FILARIASIS

A 40-year-old male from Pakshikere, Mangalore Urban, presented to the surgery OPD at Government Wenlock

Hospital with symptoms of fever, scrotal pain with swelling (mild), gross swelling of his left lower limb for one

year.

 What could be the differential diagnosis based on the presenting complaints?

 What other relevant history will you elicit to support or refute the diagnosis?
 The surgery postgraduate taking elaborate history elicited that the patient did not have any previous surgeries

for varicose veins.

 There were no aggravating or relieving factors for the swelling of the lower limb.

 There was no increase in swelling on standing for a prolonged period, neither the swelling decrease on taking

rest. (Chronic venous insufficiency)

 The patient does not give any history of prolonged recumbency in the past year.

 There is no history of acute episodes of pain or erythema of the lower limb. (Acute deep venous thrombosis).

 The patient does not complain of any lethargy, nor gives a history of treatment for thyroid problems.

(Myxedema).

 The patient does not give any history of trauma to the left lower limb.

 There is no history of cough, breathlessness, or decreased urine output

 The patient is a farmer by occupation. He resides next to the agriculture fields and belongs to low-socio-

economic status.

 The left lower limb swelling has been present for more than a year and has been gradually increasing in size.
 What is the importance of asking place of residence in medical history?

 What is the pathophysiology behind the patient’s presenting symptoms?

Examination

 What is the importance of GPE in this case?

 Physical examination revealed a significant abnormality in the left lower limb.

 The overlying tissue of the left lower extremity was indurated, possibly due to secondary infection and tissue
trauma, and

 Dermatologic changes were seen on the lower limb consistent with elephantiasis

 The temperature of the swollen areas was normal,

 There were no signs of nodular or warty excrescences.

 Asymmetrical non-pitting oedema had been present and had increased in severity over time.
 Keratosis spots were present over the entire body,

 Swelling of the scrotum – O/E suggestive of mild hydrocoele.

 A complete blood count showed no abnormality.

 Blood pressure was normal.

 USG revealed anechoic tubular channels in the Para testicular region which showed no flow on Color Doppler study.

 Ultrasound examination showed anechoic tubular channels in the inguinal region and anterior to femoral vessels
which failed to show any flow on color flow imaging.
Laboratory Workup

How will you confirm the diagnosis of filarial lymphedema?

 Night blood smear examination with Giemsa stain confirmed Bancroftian filariasis with 313 W. bancrofti mf/ml

of blood before treatment.

What is the relevance of doing a night blood survey to diagnose filariasis?

What is the DEC provocative test?

 As part of the investigation, family members were examined for LF.

 His wife tested LF positive based on both ICT and night blood smear examination.

 Both husband and wife reported taking only one round of MDA during their lifetime.

 The patient’s son, daughter-in-law and both the grandchildren tested negative.

 None of the immediate family members had anatomical abnormalities related to LF.

 However, a family history suggested that the patient’s elder brother likely also had an advanced filarial

infection, as he had progressive lymphedema of the lower right extremity that developed over the last five

years of his life.

 No MDA has been carried out in the area for the past 3 years.
What is Mass Drug Administration?

What is the significance of negative night blood smear for mf in children?

What are the criteria to stop MDA in a said area?

What is Transmission Assessment Survey?

How do you manage a case of lymphoedema due to filariasis as per NVBDCP?

 TREATMENT

 The initial treatment prescribed for the active filarial infection was a 6 mg dose of Ivermectin and a 400 mg
dose of albendazole every three months with follow-up.

 The patient has been prescribed a daily dose of 200 mg of doxycycline, which has been shown to cause a
significant reduction in lymphedema in patients with Grade II–III LF following 12–24months of treatment,
regardless of circulating filarial status.

 Two months after the initial diagnosis, following prescribed treatment with ivermectin and albendazole, a
night blood smear test showed no evidence of circulating microfilaria.

 A complete blood count, comprehensive metabolic panel, and urinalysis were all found to be within normal
limits.

 A physical examination revealed no evidence of another inciting condition.

EPIDEMIOLOGICAL EXERCISE
 Question :

A routine clinical survey for filariasis was carried out in a community health centre, serving 1 lakh population; data
collected is as follows:

Night blood smears collected :30000

Persons showing only mf positive: 300

Persons showing signs of filariasis: 80

Persons showing both mf positive and signs: 10

Calculate the possible filarial indices. And suggest the control measures.
a) Asymptomatic a microfilaraemia
= 30000-(people with signs and people with blood test +ve and both)/30000X100
= 30000-(80+300+10)/30000X100
= 29610/30000X100
= 98.7%
b) Asymptomatic Microfilaraemia
= Consider only asymptomatic ppln
= Exclude symptomatic from Nr and Dr
= People with positive blood test/asymptomatic populationX100
= 300/(30000-80-10)X100
= 300/29910X100
= 1.0%
= Carriers – important source of infection to the community
c) Microfilarial rate

= People with blood test +ve/People screened X100

= 310/30000X100

= 1.03%

d) Filarial disease rate

= No. showing the symptoms/Sample population examinedX100

= 90/30000X100

= 0.3%

e) Filarial endemicity rate

= filarial endemicity rate=signs+ number of mf patients+ Both *100 = (80+300+10/30000)*100 = 1.3%

number of persons examined

FILARIAL SURVEY
1) A filarial survey was done in 2006 in Gulbarga district with a population of 15 lakh .The
following information was available:

a). 40,000 people were clinically examined and night blood examination was done.

b). 300 people had only microfilaria of W. Bancrofti in their peripheral blood.

c). 3400 people showed visible clinical manifestations without microfilaria.

d). The 10 man hour catch of adult mosquito was 70.

I. Calculate: a) Microfilaria rate, b) Filarial disease rate , c) Filarial endemicity rate

II. Describe the control measures to be taken.

I)
a ) Microfilaria Rate (%) :-
 No: of slides positive for microfilaria x 100
Total no: of slides examined
= 300 x 100 = 0.75 %
40,000

b) Filarial disease rate (%) :-

 No: of persons with clinical manifestation of disease x 100
Total no: of persons examined
= 3400 x 100 = 8.5 %
40,000
 c) Filarial endemicity rate (%) :-

 
Total no: of people having microfilaria in blood + disease manifestation x 100
Total no: of people examined
= 300 + 3400 x 100 %
40,000
= 3700 x 100 = 9.25 %
40,000
 

The man hour catch of 70 indicates medium vector density of the adult mosquito. Hence, antilarval and antiadult,

measures have to be taken up as per the guidelines of the programme.

II) CONTROL MEASURES:

 1 ) All 3700 persons having microfilaria should be treated for 12 days with Diethylcarbamazine (DEC) i.e. 6

mg/kg body weight. In endemic areas, the Rx must be repeated every 2 years.

 2 ).CHEMOPROPHYLAXIS :

 The basic principle in the revised filariasis control strategy is a large scale treatment with albendazole (400 mg)

with DEC(6mg/kg) or ivermectin (150-200 mcg/kg) administration to the population of the entire district.

 This preventive chemotherapy should be conducted annually for 4 to 6 years.

3) Management of acute & chronic Filariasis episodes is as follows

a) Hygiene

b) Management of entry lesions after hygiene,

c) Elevation,

d) Exercise

e) Footwear

f) Cosmetic surgery

g) hydrocelectomy
4) IEC to inculcate individual/ community based protective and preventive habits are an

integral part of filariasis control strategy. Health education messages are:

a)Wash leg with soap & clean water, b)Dry leg carefully and gently, c)Elevate leg during day and night, d) Exercise

anytime anywhere, e) Manage acute attack – symptomatic treatment.

Health education to the public – motivate people to operate anti-filarial activities and to take complete treatment
 5. VECTOR CONTROL
Integrated vector control
a) Anti larval measures:
 Minor Engineering works like canalization, desilting, filling, adequate maintenance of Septic tank, etc. sufficient
gradient should be provided for drainage system.
 Removal of pistia plant, removal of scum and vegetations
 Chemical control: Mosquito larvicidal oil or pyroselene oil-E or organophosphorous larvicides like fenthion, temephos
are found to give succesful results.
 
b) Anti adult measures: Pyrethrum as space spray can be used. DDT, HCH and Dieldrin have become resistant.
 
c) Personal Protection Measures:
Use of Impregnated bed nets, repellants/ mosquito coils, full sleeved clothes, etc should be encouraged.