MEDICAL PARASITOLOGY

PHASMID 3
DR. BARTOLOME / DUENAS
OLFU • FUMC ½ COLLEGE OF MEDICINE
Ref: Medical Parasitology in the Philippines by: Belizario

Nematodes belonging to the superfamily Filarioidea are In some other species of filarial nematodes, the egg
slender thread-like worms (Latin, filum and thread), which membrane is ruptured and are known as unsheathed
are transmitted by the bite of blood-sucking insects microfilariae.
The filarial worms reside in the subcutaneous tissues,
Filaria Parasites: Once the microfilariae are classified on the basis of sheath
Note: Periodicity of Filarial Infection
• lymphatic system, or body cavities of humans
Lymphatic filariasis as ‘sheathed’ or ‘unsheathed’, their further differentiation
• Nocturnal periodicity (night) – Wuchereria bancrofti
(Table 21.1).
§ Wuchereria bancrofti can be done on the characteristic arrangement of nuclei
§ Largest number of microfilariae occurs in blood at
The adult
§ worm
Brugia generally
malayi measures 80–100 mm in (Flowchart 21.1 and Fig. 21.1).
night
length§and 0.25–0.30 mm in breadth; the female worm
Brugia timori Periodicity: Depending on when the largest number of
• Diurnal periodicity (day) – Loa Loa
• being longer than
Subcutaneous the males.
filariasis microfilariae occur in blood, filarial worms can exhibit
The tail§ of the male worm has perianal papillae and
Loa-Loa
§
nocturnal, diurnal periodicity or no Largest
periodicitymicrofilariae occur in blood during day
at all.
unequal • Nonperiodic (day or nightbe– onancall) – Onchocerca volvulus
§ spicules but novolvulus
Onchocerca caudal bursa. The basis of periodicity is unknown but it may
worms are viviparous and give birth to adaptation to the biting habits§ of theMicrofilariae circulate at constant level during day
• The female immitis
Dirofilarial vector.
and night
larvae known as microfilariae.
The microfi lariae released by the female worm, can be • Sub-Periodic or Nocturnally Sub-Periodic (seen in day but more
INTRODCUTION: LYMPHATIC FILARIASIS Nocturnal periodicity: in When the largest
detected late or night – all number
day) of
• One of thein the peripheral
oldest blood or cutaneous
and most debilitating nematodestissues, microfilariae occur in blood at § night,
When Wuchereria
e.g.the microfilariae can be detected in the blood
• depending
“Slender on the species.
thread-like” parasitic worms acquired through a bancrofti throughout the day but are detected in higher
In some bite
mosquito species, the microfilariae retain their egg
Diurnal periodicity: When the largest numbersnumberduring theof late afternoon or at night
• 3membranes which envelop them as sheath. They are
Anatomical Pathology: microfilariae occur in blood during day, e.g. Loa loa
known § as sheathed
Subcutaneous microfi lariae.
– fat under the skin “Loa-Loa” Nonperiodic: When the microfilariae circulate
§ Serous cavity – abdomen “Mansonella” at constant levels during the day and night, e.g.
Table 21.1: Classification of Filarial Worm Based on
Lymphatics – “Wuchereriasis” and “Brugiasis”
§ Onchocerca volvulus
Location in Body
Subperiodic or nocturnally subperiodic: When the
Lymphatic filariasis Subcutaneous Serous cavity microfilariae can be detected in the blood throughout
filariasis filariasis the day but are detected in higher numbers during the
Wuchereria Loa loa Mansonella late afternoon or at night.
bancrofti Onchocerca perstans Note: The microfilariae are found in capillaries and blood
Brugia malayi volvulus Mansonella ozzardi
vessels of lungs during the period when they are not present in
Brugia timori Mansonella (They are virtually
the peripheral blood.
streptocerca nonpathogenic)

• Impairs lymphatic system and can lead to abnormal enlargement

of body parts causing pain, severe disability and social stigma
• Cause of permanent and long-term disability
§ 2nd – Lymphatic Filariasis – affecting lymphatic system
§ 1st – Psychiatric illness – affecting physical and
psychological
WUCHERERIA BANCROFTI
• Widely distributed throughout the tropics and subtropics
• Elephantiasis of – lower extremities
• Intermediate host ® Mansonia ® black or brown with sparkling
wings and legs, have large size as compared to others, these
mosquitoes prefer evening to bite (laying egg in water)

• 2 common causative agents:

§ Wuchereria bancrofti – Bancroftian filariasis 206 Textbook of Medical Parasitology
§ Brugia malayi – Malayan filariasis
• Female worm is being longer than males
• Male adult worm
§ Perianal papillae and unequal spicules but no caudal
bursa
• Female adult worm
§ Viviparous
§ Given birth to a larvae “microfilariae” Fig. 21.2: Geographical distribution of Wuchereria bancrofti Fig. 21.3: Adult worm of Wuchereria bancrofti

Manson (1878) in China identified the Culex mosquito Microfilariae

• Sheathed microfilariae – retain their egg membrane as the vector. This was the first discovery of insect
The microfilaria has a colorless, translucent body with a
transmission of a human disease. Manson (1879) also
• Unsheathed microfilariae – egg membrane is ruptured demonstrated the nocturnal periodicity of microfilariae
blunt head, and pointed tail (Fig. 21.4).
It measures 250–300 µm in length and 6–10 µm in
in peripheral blood. thickness. It can move forwards and backwards within
W. brancofti is distributed widely in the tropics and the sheath which is much longer than the embryo.
subtropics of sub-Saharan Africa, South-East Asia, India, It is covered by a hyaline sheath, within which it can
Note: and the Pacific islands. The largest number of cases of
filariasis occur in India (Fig. 21.2).
actively move forwards and backwards as sheath is
much longer than the embryo.
• Insect vector ® required to complete the life cycle of filarial In India, the endemic areas are mainly along the sea When stained with Leishman or other Romanowsky
Common name
coast and along the banks of the large rivers, though
Bancroft’s filaria
stains, structural details can be made out. Along the
worms infection occurs virtually in all states, except in the central axis of the microfilaria, a column of granules
Infective stage
north-west.
L3 larva
• 3rd stage filiform larvae (L3) ® one gets the disease (infective) Habitat
Habitat Lymphatics(primary) and Blood (less)
• B. malayi and W. bancrofti – indistinguishable The adult worms reside in the lymphatic system of man. The

MOT
microfilariae are found in blood.
Bite from infected mosquito (ACA)
• Infective stage – L3 form larva Morphology
Diagnostic Specimen Giemsa Stained / Knott’s Technique (collected
• Why Lymphatics? Adult Worm
The adults are whitish, translucent, thread-like worms with at night)
§ Less aggressive than medium blood smooth cuticle and tapering ends.

§ No PLT, No Complement System, Incomplete Diagnostic

(25–40 × 0.1 mm).
Stage
The female is larger (70–100 × 0.25 mm) than the male Microfilaria
Coagulation System, No Granulocytes Vector
The posterior end of the female worm is straight, while
that of the male is curved vertically and contains 2
“ACA” ® Aedes, Culex, Anopheles
Intermediate Host
spicules of unequal length.
Males and females remain coiled together usually in the Mansonia
abdominal and inguinal lymphatics and in the testicular
tissues (Fig. 21.3).
The female worm is viviparous and directly liberates
sheathed microfilariae into lymph. 1 of 9
The adult worms live for many years, probably 10–15
years or more. Fig. 21.4: Morphology of Microfilaria bancrofti
 MEDICAL PARASITOLOGY
PHASMIDS 3
Parasitic Biology • Life Cycle: CDC
• Microfilariae [w. bancrofti]
§ Sheathed ® 240-300um “snake-like”
§ Gently curve body, tapered tail to a point
§ Nuclear column ® loose packed (cells that constitute
the body of the microfilaria)
§ Cells can be visualized individually and do not extend to
the tip of the tail
§ Microfilariae ® circulate in the blood
§ Blunt head and Pointed tail
§ Graceful in appearance and
several conspicuous
§ Central axis – serves as
important in identifying feature
§ Column of nuclei – 2 to 3 rows
and distinctly conspicuous

During blood meal: an infected mosquito introduces

third-stage filarial larvae onto the skin of the human host
where they penetrate into the bite wound (1)
¯
They develop in adults that commonly reside in the lymphatics (2)
¯
The female worms (longer) measure 80 to 100 mm in length and 0.24 to 0.30
mm in diameter while the males (shorter) measure about 40mm by 1 mm
¯
Adults produce microfilariae measuring 244 to 296 um by 7.5 to 10 um,
which are sheathed and have nocturnal periodicity, except the South Pacific
microfilariae which have the absence of marked periodicity
¯
The microfilariae migrate into lymph and blood channels moving actively
through lymph and blood (3)
¯
A mosquito ingests the microfilariae during a blood meal (4)
¯
After ingestion, the microfilariae lose their sheaths and some of them work
their way through the wall of the proventriculus and cardiac portion of the
mosquito's midgut and reach the thoracic muscles (5)
¯
• Adult W. bancrofti There the microfilariae develop into first-stage (6) larvae and subsequently
§ Adults of Wuchereria bancrofti are long and threadlike into third-stage infective larvae (7)
§ The males measure up to 40 mm long and females are ¯
80- 100 mm long The third-stage infective larvae migrate through the hemocoel to the
§ Adults are found primarily in lymphatic vessels, less mosquito's proboscis (8) and can infect another human when the mosquito
commonly in blood takes a blood meal (1)
vessels
§ Creamy white long and Note: Life Cycle 📢📢📢
filiform in shape Microfilariae ingested by the mosquito migrate to its muscles
§ Both male and female ¯
tightly coiled n nodular where they developed L1, L2, L3 stage of larva
dilated nest ¯
“lymphangiectasia”- After 6 to 20 days – 3rd stage larvae (infective) developed
lymphatic dilatation in ¯
patent infection force way out of the muscles, causes considerable pain and
§ Male – 20 to 40 mm in migrate towards the mosquitoes head and proboscis
length ¯
§ Female – 80 to 100mm During blood meal, larva emerge from the
§ produces microfilariae – which gain to enter the proboscis (skin) of the susceptible host
peripheral blood circulation, where they are picked up ¯
by the appropriated mosquito vector during a blood Actively penetrated the skin through bite
meal wound to reach the Lymphatic vessels
¯
Where adult worm develop
(lower extremities, inguinal LN, epididymis of males,
Labia of females)
¯
And can migrate to neighboring blood vessels

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PHASMIDS 3
BRUGIA TIMORY Parasitic Biology
• Microfilaria • Adult Brugia
§ Microfilaria of Brugia timori are sheathed and measure § Male – 13 to 23mm length
on average 310 um in stained blood smears and 340um § Female – 43 to 55mm
in 2% formalin • Microfilariae
§ Microfilaria of B. timori differ from B. malayi by a § 111 to 230 um in length
having a longer cephalic space, a sheath that does not § Sheathed
stain with Giemsa, and a larger number of single-file § Angular curvatures with kinks
nuclei towards the tail § 2 nuclei at the tip of the tail
§ Microfilariae circulate in the blood § Indistinct and confluent nuclei – 2 rows
§ Tail is tapered with significant gap between the
terminal and subterminal nuclei

• B. malayi adults in tissue

§ Brugia spp. have typical features of filarial nematodes
in cross-section
§ Females reach a maximum diameter of 180um
§ Males are smaller (up to 90 um)
§ The intestine is small and females have two uterine
tubes containing developing microfilariae
§ The musculature is comprised of few coelomyarian
cells per quadrant and the cuticle is smooth

BRUGIA MALAYI
• Long and Thread-Like Worms
• Caused by: Malayan filariasis
• Can selective induce CD4+ lymphocytes apoptosis, which may
contribute to immune unresponsiveness to filariasis
• Vector: Mansonia
• Habitat: Lymphatics

Common name Malayan filaria

Infective stage L3 larva
Habitat Lymphatic and blood
MOT Bite from infected mosquito (anopheles, Aedes,
Mansonia, Amigeres)
Diagnostic Giemsa Stained (collected at night) or Knott’s
Specimen Technique
• Life cycle:
§ Same pattern that of W. bancrofti
§ Genus – Mansonia

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PHASMIDS 3
• Infective stage § Lymphagiogenesis
§ L3 larvae – 3 to 9 months maturation o Live filarial parasites or filarial antigens
§ Microfilariae are produced and may be seen in the induce lymphatic endothelial cell
circulation proliferation and differentiation leading to
• Diagnostic stage collateralization
§ Adult sheathed microfilariae § Lymphedema and Elephantiasis
o Predispose to secondary bacterial infections
and trigger inflammatory reaction of the skin
and subcutaneous tissue
o Wolbachia – increase the risk for chronic
disease to LF
§ Asymptomatic microfilaremia
o Vigorously motile microfilariae in the
peripheral blood often show NO obvious
clinical signs
§ Acute Dermatolymphagioadenitis (ADLA) or
Adenolymphangitis (ADL)
o Most common acute manifestation of LF,
temephos, with localized pain, lymphadenitis and/or
lymphangitis and/or cellulites and local
d to control
warmth
an filariasis.
e restricted o With or without systemic of fever, nausea
ever, vector and vomiting
ant to DDT, o Associated with Group A Streptococcus
s still being
§ Acute Filarial Lymphangitis (AFL)
d mosquito o Rare, cause by adult worms that died
spontaneously or common observed flowing
Pathogenesis and Clinical Manifestation treatment with diethylcarbamazine (DEC)
(W. bancrofti & B. malayi) o Lymphangitis that progresses distally along
er kg body
or 2 weeks, W. bancrofti B. malayi
the lymphatic vessel, producing a palpable
Causative
Fig. 21.9: Geographical distribution of Brugia malayi
- Bancroft’s filarial worm - Malayan filarial worm “cord” – self-limiting or generally subside
agent - Bancroftian filariasis - Malayan filariasis without treatment
Microfilariae
Morphology - Minute snake-like organisms - Can selectively induce CD4+
The microfilariae of B. constantly moving among
malayi, although the are
sheathed lymphocyte apoptosis, which
red blood
different in a number of respects cellsmicrofilaria brancofti.
from may contribute to immune
who in 1927 Mf. malayi is smaller in size; shows kinks and secondary unresponsiveness to filariasis
e blood of -
curves; its cephalic The
spacecolumn of nucleicarries
is longer; is double
stylets at the anterior arranged
end; the in and appears -
Distinctcolumn
nuclear Indistinct and Confluent – 2
Conspicuous – 2 to 3 rows
blurred in Giemsa-stained films; and the tail tip carries 2 rows
by Rao and
distinct nuclei, one terminal and the other subterminal
mori, which (Fig. 21.10 and -table 21.4)
Microfilariae
. have several
a number of
curvatures and a graceful Note: “Expatriate Syndrome”
appearance
tei infecting
Vector
• Grew up outside endemic region
- Aedes, Culex, and Anopheles - Mosquito vectors of B. malayi
Table 21.4: Distinguishing Features of Mf. bancrofti belong to the genus Mansonia • Together with the usual acute manifestations of lymphadenitis
much more and Mf. malayi
urs in India and lymphangitis, individuals with this syndrome also present
a, Thailand, Features Mf. bancrofti Mf. malayi with allergic reactions such as hives, rashes, blood eosinophilia
Length 250–300 µm 175–230 µm
particularly
Ernakulam,
Appearance Graceful, sweeping
curves
Kinky, with secondary
curves
• Chronic Stage
am, Orissa, Cephalic space Length and breadth Almost twice as long
§ Characterized by fibrosis and cellular hyperplasia in and
malayi and equal as broad around the lymphatic walls – blockage of lymphatic
the same
s, B. malayi
Stylet at Single Double vessels
anterior end
crofti urban § Edema and collagen accumulation
Excretory pore Not prominent` Prominent
o Due to lymphatic endothelial cells less
Nuclear Discrete nuclei Blurred
column effective in transporting intestinal fluid
Tail tip Pointed; free of nuclei 2 distinct nuclei, § Lymphangitis and Lymphadenitis
are at tip, the other
subterminal
o Due to decalcifying adult worm leading to
y similar to lymphatic blockages with localized pain and
Sheath Faintly-stained Well-stained
swelling
• Asymptomatic Stage § Progression of lymphedema lead to elephantiasis
§ Incubation phase or no symptoms until mechanical o Lower limb is commonly affected but upper
damaged caused by highly motile adult worm in limb and male genitalia may be involved
lymphatics channels o Females – breast and genitalia (uncommon)
§ Induced an inflammatory response § Hydrocele or Chylocele
§ Seen those patients who called “endemic normal” who o Obstruction of lymphatic in Tunica vaginalis
harbor the parasite antigen instead of microfilariae in males
• Acute Stage o Clear or straw-colored hydrocele fluid
§ Characterized by infiltration of WBC, intense typically accumulates in the closed sac of
inflammation of lymphatics vessels and lymph nodes testis and rarely fluid may have a milky
and marked eosinophilia appearance “chyluria”
§ Lymphangiectasia o Common in chronic W. bancrofti and B.
o parasite-induced lymphatic dilation malayi
o common feature patent infection through
lymphedema

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PHASMIDS 3
§ Tropical Pulmonary Eosinophilia (TPE) • Detection of Microfilariae
o Classic example of occult filariasis which the § Wet Smear Method – detection of “dancing microfilaria”
o LF – taken between 9pm & 4am due to their nocturnal
typical clinical manifestation is NOT present periodicity
o Microfilaria are NOT found in blood (but in § Thick Blood Film – 20 to 40ul of blood examined
tissue) § Chronic infection – microfilariae may not be demonstrable in the
o Characterized by clinical and immunological peripheral blood due to:
o Low intensity infection
hyper-responsiveness of maturing worms o Dead worms
o Characterized by paroxysmal nocturnal o Obstructed lymphatics
cough, hyper eosinophilia (3000 to 5000 • Blood concentration techniques
cells/mm3), ­ESR, ­bronchovesicular § Knotts concentration technique / nucleopore filter – for low
intensity infection
marking, ­IgE
§ Membrane filtration technique
§ Diethyl Carbamazine Provocative test (DEC) - (3mg/kg single dose)
o Stimulates microfilariae into coming out to the
peripheral circulation, allowing blood smear collection
even during daytime
• Lymph node biopsy
§ Adult filarial worms can be seen in sections of biopsied LN
• Imaging techniques
Ppt: Pathology § Ultrasonography – “dancing” adult worm
§ Lymphangiography – potential risk for lymphatic damage
• Immunologic response, both humoral and cell-mediated
§ Lymphoscintigraphy – visualized lymphatics
• Larval or adult worms cause lymphatic dilation causing • Molecular diagnosis
mechanical damage to lymphatics § ELISA – gold standard
• Dead or dying worms elicit the most severe inflammation § PCR
§ Rapid-format immunochromatographic test
• Calcification of necrotizing granulomas with dead worms lead o ICT filariasis (W. bancrofti)
to lymphatic obstruction o Brugia Rapid test (B. malayi)
• Others:
§ DEC provocative test – (3mg/kg DEC single dose)
Ppt: Clinical Manifestation o Microfilariae stimulates into coming out to the
• Hydrocele and Scrotal Elephantiasis peripheral circulation, allowing blood smear collection
even during daytime
§ Caused: W. bancrofti § Urine – demonstration of microfilaria W. bancrofti
§ Common in Sorsogon, Phil. ...Identification of Microfilariae..
§ 5% of males Wuchereria bancrofti Brugia malayi
§ Swollen scrotal size from the size of a closed fist to 270 to 290 um 177 to 230 um
the size of watermelon Enclosed in hyaline sheath (sheathed) Angular curves and kinks
Grace appearance Long cephalic
• LF and Superimposed Bacterial and Fungal Infection Nuclei – 2 to 3 rows and distinctly 2 columns of confluent nuclei
§ Repeated acute filarial attacks with superimposed conspicuous
and untreated bacterial and fungal infections will WITHOUT terminal nuclei WITH Terminal nuclei
promote development of progressive lymphedema
and elephantiasis

Treatment
(W. bancrofti & B. malayi)
• Goal: kill the adult worm and microfilariae
• Diethylcarbamazine (DEC) - DOC
§ Doc for Lymphatic Filariasis
• Ivermectin – (100 to 200ug/kg up to 1 year)
§ Kills only the microfilariae bit not the adult worm
§ Treatment for onchocerciasis, loiasis and
strongyloidiasis
• Doxycycline – related to antibiotic (200mg OD for 4 to 6 weeks)
§ Anti-wolbachia – which is essential for growth and
development, embryogenesis and survival of the filarial
worms
§ Responsible for the pathology of lymphedema and
hydrocele
• Albendazole
§ Anthelminthic (nematodes, cestodes, flatworm)

Diagnosis Prevention and Control

(W. bancrofti & B. malayi) (W. bancrofti & B. malayi)
• History taking • Management
§ History of exposure – prolonged stay in endemic area § 2x washing on the affected parts with soap and water
§ History of recurrent febrile periods or episodes associated with § Raising the affected limb at night
pain, tenderness and swelling of limb, genitals or breast
§ History of recurrent adenolymphangitis (ADLs)
§ Exercising to promote lymph flow
§ Rule out other possible etiology of extremity, breast or genital § Keeping nails clean
swelling § Using shoes/footwear

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PHASMIDS 3
§ Using antiseptic or antibiotic creams to treat small • Adult worm
wounds or abrasions or in severe systematic antibiotic § Transparent and thin
• Prevention § 30 to 70mm length and 0.3 to 0.5mm thick
§ Development of safe and effective and well-tolerated § Live in subconjunctival tissue for 4 to 17 years
single dose microfilaria regimens
§ Identification of endemic areas (mapping)
§ Implementation of mass treatment programs
§ Personal protective measures – mosquito nets,
insecticide spraying
§ Health education

SUBCUTANEOUS FILARAIASIS

LOAISIS
• Loa loa – “African Eye Worm”
• Fugitive swelling or calabar swelling – because they disappear in
a few days, only to reappear elsewhere

• Life cycle:
§ Infective stage: L3 larvae
§ Completed by 2 hosts:
o Definitive host: man
o Intermediate host/vector: day biting flies
“chrysops” – to complete for 10days
Parasitic Biology
§ They cast off their sheaths, penetrate the stomach wall
and reach thoracic muscles where they develop into
Common name African eye worm
infective larvae (L3)
Infective stage L3 larva
Habitat Subcutaneous tissues, the eye and bridge of nose
MOT Bite from infected Chrysops silacea (blackflies) or C
dimidiate (deer fly)
Diagnostic Giemsa stained (midday 10:15 to 2:15pm) or Knotts
Specimen Technique

• Microfilariae
§ Sheathed with column of nuclei extending completely
to the tip of the tail
§ Appear Diurnal periodicity – 12nn to 2pm

Pathogenicity and Clinical manifestation

• Their wanderings through subcutaneous tissues, which appear as
swellings (calabar and fugitive swelling), of up to 3 cm in size,
usually seen on the extremities
• Disappear in few days, only to reappear elsewhere
• Ocular manifestation – ocular lesions
§ Granulomata in the bulbar conjunctiva
§ Painless edema of the eyelids
§ Proptosis

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PHASMIDS 3
• Others: – Rare
§ Nephropathy
§ Encephalopathy
§ Cardiomyopathy

Diagnosis
• Peripheral blood smear or isolation of the adult worm
§ Collected during the day Diurnal periodicity – 12nn to
2pm
• Eosinophil count
§ Expect – high

Treatment
• DEC with: • Microfilaria
§ Corticosteroid – minimizes reaction § Unsheathed and non-periodic (300 by 0.9 um)
§ Ivermectin and Albendazole – minimizes microfilaria § Found in skin and subcutaneous lymphatics
o Ivermectin – contraindicated with heavy § Also found in conjunctiva and rarely in peripheral
load microfilaria (>5000 microfilaria/mL) Filarial Worms 217 blood
• Surgical removal of the adult worms
Key points of Loa loa
•¾Loa loa is also known as African eye worm and causes
loiasis.
•¾Vectors: Day-biting flies (Chrysops).
•¾Microfilaria are sheathed and nuclei extend upto tail
tip.
•¾Microfilaria appears during the day (diurnal periodic).
•¾Clinical features: Subcutaneous swellings (calabar
swellings), ocular granuloma, edema of eyelid, and
proptosis.
•¾Diagnosis: Demostration of adult worm from skin
and conjunctiva. Demonstration of microfilaria in
peripheral blood during day. High eosinophil count.
•¾Treatment: DEC with simultaneous administration Fig. 21.11: Onchocerca volvulus
of corticosteroid of other drugs which may be used.
Ivermectin or albendazole. ¾¾ The microfilaria are found typically in the skin and
subcutaneous lymphatics in the vicinity of parent
worms.
¾¾ They may also be found in the conjunctiva and rarely in
Onchocerca Volvulus VULVOLUS
ONCHOCERCA peripheral blood.
• Caused by “convoluted
History and Distribution filaria” or “blinding filaria”
Life Cycle
• Producing
Onchocerca“onchocerciases” or “river
volvulus, the ‘convoluted blindness”
filaria’
, or the ‘blind-
Life cycle is completed in 2 hosts.
§ filaria’
ing 2ndproducing
cause ofonchocerciasis
blindness inorthe world
‘river blindness’
Definitive host: Humans are the only definitive host.
• was first described by Leuckart in 1893.
MOT ® transmitted through repeated bites by blackflies of thehosts: Day-biting female black flies of
Intermediate the
¾¾ It affects about 40 million people, mainly in tropical
genus Simulium genus Simulium (black flies).
Africa, but also in Central and South America. A small
The vector Simulium species breed in ‘fast-flowing
focus of infection exists in Yemen and south Arabia.
rivers; and therefore, the disease is most common along
¾¾ Onchocerciasis is the second major cause of blindness
the course of rivers. Hence, the name ‘river blindness’.
in the world.
¾¾ The female black flies are ‘pool feeders’ and suck in
blood and tissue fluids. Microfilariae from the skin
Habitat and lymphatics are ingested and develop within the
The adult worms are seen in nodules in subcutaneous vector, becoming the infective third-stage larvae, which
connective tissue of infected persons. migrate to its mouth parts.
¾¾ The extrinsic incubation period is about 6 days.
Morphology Infection is transmitted when an infected Simulium bites
a person.
Adult worm
Common name Blinding Filaria ¾¾ The prepatent period in man is 3–15 months.
The adult worms are whitish, opalescent, with transverse ¾¾ The adult worm lives in the human host for about 15
Infective stage L3 larva
striations on the cuticle (Fig. 21.11). years and the microfilariae for about 1 year.
Habitat¾¾ The posterior Subcutaneous
end is curved, tossue,
hencenodules
the namean eyes • Life cycle:
MOT¾¾ Onchocerca, which means ‘curved tail’.
Bite from infected simulium black Pathogenicity and Clinical Features
fly
The male worm measures about 30 mm in length and § Definitive host – human
Pathogenesis depends on the host’s allergic and infla-
Diagnostis Specimen
0.15 mm in Giemsa stained
thickness and smear
the female of skin50snips
measures cm
mmatory reactions to the adult worm and microfilariae.§ Intermediate host – day biting female black flies –
by 0.4 mm.
¾¾ The infective larvae deposited in the skin by the bite Simulium
of the vector develop at the site to adult worms. Adult
Microfilaria o Breen in fast-flowing rivers – hence, named
worms are seen singly, in pairs, or in tangled masses
The microfilariae areParasitic
unsheathed Biology
and non-periodic. in subcutaneous tissues. They may occur in the “river blindness”
• Habitat
¾¾ They measure about 300 by 0.8 µm. •
subcutaneous nodules or free in the tissues. Prepatent period – 3 to 15 mons
§ Adult worms are seen in nodules in subcutaneous • Infective stage – L3
connective tissues of infected person • Diagnostic stage – adult unsheathed microfilaria
• Transmission
§ Through the bite of blackflies ® genus Simulium
• Adult worm
§ Whitist, opalescent with transverse striations on the
cuticle
§ Posterior end – curved tail
§ Male – 30mm length and 0.15mm thickness
§ Female – 50cm by 0.4mm

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 believed to have prevented blindness in millions of children.
superficial, such as the scalp, scapulae, ribs, elbows, iliac
crest, sacrum, and knees. The nodules are painless and Treatment
cause no trouble except for their unsightly appearance
¾ Chemotherapy with Ivermectin is the main stay of
¾¾ Microfilariae cause lesions in the skin and eyes.
€ The skin lesion is a dermatitis with pruritus, MEDICAL PARASITOLOGY
treatment. Ivermectin is given orally in a single dose
of 150 µg/kg either yearly or semiannually. In areas of
pigmentation, atrophy, and fibrosis. In an immuno-
logically hyperactive form of onchodermatitis
Africa coendemic for O. volvulus and Loa loa, however, PHASMIDS 3
ivermectin is contraindicated because of severe post
called as Sowdah, the affected skin darkens as a
treatment encephalopathy seen in patients.
¾ DEC and suramin Treatment
result of intense inflammation, which occurs as
have also been used. DEC destroys
result of clearing of microfilariae from blood
Ocular manifestations range from • photophobia
Chemotherapy withbutivermectin
microfilariae, – an
usually causes main stray
intense of treatment
reaction
€
(Mazzotti reaction) consisting of pruritus, rash, lympha-
•
to gradual blurring of vision, progressing DEC
to totaland Suramin
denopathy, –fever,
destroy microfilariae
hypotension, and occasionally, eye
blindness. Lesions may develop in all parts of the eye. damage.
The most common early finding is conjunctivitis with § ¾ A Causes mazzotti reaction – pruritus, rash, fever,
6 week course of doxycycline is macrofilariastatic,
photophobia. Other ocular lesions include punctate
204 Textbook of Medical
lymphadenopathy,
rendering
Parasitology
the female worm hypotension
sterile as it targetsandthe eye damage
or sclerozing keratitis, iridocyclitis, secondary glau- wolbachia endosymbiont of filarial parasites.
•
coma, choroidoretinitis, and optic atrophy. Doxycycline – target wolbachia endosymbiont
¾ Surgical excision is recommended when nodules are
• Surgical excision
located on–the recommended whenofnodule
head due to the proximity the worm is located on the
Laboratory Diagnosis to the eyes.
head dye to proximity of the worm to the eyes
Microscopy Key points of Onchocerca volvulus
The microfilariae may be demonstrated by examination of
•¾O. volvulus, produces onchocerciasis or ‘river blindness’.
skin snip from the area of maximal microfilarial density
•¾The adult worm is white with transverse striation on
such as iliac crest or trapezius region, which is placed on
a slide in water or saline. The specimen is best collected the cuticle. The posterior end is curved.
•¾Microfilaria
is unsheathed, tail-tip free of nuclei, and
around midday. This method is specific and most accurate.
¾ Microfilariae may also be shown in aspirated material
nonperiodic.
•¾Definitive host: Humans.
from subcutaneous nodules.
•¾Intermediate host: Female black flies (Simulium).
¾ In patients with ocular manifestations, microfilariae may
•¾Clinical features: Subcutaneous nodule formation
be found in conjunctival biopsies.
¾ Adult worms can be detected in the biopsy material of
(onchocercoma). Ocular manifestations – sclerosing
the subcutaneous nodule. keratitis, secondary glaucoma, optic atrophy,
chorioretinitis. It is the second major cause of blindness
Serology in world.
•¾Diagnosis: Demostration of microfilaria from skin
Serological tests are useful for the diagnosis of cases in snips and aspirated material form subcutaneous
which microfilariae are not demonstrated in the skin. nodules. Demonstration of IgG4 antibody and PCR.
¾ ELISA is more sensitive than skin snip tests. The test •¾Treatment: Ivermectin is the drug of choice except in
Flowchart
detectes antibodies against specific onchocercal 21.1: Differentiating features of various microfilariae on the basis of presence of nuclei in tail end
antigen. areas coendemic for O. volvulus and L. loa.
¾ A rapid card test using antigen OV16 to detect IgG4 in
serum has been evaluated.

Molecular Diagnosis Mansonella Streptocerca

Pathogenesis and Clinical Features PCR from skin snips is done in specialized laboratories and is Also known as Acanthocheilonema, Dipetalonema, or Tetra-
highly sensitive and specific. petalonema streptocerca, this worm is seen only in West Africa.
• Leopard Skin

• Subcutaneous tissues
§ Vector developed in the skin, seen singly on pairs or in
tangled masses
§ Onchocercoma – firm non-tender as result or
fibroblastic reaction around worms
Fig. 21.1: Head and tail ends of microfilariae found in humans
• Skin and eyes
§ Onchodermatitis “sowdah” – pruritus, pigmentation.
Immunologically hyperactive form
§ Photophobia to gradual blurring of vision to total
blindness
§ Conjunctivitis with photophobia – early symptoms

Diagnosis Table 21.3: Difference Between Classical and Occult animals, filarial infection
• Skin snip Filariasis Elephantiasis is a feature
apparently caused by
§ Microfilariae is demonstrated in the area of iliac crest Classical filariasis Occult filariasis
consequent hydrodynami
or trapezius region Cause Due to adult and Hypersensitivity to Clinical manifestations: T
developing worms microfilarial antigen
§ Collected around midday tations of lymphatic filariasis a
Basic lesion Lymphangitis, Eosinophilic granuloma microfilaremia, acute aden
• ELISA lymphadenitis formation lymphatic disease.
§ More sensitive than skin snip test Organs involved Lymphatic vessels Lymphatic system, lung, ¾¾ Most of the patients ap
• PCR and lymph node liver, spleen, joints but virtually all of the
§ Highly Microfilaria Present in blood Present in tissues but not including microscopic
in blood dilated lymphatics (visual
sensitive and Serological test Complement Complement fixation test with W.  bancrofti infecti
specific fixation test not so highly sensitive (detected by ultrasound).
sensitive ¾¾ ADL (acute adenolymph
Therapeutic No response Prompt response to DEC high fever, lymphatic infl
response lymphadenitis), and trans
€ Fever is of high grade
Pathogenesis with rigors and last for
€ Lymphangitis is infl
Infection caused by W. bancrofti is termed as wuchereriasis as red streaks unde
or bancroftian filariasis. of the testes and sp
The disease can present as (Table 21.3): involved, with epidid
¾¾ Classical filariasis Acute8 oflymphangitis
9 is
¾¾ Occult filariasis. inflammatory reaction
often be associated wi
Classical Filariasis € Lymphadenitis: Infla
 MEDICAL PARASITOLOGY
PHASMIDS 3
DIROFILARIA IMMITIS
• "Dog heartworm” – zoonotic infection
• Dirofilariasis/Human Pulmonary Dirofilariasis
• Common parasite of dogs and cayotes
• Found in: Tropical, Subtropical and warm temperature regions
• Intermediate host: “ACE” and Mansonia
• Infective stage: L3 larvae

• Human infection
§ Larvae migrate to lungs, usually within small caliber
vessels – cause infarcts and “coin lesion” on x-ray
§ Persistent cough chest pain, hemoptysis with
Eosinophilis
• Treatment
§ Removal of nodules of needed – no need to give anti-
helminthic medication after removal
§ Ivermectin and DEC to prevent further invasive surgery
o If 2nd lesion present deep in body sites (e.g.
chest or abdomen)
§ Tetracyclines
o Target Wolbachia – kills adult worms

END

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