CLINICAL PARASITOLOGY

FILARIAL WORMS (WEEK 9 / LEC & LAB)

1st SEM, 2021
Filarial Worms
● GEOGRAPHICAL DISTRIBUTION:
○ 859 million people in 50 countries
worldwide remain threatened by
lymphatic filariasis and require
preventive chemotherapy to stop the
spread of this parasitic infection.
○ Lymphatic filariasis can be eliminated
by stopping the spread of infection
through preventive chemotherapy
with safe medicine combinations
repeated annually. More than 7.7
billion treatments have been
delivered to stop the spread of
infection since 2000.
○ 51 million people were infected as of
2018, a 74% decline since the start of
WHO’s Global Programme
Eliminate Lymphatic Filariasis in 2000.
● Filariasis Elimination Program:
○ The elimination started in 20001 after
a pilot study using the combination
drugs in 2000 in 5 selected
municipalities in 5 provinces.
○ Total number of province: 81
○ Total population in the country: 103,
741, 330 as of 2018
○ Total endemic provinces: 46 provinces
in 12 regions
○ Total endemic population: 8 million
○ Parasite: Majority is Wuchereria
bancrofti
○ Vectors incriminated: Aedes poecilius,
Anopheles flavirostris
TAXONOMY
● Kingdom: Animalia
● Phylum: Nematoda
● Class: Phasmida
● Order: Filaroidea
● Family: Filariidae
● Genus: Wuchereria
HELMINTHOLOGY
● Helminths are multicellular, bilaterally
symmetrical animals
● Helminths – 2 Phylum
● PLATYHELMINTHES: Cestodes and Trematodes
● NEMAHELMINTHES: Nematoides
Morphology and Life Cycle
● Members of the class Nematoda assume
three basic morphologic forms:
Human Filarial Worms
● Filarial worms belong to the Superfamily:
Filarioideae
● Thread like worms transmitted by blood
sucking insects (Arthropods)
● Vector borne disease / Zoonotic disease
● Infection by any filarial worm is called as
‘Filariasis’
to
● Morphological forms: Adult worm &
Microfilariae (embryo)
● Microfilaria (mf): Sheathed &
Unsheathed/naked
● Sheathed mf: Retain their egg membrane
● Unsheathed mf: Ruptures out from the egg
membranes
● 8 species of filarial worms infect humans
● Humans are the Definite hosts
Classification of Human Filarial Worms
● Lymphatic filariasis:
○ Wuchereria bancrofti (Bancroftian
filariasis)
○ Brugia malayi (Malayan filariasis)
● Subcutaneous filariasis:
○ Loa loa (Calabar swelling/Fugitive
swelling)
○ Onchocerca volvulus (River blindness,
dermatitis) &
● Serous cavity filariasis:
○ Mansonella ozzardi (Non-pathogenic)
&
○ Mansonella perstans
(Non-pathogenic)
Filarial Worms
● Sheathed microfilaria – retains embryotic
sheath
○ Wuchereria bancrofti
○ Brugia malayi
● Unsheathed microfilaria – does not retain
embryotic sheath

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 CLINICAL PARASITOLOGY
FILARIAL WORMS (WEEK 9 / LEC & LAB)
1st SEM, 2021
○ Onchocerca volvulus Wuchereria bancrofti (Life Cycle)
○ Mansonella perstans
○ Mansonella ozzardi
● Dracunculus medinensis

Lymphatic Filarial Worms

Wuchereria bancrofti
Brugia malayi
● One of the “most debilitating disease” in
tropical countries
● Filariasis – parasitic infection caused by
microscopic threadlike worms acquired
through a mosquito bite (vector borne)
● Has its social and economic impact
● MOT: Skin penetration through a vector
● Habitat: Lymphatic vessels (lymph nodes) Wuchereria bancrofti- ADULT
● Vector:
○ Aedes spp., Culex spp. and Anopheles
spp. (W. bancrofti)
○ Mansonia spp. eg. M. bonnae and M.
uniformis (B. malayi)
● Infective stages:
○ L3 larva or filariform larva (man)
○ microfilariae (mosquito)
● Diagnostic stage: microfilariae
● Definite host: man

Brugia malayi (Life Cycle)

Bancroftian Filiriasis
● Vector Biology:
○ Anopheles flavirostris
○ Aedes poecillus
● Aquatic habitat: axils of abaca and banana
plant
● Adult biting: day and night biting, indoor and
outdoor
● Adult resting: base of abaca plants, cool,
shady area
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 CLINICAL PARASITOLOGY
FILARIAL WORMS (WEEK 9 / LEC & LAB)
1st SEM, 2021
Brugia malayi ● Acute Filarial Disease
○ Adenolymphagitis (ADL) or
Dermatolymphangiodenitis (DLA)
○ Pain, tenderness & swelling of
affected areas, with or without fever
○ Epididymo-orchitis in males may
occur
● Chronic Filarial Disease – more commonly
encountered than its acute form
○ lymphedema
○ elephantiasis
○ hydroecele
○ Kidney damage – “milky urine” due to
reflux of intestinal lymph to the renal
lymphatics → (proteinuria and
Mode of Transmission and Incubation Period
hematuria)
● Lymphatic Filariasis is transmitted by the
● “Expatriate Syndrome”
bite of Infected mosquito which harbours L3
○ occurs to migrants who got infected
larva
from endemic regions
● L1: 1-3 hours
○ Characterized by clinical and
● L2: 3-4 days
immunologic hyper-responsiveness to
● L3: 5-6 days
maturing worms
● Prepatent period: (L3 to Mf) Not known
○ Acute manifestations + allergic
● Clinical Incubation period: 8-16 months
reactions (hives, rashes and blood
Microfilaria of Wuchereria bancrofti and Brugia
eosinophilia)
malayi
● “Tropical Pulmonary Eosinophilia” (TPE)
○ due to the microfilaria
○ “Weingartner’s syndrome”
○ Marked increase of IgE and IgG
antiparasite Ab as well as
hypereosinophilia
○ Nocturnal coughing, breathlessness,
wheezing

PATHOLOGY
Lymphatic Filarisasis
● Immune response (cell-mediated and
humoral)

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 CLINICAL PARASITOLOGY
FILARIAL WORMS (WEEK 9 / LEC & LAB)
1st SEM, 2021
● Uses ~20 ul of blood spread in the slide &
stained with Giemsa
● Wet smear can also be made by diluting 20-40
ul of anti-coagulated blood with water or 2%
saponin which will lyse the red cells

ADDED NOTES:
● Surround the parasite with WBC to be killed,
encapsulation is retained (cyst formation) →
TOO MANY PARASITE accumulation cause
enlargement/inflammation (body’s
mechanism)

DIAGNOSIS
● Microscopy
○ “wet smears” – demonstrate motile
microfilariae
○ “thick blood smears”
■ Giemsa stain
■ demonstration of the
microfilaria (most practical
diagnostic procedure)
● Differences in microfilariae

W. bancrofti B. malayi

● Knotts Concentration Method – for low

intensity infection; Filtration method
(Swinney filter) – use of nucleopore filter
● Diethylcarbamazine provocative test
○ (3 mg per Kg DEC single dose)
○ stimulates microfilariae to come out
to peripheral circulation
● MICROFILARIA DETECTION (Nocturnal Blood ● RDT/Immunochromatography (ICT) – detects
Examination) circulating filarial antigens (CFA)
○ Consider the nocturnal periodicity of ● Molecular methods – PCR
the filarial parasite to select the ● Ultrasonography – may demonstrate the live
optimal blood time (10 pm - 2 am) worms in the lymphatics
○ Simple technique to examine blood or KNOTT’S CONCENTRATION TECHNIQUE
other fluids (including hydrocoele ● 1 ml of anti-coagulated blood mixed with 10
fluid, articular effussions and urine) ml of 2% formalin
● Centrifuge

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 CLINICAL PARASITOLOGY
FILARIAL WORMS (WEEK 9 / LEC & LAB)
1st SEM, 2021
● Examine the sediment (stained and fixed) ULTRASONOGRAPHY
● Microfilariae seen as nonmotile and generally
● Adult worms can be accurately located in the
straight
body using simple ultrasonography machines
ADDED NOTES:
● Moving worms seen on the screen and
● Centrifuge→ Accompanied by staining the
patients also see the images if they wish.
sediment
● Formalin- destroy artifacts (not destroy the
parasite’s morphology)
● Increase the chance to find the microfilariae,
by destroying the artifacts in the sample →
specimen is concentrated in the parasite

DEC Provocative Test

● DEC injection can stimulate the appearance of
the MF in the peripheral blood irrespective of
its periodicity.
● A dose of 50-100 mg is given, 45-60 mins in Loa Loa
blood sampling
● Drug use to provoke the parasite to come out
from lymphatics to the bloodstream.
Rapid Test
● Most commonly used.
● Formation of band= positive
ICT KIT
● Simple, reliable and cost effective diagnostic
test
● No specialized lab. equipment or training
needed
● Results available within minutes
● Recommended by the WHO as an appropriate
diagnostic tool for large-scale population
testing & mapping ● PATHOLOGY: Loaisis (Fugitive swellings or
● Supplied by WHO at minimal cost basis to any Calabar swellings)
country involved in the elimination of ○ causes localized subcutaneous edema
lymphatic filariasis as the microfilaria die in the capillaries
around the eye
○ Nucleus is PRESENT at the tail
(unsheathed filarial worms)

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 CLINICAL PARASITOLOGY
FILARIAL WORMS (WEEK 9 / LEC & LAB)
1st SEM, 2021
Loa Loa (Life Cycle)

● I.S. to man : 3rd stage larva (L3)

● I.S. to vector : microfilaria
● Covering : unsheathed
● Periodicity : non-periodic
TREATMENT
● Diethylcarbamazine citrate (DEC) – drug
choice for Bancrotian filariasis and TPE
● Ivermectin – found to be as effective as 12
days of DEC in clearing microfilaremia

Prevention and Control

WHO targeted lymphatic filariasis to be eliminated by
Calabar swellings 2020
● Development of microfilaricidal regimens
(Moxidectin)
● Goal for endemic areas: Eliminate presence of
microfilariae in blood
● Personal protective measures (use of
mosquito nets)
● Residual spraying
● Health education

Loa Loa Subcutaneous Nodules Dracunculus medinensis

● “Guinea worm”, “Worm of Medina”, “Dragon
Unsheathed Microfilaria worm” or “Fiery serpent”
● Onchocerca volvulus ● Longest nematode to man (1 meter)
○ “Blinding worm”, Gale filarienne”, ● Causes “dracunculiasis” or “Guinea worm
“Craw craw” disease” (GWD)
○ causes Onchocerciasis, River ● No symptoms for one year
blindness, Roble’s disease ● Common symptoms: rashes, fever, nausea,
○ destroys optic nerve vomiting, diarrhea, dizziness
● Mansonella perstans ● Until there is formation of blister and causes a
○ old name: Acathocheilonema perstans burning sensation
○ rare parasite of man
● Mansonella ozzardi
○ rare parasite of man

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 CLINICAL PARASITOLOGY
FILARIAL WORMS (WEEK 9 / LEC & LAB)
1st SEM, 2021
Dracunculus medinensis (Life Cycle) Mass Drug Administration for Filariasis
● The MDA regimen recommended depends on
the co-endemicity of lymphatic filariasis with
other filarial diseases. WHO recommends the
following MDA regimens:
● Albendazole (400 mg) alone twice per year for
areas co-endemic with loiasis
● Ivermectin (200 mcg/kg) with albendazole
(400 mg) in countries with onchocerciasis
● Diethylcarbamazine citrate (DEC) (6 mg/kg)
and albendazole (400 mg) in countries
without onchocerciasis

TABLES

ADDED NOTES:
● Infected water (L3 Stage) ingestion of
contaminated water or fish, uncooked or raw
● Crustacean
● MALE- smaller FEMALE- larger
● Larva (L3) will release from the wound of
infected human

TREATMENT AND MANAGEMENT

● Immersion of affected body part to water
● Wound is cleaned
● Worm extraction
● Topical antibiotics are given to prevent
infection
● Aspirin and Ibuprofen are given to ease the
pain
Prevention and Control
● Surveillance and Case containment
● Provision for safe drinking water
● Vector control – use of a chemical larvicide
(Abate™)
● Health Education

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 CLINICAL PARASITOLOGY
FILARIAL WORMS (WEEK 9 / LEC & LAB)
1st SEM, 2021

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