ZOONOTIC DIROFILARIOASIS: AN OVERVIEW

DR. SHUBHAGATA DAS, Lecturer DPP,CVASU

Dirofilariosis, a filarial infection of canines and felines, commonly known as Canine Heartworm Disease is increasingly
recognized as inadvertent zoonoses. Among their several species, Dirofilaria immitis and Dirofilaria repens infects human
as an accidental infection where domistic dogs are definitive host and cats, wolves, coyotes, fox, muskrats, sea lions etc.
are the possible reservoirs. D. immitis is considered to be responsible for human pulmonary dirofilariosis (HPD) and the
D. repens for human subcutaneous dirofilariosis (HSD).
Several authors have described it as an emerging disease in different areas of the world in both forms of HPD and
HSD.Current epidemiological studies also shows its increasing prevalence (Genchi et al 2005). From 1965 to 1989, 165
pulmonary cases (HPD) were reported worldwide, mostly in three well defined areas; United States, Japan and Australia
(Vélez et al., 2001). However, in the following 13 years (1990-2003) at least 130 cases have been reported in 15 countries.
On the other hand there are 780 cases of subcutaneous/ocular dirofilariosis (HSD) reported in 30 European, Asian and
African countries (Pampiglione & Rivasi, 2000).

The frequency and distribution of human pulmonary dirofilariosis is

associated directly with the prevalence and distribution of canine
heartworm infections. The greatest numbers of human cases in USA
was in the Atlantic, Gulf Coast and Mississippi valley areas where
prevalence of canine heartworm infections is highest. Ambient
temperature of 250 C or above provides suitable for filarial lifecycle.
It is suspected that the infection will spread throughout the northern
hemisphere due to changed climatic condition (global worming). In
human infection the age and sex factor provides no significance but
elderly patients of fifty to sixty years were found infected mostly and
surprising there is almost no cases reported in children.
Fig: Canine Heart impacted with Adult
Dirofilaria immitis
 Like all filarial nematodes, dirofilaria consists of 5
developmental or larval stages in a vertebrate host; an
arthropod intermediate host (mosquito; genera Aedes,
Anopheles, and Culex), and the vector. Adult female worms
produce thousands of first-stage larvae (microfilariae) that
are ingested by a feeding insect vector. After ingestion,
microfilariae eventually transform into third-stage larvae
within the mosquito and migrate from the abdomen to the
thorax and finally to the salivary glands, allowing
transmission of infection to a new host upon a subsequent
blood meal. Humans are considered aberrant (or accidental)
hosts for zoonotic Dirofilaria, and are infected in the same
way as the animal reservoirs, by the bite of a mosquito
carrying infective larvae (L3). However, as aberrant hosts
humans do not usually harbor adult worms or circulating
microfilariae. These worms usually die either in the
subcutaneous tissues or pulmonary vessels before they
mature to adult worms. At these sites, the dead or dying
worms usually evoke a demonstrable glaucomatous response.

Human pulmonary (HPD) is mostly manifested by D. immitis characterized by formation of lung nodules that are often
confused with pulmonary neoplasia. The filarial nematode enters the subcutaneous tissue, travels to the right ventricle, dies
and then embolizes the pulmonary vessels causing a small pulmonary infarction, which subsequently appears as a solitary
nodule. Nodules usually are 1-3 cm in diameter, well-circumscribed, spherical, grayish- yellow and contain a necrotic core.
Other sites of infection with D. immitis are urinary bladder, portal caval shunt and peritoneal cavity.
Human subcutaneous Dirofilariosis (HSD) can be caused by D. repens localizing in the subcutaneous tissue and in the eye.
It is an increasingly reported zoonosis world wide. If worms are present, they can be identified by their cross-sectional
morphology. These nodules are usually identified incidentally by chest radiography in asymptomatic patients, the lesion is
generally presumed to be neoplastic. Diagnosis is made by surgical excision.

Fig: Lesions of HSD in subcutaneous tissue Fig: skin nodules containing

worm

No recorded fatalities directly due to dirofilariosis have been reported in the medical literature. Most cases are
asymptomatic, thus the condition is likely under reported. Symptoms shown in only 38%-45% of cases and sings are also
non specific (chest pain, coughing, fever, haemoptysis and dyspnoea). HPD is the almost invariable radiological
misdiagnosis of a primary or metastatic lung tumor, which usually leads to thoracotomy with open lung biopsy or wedge
resection of the lung to obtain the correct diagnosis. Thus the primary clinical significance of it is misdiagnosed as
carcinoma or metastatic disease. Awareness of this benign entity is important in the differential diagnosis of pulmonary
coin-lesions. Definitive diagnosis is usually made with wedge biopsy, videothoracoscopy or, very rarely, by fine needle
biopsy. Polymerase chain reaction (PCR) and ELISA technique recently introduced to diagnose D. repens infection.
Identification of in transverse sections can be problematic, as the variability of the morphological characteristics used for
the identification can differ at various levels of the body of the same worm (Orihel & Eberhard, 1998), and due to the
destructive change caused by the inflammatory reaction of the hosts.

Fig: X ray reveals Coin
lesions of HPD in lung
Until now it was considered that human dirofilariosis is a dead-end
infection and the filarial worm can not mature to sexually capable
adult parasite to produce further infection, and is usually eliminated
by the immune system. But new investigation suggested that there
are evidence of dirofilaria normally developing and achieving the
adult stage in the accidental host which can be considered as a type
of larva migrans. In recent years, microfilariae have been detected in
the skin tumor puncture specimen and blood of the patients (Sergiev,
et al 2009). Moreover adult male worms found in portal vena cava
and microfilariae were found present in the blood in humans (Nozais
et al., 1994). In this connection, it is conceivable that men may act
as an actual source of mosquito infection; even the presence of
mature males and females describes about the increasing trend of
human infection worldwide.

As a tropical country Bangladesh has suitable

ambient temperature to harbor canine heartworms
and it is a common parasitic manifestations in our
stray dogs (Rahman, 1973). There are several other
reported cases of adult heartworm infestation and
microfilaria in blood in stray dogs and foxes
throughout the country. Though the mosquito vectors
and canine host are available, not a single case of
human dirofilariosis reported yet. As it mostly
asymptomatic and repeatedly misdiagnosed as
pulmonary metastatic carcinoma it is not unlikely
that it is escaping the physician’s eye. So, we should
remain careful to make diagnosis in dysphonic,
painful lung condition with coin shape lung lesions Fig: Microfilaria
Fig: Nodule of HPD in
revealed in X-rays and considerer the probability of in Blood
Lung tissue
HPD.
REFERENCE

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