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LIFECYCLE OF AGENTS OF FILARIASIS

Geographic VECTOR deposits L3 Develop into adults that LIVE IN Adults that are And migrate to
Distribution into bite wound produce
microfilariae
FEMALES MALES
WUCHERERIA Tropical areas A. poecilus 80-100 mm x 40 mm x .1 lymphatics 244-296um x Sheathed  Lymph and blood
BANCROFTI Anopheles minimus var .24-.30 mm mm 7.5-10 um nocturnal activity (except S.
flavirostris: Mt. Prov., creamy, white, long and Pacific microfilariae)
Sulu, Palawan filiform tail pointed and clear
BRUGIA MALAYI Asia Aedes 43-55 mm x 13-23 mm x lymphatics 177-230 um x Sheathed lymph  blood
Mansonia 130-170 um 70-80 um 5-7 um tail pointed with 2 nuclei streamperipheral
M. bonnae: freshwater blood
swamps
M. uniformis: rice fields
Night biters (5-11pm)
**cat-mosquito-man
LOA LOA Africa Chrysops 40-70 mm x . 30-34mm x . Subcutaneous tissue 250-300um x Sheathed peripheral blood at
African eye worm (day biting flies/ deer 5mm 33-.43 mm 6-8 um diurnal periodicity: day
flies) - day= peripheral lungs during
blood. noncirculation phase
- Noncirculation  also seen in spinal
phase= lungs fluids, urine, sputum
tail blunt with nuclei
MANSONELLI Carribean, Culicoides 65-81mm x . unknown Subcutaneous tissue 250um x 6- Unsheathed and Blood stream
OZZARDI Central and South (Midges) 21-.25mm Mesentery and visceral fat 7um nonperiodic
America Simulium (black flies) tail pointed and clear
MANSONELLA Africa and S. Culicoides Body cavities (peritoneal, pleural, 200um x 6um Unsheathed and Blood stream
PERSTANS America (Midges) pericardium), connective tissues of subperiodic
abdominal organs tail blunt with nuclei
MANSONELLA West and Central Culicoides Dermis, <1mm from skin surface Unsheathed and skin
STREPTOCERCA Africa (Midges) nonperiodic peripheral blood
ONCHOCERCIASI Africa, M. East, C. Simulium (black flies) wirelike, whitish, lie coiled Subcutaneous and deeper tissues For ~9 years Unsheathed  peripheral blood,
S and S. America within fibrous tissue Has lifespan urine, sputum
capsules ~2yrs skin and lymphatics
of connective tissue
DISEASE CLINICAL PRESENTATION
WUCHERERIA Bancroftian  hydrocele and scrotal elephantiasis
BANCROFTI filariasis
BRUGIA MALAYI Malayan  Manifestations are caused by adult worms, living, dead, or degenerating
filariasis
 Microfilariae cause less pathology but a/w TPE, granulomas of the skin, and allergic reactions following destruction by drugs

Asymptomatic stage
 Presence of thousands to millions of microfilariae in the peripheral blood and adult worms in the lymphatic system with no manifestations of filariasis
 Seen among those with a highly down regulated immune system
 May have hidden lymphatic pathology and kidney damage

Acute stage
 Early manifestations: Fever, inflammation of lymph glands (especially of the male genital organs, arms and legs)
 Recurrent attacks: Swelling and redness of the arms and legs accompanied by vomiting, headache
 S/sx reflect immunologic phenomenon caused by sensitization to the products of living or dead worms collectively called adenolymphangitis (ADL) or
dermatolymphangitis (ADL) or dermatolymphangioadenitis (DLA)

Chronic stage
 With repeated acute manifestations merge into a chronic proliferative overgrowth of fibrous tissue around the dead worms – lead to lymphatic obstruction, recurrent
attacks of DLA and lymphedema, elephantiasis, or hydrocoele
 Cellular reaction and edema are replaced by fibrous hyperplasia
 TPE (tropical pulmonary eosinophilia): occult filariasis
 Immunologic hyperresponsiveness to filarial infection characterized by nocturnal cough, wheezing, hypereosinophilia, elevated ESR, diffuse military lesions or increased
vascular markings
 Chyluria- rupture of lymphatics in the kidney due to blockage of retroperitoneal lymph nodes
 Several reports of glomerulonephritis in bacroftian filariasis

 “Expatriate syndrome”: lymphadenitis and lymphangitis with allergic reactions such as hive, rashes and blood eosinophilia (infected after migration to endemic
regions)
LOA LOA Loasis (same as onchocerciasis)
 often asymptomatic
 Episodic angioedema and sunconjunctival migration of an adult worm can occur
 Non painful migration through tissues
 Conjunctival edema; patches of localized subcutaneous edema (Calabar swellings)
 Eosinophilia
MANSONELLI  Asymptomatic
OZZARDI
 Inguinal adenopathy has been reported
 Skin lesions, arthritis, fever, marked eosinophilia
 Pulmonary symptoms, adenopathy, hepatomegaly, and pruritus
MANSONELLA  Often asymptomatic, can be associated with angioedema, pruritus, fever, headaches, arthralgias, and neurologic manifestations
PERSTANS
 Edema and inflammatory changes and granulomas form around dead filariae
 Eosinophilia
ONCHOCERCIASIS Onchocerc  Most worms become encapsulated -- nodules are produced
iasis
river blindness
 Onchocerciasis can cause pruritus, dermatitis, onchocercomata (subcutaneous nodules), and lymphadenopathies. (skin nodules and progressive keratitis)
 The most serious manifestation consists of ocular lesions that can progress to blindness
 onchocercomas of the forearm skin, also called sowda, in a Sudanese man
LABORATORY DIAGNOSIS OF FILARIASIS a. Centrifugation (Knott’s technique) – uses 2% formaldehyde
A. Identification of adult worms i. Prepare 2% formaldehyde (2 ml of 37% formaldehyde + 98 ml H2O).
ii. Mix 9 ml of this 2% formaldehyde with 1 ml of patient’s venous blood.
• from tissue samples:
o nodulectomies (onchocerciasis) iii. Centrifuge at 500 × g for 10 minutes; discard supernatant. Sediment is composed of
o subcutaneous biopsies WBCs and microfilariae (if present).
o worm removal from the eye (loiasis) iv. Examine as temporary wet mounts.
B. Examination of blood samples to identify microfilariae v. Prepare thick and thin smears; allow to dry; dip in absolute methanol before Giemsa
• Blood sample can be a thick smear, stained with Giemsa or H&E staining to enhance staining of microfilariae.
b. Filtration – uses membrane filter (Millipore® or Nucleopore® membrane filter)
• Finding of microfilariae in the blood as seen in wet or thick blood smears taken
i. Place Millipore® or Nucleopore® membrane filter (5 µm pore) in filter holder with
between 8 pm and 4am (nocturnal periodicity – W. bancrofti)
syringe attachment.
 B. malayi microfilariae – subperiodic periodicity
ii. Mix 1 ml of venous blood (in EDTA) with 10 ml of 10% Teepol® 610 (Shell Co.); allow to
• For increased sensitivity, concentration techniques can be used: stand for several minutes to allow lysis; transfer to a 10 ml Luer-Loc® syringe; attach
1. Knott's technique: Centrifugation of the blood sample lyzed in 2% formalin. Also used for the filter apparatus.
low-intensity infection iii. Force the solution through the 5 µm pore filter, followed by several syringes of water to
2. Filtration through a Nucleopore® membrane. wash out the remaining blood, then 1 or 2 syringes full of air to clear excess fluid.
iv. Prepare a temporary wet mount by removing the filter and placing it on a glass slide,
• Examination of skin snips will identify microfilariae of Onchocerca volvulus and adding a drop of stain or dye and a coverslip.
Mansonella streptocerca. v. For permanent preparations, pass 2 to 3 ml of methanol through the filter while it is still
 Skin snips are obtained using a corneal-scleral punch, or a scalpel and in the holder; remove filter and dry it on a glass slide; then stain it with Giemsa stain,
needle. horizontally (so that the filter does not wash off the slide); coverslip filter before
 Allow sample to incubate for 30 minutes to 2 hours in saline or culture examining.
medium, and then examined for microfilariae that would have migrated from the tissue to
the liquid phase of the specimen Comparison of microfilariae of W. bancrofti and B. malayi
• DEC (diethylcarbamazine) provocative test stimulates microfilariae to come out W. bancrofti B. malayi
to peripheral circulation allowing blood smear collection even during daytime Mean length (µm) 290 222
C. Antibody detection - limited value Cephalic space; 1:1 2:1
• Substantial antigenic cross reactivity exists between filaria and other helminths, and breadth
a positive serologic test does not distinguish between past and current infection. Sheath in Giemsa Unstained Pink
Nuclei Regularly spaced, Irregularly spaced
D. Antigen detection techniques to detect circulating filarial antigens (CFA) separately situated and overlapping
• useful in low and variable infection Tail Single row of nuclei Single row of nuclei
• A rapid-format immunochromatographic test, applicable to Wuchereria bancrofti that does not reach that reaches tail’s
antigens, has been recently evaluated in the field. the tail’s ends end
E. Molecular diagnosis using PCR Terminal nuclei None 2 nuclei which bulge
the cuticle,
• available for W. bancrofti and B. malayi. conspicuously
F. Ultrasonography, contrast lymphagiography and lymphscintigraphy places
• May demonstrate live worms in the lymphatics Appearance in blood Smoothly curved Kinky
• Contrast lymphangiography and lympscintigraphy using radiolabled albumin or film
dextran may demonstrate obstructed lymphatics
G. Special Procedures for Detecting Microfilariae (Blood microfilariae)
1. Capillary (fingerstick) blood Periodicity: Fluctuation in numbers of microfilariae present in the peripheral blood during
a 24 hour period
• Since microfilariae concentrate in the peripheral capillaries, thick and thin smears
prepared from fingerstick blood are recommended. 1. Nocturnally periodic - species found in the blood ruing night-time hours but absent at other
2. Anticoagulated (EDTA) venous blood (1 ml) should be concentrated by one of the times
e.g. W. bancrofti and B. malayi
following methods:
2. Diurnally periodic: present only during certain daytime hours
e.g. Loa loa • Diethylcarbamazine citrate (DEC) – drug of choice for bancroftian filariasis: 6 mkday
3. Nonperiodic or aperiodic: microfilariae that circulate in the blood throughout a 24 hour period orally for 12 days [given in divided doses after meals]
without significant changes in their numbers – Brugian filariasis – 3-6 mg per kg per day up to 36 to 72 mg/body weight
e.g. Mansonia spp
• Ivermectin 200 to 400 ug/kg single oral dose – as effective as 12 days of DEC
4. Subperiodic: microfilariae normally present in the blood at all hours but whose density increases
significantly during either the night or day
Prevention and control
There are two strains of B.malayi;
• Goal for endemic communities: eliminate microfilariae in the blood to prevent transmission of
• the nocturnal periodic strain which is widely distributed in Asia, the microfilariae being in disease by vectors
their highest concentrations between the hours of 10pm and 2am, and • Control of transmission:
• the sub-periodic strain which is found in Malaysia, Indonesia and the Philippines where – Identification of endemic areas
humans exhibit a microfilaraemia all the time with the highest numbers being detected – Implementation of mass treatment programs using albendazole/DEC or
between noon and 8pm DEC/ivermectin combination in areas where onchocercosis or loaiasis is prevalent
• Personal protective measures
Treatment • Vector control: dev’t sprays and polystyrene beads to seal latrines
• Different drugs are recommended for the treatment of filariasis depending on the specific
causal agent.
MORPHOLOGIC FEATURES OF MICROFILARIAE
WUCHERERIA BANCROFTI
 snake-like organisms  Central axis: shows dark staining nuclei; column
 Enclosed in a hyaline sheath which is longer than of nuclei arranged in 2 or 3 rows and is distinctly
the microfilaria itself conspicuous
 Graceful appearance

• Thick blood smears stained with hematoxylin). • Microfilaria of Wuchereria bancrofti collected by
• microfilaria is sheathed, body is gently curved, & tail is filtration with a Nucleopore® membrane.
tapered to a point. • The pores of the membrane are visible
• nuclear column (the cells that constitute the body of the
microfilaria) is loosely packed, the nuclei can be
visualized individually and do not extend to the tip of
the tail
BRUGIA MALAYI
 Enclosed in a sheath and with angular curvatures with secondary kinks and 2 nuclei at the tail tip
 Column of nuclei is in 2 rows which are indistinct or confluent

[Thick blood smear Via Knott’s technique • Tapered tail The tail of Brugia malayi
(hematoxylin stain]: Note the clearly visible • subterminal and a showing the sheath and the
Like W. bancrofti, this sheath that extends beyond terminal nuclei (seen as 2 distinct nuclei at the tip of
species has a sheath the anterior and posterior swellings at the level of the tail
(slightly stained in ends of the microfilaria. the arrows), separated
hematoxylin). There are four sheathed by a gap without
unlikeWuchereria, the species: Wuchereria nuclei.
microfilariae in this species bancrofti, Brugia malayi,
are more tightly coiled, and Brugia timori, and Loa loa.
the nuclear column is more
tightly packed, preventing
the visualization of
individual cells.
Loa loa (right) and Mansonella perstans (left). M.streptocerca
{thick blood smear stained with hematoxylin.}
• Mansonella perstans is • Loa loa is sheathed, with • microfilaria is unsheathed, has a nearly straight body
smaller, has no sheath a relatively dense nuclear attitude
• blunt tail column; • tail is typically coiled into a “shepherd’s crook”
• nuclei extending to the • tail tapers and is • terminal nuclei extend as a single row to the end of
end of the tail frequently coiled the tail.
• nuclei extend to the end
of the tail
Mansonell ozzardi Onchocerca volvulus

(Giemsa stained) • from skin snip from a patient seen in Guatemala


• microfilaria is typically small, unsheathed (Wet preparation)
• slender, tapered tail that Is hooked • No sheath present;
("buttonhook"). • Tail is tapered and is sharply angled at the end
• The nuclei do not extend to the end of the tail.