be positive in
microfilaria positive cases. 45 Only antibody positivity without
antigen or microfilaria may indicate early infection especially
the IgM variety but commercial kits for its detection are hardly
available.11, 12
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