Tissue helminth

Sitti Wahyuni, MD, PhD

wahyunim@indosat.net.id

Department of Parasitology
Medical Faculty
Hasanuddin University

Species & disease

• Filaria----
lymphatic filariasis

• Schistosome----
Bilharziasis

• Trichinella spiralis

• Toxocara & animal Ancylostoma---
visceral & cutaneus larva

migrans

• Onchocerca volvulus & Loa-loa ----
cutaneus & subcutaneus

filariasis

• Capillaria hepatica
Capillariasis

• Fasciolopsis buski

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 Lymphatic Filariasis
• a vector born disease of lymphatic system
caused by:
Wuchereria bancrofti
Brugia malayi
Brugia timori
• not lethal but can be seriously debilitating
• causing an economic burden on infected
individuals

Clinical manifestation

It is an old disease…….

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But still found nowadays…..

Epidemiology
• affect 120 million people over 80 tropics &
subtropics countries
44 million have visible signs of disease
76 million have preclinical infection
WHO has considered as one of the six
potentially eradicable diseases
• WHO: global elimination of filariasis by
2020

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 Prevalence in Indonesia
• extensive surveys since 1970: prev. 0-70%
• Health Minister & UI (1983): mf prev. has
declined to 0-19,6%
• WHO (2000) stated:
- endemic in 22 of 27 provinces
-150 million people at risk of infection
- the highest prev. in South East Asia

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 Adult
• creamy-
creamy-white,minute, thread
like nematodes with smoth
cuticula

• tapering toward both end,&

terminations are bluntly rounded

•head: slighty swollen,

surmounted by 2 rings of small
papillas

•Mouth: unarmed, no buccal

vestibule

Adult
• Live in lymph nodes

• Can stay alive for 15 years

• Vivipar & produce microfilaria

• Causes clinical manifestation

(febrile, extremitas oedema,
oedema,
hidrochele & elephanthiasis

•Can only be seen if it circulate

in hidrocele/incision
hidrocele/incision of lymph
nodes

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 Microfilaria
Wuchereria bancrofti
• Body: gently curved
• Tail: tapered to a point
• Nuclear column: loosely
packed, & nuclei can be
visualized individually
and do not extend to the
tip of the tail.
• Sheath: slightly stained
Thick blood smears stained
with hematoxylin.
with hematoxylin

Microfilaria
Wuchereria bancrofti
• collected by filtration
with a Nucleopore®
membrane.
• The pores of the
membrane are
visible.

Thick blood smears stained

with Giemsa can not demonstrate the
sheath

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 Microfilaria
Brugia
• Shape: more tightly
coiled
• nuclear column:
more tightly packed,
individual nuclei can
not be visualize
• Sheath: slightly
stained with
hematoxylin. Thick blood smears
stained with hematoxylin

Microfilaria
Brugia

• collected by the Knott

(centrifugation)
concentration technique,
in 2% formalin wet
preparation

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 Host
• Definitive:
-humans: W. bancrofti and B. timori
-human & animals: B. malayi
• Intermediate: masquitos
- urban W.bancrofti: Culex quenquefasciatus
- rural W.bancrofti: A. farauti & A. punctulatis
- nocturnally B. malayi (Sulawesi):
Anopheles barbirostris
- sub-periodic B.malayi (Sumatra & Kalimantan):
Mansonia spp.
- nocturnal B timori : A. barbirostris

How to get infection?

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Breeding site

Breeding site

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 spectrum of clinical and
parasitological manifestations

• endemic normals/asimptomatic
amicrofilaraemics
• Microfilaraemics
• Chronic obstructive disease

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 Acute
lymphangitis/lymphadenitis

• Often occur in chronic patients

• Caused by dying or degenerating adult
worms
• Bacterial or fungal superinfections in limbs
with compromised lymphatic dysfunction
play a significant role

Chronic obstructive

• Bancroftion filariasis
-main clinical manifestation: hydrocele
-can be accompanied by lymphoedema
(elephantiasis) of the whole arm/leg
-enlargement of vulve/breast
• Brugian filariasis
- lymphoedema (elephantiasis) of leg below the
knee or arm below the elbow
-hydrocele has seldom been recorded

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 Tropical pulmonary eosinophilia
(TPE)

• A relatively unusual manifestation of

infection
• microfilariae are generally absent from the
circulation
• hypereosinophilia, elevation of anti-filarial
antibodies (lgE) & pulmonary symptom
such as bronchial asthma

Diagnosis

• Detection of microfilariae
• Antigen detection assays
• Molecular Diagnosis
• USG detection of adult worms
• Antibody assays

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 Detection of microfilariae

• Classic diagnosis of
lymphatic
• Still the golden
standard
• The time accord to
the periodicity
• Two methods: finger
prick & whole blood
filtration

Finger prick method

• The blood is obtained by pricking the

finger with a lancet
• Collect 20-60 ul blood on a slide glass
• Stained with Giemsa's stain
• Screen presence of mf under a light
microscope
• sensitivity of this assay is low
• Time collecting blood is inconvenient

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 Whole blood filtration
• 1-10 ml blood filtrated to the filter
• The filters: stained and examined in the same
manner as finger prick blood
• Distribution of mf in the periphery non-random,
mf can be missed as they are subject to
periodicity
• The time of blood collection is inconvenient
• Many people object to vena puncture
• Requires skilled personnel & proper precautions

Antigen detection assays

• Developed for detection CFA

• Based on a monoclonal raised against bovine
Onchocerca gibson, named Gib-13
-93% W. bancrofti mf(+) were found positive
-Detect CFA in mf (-) subjects with acute
symptoms
-53% of asymptomatic mf(-) subjects

• Unfortunately, no CFA has been developed for

detection of brugian filariasis

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 Molecular Diagnosis
• Characterization of filaria species-specific
DNA using PCR-based assays
• primers for both W.bancrofti & B malayi
have been designed successfully
• Positive only in the presence of circulating
mf
• Problem for diagnosis of cryptic infections
• PCR is an expensive assay
• Requires well-equipped laboratories &
personnel

USG detection of adult worms

• can be observed in dilation of lymphatic

vessels/scrotal area: 'filaria dance sign‘
• Can be used to investigate the
macrofilaricidal effects
• Non-invasive & portable equipment is
available
• Restricted to the male population
• Not available for B.malayi

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 Antibody assays

• Anti-filarial lgG4 : have high specificity &

sensitivity
• Anti-filarial lgG4 correlate strongly with the
presence of mf
• Can discriminate active from past infection

Management

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 general
strategies to reduce transmission

• Treat the infection person

• decrease human-vector contact
• Reduce the population of mosquito
vectors by insecticides,polystyrene beads
or biocides

Diethylcarbamazine citrate
(DEC)
• For the past 50 years has been the
primary drug of choice
• Has excellent microfilaricidal properties
• Demonstrated the rapid decline of mf in
the periphery after treatment
• Have macrofilaricidal potential, if
prolonged treatment is supplied
• A part of individuals seem resistant
• Side effects are recorded

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 Dosage of DEC

• Standard : 12-14 day course of 6 mg/kg BW

• Meta-analysis of studies : a single dose/a
year for several years equivalently reduce
mf levels
• New opplications : mass administration of
DEC fortified salt
• Combination therapy ivermectin
/albendozole can give 10% better results.
• Have a long-term effects

Current control programs

in Indonesia
• Health ministry recommend annual mass
drug administration (MDA): DEC 6 mg/kg
+ albendazole 400 mg for at least 4-5
subsequent years.
• Has been shown to be effective in
reducing mf prevalence of B.timori and
intestinal helminth infections in Alor island,
East Nusa Tenggara from 26.8% to 3.8%

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