Wuchereria bancrofti

Filarial Nematodes
Common Name: ___________________________________________________________________________________
General Characteristics Associated Diseases: _____________________________________________________________________________
 Filariae or filarial nematodes Mode of Transmission: __________________________________________________________________________
 Adult worms live in tissue or the lymphatic system (thus rarely seen) Habitat: ____________________________________________________________________________________________
 Microfilarie (larvae) that are usually detected in the blood; they may exhibit periodicity Infective stage: ___________________________________________________________________________________
 Morphologic forms: ____________________ and ________________________
Diagnostic stage: _________________________________________________________________________________
 Adults usually appear creamy white and assume a threadlike appearance
 Two key characteristics of speciating the microfilariae: distribution of nuclei within
the tip of the tail and the presence/absence of a delicate transparent covering (sheath)  W. bancrofti is responsible for 90% of lymphatic filariasis. Recently, 120 million
worldwide cases of lymphatic filariasis were estimated.
 It largely affects areas across the broad equatorial belt (Africa, the Nile Delta, Turkey,
Life Cycle
India, the East Indies, Southeast Asia, Philippines, Oceanic Islands, and parts of South
 Only one to four infective larvae, injected by an arthropod at the feeding site, are
America.)
required to initiate human infection
 The mosquito vectors of W. bancrofti have a preference for human blood; humans are
 Once inside the body, the larvae migrate to the tissues, where they complete their
apparently the only animals naturally infected with W. bancrofti.
development (a process that may take up to 1 year)
 Adult worms may reside in the lymphatics, subcutaneous tissue, or internal body
 Morphology
cavities.
 Microfilariae
 Fertilized adult female worms lay live microfilariae, which take up residence in the blood
 Appear as minute snake-like organisms constantly moving among the RBCs
or dermis.
 Measures 270-290µm and is enclosed in hyaline sheath
 The microfilarie exit the body via a blood meal by the appropriate arthropod vector
 The column of nuclei is arranged in two or three rows and is distinctly
 Intermediate host: arthropod; where the larvae development into the infective stage
conspicuous
takes place
 The cephalic or anterior end is blunt and round
 The posterior tail end culminates in a point that is free of nuclei
Laboratory Diagnosis
 Periodicity – a phenomenon whereby the parasites are present in the bloodstream
during a specific time period (thus helping a technologist in selecting the appropriate
time for specimen collection); it depends to the arthropods feeding schedule
o Nocturnal – occurring at night
o Diurnal – occurring during the day  Adult worms
o Subperiodic – timing of occurrences not clear-cut  Long hair-like transparent nematodes; creamy white in
 Giemsa-stained blood smear / tissue scraping of an infected nodule – primary color
method of filarial diagnosis  Filiform in shape, both ends are tapering
 Knott’s technique – lysing cells followed by concentrating and examining the sample  Male: 2.5-4cm in length and 0.1 mm thick; tail is curved
for microfilariae ventrally containing 2 spicules
 Female: 8-10 cm in length and 0.2-0.3 mm thick

Review Notes in Clinical Parasitology by RMDM 26

 Life Cycle
 Intermediate host: Culex, Aedes, and Anopheles spp.
 Definitive host: humans (live in the lymphatics where adults lay their microfilariae.
These microfilariae live in the blood and lymphatics)
 Laboratory Diagnosis and Treatment
1. During a blood meal, an infected mosquito introduces third-stage filarial larvae onto the
skin of the human host, where they penetrate into the bite wound.
2. They develop in adults that commonly reside in the lymphatics.
3. Adult worms produce microfilariae which are sheathed and have nocturnal periodicity.
The microfilariae migrate into lymph and blood channels moving actively through lymph
and blood
4. A mosquito ingests the microfilariae during a blood meal.
5. After ingestion, the microfilariae lose their sheaths and some of them work their way
through the wall of the proventriculus and cardiac portion of the mosquito’s midgut and
 Prevention and Control
reach the thoracic muscles.
6. There, the microfilariae develop into first-stage larvae and subsequently into third-stage
infective larvae.
7. The third-stage infective larvae migrate through the hemocoel to the mosquito’s
proboscis and can infect another human when the mosquito takes a blood meal.
 Clinical Manifestation
 Asymptomatic
 Infections of this type are self-limiting because the adult worms eventually die and
there are no signs of microfilariae being present.
 Once blood is collected, eosinophilia may be noted; physical examination reveals only
enlarged lymph nodes, particularly the inguinal region, the groin area.
 Symptomatic Bancroftian Filariasis
 General: fever, shaking chills, body aches, and swollen lymph nodes
 Invasion of larvae: formation of granulomatous lesions, lymphangitis, and
lymphadenopathy
 Lymphaginitis: episodes of acute inflammation of the lymphatic vessels
 Lymphadenopathy: chronic lymph node swelling
 Elephantiasis (swelling of the lower extremities) develop due to obstruction of the
lymphatics
 Genitals and breast may also be involved
▪ Orchitis, funiculitis, and epididymitis
 On the death of the adult worms, calcification or the formation of abscesses may
occur.
 Wuchereria bancrofti exhibits nocturnal periodicity, therefore, blood for the test should
be taken at night
 Collect blood specimen from 8pm to 4am - Thick Smear (Giemsa or H&E)
 Knott’s test
 Serologic tests such as immunofluorescence be done by identifying positive antibody
titers
 Others: PCR, Ultrasonography, and X-ray examinations
 Gold standard: Antigen-detection (ELISA) to detect CFA (Circulating Filarial Antigen)
 Alternative method: filtering heparinized blood through a special filter, known as
nuclepore filter, and then staining and examining the filter contents
 Drug of Choice: Diethylcarbamazine (DEC)
 Alternatice drugs: Ivermectin and Albendazole
 Prevention involves mosquito control with insecticides
 Use of protective clothing to prevent mosquito bites
 Use of mosquito netting for sleeping and on windows of houses
 Use of mosquito repellent cream
 Clearing of bushes around residential houses and clearing of drainages to ensure there is
no breeding place for mosquitoes.
Review Notes in Clinical Parasitology by RMDM 27
 Brugia malayi  Life Cycle
 Intermediate host: Aedes, Anopheles, or Mansonia
Common Name: ___________________________________________________________________________________  Definitive host: man, felines and monkeys
Associated Diseases: _____________________________________________________________________________  Since Anopheles mosquito also transmits W. bancrofti, coinfection is possible.
Mode of Transmission: __________________________________________________________________________  Similar life cycle with W. bancrofti
Habitat: ____________________________________________________________________________________________
Infective stage: ___________________________________________________________________________________
Diagnostic stage: _________________________________________________________________________________

 Lymphatic filariasis affects over 120 million people in 73 countries throughout the tropics
and sub-tropics of Asia, Africa, the Western Pacific, and parts of the Caribbean and South
America.
 In the Americas, only four countries are currently known to be endemic: Haiti, the
Dominican Republic, Guyana and Brazil.
 In the United States, Charleston, South Carolina, was the last known place with lymphatic
filariasis. The infection disappeared early in the 20th century. Currently, you cannot get
infected in the U.S.

 Morphology
 Microfilariae
 Slightly smaller than those of W. bancrofti
 Sheathed and measures about 200-275µm
 Possess a sheath, rounded anterior end, and numerous nuclei
 Presence of two distinct nuclei in the tip of the somewhat pointed tail (these two
nuclei are distinct and separated from the other nuclei present)

 Clinical Manifestation
 Often asymptomatic
 Fevers may take months to years to develop after initial infection
 Formation of granulomatous lesions following microfilarial invasion into the lymphatics,
 Adult worms chills, lymphadenopathy, lymphangitis, and eosinophilia
 Male and female adult worms of B. malayi and W. bancrofti are indistinguishable  Elephentiasis of the legs; elephantiasis of the genitals may also be possible but less
 Male: 13-23 mm in length common
 Female: 43-55 mm in length

Review Notes in Clinical Parasitology by RMDM 28

 Laboratory Diagnosis and Treatment  Morphology
 Blood  Microfilariae
 Thin and thick blood smear  Sheathed and measures about 0.25 mm long and 6-8µm thick
 Wet preparations and concentrations (Knott’s)  posterior extremity of the microfilaria showing a column of five nuclei (nu) reaching
 PCR the extremity of the tail excluding the sheath.
 Serologic testing: Antigen and antibody detection  Exhibits diurnal periodicity
 Ultrasonography
 Drug of Choice: Diethylcarbamazine (DEC)
 Alternatice drugs: Ivermectin
 Since inflammatory reactions are more common, anti-inflammatory drugs may be
necessary
 Adult worms
 Prevention and Control  White in color and exhibit a cylindrical threadlike
 The best way to prevent lymphatic filariasis is to avoid mosquito bites. The mosquitoes appearance
that carry the microscopic worms usually bite between the hours of dusk and dawn.  Male: 30-34 mm long
 sleep in an air-conditioned room or  Female: 40-70 mm long
 sleep under a mosquito net ▪ With narrow straight buccal canal and muscular
 wear long sleeves and trousers and esophagus
 use mosquito repellent on exposed skin. ▪ Extremities contain anus and posterior uterine loop of the posterior uterus
 Another approach to prevention includes giving entire communities medicine that kills
the microscopic worms — and controlling mosquitoes.
 Life Cycle
 Intermediate host: Chrysops fly
 Definitive host: man
Loa loa  Adult worms take up residence and multiply throughout the subcutaneous tissues.
 The microfilariae are present in the blood but not until years after the initial infection
Common Name: ___________________________________________________________________________________
making the diagnosis more difficult.
Associated Diseases: _____________________________________________________________________________
Mode of Transmission: __________________________________________________________________________
1. During a blood meal, an infected fly introduces third-stage filarial larvae onto the skin of
Habitat: ____________________________________________________________________________________________ the human host, where they penetrate into the bite wound.
Infective stage: ___________________________________________________________________________________ 2. The larvae develop into adults that commonly reside in subcutaneous tissue.
Diagnostic stage: _________________________________________________________________________________ 3. Adults produce microfilariae, which are sheathed and have diurnal periodicity.
4. The fly ingests microfilariae during a blood meal. After ingestion, the microfilariae lose
their sheaths and migrate from the fly’s midgut through the hemocoel to the thoracic
 Loa loa parasites are found in West and Central Africa (more than 40% of the people who
muscles of the arthropod.
live in that area report that they have had eye worm in the past)
5. There, the microfilariae develop into first-stage larvae and subsequently into third-stage
 In the case of L. loa, the Chrysops fly inhabits Africa especially the rainforest belt region. infective larvae.
 It is estimated that infection rates may be over 70% in the areas in which a large vector 6. The third-stage infective larvae migrate to the fly’s proboscis and can infect another
population exists. A less than 10% infection rate occurs in regions in which minimal human when the fly takes a blood meal.
numbers of vectors reside.

Review Notes in Clinical Parasitology by RMDM 29


 Prevention and Control
 Clinical Manifestation
 Pruritus or itchiness and localized pain usually near the joints
 Calabar swelling (localized subcutaneous edema) at the site of discomfort follows
 Muscle and joint pain, tiredness and fatigue
 Adult worms may only be noticeable when seen migrating in the conjunctiva of the eye /
under the skin of the bridge of the nose.
 CNS involvement
 Occasional intense swelling can cause nerve compression and subsequent
neuropathies
 Can lead to carpal tunnel syndrome developmentt
 Meningoencephalitis (increase in microfilarial burden 2,500 microfilaria/ml)
 Microfilaria can be found in CSF with high organism burden
 Renal failure
 Glomerular damage
 Rarely, microfilariae are evident in urine
 Infrequent complications
 Lymphadenitis, pulmonary infiltrates, hydroceles, scrotal swelling, and joint
involvement
 Endomyocardial fibrosis
 Laboratory Diagnosis and Treatment
 The main methods of diagnosis include:
 The presence of microfilariae in the blood
 The presence of a worm in the eye; and
 The presence of skin swelling
 Specimen of choice: Giemsa-stained blood
 Knott technique and other serologic testing may also be performed
 Time of collection: 10:15am and 2:15pm (diurnal periodicity)
 The migrating adult worms may be extracted from a variety of body locations, including
the eye.
 Other methods:
 Blood count
 Urine and saliva testing
 Drug of Choice: Diethylcarbamazine (DEC) (one side effect is encephalitis; it should be
used with caution)
 Avoiding areas where the deerflies are found
 You may reduce your risk of bites by using insect repellants that contain DEET (N,N-
Diethyl-meta-toluamide)
 Wearing long sleeves and long pants during the day, which is when deerflies bite
 Treating your clothes with permethrin may also help.
Onchocerca volvulus
Common Name: ___________________________________________________________________________________
Associated Diseases: _____________________________________________________________________________
Mode of Transmission: __________________________________________________________________________
Habitat: ____________________________________________________________________________________________
Infective stage: ___________________________________________________________________________________
Diagnostic stage: _________________________________________________________________________________
 The World Health Organization (WHO) estimates that at least 25 million people are
infected with O. volvulus worldwide; of these people 300,000 are blind and 800,000 have
some sort of visual impairment. Some 123 million people are at risk for becoming infected
with the parasite.
Review Notes in Clinical Parasitology by RMDM 30
 Morphology 5. There the microfilariae develop into first-stage larvae and subsequently into third-stage
 Microfilariae infective larvae. The third-stage infective larvae migrate to the blackfly’s proboscis and
 Unsheathed, non-periodic and measure 220-360mm can infect another human when the fly takes a blood meal.
 The body contains numerous nuclei that extend from the rounded anterior end,
almost to but not including the tip of the somewhat pointed tail
 Normally found in dermis, rarely in the blood, sputum or urine

 Adult worms
 are long and slender, have a smooth cuticle, and have blunt anterior and posterior
ends.
 no lips or buccal capsule, and the mouth is surrounded by 2 circles made up of four
papillae each
 White, opalescent and transparent with traverse striation in the muscle
 Male: 1.9-4.2 cm
 Female: 33-50 cm
 Adult worms have a longevity of 10-15 years

 Life Cycle
 Intermediate host: blackfly genus Simulium
 Definitive host: man
 The microfilariae are rarely seen in the peripheral blood making this a poor specimen for
 Clinical Manifestation
diagnosis.
 Symptoms may not appear for months to years
 Adults can live in the nodules for approximately 15 years. Some nodules may contain
 Early signs include raised nodules that can be seen under the skin around areas over body
numerous male and female worms.
prominence
 Symptoms: skin changes, itching, nodules, and alterations in vision
1. During a blood meal, an infected blackfly (genus Simulium) introduces third-stage filarial  Onchocerciasis (River blindness)
larvae onto the skin of the human host, where they penetrate into the bite wound.  When the eye becomes involved, lesions, due to the body’s reaction to the
2. In subcutaneous tissues the larvae develop into adult filariae, which commonly reside in microfilariae, may lead to blindness. Blindness has proven to be a significant
nodules in subcutaneous connective tissues. complication for many infected adults.
3. In the subcutaneous nodules, the female worms are capable of producing microfilariae for
approximately 9 years.
4. A blackfly ingests the microfilariae during a blood meal. After ingestion, the microfilariae
migrate from the blackfly’s midgut through the hemocoel to the thoracic muscles.

Review Notes in Clinical Parasitology by RMDM 31

 Laboratory Diagnosis and Treatment
 Specimen of choice: Multiple Giemsa-stained slides of tissue biopsies, known as skin
snips (should be collected with as little blood as possible to avoid contamination)
 Skin snip: most common method of diagnosis
 Infections in the eye can be diagnosed with a slit-lamp examination of the anterior part of
the eye where the larvae or the lesions they cause are visible.
 Drug of Choice: Ivermectin
 In patients with nodules in the skin, the nodule can be surgically removed and examined
for adult worms.
Mansonella perstans
Common Name: ___________________________________________________________________________________
Associated Diseases: _____________________________________________________________________________
Mode of Transmission: __________________________________________________________________________
Habitat: ____________________________________________________________________________________________
Infective stage: ___________________________________________________________________________________
Diagnostic stage: _________________________________________________________________________________

 M. perstans is widely distributed in Africa, with the exception of the most northern
 Prevention and Control (Mauritania, Morocco, Algeria, Tunisia, Libya, Egypt), southern (South Africa, Botswana,
 There are no vaccines or medications available to prevent becoming infected with O. Lesotho, Swaziland, Namibia) and western (Eritrea, Ethiopia, Djibouti, Somalia) parts and
volvulus. some of the island countries (Madagascar, Comoros, Mauritius, Seychelles, Cape Verde)
 The best prevention efforts include personal protection measures against biting insects. from which indigenous cases have not been reported.
This includes wearing insect repellant such as N,N-Diethyl-meta-toluamide (DEET) on  A total of 33 countries in Sub-Saharan Africa, with a total of about 580 million inhabitants,
exposed skin,
appear to be endemic for transmission.
 Wearing long sleeves and long pants during the day when blackflies bite, and wearing
permethrin- treated clothing.
 Morphology
 Microfilariae
 Unsheathed and measure 190-200 µm in stained blood smears and 180-225 µm in
Parasite Disease Geographic Location of Location of Vector 2% formalin.
genus distribution adult worms microfilariae  The tail is blunt, and nuclei extend to the tip of the tail. Microfilariae circulate in the
Onchocerca river blindness, Africa, Central subcutaneous tissues black-fly
skin lesions America blood.
Wuchereria Bancroftian Africa, Asia, lymphatics blood mosquito  Adult worms
filariasis South America  are cylindrical in shape
(elephantiasis)
 Male: 35-45 mm by 50-60 μm
Brugia Malayan/Timorian Malaya/Timor lymphatics blood mosquito
filariasis  Female: 50-80 mm by 80-120 μm
(elephantiasis)
Loa Calabar swellings Central/West subcutaneous blood tabanids  Life Cycle
Africa
 Intermediate host: Culicoides
 Definitive host: man
 Vector: Culicoides (biting midges)

1. During a blood meal, an infected midge (genus Culicoides) introduces third-stage filarial
larvae onto the skin of the human host, where they penetrate into the bite wound .
2. They develop into adults that reside in body cavities, most commonly the peritoneal cavity
or pleural cavity, but less frequently in the pericardium.

Review Notes in Clinical Parasitology by RMDM 32

 3. Adults produce unsheathed and subperiodic microfilariae, measuring 200 by 4.5 µm that
reach the blood stream.
4. A midge ingests microfilariae during a blood meal. After ingestion, the microfilariae
migrate from the midge’s midgut through the hemocoel to the thoracic muscles of the
arthropod.
5. There the microfilariae develop into first-stage larvae and subsequently into third-stage
infective larvae. The third-stage infective larvae migrate to the midge’s proboscis and can
infect another human when the midge takes a blood meal.
 Combination of DEC and mebendazole: A combination of the aforementioned drugs has
proven to be effective in clinical trials towards reducing the amounts of circulating M.
perstans microfilariae and adult M. perstans
 Prevention and Control
 The best way to prevent Mansonella Perstans Infection is through the use of an insect
repellent.
 Mosquito nets are mostly ineffective because the midges that transmit the M. perstans are
small enough to fly through the net/mesh.
 Eliminating the swamp-like areas where Culicoides midges breed is proven to be more
effective in prevention.
 Avoiding travel to the endemic areas can also help eliminate the risk of contracting the
infection.

Additional Notes :

 Clinical Manifestation
 It is a rather mild infection in comparison to similar types of filarial worm infections. Many
individuals do not have any signs and symptoms, but those that do, typically present with
the following:
 Itchiness, red, itchy swelling on the arms or underneath the eye, hives, headaches,
fever, pain in the abdomen, and neurologic abnormalities

 Laboratory Diagnosis and Treatment

 Diagnosed by the finding of microfilariae circulating in blood.
 Identification of microfilariae in a blood smear by microscopic examination.
 Specimen of Choice: Giemsa-stained blood smear

Review Notes in Clinical Parasitology by RMDM 33