BLOOD AND TISSUE

DWELLING NEMATODES
 Filarial Parasites
• Slender, filiform, creamy white worms
• Range from 2 to 50 cm. long (adult)
• Females are 2x the size of males
• Arthropod transmitted
• Affect the circulatory, lymphatic and
muscular systems, connective tissues and
serous cavities
Wuchereria bancrofti

• Bancroftian filariasis, wuchereriasis

• Elephantiasis
• Humans are the only known definitive host
• Adult worms are located in the lymphatics
• Microfilaria (larval stage) are found in the blood and
lymph
• Microfilariae are sheathed
• Adults are tightly coiled in the nodular dilations of the
lymphatic vessels and sinuses of lymph nodes
• Nocturnal periodicity is very distinct
Microfilaria
Brugiya malayi
• Causative agent of malayan filariasis
• Adult and microfilaria closely resembles that of W.
bancrofti
• Nocturnal periodicity is less distinct
MICROFILARIA DIFFERENTIATION

POSTERIOR ANTERIOR
Life Cycle
• Adult females are viviparous
• Microfilariae migrate into the bloodstream and are ingested
by mosquitoes during blood meal
• Microfilariae migrate to the muscles of the mosquito
• Larvae develop 6 – 20 days and force their way out of the
muscles and migrate to the proboscis
• Developed larvae are transferred to another human host
during blood meal
• Larvae pass to the lymphatic vessels and nodes and mature
(6 months or more)
• Adults frequent the lymph vessels of the lower extremities,
groin glands, epididymis or labial glands
 Mosquito vectors of W. bancrofti

Aedes polynesiensis
Brush mosquito
Day biter, nondomesticated, rural, sylvatic

Culex quinquefasciaticus
Night biter, domesticated, urban
mosquito
Vectors of B. malayi

Anopheles Aedes
(Urban or sub-urban) (brush mosquito)
B. malayi

Mansonia Pistia
Night biters (breeding site of mansonia)
 Epidemiology (W. bancrofti)
• Tropical and subtropical
• Africa, Asia, Philippines
• Correlated with the population density, presence of
vector, and poor sanitation

Epidemiology (B. malayi)

• Sri Lanka, Indonesia, Philippines, China, Korea, Japan and other Asian
countries
• Correlated with the population density, presence of vector, and poor
sanitation
Pathology and Symptoms

•Bancroftian filariasis
•Malayan filariasis
•Caused mainly by living, dead and
degenerating adult worms
•Microfilariae cause less pathologic response
Course of Infection

Pseudotubercular The walled

Adult worms in the granulomatous degenerating worm
lymph reaction around the occludes the
trapped adult lymphatics
worm

Lakes of lymph Dead worm is

fluids develop in Lymphatics become absorbed and
the lymph sinuses varicose replaced with
and lymph nodes hyalinized or
calcified scar tissue
Classification of Filarial Infection
• Asymptomatic filariasis
• Inflammatory filariasis
• Obstructive filariasis
 Asymptomatic Filariasis

•When children are exposed to infection at an

early stage
•Adults exhibit microfilariae in the blood without
symptoms
•Moderate to general enlargement of the lymph
nodes during physical examination
•Blood examination shows numerous microfilariae
•Adults die and microfilariae disappear without
symptoms
 Inflammatory Filariasis
•Immunologic phenomenon caused by sensitization
to the product of living and dead adult worms
•Characterized by funiculitis, epididymitis, orchitis,
retrograde lymphangitis of extremities, localized
swelling and redness of arms and legs
•May be accompanied by fever, headache, vomiting
and malaise
•Most patients do not have microfilaremia
Obstructive Filariasis
•Elephantiasis
•End result of filariasis
•Develops slowly usually following years of
continuous filarial infection
•Preceded by chronic edema and repeated
inflammatory attacks
•Cellular reaction and edema are replaced by
fibroblastic hyperplasia
•High protein content of the lymph stimulates the
growth of dermal and collagenous connective tissue
•Over a period of time, the enlarged areas harden
Chronic Elephantiasis
Enlargement of Genitalia

Epi dydimitis Hydrocele

Difference in Pathogenicity

•Lymphangitis, lymphadenopathy, abcess

formation in the inguinal nodes occur more
frequently with B. malayi
•Elephantiasis in B. malayi is generally
confined to the distal extremities
•Involvement of the male genitalia (funiculitis
and orchitis) is more common in W. bancrofti
•Rupture of the lymphatics of the kidney can
occur in W. bancroftie resulting in chyluria
Diagnosis

• Identification of microfilariae in the blood

• History of exposure to endemic areas
• Place a drop of blood on a slide and examine under LPO for
actively moving microfilariae
• Recommended time to collect blood: 8pm. – 4am. Best
time: 10pm. – 2 am.
• To determine the species: stain thick or thin blood smear
with Wright’s or Giemsa to bring about the differential
characteristics
• W. bancrofti microfilariae may be present in urine
Other Diagnostic Methods
Knott’s concentration nucleopore

•Used to detect light • Slightly more sensitive

infection
• Filtration of 1 – 5 ml. of
•1ml. of night blood is heparinized blood
laked in 10ml. of 2% through a 5µ of
formalin solution Nucleopore filter
•Sediment is • The stained filter is
examined directly or placed on a slide and
examined
may be dried and
stained.
NO MICROFILARIAE IN THE BLOOD DOES NOT
ALWAYS MEAN NO INFECTION

•Approximately 6-12 months may elapse

from time of infection until worm
matures and produce microfilariae
•Late in the disease (elephantiasis), adult
worms and microfilariae may both have
died
 Diethylcarbamazime
(DEC, Hetrazan)
• The standard drug for treatment of most filariasis
• Dosage is 2 mg. per kg t.i.d. for 12 days
• Clears the blood of microfilariae but is also believed to affect adult
worms
• Has the important disadvantage of producing significant/severe side
effects
• Fever, arthralgia, adenopathy, headache, prostration
• May be the effect of the sudden death of large number of microfilariae
• Exact mechanism of side effects still unknown
 Ivermectin
•Found to be almost equally effective as 12 days of
DEC in rapid clearance of microfilaremia
•Unlike DEC, it is given in single dose only
•10% to 20% recurrence occurs 3 to 6 months after
treatment
•Has approximately the same side effects as DEC.
•Mechanical devices can be used to reduce edema
•Surgery to remove excess connective tissues in
elephantiasis give short term benefits but long
term complications
Prevention

•Control of mosquitoes and human sources of

infection
•Spraying of houses with insecticides and
larvicides are effective for domesticated
mosquitoes only
•Protection of individual by screened quarters,
bed nets, mosquito repellant and protective
clothing (educational and economic problem)
Loa loa

•Human loiasis is confined to the rain

forest and swamp forest areas of West
Africa. It is especially common in
Cameroon and on the Ogowe river.
•Loiasis is caused by the filarial
nematode Loa loa which is transmitted
to humans by day-biting Chrysops flies
Life Cycle

• Once inside the body the infective larvae develop

slowly into a mature adult (the process takes about
a year).
• During this period it lives and moves around the
fascial layers of the skin.
• Loa loa often makes frequent excursions through
the subdermal connective tissues.
• Once they reach maturity (measuring 3-3.4 cm x
0.35-0.43 mm for males and 5.7 x 0.5 mm for
females) the adults mate and produce sheathed
microfilariae 298 x 7.5 micrometers in size.
Vector: Chrysops fly Loa loa
Pathology and Symptoms

• Damage is usually caused by migrating worm

• Worm may migrate to the eye and damage the cornea
• Immune reactions to the worm may cause inflammation
called Calabar swelling: painful swelling usually in the
extremities
• Recurrent swelling can lead to the formation of cyst like
enlargements of the connective tissues around the tendon
sheaths.
• Dying worms can also cause chronic abscesses followed by
granulomatous reactions and fibrosis.
Calabar Swelling

DIAGNOSIS
• Detection of the microfilariae
• May be found in the blood, urine, sputum, and spinal fluid
Onchocerca volvolus

• Human onchocerciasis is found in both the Old and New

World but about 95% of all cases are in Africa.
• Caused by the filarial parasite Onchocerca volvulus. The
infective larvae are normally transmitted by the bite of
Simulium flies
• Simulium flies can only breed in well oxygenated water
because their larvae have an obligatory aquatic stage during
which they require high oxygen tension
• Accordingly onchocerciasis and the blindness it can lead to
are associated with fast flowing rivers with rapids and
onchocerciasis is often referred to as 'river blindness'
Life Cycle

• The infective larvae of Onchocerca enter the body through the wound
made by the bite of its host fly.
• The larvae then move to the subcutaneous tissues where they become
encapsulated nodules and mature into adults in approximately one
year
• After mating the female vivipariously gives birth to microfilariae 300
mm in length and 0.8 mm in diameter. The microfilariae are sheathless
with sharply pointed recurved tails.
• The microfilariae can be found free in the fluid within the nodules and
in the dermal layers of the skin spreading centrifugally from the area
where an adult lies.
• Microfilariae also can be found in the blood and eye during heavy
infections. They infect their fly vectors while the flies are feeding on
the human host and mature into stage three infective larvae in the
flies' flight muscles
Life Cycle
O. volvolus in tissues
Pathogenesis and Symptoms
• One of the earliest signs of infection with Onchocerca is the
raised nodules that can be seen under the skin around areas
over bony prominence. It is suggested that this phenomenon
occurs because the larvae are immobilized in these locations
(while the host is sleeping) long enough for them to be
trapped by the body's cellular defense mechanisms
• Reactions to dead microfilariae around these nodules can
lead to several unpleasant conditions. In the skin there is
destruction of the elastic tissues and the formation of
redundant folds.
• There is also often a loss of pigmentation and the
histological appearance of advance cases often resemble the
skin of very old normal subjects
River Blindness
• The microfilariae can also enter the eye by passing
along the sheaths of the ciliary vessels and nerves
from under the bulbar conjunctiva directly into the
cornea, via the nutrient vessels into the optic nerve,
and via the posterior perforating ciliary vessels into
the choroid.
• Dead microfilariae in the eye lead to an inflammatory
immune response and the eventual formation of
secondary cataracts and ocular lesions. Because of
this, heavy infections often lead to progressive
blindness.
Infammatory Reactions
• The microfilariae can also cause inflammation of
regional lymph glands which remove foreign
material from the distal skin.
• This inflammation along with the loss of tissue
elasticity can lead to protruding lymph glands
enfolded in pockets of skin.
• This condition is especially prominent in the areas
around the scrotum (often called the 'hanging
groin' effect) and in severe cases is classified as
minor elephantiasis
Onchocercaiasis

Raised nodules Hanging groin

River Blindness
River Blindness
Mansonella

•Mansonella ozzardi
•Mansonella streptocerca
•Mansonella perstans
•Causative agents of mansonelliasis
•Cilicoides flies serve as vectors
Mansonella ozzardi
•Only filarial worm parasitizing humans in South
America
•Adult worms are found in the mesenteries and
visceral fats
•Microfilaria are found in the blood and sometimes in
the capillaries and intravascular spaces of the skin
•Usually asymptomatic
•May cause adenopathy, pruritic and maculopapular
skin lesions, arthritis, fever, and marked eosinophilia
•Simulium fly may also become a vector
Mansonella streptocerca
•Infects both humans and monkeys in Africa
(Congo)
•Microfilariae are found primarily in the skin,
sometimes in the blood
•Posterior end of microfilaria resembles a
shepherd’s crook
•Causes pruritic dermatitis with
hypopigmented macules ans inguinal
adenopathy
Mansonella perstans
• Dipetalonema perstans and Acantholeinema perstans
• Common parasite of humans and apes in Africa
• May also be found in Latin and South America
• Adult worms are found in deep connective tissues
• Microfilariae are found in the blood, and in the skin
• Periodicity is not exhibited

Mansonelliasis perstans
• Majority of infections are benign
• May cause Calabar-like swellings, pruritis, hives, fever, and
headache
• Causes Ugandan or Kampala eye worm condition when adult
worms invade the conjunctiva and periorbital connective tissue
Mansonella perstans microfilaria
Angiostrongylus cantonensis

• Also known as the Rat Lungworm

• Humans are accidental hosts
• Usually infect rodents
• Migrates to the CNS of humans (inc. Eosinophil in
CNS)
• Humans get the infection by ingesting the
intermediate host snail (Achitina fulica)
• Pila luzonica and Brotia asperata are also I.H
• No effective treatment
A. Cantonensis Adult
Dirofilaria immitis

•Common name: Dog Heartworm

•A very common filarial parasite of dogs
•Almost all human infections come to medical
attention as solitary, peripheral nodules in
the lung (Coin lesions), or as subcutaneous
nodule

Dirofilaria in Dog’s Heart

Life cycle
Dracunculus medinensis

•Longest nematode of man (May reach 1 meter)

•Common name: Guinea worm, Fiery serpent of
the Israelites, medina worm, Dragon worm,
Serpent worm
•Habitat: Subcutaneous tissue
•Intermediate host: Aquatic crustacean- cyclops
•No treatment, removal only
•Life cycle:
1. Intermediate host is in aquatic crustacean
2. Infection: accidental ingestion of
crustacean with larva
3. Larava digested free in the intestine,
penetrates wall and develops in body
cavity or connective tissue
4. Gravid female migrates to subcutaneous
tissue, causes ulcer
5. Ulcer, on contact with water, releases
larvae
Life cycle
Cyclops