GEOGRAPHIC DISTRIBUTION

 Widely distributed in Tropics and Subtropics

 In India…. Endemic along sea coast and banks of
major rivers
 Delhi, Punjab, UP, Rajasthan

HABITAT
ADULT WORM
 Lymphatics and lymph nodes of man

MICROFILARIA
 Found in the blood
MORPHOLOGY

ADULT WORM
Long, hairlike, transparent / creamy white in color
Filiform, both ends tapering
Head end shows a slightly rounded swelling
Although females liberate active embryos… they are
ovoviviparous
Male and female worms remain coiled together
Sex differences

MALE FEMALE
1 Short and narrow Long and broad
2 Tail end …. Tail end
~ curved ventrally ~ narrow
~ Has two spicules of ~ abruptly pointed
unequal length
Adult male and female
MICROFILARIA
 Pass through the lymph nodes into the lymphatic
trunks and into the blood

 Mobility
…. very active
…. move with and against the blood stream

 When unstained
…. colourless transparent bodies
…. blunt end and pointed tail

 When stained
…. show the following features
 Hyaline sheath
…. structureless sac
…. longer than the larval body
…. projects beyond the extremities of the embryo
…. larva can move to and fro within it

 Cuticula
…. lined by subcuticular cells
…. seen with vital stains

 Nucleii / Somatic cells

…. darkly stained granules
…. in the central axis of body from head to tail
…. absent from the tail tip (terminal 5%)
 Cephalic space
… anterior end, square shaped, devoid of nucleii

 Nerve ring
… oblique area in the anterior half of the body
… devoid of nucleii

 Anterior V spot
… rudimentary excretory system
… midway of the body

 Posterior V spot / tail spot

… represents the rudimentary cloaca
 Genital Cells
… G1 – G4
… anterior to the anal pore

 Central /Internal Body of Manson

… extends from Anterior V spot to G cell 1
… represents the rudimentary alimentary canal

 Life Span
…. do not undergo any further devp. in man
…. Need to be taken up by mosquito vector
…. Survive for 70 days
 Periodicity
…. Nocturnal
…. Found in the peripheral blood at night
…. Between 10 pm and 4 am
…. During the day
Mf reside in the capillaries of the heart,
lungs, kidneys, major arteries – carotid
…. Related to the night feeding habit of vector
 LIFE CYCLE
¤ Definitive Host
…. Man

¤ Intermediate Host
… mosquito -- Culex, Aedes, Anopheles
… In India -- Culex fatigans

¤ Infective forms
… Third stage larva

¤ Mode of Infection
… by bite of infected mosquito
DEVELOPMENTAL CYCLE IN THE MOSQUITO

Human with Mf in blood is infective to the mosquito

… Infectivity … 15mf/drop of blood

On ingestion
… collect round the anterior end of the stomach
… cast off their sheaths

Mf penetrate stomach wall

… within 1 – 2 hours
… migrate to the thoracic muscles
… undergo metamorphosis
 Metamorphosis
~ First stage larva
… within 2 days
… thick, short sausage shaped forms
… with a short, spiky tail
… possess a rudimentary digestive tract
~ Second stage larva
… within 3 – 7 days
… grows rapidly
… moults once or twice A…. Mf
B…. 1st stage L
… increases in size C…. 2nd stage L
D…. 3rd stage L
~ Third stage larva
… formed on the 10th / 11th day
… tail atrophies to a stump
… Body cavity with the digestive system and
genital organs are well developed
… has three subterminal caudal papillae
… enter the probosis sheath on the 14th day
… infective to man

Period taken … 10 – 20 days

~ Extrinsic incubation period
… depends on temp., humidity, species of mosquito
DEVELOPMENTAL CYCLE IN MAN
> Infection occurs by mosquito bite
… third stage larva deposited on the skin near the
puncture site
… attracted by the skin warmth, larva enter the
puncture wound OR
… penetrate the skin on their own

> Larva reach the lymphatic channels

… inguinal, scrotal, abdominal lymphatics
> Growth and fertilization
… begin to grow into adult forms
… within 5 – 18 months
… develop into sexually mature adults
… male fertilizes the female to produce Mf
… pass through the thoracic duct/ right lymphatic
duct to the venous system

> Pre patent period

… Biological Incubation period
 PATHOGENESIS
Pathogenic effects are due to the adult worm – living or dead

 Injurious influence excited by the adult worm on the host is

‘Inflammation of the Lymphatic System’ ….. LYMPHANGITIS

 Living Microfilaria do not produce any pathological

effect, except in Occult Filariasis

 Lesions in Occult Filariasis seen in lymph nodes, lung, liver,

spleen

 The metabolites of growing larvae may give rise to

 Allergic manifestations eg. Urticaria, fugitive swellings
 Lymphoedema
PATHOLOGICAL FEATURES

 Lymphangitis (causes)
 Lymphadenitis
 Lymphatic obstruction ( causes and effects)
  Lymphangitis (causes)
 Lymphadenitis
 Lymphatic obstruction
 Causes of Lymphangitis (causes and effects)

~ Mechanical irritation by movement of adult

parasite

~ Liberation of toxic metabolites of growing larvae

~ Secretion of toxic fluid by fertilized females at the

time of parturition

~ Absorption of toxic products liberated by dead

worms

~ Bacterial infection … secondary invaders

  Lymphangitis (causes)
 Lymphadenitis
 Lymphatic obstruction
 Causes of Lymphatic obstruction (causes and effects)

~ Mechanical blockage of the lumen by dead worms

~ Obliterative endolymphangitis
 endothelial proliferation
 inflammatory thickening of the
lymphatic vessel wall
~ Fibrosis of lymph vessels
 caused by repeated attacks of lymphangitis

~ Fibrosis of the afferent Lymph nodes

  Lymphangitis (causes)
 Lymphadenitis
 Effects of Lymphatic Obstruction  Lymphatic obstruction
(causes and effects)

~ Lymph varix
 Dilatation and varicosity of lymphatic vessels

~ Lymphorrhagia
 Rupture of Lymph varix

~ Elephantisis
 Hyperplasia of skin and connective tissue
 PATHOLOGICAL LESIONS
1. Inflammation

2. Dilatation of lymphatics

3. Rupture of lymphangiovarix

4. Hyperplasia of the skin & connective tissues

5. Secondary bacterial infection

6. Occult Filariasis
1. INFLAMMATION
 Due to sensitization to metabolites of the worm
located elsewhere

 Presentation
 Filarial fever
 Lymphangitis
 Lymphadenitis
Filarial fever
 High grade, lasting for 3-5 days, coming down
with profuse sweating

Lymphangitis
 Site
 Lymphatics of the testis
 Epididymis ( globus major – most common)
 Spermatic cord lymphatics
 Abdominal lymphatics
 Lymphatics of the upper and lower extremities
 Clinical
 lymphatic vessels appear as painful cord like
swellings
Lymphadenitis
 Inflammation of the regional lymph nodes
 May precede the attack of Lymphangitis
 Usually involve the groin
 Lymph nodes
 soft, lobulated masses
 non tender
 not adherent to the overlying skin

Hydrocele
 Caused by recurrent attacks of orchitis and epididymitis
 Fluid may contain microfilaria
 Wall of the sac is thickened – granulation tissue may
contain the adult worm
2. DILATATION OF LYMPHATICS
 causes varicosity of the lymphatic vessel

3. RUPTURE OF LYMPHANGIOVARIX
 Lymphorrhagia
 Lymph scrotum, lymphocele, lymphuria

 Chylorrhagia
 Chylocele, chyluria, chylous diarrhoea, chylous
ascites, Chylothorax
4. HYPERPLASIA OF SKIN AND CONNECTIVE TISSUE
Elephantisis
 Usually follows years of continuous infection
 Hypertrophy and hyperplasia of the connective tissue
 Clinically
 Affected part becomes enlarged
 Tumor like solidity
 Skin becomes rough, fissured
 Hair become rough and sparse
 Skin cuts like an unripe pear …. thick, dense and
fibrous
 Subcutaneous tissue … blubbery appearance,
showing dilated lymphatics
5. SECONDARY BACTERIAL INFECTION
Septic Lymphangitis
 Usually caused by Streptococcus pyogenes and
Staphylococcus aureus

6. Occult Filariasis (TPE)

Also called as Meyers Kouwenaar Syndrome
Due to hyper responsiveness of host to mf
Development of an eosinophilic granuloma
Eosinophils aggregate around a microfilaria
Mf are produced but destroyed in the tissues
Characterised by ….
 Massive eosinophilia
 Generalised lymphadenopathy
 Hepatospenomegaly
 Pulmonary symptoms
 Absence of Microfilaria in the blood
 DEC … Rapid improvement

Tropical Pulmonary Eosinophilia (Weingarten’s Syndrome)

 Manifestation of Occult Filariasis
 Characterized by …
--- Low fever, loss of weight, paroxysmal cough,
blood tinged sputum, dyspnoea, splenomegaly
LABORATORY DIAGNOSIS

A) DEMONSTRATION OF MF
Samples
Blood, lymph, chylous urine, hydrocele fluid

Methods employed
Unstained film
Stained film
Concentration Techniques
DEC Provocation Test
Unstained film
> drop of blood on a slide
> cover with a coverslip with vaseline
> actively mobile Mf are seen
> viable for 24 – 48 hours at RT
> Mf density … more than 10 mf/ml blood

Stained film
> Thick and thin smear
> Stained by Romanowsky, Giemsa, Acridine
orange
Concentration Techniques
---- Done in low level infection
Knott’s Concentration
Membrane filtration
Saponin lysis

DEC Provocation Test

DEC provokes the mf to come into the
circulation during the day
Examination is done after 1 hour of DEC
intake
Conditions wherein Mf are absent in the blood
> Occult filariasis
> Elephantisis cases … due to lymphatic obstruction
> After an attack of lymphangitis … due to death of the
adult worm
> During early allergic manifestations

B) DEMONSTRATION OF ADULT WORM

 Biopsy
 Xray … if calcified
C) IMMUNODIAGNOSIS
Demonstration of antigen
 Rapid strip test (Immunochromatographic assay)
 Dot ELISA, RIA
Demonstration of Antibody
 IHA, IFA, ELISA

D) XENODIAGNOSIS

E) NON SPECIFIC TESTS

Allergic  Eosinophilia, Skin Tests
Immunologic  CFT
 Microfilariae invade the eye

(occur as microfilariae die in the

eye)
Microfilariae invade the eye

In many parts of Africa, the sighted young are responsible for

leading the older blind adults
 PERSONAL ACCOUNT
June/July 1996: 29-participant study done by Jennine
Coreil in Haiti
• Lack of Mobility:
– “I had a child to be baptized and I had to send
someone to stand in my place as father”

• Embarrassment:
– “When I went to school I felt very embarrassed. I
didn’t have the desire to go back.”
– “The hardest part for me is having to get help
from someone to urinate”
• Regret:
– The first sign of the disease usually appears on the
foot

– The first thing patients notice is that their shoes

become tight

– A cobbler remembered feeling sad that his wife

eventually could not wear the lovely shoes he had
made for her

– “I never liked my mother to come to my school as

she could not fit into her shoes”
• Lack of Knowledge:
– “When I was little I was playing in the street and a
truck’s tyre ran over my feet.”

– “I thought the injury made my foot ‘cold’ and that

is what made my foot become big.”

– “I believed that it was a mystical illness caused by

the placement of magical powder along the
footpath”
– “If the wrong person stepped in the powder, they
developed elephantiasis”
• Lack of Trust in Doctors:
– “When you go to the hungan’s house, your foot
gets even bigger.”

• Severity:
– “I ask for death because it makes me very sick. I
have been suffering with this for 35 years.”

– “ I’d like to have another remedy for the inside

because the oil only makes the skin soft. I’d like to
find a definite result”
• Impact on work :
– “I cant harvest because I cant stand out too long”

– “I should be out selling but I cant get up as my leg

feels heavy”

– “I cant do the housework, my husband helps me

but my children don’t like it”