Erbil polytechnic University

Erbil Technical Health College

MLT Department
Stage: third

Subject: helminthology
Report :(Filarial Worms)

Prepared by:

‫عمر فاریق محمد‬ ‫هاورێ نجم الدین سعید‬

‫بلیمەت کامران صدیق‬ ‫بوشراطارق عفان‬
‫زەهرا گۆڤەند رەسول‬ ‫ریان مغدید خورشید‬

Supervisor:Lecturer Himdad H.Mawlood

Ph.D in Parasitology

Date: 8/10/202
Filarial Worms

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Nematodes belonging to the superfamily Filarioidea are slender thread-like
worms (Latin, filum—thread) which are transmitted by the bite of blood-
sucking insects. In the bodies of infected vertebrate hosts, they occur both as
adults and the embryos, which are known as microfilariae. In some species,
the microfilariae retain their egg membranes which envelope them as a sheath.
These are known as ‘sheathed’ microfilariae, in contrast to others which
rupture their egg membranes and come out as ‘unsheathed’ or naked
microfilariae.Eight species of filarial worms infect humans, who are the
definite hosts. Of them 6 are pathogens—Wuchereria bancrofti, Brugia
malayi, and B.timori cause lymphatic filariasis; Loa loa causes calabar
swellings and allergic lesions; Onchocerca volvulus causes eye lesions and
dermatitis; Mansonella streptocerca leads to skin diseases; and 2 of them,
Mansonella ozzardi and M. perstans are virtually nonpathogenic. They can be
classified according to their sites of election in the body and the characteristics
of their microfilariae (Table 18.1, Fig. 18.1).

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According to the normal habitat of the adult worm, human filarial infections
can be classified as follows.
I. Lymphatic filariasis
W.bancrofti
B.malayi
B.timori
II. Subcutaneous filariasis
Loa loa
Onchocerca volvulus
Mansonella streptocerca
III. Serous cavity filariasis
Mansonella ozzardi
Mansonella perstans
Infection with any of the filarial worms may be called filariasis, but
traditionally, the term filariasis refers to lymphatic filariasis caused by
Wuchereria or Brugia species.

LYMPHATIC FILARIASIS
WUCHERERIA BANCROFTI
History
Filariasis has been known from antiquity. Elephantiasis had been described in
India by Sushrutha (circa 600 BC) and in Persia by Rhazes and Avicenna. The
term ‘Malabar leg’ was applied to the condition by Clarke in 1709 in Cochin.
Microfilaria was first observed by Demarquay (1863) in the hydrocoele fluid
of a patient from Havana, Cuba. The genus is named after Wucherer, a
Brazilian physician who reported microfilariae in chylous urine in 1868.
Microfilaria was first demonstrated in human blood in Calcutta by Lewis
(1872), who called it Filaria sanguinis hominis. The female adult worm was
described by Bancroft (1876) in Brisbane, Australia and the male worm by
Bourne (1888). Manson (1878) in China identified the Culex mosquito as the
vector. This was the first discovery of insect transmission of a human disease.
Manson (1879) also demonstrated the nocturnal periodicity of microfilariae in
peripheral blood.

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Distribution
W. bancrofti is distributed widely in the tropics and subtropics of Asia, Africa
and South America (Fig. 18.2). Over 900 million persons live in areas
endemic for lymphatic filariasis and are therefore at risk of infection. In 1999,
over 90 million persons were
estimated to be infected, with or without clinical manifestations—over 81
million with Wuchereria and over 8 million with Brugia.
The largest number of cases of filariasis occur in India, where over 300
million people live in endemic zones. It is estimated that at least 6 million
attacks of acute filarial disease occur every year in India and that over 15
million persons have chronic filarial disease. The endemic areas are mainly
along the sea coast and along the banks of the large rivers, though infection
occurs virtually in all states, except in the North West

Morphology and Life Cycle

Adult worm
Adult worms are located in the lymphatic vessels and lymphnodes.
z They are long, slender, creamy white thread like filariform shaped with tapering ends
z Adult males (4 cm × 0.1 mm) are smaller than females (6–10 cm × 0.2–0.3 mm) (Fig. 14.2)
z Male worms can be differentiated from female worms by their small size, corkscrew like tail and

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presence of two spicules (helps in copulation) at posterior end
z Both adult male and female remain coiled together
z Females are viviparous and they directly discharge larvae without any eggs.

Larva
Like other nematodes, there are four larval stages. The first stage larva is
called as microfilaria. The third stage larva is called as filariform larva;
which is the infective form to humans.
Microfilaria
Microfilariae are the diagnostic forms, found in the blood vessels (Fig. 14.2).
z It measures 240–300 µm × 7.5–10 µm covered by a long hyaline sheath
(360 µm) within which it moves
z The head end is blunt while the tail end is pointed
z In unstained film, microfilariae are transparent and colorless. But when
stained with Giemsa or other Romanowsky stains they look pink with a
column of violet nuclei
z The nuclei are present throughout the body except near the head and the tail
end. Nuclei are also absent in few places which represent various primordial
organs like nerve ring, excretory pore, anal pore and genital cells
z Based on the structure of microfilaria, different filarial nematodes can be
differentiated

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Life Cycle (Fig. 14.3)
Host: W. bancrofti completes its life cycle in two hosts.
1. Definitive host: Man
2. Intermediate host: Mosquito named
Culex quinquefasciatus is the principlebvector worldwide. Rarely Anopheles(rural
Africa) or Aedes (Pacific Island) can serve as a vector.
Infective form: Third stage filariform larvae are the infective form found in the
proboscis of the mosquito.
Mode of transmission: L 3 filariform larvae get deposited in skin by the insect bite.
Residents living in the endemic areas are exposed to about 50–300 L 3 larvae every
year.

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Human cycle
- Develop into adults: Larvae penetrate the skin, enter into lymphatic vessels and
migrate to the local lymph nodes where they molt twice to develop into adult
worms in few months (4–6 weeks for B. malayi)
- Adults lay L1 larvae (microfilariae): Adult worms reside in the afferent
lymphatics or cortical sinuses of the lymph nodes where they mate and start laying
the first stage larvae (microfilariae). Male worms die after mating where as the
female worms live for 5–10 years. A gravid female can discharge 50,000
microfilariae/day

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 - Prepatent period: It is the time period between the infection (entry of L3
larvae) and diagnosis (detection of microfilariae
in blood). This is variable ranging from 80 days to 150 days. Mosquito cycle
- Transmission: When the mosquito bites an infected man, the microfilariae are
ingested. Culex bites in night where as Aedes bites in daytime
- Exsheathing: Microfilariae come out of the sheath within 1–2 hours of ingestion
- Migration to thoracic muscle: L1 larvae penetrate the stomach wall and migrate
to thoracic muscle in 6–12 hours where they become sausage shaped (short and
thick)
- Develop to infective L3 larvae: L1 larvae molt twice to develop L2 (long and
thick form) followed by L3 (long and thin form). The highly active L3 larvae
migrate to the labella (distal part of proboscis) of the mosquito and serve as the
infective stage to man
- Extrinsic incubation period: Under optimum conditions, the mosquito cycle
takes around 10–14 days.

Pathogenesis
Pathogenesis and Pathology
The pathologic changes occur as a result of inflammatory damage to the lymphatics
which in turn is due to summation of many
effects such as:
- Tissue alterations related to migration of live adult worms such as lymphatic
dilatation and thickening of the vessel walls
- Tissue alterations related to antigen and toxic metabolites released from dead adult
worm
- Secondary bacterial and fungal infections
- Host’s inflammatory response to both live and dead parasite
Infiltration of plasma cells, eosinophils, and macrophages in the infected vessels,
along with endothelial and connective tissue proliferation
This leads to tortuosity of the lymphatics and damage to lymph valves resulting in
lymph edema of limbs and brawny edema on the overlying skin

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- As long as the worm remains viable, the lymphatic vessels though damaged, still
remains patent
- However, the death of the worm leads to enhanced granulomatous reaction, thrombi
formation and fibrosis of the lymph vessels
with extensive perilymphangitis
- This results in severe lymphatic obstruction. The lymphatic function is severely
compromised
- Endosymbiosis: Pathogenic W. bancrofti is found to be infected with a Rickettsia
group of bacteria called Wolbachia and maintain an endosymbiotic relationship.
It is proved that this symbiosis is essential for the parasite survival, fertility and larval
development.
Clinical Features
Incubation period is about 8–16 months. Clinical manifestations can be categorized
into:
1. Lymphatic filariasis
2. Tropical pulmonary eosinophilia (TPE)/(Occult filariasis)
3. Immune complexes mediated manifestations.
Lymphatic Filariasis
Endemic normal These are the normal people residing in endemic area. Their
prevalence ranges from 0 to 50%. They are not infected by the parasite.
This might be due to:
- Insufficient exposure
- Immunological resistance
- Prepatent period at the time of study.
Asymptomatic microfilaremia
In endemic area, many infected individuals don’t exhibit any symptoms of filarial
infection.
- These people have a down regulated T helper 1 cells response (low IFN-γ) and
elevated T helper 2 cells response (↑IL-4)
-However, it is observed that most of the asymptomatic people have some degree
evidence of subclinical infection like:
Microfilaremia demonstrated in their peripheral blood

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Microscopic hematuria and/or proteinuria
Dilated and tortuous lymphatics (visualized by imaging)
Filarial dance sign (ultrasound showing motile adult worm in scrotal lymphatics).
Acute filariasis (acute adenolymphangitis)
It is characterized by recurrent episodes of:
-Filarial fever (high-grade fever)
-Lymphatic inflammation (lymphangitis and lymphadenitis):
Common lymph nodes enlarged areinguinal, axillary and epitrochlear nodes
In addition, lymphatics of the male genital organs are frequently involved
that leads to funiculitis, epididymitis and orchitis
- Transient local edema: Early pitting edema; reversible on limb elevation
- Dermatolymphangitis: Plaque like lesion is formed over the affected skin with fever,
chill and lymphatic inflammation
- In Brugian filariasis, the episodes are more frequent and abrupt in onset.
Chronic filariasis It develops 10–15 years after infection.
-Chronic host immune response against the dead worm leads to enhanced granuloma,
thrombi formation and fibrosis of the lymph vessels leading to severe lymphatic
obstruction and pedal edema
- Grading of edema: Early pitting edema ( grade-1) becomes nonpitting and
irreversible on limb elevation (grade-2) followed by brawny edema with thickening of
the skin (grade-3), finally lead to fibrosis and fissuring (grade-4)
- The manifestations in descending order of occurrence are
Hydrocele (most common manifestation): Accumulation of fluid in the cavity of
tunica vaginalis of testes
Elephantiasis (swelling of lower limb or less commonly arm, vulva or breast)
Chronic funiculitis and epididymitis
Chyluria excretion of chyle, a milky white fluid in urine. This occurs rarely.

Laboratory Diagnosis
Microscopy (To detect Microfi lariae)
- Sample: Microfilariae can be found in blood, and occasionally in hydrocele fluid,

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urine or other body fluids
- Direct wet mount: Demonstrates serpen tine movement of microfilariae
- Thick smear stained with Leishman’s, Giemsa or hematoxylin and eosin stain can be
performed to observe the sheath and nuclei of microfilaria.
- Concentration techniques: Blood can be examined after concentration techniques to
increase sensitivity
Membrane filtration technique
Knott’s centrifugation technique
- Collection time: It is critical and should be based on the periodicity of the
microfilariae. For nocturnal periodicity, blood should be collected between 9 pm and 2
am.
- DEC provocation test: Th is test is done to collect the blood in the day time
Patient takes a tablet of DEC orally (2mg/kg) so that the nocturnal
microfi lariae are stimulated and come to peripheral blood within 30 minutes
Th is test is contraindicated in Onchocerca and Loa loa infection
- QBC (Quantitative buffy coat examination): Th is test is commonly performed
for malaria diagnosis, however it can also be used to detect microfi lariae. It involves
centrifugation of blood, staining with acridine orange stain and examined under
fluorescent microscope. Th is technique is more sensitive than smear microscopy
Microfilariae may not be found in blood because of many reasons such as:
Occult filariasis Chronic filariasis and endemic normal people Wrong time of blood
collection.
Antigen detection
Circulating antigens of W. bancrofti can be detected by using monoclonal antibodies
against Og4C3 and AD12 antigens.
- Both enzyme-linked immunosorbent assay (ELISA) and rapid
immunochromatographic test (ICT) are commercially available
- ELISA is 100% sensitive and 99–100% specific, where as ICT is 96–100% sensitive
and 95–100% specific
- No antigen detection methods are available for Brugia infection
- Advantages of antigen detection:

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More sensitive than microscopy
Can be detected in day time
Can differentiate the current and past infection. Antigen disappears after
clinical cure
Can be detected in urine
Antibody detection
Older methods Earlier, crude parasitic extract was used todetect serum antibodies.
Various formats are used like indirect hemagglutination (IHA),
indirect fluorescent antibody test (IFA) and ELISA. They are useful for
Seroepidemiological purpose. These tests suffered a lot of criticism because:
- Low specificity: Due to cross reactivity with other parasites
- Cannot differentiate the current from the past infection: Antibodies persist even after
clinical cure Newer approach
- Improvements have been made by detecting specific IgG-4 antibodies against
recombinant W. bancrofti antigens.
- They show less cross reactivity and correlate well with intensity, duration of filarial
exposure and level of microfilaremia
- Anti-sheath antibodies are raised even before microfilariae appear in the blood
- Can also be used to diagnoseBrugiainfection.

Imaging Methods
Ultrasound High-frequency ultrasound with doppler techniques are employed to
detect:
- Anatomical abnormalities of lymphatics, dilated and tortuous vessels
- Filarial dance sign: Serpentine movement of adult worms within the lymphatic
vessels of scrotum—positive in 80% of cases
Lymphoscintigraphy
Lymphoscintigraphy of the limbs reliably demonstrates the functional abnormalities of
lymphatics (like fl ow abnormalities) even in asymptomatic microfi laremic persons.
X-Rays It can detect:

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- Dead and calcifi ed worms
-Pulmonary infi ltrates in patients with TPE.

Molecular Methods
- Polymerase chain reaction (PCR) based assays have been developed to detect DNA
of W. bancrofti and B. malayi in blood. PCR is highly sensitive and can detect as little
as one microfi laria per/mL of blood
- PCR-RFLP based assay using ITS 1- rRNA gene as primer can differentiate all the
species of human and animal fi larial parasites.Xenodiagnosis Mosquitoes are allowed
to feed on the infected patients and are dissected 4–6 weeks later to demonstrate
microfi lariae. Th is may be helpful in detecting low density microfi laremia. Other
Methods
-Eosinophilia (absolute eosinophil count >3000/µL)
- Elevated serum concentrations of immunoglobulin (IgE) (> 1000 ng/mL)
-Cellular assays: Filarial skin test and lymphocyte response to fi larial antigen, both
are less specific
-Biopsy of enlarged lymph node to demonstrate adult worm.
Prevention
Mass chemoprophylaxis Global Programme to eliminate lymphatic filariasis (launched
by WHO, 1997) had aimed at administrating:
- Single annual doses of DEC plus albendazole. In India and other non-African
endemic area
-Albendazole plus ivermectin in Africa.
Vector control
Antilarval measures
Antilarval measures are highly expensive hence mainly restricted to urban areas.
Chemicals can be used like:
- Mosquito larvicidal oil
- Pyrethrum based oil (pyrosene oil-E)
- Organo-phosphorus larvicides like fenthion,temephos.
Antiadult measures

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Antiadult measures like pyrethrum spray can be used. However, DDT and
hexachlorocyclo hexane (HCH) are not eff ective. Personal care by using mosquito
net.
Treatment

DEC is the drug of choice. It is actively microfilaricidal, and in large enough doses may be fatal to
adult worms also. Allergic reactions may occur due to the release of antigens from the large
numbers of microfilariae which die on administration of the drug.

References
• Textbook of MEDICAL PARASITOLOGYSIXTH EDITION
JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD
CK Jayaram Paniker MD Formerly Director and Professor of Microbiology
and Principal, Medical College Calicut Dean, Faculty of Medicine Calicut
University Emeritus Medical Scientist Indian Council of Medical
Research,2007

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• Paniker's Textbook of MEDICAL PARASITOLOGY (late} CK Jayaram
Paniker MD Formerly,Director and Professor, Department of Microbiology,
Principal government Medical College, India
Emeritus Medical Scientist Indian Council of Medical Research New Delhi,
India
Revised and Edited by Sougata Ghosh MD ocH Professor ,Department of
Microbiology Government Medical College Kol kata, West Bengal, India
Formerly Faculty Institute of Postgraduate Medical Education and Research
(IPGMER) and Calcutta School ofTropical Medicine Kolkata, West Bengal,
India 2018

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