Lesson 7: Filarial Worms MOT: Skin penetration through a vector

Habitat: Lymphatic vessels (lymph nodes)

Eight known species of filarial nematodes: Vector: Aedes spp., Culex spp. and Anopheles spp. (W.
bancrofti)
Serous cavity filariasis
Mansonia spp. eg. M. bonnae and M. uniformis (B.
• Mansonella
malayi)
Subcutaneous filariasis (fat under the skin):
Infective stages: L3 larva or filariform larva (man)
• Loa loa
microfilariae (mosquito)
• Mansonella streptocerca
• Onchocerca volvulus Diagnostic stage: microfilariae

Lymphtatic filariasis Definite host: man

• Wuchereria bancrofti NOTE:

• Brugia malayi
- With adult worms become lodge in the lymphatic
• Brugia timori
system, these worms causes lymphedema,
lymphangitis and elephantiasis in chronic cases.

 FILARIAL WORMS Parameter Wuchereria Brugia malayi

bancrofti
Common name Bancroft’s Malayan filarial
filarial worm worm
1. Sheathed microfilaria – retains embryotic sheath
Vector Anopheles, Mansonial spp.
 Wuchereria bancrofti Aedes, Culex
 Brugia malayi spp.
 Loa loa Area affected Lower Upper
lymphatics lymphatics
2. Unsheathed microfilaria – does not retain Periodicity Nocturnal Subperiodic
embryotic sheath (8pm-2am)
 Onchocerca volvulus
 Mansonella perstans - Periodicity: rhythmical appearance of the
 Mansonella ozzardi microfilaria in the PBS

3. Dracunculus medinensis – unique nematode

Bancroftian filariasis
Vector Biology :
Lymphatic Filarial Parasites
Anopheles flavirostris
 Wuchereria bancrofti
 Brugia malayi Aedes poecillus

• Aquatic habitat: axils of abaca and banana plant

(sheathed)
• Adult biting: day and night biting, indoor and
• One of the “most debilitating disease” in tropical outdoor
countries • Adult resting: base of abaca plants (cool, shady
• Filariasis – parasitic infection caused by microscopic area)
threadlike worms acquired through a mosquito bite
(vector borne)
• Has its social and economic impact
 PATHOLOGY

Lymphatic Filariasis

PATHOLOGY

L3 larvae (enter the skin)  Adults in lower lymphatics

 sheathed microfilariae (migrate into lymphatic and
peripheral blood circulation  ingests microfilariae 
shed sheaths  L1 larvae  L3 larvae  Migration to
mosquito head and proboscis
Immune Response
(cell-mediated and humoral)
NOTE: Adult or Larval worm
- Adult worms are usually localized at in the lymph Causes lymphatic dilation
vessels of the lower extremities, inguinal lymph
nodes, epididymis of males and labia of females. 

Causing mechanical damage to the lymphatics



Dead worms

Elicit the most severe inflammation



Calcification of necrotizing granulomas


LYMPHATIC OBSTRUCTION

L3 larvae (enter the skin)  Adults in upper lymphatics
 sheathed microfilariae (migrate into lymphatic and
peripheral blood circulation  ingests microfilariae 
shed sheaths  L1 larvae  L3 larvae  Migration to
mosquito head and proboscis
NOTE:
- Lymph is less aggressive than blood: no platelets,
no complement system, incomplete coagulation
system, no granulocytes and the flow is much less
violent.
PATHOLOGY
Lymphatic Filariasis
A. Acute Filarial Disease
• Adenolymphagitis (ADL) or
Dermatolymphangioadenitis (DLA)
• Pain, tenderness & swelling of affected areas, with
or without fever
• Epididymo-orchitis in males may occur
B. Chronic Filarial Disease – more commonly
encountered than its acute form
• Lymphedema: fibrosis and cellular hyperplasia in
and around the lymphatic walls postulated to
render lymphatic endothelial cells less effective in
transporting interstitial fluid, abnormal
accumulation of lymph in tissues causing swelling of
legs, arms, breast, and genitals
• Lymphangitis and lymphadenitis with localized pain
and swelling
- Lymphangitis is defined as an inflammation of the
lymphatic channels that occurs as a result of
infection at a site distal to the channel
- Lymphadenitis is the inflammation of the lymph
node
• Elephantiasis: lower limbs are commonly affected
but upper limb and male genitalia may be involved,
breast and genitalia of females may be affected but
relatively uncommon. Disabling and disfiguring
lymphedema of limbs, breasts, and genitals
accompanied by marked thickening of the skin
• Hydrocele: results in the obstruction of the
lymphatics on tunica vaginalis. Clear or straw
colored hydrocele fluid typically accumulates in the
closed sac of the testis.
 Common chronic disease manifestation of
Bancroftian filariasis (W. bancrofti prefer
localization in scrotal lymphatics).
• Chylocele: milky appearance caused by the
presence of lymph
• Chyluria: kidney damage – “milky urine” due to
reflux of intestinal lymph to the renal lymphatics 
(proteinuria and hematuria)
PATHOLOGY
“Expatriate Syndrome”
- occurs to migrants who got infected from
endemic regions
- Characterized by clinical and immunologic
hyper-responsiveness to maturing worms
- Acute manifestations + allergic reactions
(hives, rashes and blood eosinophilia)
“Tropical Pulmonary Eosinophilia” (TPE)
- Classic example of occult filariasis, microfilaria
are not found in the blood but may be found in
tissues
“Weingartner’s syndrome”
- Marked increase of IgE and IgG antiparasitic Ab
as well as hypereosinophilia
- Nocturnal coughing, breathlessness, wheezing
Staging System for Chronic Lymphedema (Dreyer
et. al 2002):
• Stage 1: swelling increases during day but reversible
once the patient lies flat in bed
• Stage 2: irreversible swelling
• Stage 3: presence of shallow skinfolds
• Stage 4: knobs, lumps and protrusions
• Stage 5: deep skin folds
• Stage 6: mossy lesions with leaking of translucent
fluid
• Stage 7: foul-smelling infected area, patient is
unable to adequately or independently perform
activities of daily living
DIAGNOSIS
1. Microscopy
A. “wet smears” – demonstrate motile
microfilariae
B. “thick blood smears”
 Giemsa stain
 demonstration of the microfilaria (most
practical diagnostic procedure)
Differences in microfilariae
Parameter Wuchereria Brugia malayi Pathology:
bancrofti
Mean length 290 222 Loaisis, Fugitive swellings or Calabar swellings
(μm)
*causes localized subcutaneous edema as the
Cephalic space/ 1:1 1:1
microfilaria die in the capillaries around the eye.
breadth
Sheath affinity Unstained Pink
to
Giemsa
Body nuclei regularly irregular and
spaced overlapping
Terminal nuclei none 2 nuclei
Appearance in smoothly or kinky
blood gracely curve
film

2. Knotts Concentration Method – for low intensity

infection
- employs Filtration method (Swinney
filter)
- use of nucleopore filter
*Vector = Fly (genus Chrysops)
3. Diethylcarbamazine citrate provocative test (3 mg
per kg DEC single dose) L3 larvae (enter the skin)  Adults in subcutaneous
- stimulates microfilariae to come out to tissues  sheathed microfilariae (migrate into
peripheral circulation lymphatic and peripheral blood circulation  ingests
microfilariae  shed sheaths  L1 larvae  L3 larvae
4. RDT/Immunochromatography (ICT) – detects  Migration to mosquito head and proboscis
circulating filarial antigens (CFA)

5. Molecular methods – xenomonitoring of parasites

in a pool of mosquitoes and PCR
UNSHEATHED MICROFILARIA
6. Ultrasonography – may demonstrate the live
worms in the lymphatics • Onchocerca volvulus -eyes
- “Blinding worm”, “Gale filarienne”,
“Craw craw”
- causes Onchocerciasis, River blindness,
 Loa loa- eyes Roble’s disease
Parameter Loa loa - destroys optic nerve
Common African eye worm
name • Mansonella perstans
Vector Chrysops spp. – - old name: Acathocheilonema perstans
deerflies - rare parasite of man
(aka mango flies or
mangrove flies)
Area Subcutaneous
• Mansonella ozzardi
affected tissue - rare parasite of man
Periodicity Diurnal
 Parameter O. volvulus M. M. ozzardi  Dracunculus medinensis
perstans
Vector Black flies Small flies Small flies - Not a filarial worm
Simulium (gnats) (gnats)
- “Guinea worm”, “Worm of Medina”,
damnosum Culicoides Culicoides
“Dragon worm” or “Fiery serpent”
austeni furens
- Longest nematode to man (1 meter)
Habitat Subcutaneous Body Body - Causes “dracunculiasis” or “Guinea
tissues cavities cavities worm disease” (GWD)
Pathology Onchocerciasis, Non- Non- - Mature female worms migrate along the
River pathogenic pathogenic subcutaneous tissue to reach the skin
blindedness below the knee, forming a painful
ulcerating blister
Specimen Skin - Can also emerge to the head, torso,
shadings/nips upper extremities, buttocks and genitalia
- No symptoms for one year
- Common symptoms: rashes, fever,
• I.S. to man : 3rd stage larva (L3)
nausea, vomiting, diarrhea, dizziness
• I.S. to vector : microfilaria
- Until there is formation of blister and
• Covering : unsheathed
causes a burning sensation
• Periodicity : non-periodic
- Complications: cellulitis, abscess, sepsis,
TREATMENT lock jaw (tetanus)

1. Diethylcarbamazine citrate (DEC) – drug choice for

lymphatic filariasis, Bancroftian filariasis and
Tropical Pulmonary Eosinophilia
2. Ivermectin – found to be as effective as 12 days of
DEC in clearing microfilaremia
3. Surgery is the recommended treatment for
hydrocele

PREVENTION AND CONTROL

WHO targeted lymphatic filariasis to be eliminated by
2020

• Development of microfilaricidal regimens

(Moxidectin)
• Goal for endemic areas: Eliminate presence of
microfilariae in blood LIFE CYCLE
1. Personal protective measures (use of mosquito Ingestion of L3 larvae (water)  Larvae released =
nets) Copepodes die  Larvae penetrate the host’s stomach
2. Residual spraying and intestinal wall (Mature and reproduce)  Fertilized
3. Health education female worm migrated to surface of skin, causes a
blister, and discharge of larvae  L1 larvae released to
water  comsumed by a Copepod L3 larvae

- Copepods are a group of small

crustaceans found in the sea and nearly
every freshwater habitat.
TREATMENT AND MANAGEMENT
1. Immersion of affected body part to water
2. Wound is cleaned
3. Worm extraction
4. Topical antibiotics are given to prevent infection
5. Aspirin and Ibuprofen are given to ease the pain

PREVENTION AND CONTROL

1. Surveillance and case containment

2. Provision for safe drinking water
3. Vector control – use of a chemical larvicide
(Abate™)
4. Health Education

Rod of Asclepius (the symbol which represents

medical practice since ancient times)