Elephantiasis

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Filariasis
• Filarial worms are nematodes that dwell in the
subcutaneous tissues and the lymphatics.
• Eight filarial species infect humans of these four are
responsible for most serious filarial infections.
1. Wuchereria bancrofti
Vector- Culex, Anopheles and Aedes mosquitoes)

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2. Brugia malayi- Vector- Mansonia, Anopheles
(mosquitoes; Brugia timori-Anopheles mosquitoes
3. Loa loa- Vector- Chrysops (deerflies)
4. Onchocerca Volvulus-Vector- Simulium (black flies)

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Lymphatic filariasis:- Parasitic disease caused by a
worm that affects Lymphatic system.
• Lymphatic filariasis, commonly known as
elephantiasis, is a neglected tropical disease.
Causes:- Lymphatic filariasis is caused by infection with
parasites classified as nematodes (roundworms) of
the Filarial family.
• Wuchereria bancrofti- is the most common cause of
L. filariasis (>90%), Brugia malayi or B. timori
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• Eliminating lymphatic filariasis can prevent
unnecessary suffering and contribute to the reduction
of poverty.
• L. filariasis is common in western parts of Ethiopia
such as Illubabor, Keffa, Jimma, Wollega, Gambella
and Pawe.
Reservoir: Humans are definitive hosts

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Life cycle

• Adult worms lodge in the lymphatic vessels or lymph

nodes and disrupt the normal function of the lymphatic
system.

• The worms can live for more than two decades, an

average of 6–8 years and, during their life time, produce
millions of microfilariae (immature larvae) that circulate
in the blood.

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• Mosquitoes are infected with microfilariae by ingesting blood

when biting an infected host.

• Microfilariae mature into infective larvae within the

mosquito.

• When infected mosquitoes bite people, mature parasite

larvae are deposited on the skin from where they can enter
the body.

• The larvae then migrate to the lymphatic vessels where they

develop into adult worms, thus continuing a cycle of

transmission. 7
Life cycle

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Wuchereria bancrofti worm

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Pathology

• Consequences of filarial infection are due both to

the direct effects of the worms (block the lymph
vessels) and to the host's inflammatory response
to the parasite.

• Inflammatory damage to the lymphatic, which is

typically caused by adult worms and not by
microfilariae.
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Clinical manifestations
1. Asymptomatic (or subclinical) microfilaremia
• The majority of individuals appear to remain clinically
asymptomatic for years; In relatively few does the
infection progress to either acute or chronic disease.
• asymptomatic infections still cause damage to the
lymphatic system and the kidneys, and alter the body's
immune system.

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2. Acute adenolymphangitis (ADL)

• characterized by high fever, lymphatic

inflammation (lymphangitis and lymphadenitis),
and transient local edema.

• The local edema Involving both the upper and

lower extremities as well as the genital area.

• Genital involvement- funiculitis, Epididimo-orchitis,

and scrotal pain and tenderness
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3. Chronic (obstructive) lymphatic disease-
Lymphedema
 These take 5–15 years to develop.
 Result from permanent damage to lymph vessels
by the adult worms. Recurrent inflammatory
reactions to the worms cause dilation of the lymph
vessels, which results in oedema.

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The chronic lymphedema is characterized by
• Elephantiasis- Brawny edema, and thickening of the
SC tissues and hyperkeratosis occur. Most
commonly seen in the legs or scrotum but May also
is present in vulva, breasts, or arms.
 Fissuring of the skin develops and super infection of
these poorly vascularized tissues becomes a
problem.
 Hydrocele; kidney damage
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• Leg lymphoedemas are commonly classified
as grade I: pitting lymphoedema
spontaneously reversible on elevation;
• grade II: non-pitting lymphoedema, loss of
skin elasticity; and
• grade III: evident elephantiasis with skin folds
and papules.
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Conti…

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Diagnosis
• Clinical and epidemiological grounds- Diagnosis is
clinical in late disease .
• Obstructive signs with history and travel to and
residence in endemic areas.
• CBC: extremely high eosinophilia count and elevated IgE
and antifilarial antibody support the diagnosis of L.
filariasis.
• The Microfilariae can be found in blood, in hydrocele
fluid, or (occasionally) in other body fluids at night. 18
• Mazoti test (filarial skin test

• Immuno-chromatographic (card) test to demonstrate

filarial antigens
• Diethylcarbamazine (DEC) provocative test
(2mg/kg). After taking DEC, microfilariae enter the
peripheral blood within 15 minutes
• Ultrasonography: organisms may be visualised ih the
lymphatics of the female breast or male scrotum
• Chest X ray 19
N.B. Filarial parasites exhibit a daily periodicity in the
concentration of microfilariae in the peripheral
blood of the host. a nocturnal or diurnal periodicity.
Differential diagnosis
• Lymphatic filariasis should be differentiated with
podoconiosis ("non-filarial elephanthiasis") a non-
communicable diseases which is common in some
areas of Ethiopia.

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Non pharmacologic
1. Supportive treatment and prevention of acute ADL
attacks: hydration and rest; antipyretics and analgesics
2. Treatment and prevention of lymphoedema:
• Hygiene measures for the affected limb: wash twice daily
with soap and clean water and dry well; keep nails short
and clean
• Wear comfortable footwear, prevent and treat entry
lesions
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• Elevate the affected limb at night
• Frequent exercise of the affected limb to promote
lymph flow: standing on toes, flexing and circling
ankles while sitting
3. Use of antiseptic, antibiotic, and antifungal creams
for small wounds and abrasions
• Systemic antibiotics or antifungals in severe cases

4. Surgical treatment of hydrocele

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Drug treatment
• Diethylcarbamazine citrate (DEC), 6mg/kg P.O.daily for 12 days
OR
• Diethylcarbamazine citrate, 6 mg/kg P.O., plus albendazole
400mg P.O., as single dose.
Prevention and control
• Integrated vector control (IVC)

• Mass administration of single annual doses of Albendazole plus

Ivermectin (where Onchocerciasis is also endemic) for 4-6
years.
• Personal protection against mosquito bite 24
Onchocerciasis
• Onchocerciasis ("river blindness") is a parasitic vector
born diseases caused by the filarial nematode called
Onchocerca Volvulus.
• Also called Blinding filariasis, river blindness, Coastal
erysipelas
• Onchocerciasis primarily affects the skin, eyes, and lymph
nodes.
• The damage in Onchocerciasis is elicited by microfilariae
and not by adult parasites. 25
Epidemiology
• O. volvulus infects an estimated 37 million individuals in
35 countries worldwide.
• The majority of individuals live in the equatorial region
of Africa Like DRC, Uganda, Rwanda and etc.
• Onchocerciasis is found in the western parts of Ethiopia.
The most affected areas are Keffa, Illubabor, Wollega
and Gambella.

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• Rapidly flowing rivers and streams, with vegetations
along the banks that provides good habitants for
blackflies.
Mode of transmission
• Transmitted from person to person by a bite of
blackflies.

• Flies bite the day time when peoples are active.

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Black fly

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Life cycle

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Clinical manifestations
• Due to an inflammatory reaction surrounding dead or
dying microfilariae
1. Skin:- Pruritus and generalized papular rash are the
most common manifestations of onchocerciasis.
• Can cause itching suicide. Peoples commit suicide due to
continuous and severe body itching.

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Long-term infection results in
• Exaggerated & premature wrinkling of the skin (rough
skin)
• Loss of elastic fibers, and epidermal atrophy that can
lead to loose, hypo pigmentation
• Nodule formation- Onchocercomata
• Subcutaneous nodules, which can be palpable and/or
visible, contain the adult worm.

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• Nodules vary in size and characteristically are firm and
not tender.
• Nodule formation is common over the coccyx and
sacrum, the Trochanter of the femur, the lateral anterior
crest, and other bony prominences.

2. Eye – oncophthalmia:- Visual impairment which leads

to blindness
3. Lymph Nodes- Mild to moderate LA is common

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• Particularly in the inguinal and femoral areas, where the
enlarged nodes may hang down in response to gravity
("hanging groin"),
• Sometimes predisposing to inguinal and femoral
hernias.
• Heavily infected patients could have severe wasting
(cachexia), with loss of adipose tissue and muscle mass.
Diagnosis
• CM- pruritus, oncocercoma and oncophthalmia
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• Definitive diagnosis demonstration of the microfilariae
in the skin snip or nodules or detection of an adult
worm in an excised nodule.

• Eosinophilia and elevated serum IgE levels are common

• Mazoti test (filarial skin test)

Treatment

• Ivermectin, single oral dose of 150 micrograms/kg is the

drug of choice

• Alternative- Diethylcarbamazine 35
PLUS Doxycycline, 100mg P.O., BID for 8weeks prior to treatment
with Ivermectin
PLUS Antihistamines- Promethazine, 25 mg two or three times a day
until the pruritus subsides
• Nodulectomy may have a place for eradication of the adult worm

Prevention
• Vector control

• Community-based MDA of Ivermectin every 6–12 months is being

used to interrupt transmission in endemic areas.

• Personal protective clothing

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