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Lymphatic Filariasis

Lymphatic Filariasis

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Published by: jslum on Jul 06, 2011
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05/20/2012

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ympac arassFilariasis
Filariasis - Parasite disease caused by filarial wormsFilaria  Nematodes that dwell in lymphatics & subcutaneous tissues
Lymphatics(Lymphatic filariasis)Subcutaneous tissues
Wuchereria bancroftiBrugia malayiBrugia timoriOnchocerciasis (river blindness) -Onchocerca volvulusLoiasis Loa loaOthers
y
 
M
ansonella perstans
y
 
M.
streptocerca
y
 
M.
ozzardi
E
pidemiologyW. bancrofti B. malayi B. timori
M
ost prevalent(90-95%lymphatic filariasis)115 millionpeople14 millionpeople Less commonSouth Asia & SEA
y
 
C
hina
y
 
I
ndia
y
 
I
ndonesia
y
 
K
orea
y
 
M
alaysia
y
 
Philippines
I
slands of 
I
ndianarchipelagoTropic & subtropic
y
 
Asia
y
 
Pacific
I
sland
y
 
Africa
y
 
South America
y
 
C
aribbean40 millionpeople havesevere chronic disease
Filaria
Long, threadlike nematodes (round worms)
2 Forms
 
Adult worm Microfilaria
Parasite of avertebratehost1
st
stage larvaeHighly modified eggs
C
apable of living for long periods withinvertebrate hosts (not of developingfurther until ingested by vector)
Microfilaria
Light microscopeUseful in species identificationShealth (sh)  may extend ashort/long distance beyond eitherextremity of 
M
FNuclei  crowded/ disperseHead space (hs)  anterior extremity,devoid of nuclei
Life CycleW. bancrofti, B. malayiWuchereria bancrofti Brugia malayi
Short cephalic space 1:1Discretebody nucleiNo terminal nucleiSmoothbody curvatureLong cephalic space 2:1Overlappingbody nuclei2 Terminal nuclei
K
inkybody curvatureVector (mosquitoes)
y
 
C
ulex (urban area)
y
 
Aedes (rural area)
y
 
AnophelesVector (mosquitoes)
y
 
M
ansonia
y
 
Anopheles
y
 
C
oquillettidiaNocturnally periodicNocturnal subperiodic(only in South Pacific
I
sland)
P
eriodicity
Fluctuation in number of microfilaria in peripheral blood during a 24h period
Nocturnal Diurnal Subperiodic Aperiodic
Species found inblood duringnight time(absent at day)Present onlycertain day timehoursPresent in bloodat all hours(density increasesignificantlyeither night orday)
C
irculate inbloodthroughout 24hperiod withoutsignificantchange in no
.
 
P
eriodicity
(Brugian filariasis)
Nocturnal periodic Nocturnal subperiodic
M
ore common species
I
n area of coastal rice field by
y
 
M
ansonianmosquito
y
 
AnophelinemosquitoTransmitted in forest area by
M
ansonianmosquito
P
athogenesis
I
nflammatorydamage to lymphatics by adult worms(lymphangiectasia)
Accumulation of adult worms inlymph vessels
I
nflammatory changes in & around lymphatic vessels(lymphangitis)
Repeated attacks of lymphangitisDilatation & thickeningof affected lymphatic vesselsLymphatic incompetent(lymphoedema)
With chronic lymphoedema, there is hyperplasia of connective tissues,infiltration of plasma cells, eosinophils & macrophage
C
hronic inflammatory changesFibrosisof lymphatic vessels
Finallywoody indurationof tissues take placeThickening & verrucous changes of skin(elephantiasis)
 
 
Clinical Features
Depend on
y
 
Sites occupied by worms
y
 
Number of worms present
y
 
Strain differences in parasites itself 
y
 
Length of infection
y
 
Host immune responsesAsymptomaticAcute lymphatic filariasis (due to acute inflammation)
C
hronic lymphatic filariasis (due to chronic lymphatic obstruction)
Acute lymphatic filariasis Chronic lymphatic filariasis
Recurrentfever, painful inflammationof lymph nodes (lymphadenitis),lymphatic ducts (lymphangitis),adenolymphangitis(ADL)HydroceleLymphoedemaElephantiasis
y
 
C
omplication of advanceddisease
y
 
C
oarse thickening, hardening,cracking of skin overlyingenlarged fibrosed tissueRashEosinophilia Lymphangitis
y
 
Limbs (common)
y
 
G
enital organ (spermatic cord)
y
 
BreastSecondary bacterial & fungalinfection (can occur)Distended lymphatic vesselsAcutely tenderTense, erythematous, hot skin
BancroftianfilariasisBrugian filariasis
I
nfection developsmore rapidly
C
hildren (often)Elephantiasis (often)Hydrocele (rare)
C
omplicated by secondary bacterialinfection/ abscess formation
BancroftianfilariasisBrugian filariasis
HydroceleLower limbsaffected
Clinical Features
ElephantiasisBreastlymphoedemaHydrocele
Complications
Lymphorrhoea lymph oozes out to exterior (from ruptured lymphatic vessels)
C
hyluria passing of chyle in urine
y
 
Only inchronic bancroftian filariasis
y
 
M
ilky urine/ creamy white/ pinkish white if mixed with bloodOccurs when swollen lymphatics burst into urinary tract
M
icrofilaria can often be found in fibrin clots (which forms in urine) 
Microfilariae  Human beingsLaboratory Diagnosis
History of exposure in endemic areasDemonstration of parasites (definitive diagnosis)
y
 
M
icroscopy(definitive diagnosis)
o
 
Thick & thin smear
o
 
C
oncentration technique
y
 
Antigentest
y
 
M
olecularmethod
y
 
Antibodytest
Sample for Microscopy
C
apillary (fingerstick) bloodAnticoagulated (EDTA) venousOther body fluid (urine, hydrocele fluid)
Capillary Blood
M
icrofilariae concentrate inperipheral capillaries Thick & thin smears (recommended for identification of parasite)
Blood smears
Thick & thin blood smearspreparedBlood smear can be stained with
y
 
G
iemsa stain
y
 
H&E stain
T
hick smear
T
hin smear
Thick layer of dehemoglobinized(lysed) RB
C
sSpread in a layer (thickness decrease)Feathered edge  monolayer(not touching one another)Efficientdetection of parasites ( sensitivity)
Venous Blood
Anticoagulated (EDTA) venous blood (1ml)
C
oncentration techniques
y
 
K
notts technique
y
 
M
embrane filtration technique
Antigen detection
EL
I
SARapid test(
I
mmunochromatographic test)
y
 
Wuchereria bancrofti antigens (
IC
T filariasis)
y
 
B
.
malayi antigen (BrugiaRapid)
Brugia Rapid Dipstick
Test line  Brugia malayi recombinant antigen
C
ontrol line 
G
oat anti-mouse
I
g
G
 
C
onjugate well
y
 
M
ouse anti-human
I
g
G
4 monoclonal antibody
y
 
C
onjugated to colloidal gold
I
nterpretation+ve test -ve test
2 lines 1 top line
I
f dipstick show 1 bottom line only or no line at all (test is defective)Advantage  diagnosis of microfilareamic & cryptic (amicrofilareamic) infection
Molecular method
P
C
RW
.
bancrofti & B
.
malayi
G
reater sensitivityDetect cryptic infection  amicrofilaraemic & circulating antigen +veSpeciation of parasite material removed at surgery (sometimes used)
Antibody detection
Limited use (antibody detection)
y
 
Substantial antigenic cross reactivity, exists between filarial & otherhelminths
y
 
+ve serologic test  does not distinguish past & current infection-ve antibody assay  effectively exclude past/ present infection
O
ther method
(Filarial diagnosis)
I
maging studies - Doppler technique(
I
dentify motile adultworm within dilated lymphatic  filarial dance sign)

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