I I

t'

I
I'
0[ I I

Symptomatology, pathology, diagnosis

I

Edited by A.A. Buck

l
!

@ World Health Organization Geneva

 The ll/orld Heolth Organization ( ,yHO ) is one of the specialized agencies in realtion-
ship with the United Nations. Through this organization, which came into beine in 7948,
the public health and medical professions of more than 130 countries exchange their know-
ledge and experience and collaborate in an effort to achieve the highest possible level of
health throughout the world. ll/HO is concerned primarily with problems that individual
countries or territories cannot solve with their own resources-for example, the eradication
or control of malaria, schistosomiasis, smallpox, and other communicable diseases, as well
as some cardiovascular diseases and cancer. Progress towards better health throughout
the world also demands international cooperation in many other activities: for example,
setting up international standards for biological substances, for pesticides andfor pesticide
spraying equipment ; compiling aninternationalpharmacopoeia ; drawing up and administer-
ing the International Heolth Regulations; revising the international lists of diseases and
causes of death ; assembling and disseminating epidemiological information ; recommending
nonproprietary names for drugs; and promoting the exchange of scientific knowledge. In
many parts ofthe world there is need for improvement in maternal and child health, nutrition,
nursing, mental health, dental health, social and occupational health, environmental health,
public health administrotion, professional education and training, and health education of
the public. Thus a large share oJ'the Organization's resources is devotedtogivingassistance
and advice in these fields and to making available-often through publications-the latest
information on these subjects. Since 1958 an extensive international programme of colla-
borative research and research coordination has added substanlially to knowledge in many
fields of medicine and public health. This programme is constantly developing and its many
facets are reflected in I|/HO publications.
 rsBN 92 4 156041 X

@ World Health Organization 1974

Publications of the World Health Organization enjoy copyright protection in

accordance with the provisions of Protocol 2 of the Universal Copyright Convention.
For rights of reproduction or translation of WHO publications in toto, application should
be made to the Office of Publicatrons and Tranlction, World health Organization,
Geneva, Switzerland. The World Health Organization welcomes such applications.
The designations employed and the presentation of the material in this publication
do not imply the expression of any opinion whatsoever on the part of the Director-
General of the World Health Organization concerning the legal status of any country or
territory or of its authorities, or concerning the delimitation of its frontiers.
Authors alone are responsible for the views expressed in this publication.
The mention of specific companies or of certain manufacturers' products does not
imply that they are endorsed or recommended by the World Health Organization in
preference to others of a similar nature that are not mentioned. Errors and omissions
excepted, the names of proprietary products are distinguished by initial caprtal letters.

PRINTED IN S'WITZERLAND
ONCHOCERCIASIS
Symptomatology, pathology, diagnosis

Edited by

A. A. BUCK
Division of Malaria and Other Parasitic Disease.",
World Health Organization, Geneva, Switzerland

WORLD HEALTH ORGANIZATION

GENEVA
1974
ONCHOCERCTASIS
 CONTENTS
Page

Preface . 7

Introduction 8

Clinical and pathological aspects, excluding ocular oncho-

cerciasis 9
Onchocercomata 9
Onchocercal dermatitis . l0
Lymphatic involvement t4
Systemic onchocerciasis 14
Loss of weight. r5

Diagnosis. l7
Microfilariae in the skin t7
Onchocercomata 20
The Mazzotti test 20
Microfilaruria . 2t
Ocular onchocerciasis and its diagnosis . 23
General comments . 23
Microfilariae in the eye . 24
Keratitis 25
Iridocyclitis . 27
Cataract 28
Choroidoretinal lesions . 28
Postneuritic optic atrophy. 29
Histopathology 29

Annex l. Onchocerciasis survey forms 3r

Annex 2. The measurement of visual acuity 35

Annex 3. Recommended diagnostic facilities for use in field

studies . .37
Acknowledgements .38
References .39
Figures l-85 43-80

5
 CONTRIBUTORS

J. ANoEnsoN, Ophthalmologist, British Medical Research Council,

Helminthiasis Research Unit, Kumba, Cameroon
A. A. Bucx, Division of Malaria and Other Parasitic Diseases, World
Health Organization, Geneva, Switzerland
F. H. BuoopN, Ophthalmologist, South Warwickshire Hospital Group,
Birmingham Regional Hospital Board, Stratford-upon-Avon, War-
wickshire, England
D. H. CoNNon, Chief, Ceographic Pathology Division, Armed Forces
Institute of Pathology, Washington, D.C., USA
H. FuclsnNc, Epidemiologist, British Medical Research Council,
Helminthiasis Research Unit, Kumba, Cameroon
J. J. Prcq, M6decin-chef, Section Parasitologie, Centre Muraz, Organisa-
tion de Coordination et de Coop6ration pour la Lutte contre les
Grandes End6mies (OCCGE), Bobo-Dioulasso, Upper Volta
A. RoruNo, Ministry ol Health, Ouagadougou, Upper Y olla; formerly:
Directeur-adjoint, Institut d'Ophtalmologie tropicale de l'Afrique
occidentale, Bamako, Mali
B. B. W.roov, WHO Consultant, Division of Malaria and Other Parasitic
Diseases, WHO, Geneva, Switzerland

6
 PREFACE

Great interest is at present being shown in onchocerciasis, a serious parositic

diseasetltat is now' recognized a.e one of tlrc most important public health
problems in Af ica and a local problem in some other parts of tlrc w'orld.
A major drive to control the disease in seven West Af ican countries is just
beginning. WHO is the execuling ogetrcy for an internationalll' assistecl
programme to eliminate oncltocerciasis ft'ont the Volta River basin and to
reslore the econonic potential of this vast region covering approximatell'
700000 km2. In other countrie.s preparations are being made to carr)'oul
surve.t's to a,tse.\.t tlrc onclrccet'ciasis sittetion or to collect infonnation for
planning control operatiorts.
To prot'ide aJirm basisfor all tlte clinical and epidemiological inrestigalion.r
tlrut v,ill be ntade in the course of llte control programme in the Volta Rit'er
area and elsev'here, a nteeting v'as convened in Geneva fi"om l8 to 29 June
1973 to discus.s tlte s1'mptomatology, cliagnosis, and pathologl' of tlrc disease,
u'ith special reference to the stanclardization of diagnostic methods and tlrc
classiJication oftl'pical and atypical ntanifestations ofonchocerciasis. A relised
yer.sion of the draft report v'qs subsequently prepared and editedfor publication.
This hondbook i.s therefot'e the outcome of much preparator.t' u,ork by an
international group of experl.s.
Since the last report on onchocerciasis by a WHO Expert Committee was
published o't'er 8 reors ago, the opporlunit)'has been taken to include in the
handbook o great deal that is new about the patltology of the disease. Althouglt
emphasi.s has been placed on tlrc endentic Af ican form of the disease, it should
be of considerable interesl to heqlth personnel v'orking in other onchocerciasis
infected areas ancl to medical parasitologists generally.
The preparation of tltis handbook v,as nrude possible tltough lhe contri-
bution of the United Nations Development Programme towords tlrc finan-
cing qf the epideniology and chemotherap.r'components of the Onchocerciasis
Control Progronrme in the Volta Riyer basin area.

7
 INTRODUCTION

Recommendations for classifying the clinical manifestations of oncho-

cerciasis and determining the prevalence and intensity of infection with
Onchocerca voltulus in clinical and epidemiological studies were made in
1965 by a WHO Expert Committee on Onchocerciasis (l). The present
state of knowledge about this parasitic disease is reviewed here and some
of the problems that have arisen in recent studies are summarized.
In the classical form of the disease the adult filarial worms are located
in the subcutaneous tissue, where they are either free or encapsulated in
nodules, the onchocercomata. Typically, the filarial larvae (microfilariae)
are confined to the subcutaneous tissue and the eye but a number of studies
have shown the presence of microfilariae in many other body tissues.
In its most severe clinical form onchocerciasis combines various types
of skin lesion with ocular manifestations that may involve both the anterior
and posterior segments of the eye and may lead to blindness. However,
there are also completely asymptomatic infections as well as intermediate
clinical manifestations ranging from benign to severe forms of the disease.
Only the microfilariae, and not the adult worms, appear to be responsible
for the cutaneous and ocular lesions of onchocerciasis.
It must also be realized that the clinical features of onchocerciasis may
vary according to the different bioclimatic zones and even between different
foci in the area, and that within any one focus the severity of individual
cases of the disease is Iargely dependent on the duration and intensity of
the infection. This intensity can be assessed by quantitative techniques.

8
 CLINICAL AND PATHOLOGTCAL ASPECTS,
EXCLUDING OCULAR ONCHOCERCIASIS

Onchocercomata

Adult worms are generally found in subcutaneous nodules, but they can
also lie free in the subcutis (2, 3), and nodules may be so deeply situated
as to be impalpable (4). A nongravid female has even been seen in the
aortic wall of an African patient (Fig. I ). Because of the paucity of autopsy
studies it is impossible to say what proportion of adult worms lies hidden.
Among Africans over 20 years of age who are found to have O. t'olvulu.s
microfilariae in a skin snip, 60 \ or more have palpable nodules. In the
10-19 years age group 3V60% of individuals have nodules, while in the
5-10 years age group nodules are found in less than 30 [. Nodules can be
found in children as young as 2 years of age.
With experience, a typical onchocercoma is easy to recognize. lt is a
firm, round or elongated, nontender, well defined subcutaneous tumour.
The size may vary from a nodule 0.5 cm in diameter to a mass measuring
l0 cm or more across. Nodules are usually freely mobile but may be fixed
to the periosteum, deep fascia, or skin. Although isolated nodules are
found, nodules are often closely applied to each other in big masses and
small satellite nodules, which contribute to the lobulated feel of the tumour,
may also be present. The removal of these lobulated masses usually reveals
many more nodules than had been palpated, and there is also little doubt
that many small isolated nodules, particularly in the scalp, remain undetected.
Usually, onchocercomata can easily be distinguished from lipomata,
sebaceous cysts, and ganglia. However, lymph nodes in children, as well
as juxta-articular nodes in late yaws, can cause difficulties in differential
diagnosis. Certainty in diagnosis can only be achieved when the worm
within the tumour is identified.
In hyperendemic villages the average number of palpable nodules in
males over 40 years of age is about 10, but more than 100 have been reported
in some individuals (5). In Africa the nodules are commonly distributed
around the pelvis, particularly over the iliac crest, femoral trochanter,
coccyx, and sacrum (Fig. 2). Another common site is the lateral chest wall.
A small proportion of nodules occur around the knee or on the lower leg,
ankle, or foot. Less than 2l of onchocerciasis patients, mainly children,
have nodules on the head and neck, and nodules are also rare on the arm.
In Central America, by contrast, over 50 /, of the nodules are found on
the head, about 5 /, on the arm, I 5 /, on the chest wall, and oriy 25 /,
around or below the pelvic girdle (6). In patients studied in the Yemen
focus nodules were present on the lower part of the body and were relatively
uncommon (7).

9
 Nodules on the lateral chest wall may appear as soft tissue swellings in
X-ray pictures and this may furnish a lead to unrecognized foci of oncho-
cerciasis (8). Adult worms are known to remain viable in the human body
for 16 years (9, l0).
Microscopically, the nodule has an outer shell of hyalinized scar tissue
enclosing the adult worms. In some nodules, scar tissue permeates the
entire nodule, confining the worms to narrow tunnels and thus immobilizing
them (Fig. 3). ln other nodules portions of the worms lie free in a "soft"
centre (Fig. 4) composed of variable components including granulation
tissue, fibrin, immune complexes, polymorphonuclear neutrophils, lipo-
phages, eosinophils, giant cells, lymphocytes, plasma cells, and Russell
bodies (Fig. 5). Any combination of these components may be present.
Each nodule may contain one or more female worms, nongravid or gravid,
intact or degenerating. Male worms may or may not be present. A thin
layer of eosinophilic material with the histochemical characteristics of an
rmmune complex may form around degenerating adult worms (Fig. 6).
Microfilariae, sometimes in great numbers, are present in the centres and
walls of the nodules. These microfilariae may degenerate and provoke
focal granulomata (Fig. 7). It has been reported from Guatemala (ll)
that the adult worms may discharge microfilariae through channels in the
nodule wall, but in serially cut African nodules the anterior ends and vulvae
of the worms were located within the nodule centre (12) (Fig. 8).

Onchocercal dermatitis

General commenls
The following outline, in which clinical and histopathological features
are correlated, is presented as a guide to the further study of the variety
of clinical and pathological changes in onchocercal dermatitis although
many patients develop only a few ofthe changes described and those changes
do not necessarily follow the sequence listed. Of the pathological changes,
fibrosis is probably the most serious. It begins early, persists throughout
the course of infection, and ultimately replaces the specialized dermal
structures (the areolar connective tissue supporting the epidermis, the inter-
lacing strands of collagen and elastica, and the dermal appendages).
The microscopic features that are virtually constant in onchocercal
dermatitis include (a) fibrosis, as recognized by an increase of fibroblasts
between the collagen fibres, of reticulum fibres throughout the dermis and
around the dermal vessels, and the early appearance of scar tissue in the
dermal papillae; (b) acid mucosaccharide, as determined by diffuse and
focal deposits of alcian-blue-staining material between collagen strands and
in proliferating stellate mesenchymal cells; and (c) melanin within phagocytic
cells in the upper dermis.
Itching and scratching can be the most important early manifestations
of onchocercal dermatitis. Any part of the body may be involved, and
l0
these may be the only manifestations of the disease in lightly infected
persons. The itching may be mild and intermittent or intense and virtually
continuous, and excoriations may be prominent. On the other hand, itching
is often entirely absent.

Early changes
Altered pigmentation is usually the first objective change. As with
pruritus, any part of the body may be involved, but in Africa it is most
common on the lower trunk, buttocks, thighs, and shins. In very dark
skins, areas of hyperpigmentation may be barely perceptible, even in sun-
light, but sharply focused photographs may reveal such changes if intense
lighting is used and the film is somewhat overexposed (Fig. 9). The hyper-
pigmented areas may be macular-several millimetres to several centimetres
in diameter-or irregular in outline, presenting as varied "geographic"
patterns. Their margins are not raised or infiltrated and they are not
associated with any loss o[ sensation. Rarely, onchocercal dermatitis may
present as one or more hypopigmented macules resembling the macules of
other dermatoses including streptocerciasis, granuloma multiforme, tuber-
culoid leprosy, the treponematoses, and some dermatomycoses.
Biopsy specimens taken in the early stages of onchocercal dermatitis
reveal normal skin or only minimal changes, including a light infiltrate of
inflammatory cells around the dermal vessels and appendages (Fig. l0).
Lymphocytes. histiocytes, plasma cells, and eosinophils are usually present
in varying numbers but polymorphonuclear neutrophils are absent. Changes
in the dermal collagen include slight oedema and increased numbers of
fibroblasts between the collagen fibres. Microfilariae may be difficult to
find. If onchocerciasis is suspected many sections should be cut, stained
by the Giemsa method, and searched carefully for microfilariae (Fig. ll
and I2).
By the time, a pigmentation change is established there is an infiltrate
of inflammatory cells around the vessels and appendages (Fig. l3). In
addition, there is usually acanthosis, slight hyperkeratosis, focal para-
keratosis, and the presence of a few melanophores in the upper dermis.
Fibroblasts are more numerous and they may be large, with a deep baso-
philic cytoplasm and conspicuous pointed processes (Fig. 14). A narrow
band of scar tissue may be present in the dermal papillae just beneath the
basal layer (Fig. l5). The dermal papillae may be slightly broadened and
contain acid mucopolysaccharides. Microfilariae may be few or numerous
and they tend to concentrate in the upper dermis (Fig. l6).

"Craw crqv:' or "gale filarienne"

Papules may develop at any time and on any part of the skin. The
papules may be small and closely spaced or large and more widely separated
(Fig. 17 and 18). Clear fluid or pus may be extruded. Pruritus is usually
severe and leads to scratching, small bleeding points, and sometimes ulcera-

rl
tions with secondary infections-the appearance known in English as "ctaw
craw" and in French as "gale filarienne" (Fig. 19 and 20).
Microscopically, these papules are intra-epithelial abscesses composed
of varying amounts of fluid, polymorphonuclear neutrophils, and fibrin
(Fig. 2l). Serially cut sections usually reveal I or more microfilariae within
the abscess (Fig. 22). A thickened parakeratotic scale or crust forms over
the pustule.

Sowda
Sov'da, the Arabic word for black, is the local name in Yemen for the
most important clinical manifestation of onchocerciasis (13). The affected
area of skin is intensely pruritic, dark, and thickened. There is a papular
eruption (Fig. 23 and 24) and the regional lymph nodes are soft and greatly
enlarged, but not tender. The condition is usually localized and typically
involves one lower extremity only. A more generalized form involving
both legs, or any part of the body, can also be seen. Similar cases have
been observed in Africa, but they are rare. Microfilariae are usually absent
in skin snips, but they can be found in full thickness skin biopsies (Fig. 25).
Hyperkeratosis, parakeratosis, follicular plugging, and acanthosis with
some papillary elongation of the rete ridges, are all prominent features.
Scattered foci of intraepidermal oedema can be seen. The most striking
feature, however, is the extensive inflammatory cell infiltrate composed of
many plasma cells, fewer lymphocytes and eosinophils, and a smaller number
of histiocytes. This infiltrate forms broad cuffs around dermal appendages
and vessels, greatly thickens the dermis, and extends into the subcutaneous
fat. Oedema and fibrosis of the dermis are also prominent features, and
the dermal papillae are sclerotic. ln the upper dermis there is incontinence
of the pigment and the elastic fibres are reduced in number. Specimens
taken through papules with formed craters reveal intraepidermal abscesses
with an overlying thickened keratin scale. The microscopic appearance of
the lymph nodes is dealt with in the section on lymphatic involvement (p. l ).

Oedema

In heavily infected patients the skin may be focally swollen ("peau

d'orange") or may present a more diffuse lymphoedema (Fig.26). Micro-
scopically, the dermis is oedematous and contains many microfilariae, some
of which form clusters within dilated lymphatics (Fie.2l). Many fibroblasts
are present in the ground substance. These changes may be associated with
epidermal atrophy (see Atrophy, p. l3).

Ltcltenoid change
In some patients areas of the skin may be dry and scaling, often with a
mosaic pattern. This appearance has been called "lizard skin" (Fig. 28).
As with the early changes, the distribution is variable and there may be

l2
intense itching leading to scratching. Uneven pigmentation may also be
present.
Microscopically, this change is characterized by a separation of the layers
of keratin (Fig. 29) and of the keratin from the epidermis. Atrophy of the
epidermis is also present and characterized by thinning, especially of the
suprapapillary portion, and a reduction in the number and depth of the rete
ridges. In the upper dermis, there is also scarring and a reduction in the
numbers of elastic fibres (Fig. 30).

Late depigmentatiott or "leopard skin"

A striking feature commonly occurring in long-standing onchocercal

dermatitis is localized spotty depigmentation (Fig. 3l ). This is most common
on the lower limbs, especially the shins, and is also over the penis and
scrotum; more rarely, it occurs in the groin or axilla. The depigmented
areas are white and interrupted by foci of persistent pigmentation around
the pores and hair follicules. The areas may be slightly depressed or atrophic
(Fie. 32).
Microscopically, there is an absence of melanin in the epidermis (basal
layer, prickle cell layer, and keratin). The underlying dermis may show a
variety of mild to severe inflammatory changes, as already described. In
the small number of biopsies studied microfilariae were very few beneath
the depigmented areas and more numerous in the adjacent pigmented areas.

Atrophl

This is a late stage of onchocercal dermatitis. The surface of the skin

has a shiny fragile appearance that has been compared to crushed tissue-
paper. The skin is dry and may be unevenly pigmented. It is inelastic,
recovering slowly from stretching or pinching, and may be wrinkled and
hang in loose redundant folds (Fig. 33).
Microscopically, the keratin is thin and, as with the lichenoid skin,
separates easily from the epidermis (Fig. 29). The epidermis is also very
thin, only 2-3 cells thick in some places, and the rete ridges have vanished,
giving it a smooth or "ironed-out" undersurface. The dermis may be
oedematous and contain acid mucosaccharide, but the most striking change
is replacement of normal dermal structures by scar tissue, which tends to
have a circular arrangement around blood vessels. At this stage, silver
stains reveal abundant reticulum fibres throughout the dermis and also
oriented around blood vessels. These fibres tend to follow the pattern of
dermal collagen fibres (Fig. 34). Hair follicles and sweat glands are reduced
or absent. Microfilariae vary in number from few to many. Elastic fibres
have disappeared from the upper dermis but those in the lower dermis
may be thickened and formed into disorganized knots or entanglements
(Fig. 35).

t3
Lymphatic involvement

Any of the superficial groups of lymph nodes, including cervical, axillary,

epitrochlear, inguinal, femoral, and popliteal, may be involved. The nodes
particularly affected are usually those draining areas of onchocercal derma-
titis, and they tend to be discrete and not painful or tender.
Microscopically, these nodes show fibrosis of the capsule, trabeculae,
and medulla. Germinal centres are few and reduced in size, or they may be
absent (Fig. 36). Subcapsular sinusoids are dilated, as are lymphatics in
the medulla. There are collections of histiocytes in the sinusoids and large
numbers of inflammatory cells, including plasma cells, eosinophils, and
mast cells throughout the substance of the node (Fig. 37). These nodes
contain varying numbers of microfilariae, most frequently in the capsule
and the subcapsular sinusoids. Some microfilariae are intact and appear
viable, while others are degenerating and surrounded by a granulonatous
reaction composed of epithelioid cells, giant cells, and, sometimes, eosino-
phils and fibrous tissue (Fig. 38).
In endemic areas of Africa this lymphadenitis has features of a competent
cell-mediated immune response. A quite different picture was seen in lymph
nodes removed from 3 patients with sowda in Yemen. The nodes were
much larger than those seen in Africans, measuring up to about 6 cm.
Clinically tl.rey were soft nontender tumour-like masses. Macroscopically,
the nodes were pale yellow homogeneous and without gross evidence of
scarring or other focal lesions (Fig. 39). Microscopically, their capsules
were slightly thickened but there was no scarring of the trabeculae or
medullae. In contrast to the African nodes with atrophic follicles, there
was marked follicular hyperplasia with many histiocytes and large numbers
of plasma cells (Fig. 40). Microfilariae were not found in these nodes.
The pronounced histopathological differences between the lymph nodes
from African and Yemeni patients suggest different host response mecha-
nisms to the microfilariae of O. volvulus.
Other clinical manifestations of onchocercal lymphadenitis in Africa
include hanging groins (Fig. 4l and 42) (14) and other regional lympha-
denopathies. An association between onchocerciasis and elephantiasis of
the genitalia has been noted in Zaire (15) and Chad (16) (Fig. 43) but
further studies are required to determine both the pathogenesis and the
apparent geographical differences of this complication (Fig. 4a).

Systemic onchocerciasis

Textbooks of communicable diseases and parasitology refer to oncho-

cerciasis as a disease in which the distribution of the infective agent and of
the lesion are confined to the skin and the eye. The possible role of O.
t'ol'r'ulus as a cause of systemic infection and disease has been questioned'
The rapidly increasing number of studies reporting microfilariae of O. vol-
tulus in organs other than the skin and the eye requires a critical review,

14
 not only of the clinical picture and the diagnosis of onchocerciasis, but
also of its pathogenesis. A list of the sites other than the skin and the eye
from which the parasites have been recovered is given in Table l, and the
geographical distribution of microfilaruria is shown in Table 2.
Systematic examinations of blood and lymph have not yet been carried
out but large numbers of O. ,toh'ulus microfilariae have been seen in the
superficial dermal lymphatics (Fig. 5l) and the regional lymph nodes. The
microfilariae have also been seen occasionally in blood vessels (Fig. 52).
These observations, together with deep organ involvement, suggest that the
pathway of microfilarial dissemination is via the haemolymphatic system.
To determine the frequency and clinical significance of disseminated oncho-
cerciasis, detailed comprehensive clinical and pathological studies are needed.

Loss of weight
More recently, systemic effects of chronic onchocerciasis have come
under closer scrutiny. Rolland & Balayr found that marked differences in
the body weight of adult males and females were associated with the
intensity of infection. Comparing hyperendemic with mesoendemic and
hypoendemic villages, they observed an average difference in body weight
of 4 kg in males and of 3 kg in females. Buck et al. (16) followed-up oncho-
cerciasis patients with different infection loads, as determined by standardized
skin snips, for 3 years and found significant weight losses in heavily infected

Table 1 . Evidence of systemic onchocerciasis

Organ or O. volvulus Frequency and type Geographrcal area
srte adults mlcrofrlarrae of observatron and reference
Blood + Occasronal rn hrstopathologrcal
spectmens Zarre ('l 5)
+ 5 hosprtal patrents Mexrco (39)
Blood vessel + 1 autopsy Zarc (40)
Aorta (Frg. 1) + + 1 autopsy Zarre (1 5)
Lrver (Frg. 45 + autopsy Zare (15)
and 46) + aulopsy Zane (4Ol
Krdney (Frg. 47 + autopsy Zare (15)
and 48) + autopsy Zaie (40)
Lungs (Frg. 49) + autopsy Zaie (15)
Spleen + autopsy Zave (4O)
Lymphatrc system + Routrne frndrng tn htstologtcal
(Frs. 50) examrnations of lymph nodes Troprcal
rn endemrc areas Afnca
Cubrtal nerve + 1 autopsy Zare (4O)
Cerebrosptnal flurd + 5 cases Mexrco (39)
a number of cases Zaire (5)
Urine + See Table 2
Vaginal smear + 2 9$ ot Papancolaou smears rn Cameroon (41 )
a hyperendemrc focus (savanna)
Sputum + 3 cases followrng frrst dose of Cameroon (42)
drethylcarbamazrne (treatment (savanna)
tflal )

-. ' 9!ta1A,4. & Balay, G. (1969) L'oilchocercose dans lefoyer Bra. Unpublished document
No. lll/oNCHo. of the centre Muraz of-the organisatlon de Coordinitron et de Coop6-
ratlon po--ur la Lutte contre les Grandes End6mies and the Minrstry of Public Health and
Socral Affarrs of Upper Volta.

t5
 Table 2. Geographical occurrence of microfilaruria in onchocerciasis from
tropical Africa' and Mexico

Country where Type ot Frequency of Type ol Method of

cases were seen poPulatton mtcrofrlarufla study urine
examrnalton

Nrgena (44) hospltal Patlents 1 case clrnrcal study routrne

Mexrco (39) hospital patrents 5 cases clrnical study routrne

nonrandom sample of 71300:23% survey wrth routlne routrne

Uganda
(45) uflne examinattons
Zare ) general populatron
Ethiopra (46) hosprtal rnpatrents 1 case rncrdental findrng routrne
in hosprtal lab.
(47) hospltal Patrents 1 case rncidental frnding roulrne
Lrberra
rn hosprtal lab.

Chad (8) total vrllage 441386 = 11.4% eprdemtologtcal lflple

populatron study concentlatton

selected vrllage 461135 = 34.1 % clrnrcal study oI tilple

Chad(1 6) concenliatton
populatron mrcrofrlaruria

Cameroon Patlents selected 3140 : 7.5o/o routtne unne routrne

(forest)b lor treatment examrnatton

UpperVolta' outpatrents 1 3/1 00 = 1 3.0 % chnrcal studY tnple

concentratton

nonrandom sample of 5/100:50% survey trrple

lvory Coasl" concentrallon
populatron
hosprtal pattents occasronal not specrfied routrne
N rgen ad
observatrons
1a847 = 52% eprdemrologrcal sludY tflple
Cameroon representatlve sample
concentratton
(savanna) (41 )of general populatlon
Yo c|nrcal studY wrth tflple
Ghana (48) hosprtal Patrents 81176 = 4.5
concentratton
routrne urlne
examrnatton

22/85 = 259ok chntcal studY tfl ple

Malr' outpattents concentration

Cameroon nonrandom sample of 35194 : 37 % survey routtne

(savanna) vrllage populatton tn
(42]. hyperendemrc area

^ ln Buck (43)
'i;Loonit'"oi".unrcatron from Dr B O, L Duke, 1972'
F;;:i"i ['il;rii, i. i-lin,tna,l studics on tlrc prest'nce ofntttrcrtlanae oJ Otchocerca volvulus
iiszii 96 ' A.lrmrted number
tn th? uttne ol onchocerctosts plr*rirl ,"p,jOri.'n"a wnO'a""u'ent ONCHO/72rnterested rn the subiect
of copres of rhrs document ,," "iliiiuiii.-p"i.ont orrLirrrv or Jrofessronaliv
1211 Geneva2T'
from rhe orvrsron of rvr"ru,,a unj.bli'-"t Fa*.itiCb,.eas"s, wbrld tiJatth orgairrzauon,
Swrtzerland.
--';p"ri6"rt communrcalron from Dr O. O Kale, 1972-
---
. i;;;;;;i io..rn,"ut,on from Dr. A Rousemont. 1973'

Table 3. Changes
- of the weight: height ratio-(W:H) between the 1967 and 1970
siuiies in Chad in relation io microfilarral counts in skin snips

No. rn Mean W:H Drflerence tn I for

Skrn snip
count group for 1 970 w.H 1967-70 drfference

-: 50 25 1 .74 +0 01 0.5
50-1 00 14 1 .67 -0.05 1.1
.27 -o.27 3.5
- 100 4 1

persons (Table 3). These preliminary studies by Rolland & Balay have
utro p.orid.d the information that severe onchocerciasis may lead to
excessive mortality in adults.

l6
 DIAGNOSIS

Microfilariae in the skin

Most authorities agree that the best method for the parasitological
diagnosis of onchocerciasis is the skin snip. The method can be standardized
and used for both qualitative and quantitative assessment. The number of
microfilariae emerging from a skin snip is a reflection of the intensity of
infection.
Skin snips can be taken with a needle and razor blade or with forceps
and curved scissors. These techniques produce snips of varying size and
shape and it is therefore necessary to weigh the snips to calculate the number
of microfilariae per mg (17). Scheffell introduced the corneo-scleral punch
for taking skin snips. With this instrument it is possible to take snips of
uniform size and depth and an average weight of 0.8 mg (range, 0.4-l .2 mg)
(18). The method is fast and painless, and leaves a small lesion that heals
rapidly. It is therefore well accepted.
The available instruments are shown in Fig. 53, and the recommended
sizes are indicated. Instruments with ring handles like those of scissors
are easier to manipulate than those with spatulate handles because they
allow sufficient pressure to be applied to produce the ideal thickness of
skin snip. Whatever method is used, the specimen should be of such a
thickness that the outer parts of the dermal papillae are sampled, this being
the level at which microfilariae are most commonly found. Blood staining
should develop in the wound after a few seconds (Fig. 5a).

Qual itat ive assessme n t

In prevalence surveys it is sufficient to taken one snip from each person
at the site most likely to be heavily infected. The site of choice may have
to be determined by taking multiple snips from different sites in a random
sample of the population. In Africa the best site is just above the iliac
crest, in Central America over the scapula or iliac crest, and in Yemen over
the lower calf.
The snip is transferred immediately to a drop of normal saline or
distilled water on a microscope slide. To prevent the evaporation of the
examination medium the slide can be kept in a covered dish on a sheet of
wet foam rubber. The microscopic examination is made with the low power
(,< l0 objective; ,,<5-x l0 eyepiece). If normal saline is used a search can
be made for microfilariae after l0 min., but with distilled water it is necessary
to wait 30 min. Since microfilariae emerge slowly in distilled water, snips

' Unpublrshed data.

t7
are teased and re-examined after a further 30 min. if no microfilariae are
seen at first. II the presence of microfilariae of Dipelalonema streptocerca
is suspected, the snip is allowed to dry, and then fixed and stained for the
identification of the infective species (see below, differential diagnosis).
After taking a skin snip, the instrument is disinfected.

Quant i tat ive ossess men t

The same technique is used for quantitative assessments, but in order

to obtain comparability between surveys the following procedure is strongly
recommended as standard. The snip is placed io distilled v'ater and all
emerging microfilariae of O. volvulu.r are counted with a tally counter after
30 min. Distilled water is used instead of physiological saline for the
following reasons (18): (a) the emergence of microfilariae in relation to time
seems to be less variable; (b) with reasonable consistency, 50f of the
microfilariae will have emerged at the end of 30 min. (Fig. 55); (c) the
counting of microfilariae is easier because they move more slowly and do
not form clumps; (d) there is no risk of variations in the salt concentration
resulting from evaporation.
The recommended sites for obtaining snips are, again, over the scapula,
both iliac crests, and the lower calf (Fig. 56). The total number of micro-
filariae found at each site should be reported separately. If many snips are
taken from the same site it is necessary to leave a distance of I cm between
cach snip (Fig. 57).
This method allows the measurement of variations in the microfilarial
density, not only between individuals but also at different sites in the same
individual, under varying conditions and at different times. It is also
sufficiently sensitive to be used for the evaluation of drug trials and control
measures.
Periodicity in the appearance of O. volvulus microfilariae in the superficial
layers of the dermis does occur, but the amplitude is small in comparison
with that of Wuchereria bancrofti, for example. Also, variations in the
physiological rhythm of individuals, and between different parts of the body
in the same individual, reduce the effect of periodicity-as observed in a
prevalence survey-below the level of practical significance. Picq et al.1
showed that in a patient infected with W. bancrofti, Dipetalonema perstqns,
and O. tol'tulus, the maximum to minimum ratios for microfilarial patency
during 24 hours were, respectively, gg:1,2.1: l, and 1.7:1. The influence
of the ambient temperature, the skin temperature, and the season on the
microfilarial density in the superficial layers of the skin may be important
and require to be studied.

'picq. J. J. & Jardel, J. P. (1973) LIne nithode d'ivaluation des densitts nicrofilariennes
d'Onchiterca volvulus Leuckart l'893, chez des onchocerquiens. Part 2(Frenchonly), unpublished
WHOdocumentONCHO/71.10-1. Altmttednumberofcopiesofthisdocumentare-avatlableto
persons officially or professionally interested rn the subject from the Division of Malaria and
bther Parasrtic b,scisct, World Health Organtzatton' l21l Ceneva 27, Swrtzerland'

l8
Thc dffirential diagnosis of microJilariae scert in skin snips

Besides the microfilariae of O. t,olvulus, those of D. .streptocerco may

also inhabit the human dermis. lf
blood is taken with the skin snip, the
possibility of finding other microfilariae, particularly D. perstans and Loa
loa, must be remembered.
The distribution of D. streptocerca, as at present known, is confined to
Africa and the affected area includes Cameroon, Ghana, Nigeria, Zaire,
and probably Angola. The species seems to be more prevalent in forest
than in savanna country. The adult worms live in the dermal tissue (Fig. 58)
(19). The microfilariae are usually much less numerous than in oncho-
cerciasis and they are found almost exclusively above the waist; Kershaw
et al. (20) stated that they are commonest at the shoulder, next on the torso,
and few in number or absent at the extremities.
The distribution of O. volvulus microfilariae in the body varies according
to the geographical location of endemic foci. ln Africa, the highest con-
centrations of these microfilariae are found over the iliac crests. High
concentrations are also found over the calf and ankle, where D. streptocerca
microfilariae seldom, if ever, penetrate.
The movements of the two species of microfilariae are different, with a
tendency to more active writhing by O. t,olvulus and a slower, more
concertinaJike action in D. streplocerca.
There should be no difficulty in distinguishing stained specimens (see
Table 4). Apart from the size difference, the different lengths of cephalic
space, the clear space at the tail, and the different shape and grouping of
the nuclei are characteristic. The sharply pointed tail of O. volvulus is very
different from the rounded tip of D. streptocerca (Fig. 59 and 60).

Table 4. Diagnostic characters of microfilariae oI D. strcptocerca and O. volvulus

(Fig. 61)

D. strcptocerca O. volvulus

Geographical distnbution
Anatomical drstnbutron
Numbers of microfrlarrae in snrp
Movemenls
Tip of tail rn stained specrmens
West and Central Afflca, forest
country; lare rn dry savanna
Shoulder, then trunk, seldom
on extremrtres
Few
Slow, concertrna-lrke
Bluntly rounded
Troprcal Afflca, Central and South
Ameilca, Yemen, forest and savanna
ln any part of the body: common or
at least present at calf or ankle
Few - many
Vrolent wrthrng (less so rn drstrlled
water than rn salrne)
Frnely pornted

Characteflstrcs of starned specrmens (1 9)

Length (pm) 230-250 300-350
Maxrmum wtdth (Em) 2 5-5 5-9
Cephahc space (length) (pm) 3-5 7-1 1

Antelior end to nerve rng ( pm) 60-70 60-70

Anterior nuclei (shape and Oval, staggered but not Elongate, frrst 4 overlapprng, even
arrangement) overlappi ng 3 abreast

Features of tatl
Nucler rn row at end 9-1 2, round or quadrate 4-8 elongate
Shape of termrnal nucleus Oval or round elongate
Length of clear space ( um) 1 9-l 5
Shape at trp Bluntly rounded Frnely pointed

19
Onchocercomata

The correlation between onchocercomata and the microfilarial density

in the skin and eye varies between individuals and areas. However, valuable
information on the prevalence and intensity of infection can be obtained
by finding and counting nodules. The examination is carried out both by
inspection and palpation, with the subject as nearly naked as possible.
The number and distribution of nodules are recorded and in conglomerate
onchocercomata the number of palpable lobules is counted.

The Mazzotti test

In 1948 Mazzotti (21) described allergic reactions following the admin-

istration of a single dose of diethylcarbamazine. This procedure, using a
dose of 50 mg, has since been referred to as the "Mazzotti test" and has
been extensively used in some areas as a diagnostic aid.
The reaction usually starts within 15-30 min, but, rarely, may be delayed
up to 24 hours or more. The first and most prominent feature of the reaction
is pruritus, and this tends to be most intense where the microfilariae are
most numerous. Pruritus is soon followed by erythema, and this in turn
by the outbreak of a papular eruption. The papules are often discrete but
may coalesce to give a more generalized brawny induration. In heavy
infections the skin may become oedematous and hot after some hours.
These changes are particularly prominent in the skin of the groin and axilla,
where the lymph nodes often become swollen, tender, and painful, some-
times severely enough to render the patient almost immobile (Fig.62 and 63).
Oedema can also involve the skin of the head and neck, and may be pro-
minent in the eyelids, where it is accompanied by epiphora and conjunctival
hyperaemia. At this stage the patients are extremely miserable and may
also suffer from general effects including fever, headache, and joint and
muscle pain. The reactions usually reach a maximum within 24 hours
and then subside gradually over the following 48 hours. The affected skin
often desquamates (Fig. 64).
In other cases the reactions are far less marked and the skin changes
are more Iike an urticaria. A small proportion of infected persons show
no reaction. However, the administration of 50 mg of diethylcarbamazine
to very heavily infected persons has caused cough, tachypnoea, tachycardia,
and, more dramatically, shock with pulmonary oedema, collapse, and loss
of consciousness.
Clinical changes in the skin during the Mazzotti reaction can be cor-
related with the microscopic changes. Biopsy specimens taken t hour after
the administration of diethylcarbamazine reveal hyperaemia, increased
oedema, and an accumulation of eosinophils around degenerating micro-
filariae (Fig. 65). This phenomenon is seen even in subjects who have few
or no eosinophils in the dermis before taking diethylcarbamazine. Between
I and 3 days after the diethylcarbamazine the microfilariae show advanced

20
degenerative changes. Sometimes only fragments of the microfilarial nuclei
remain and these are surrounded by eosinophils, many of which have
ruptured and released their granules into the tissues (Fig. 66). [n other
patients, eosinophils are inconspicuous and epithelioid cells and giant cells
surround and phagocytose the degenerating microfilariae (Fig. 67). There
is also a third fate for microfilariae following the administration of diethyl-
carbamazine. Some migrate, cephalic end first, into and through the
epidermis (Fig. 68), reaching the keratin layer after several days (Fig. 69).
Here, they remain coiled and are subsequently lost by desquamation. Some
of these microfilariae provoke little reaction during their transepidermal
migration but others provoke intra-epidermal oedema (Fig. 70) and an
aggregation of polymorphonuclear neutrophils, resulting in the formation
of intra-epidermal abscesses (Fig. 7l).
It has also been shown that diethylcarbamazine causes the migration
of O. volvulus microfilariae into the cornea (22). Furthermore, there is a
considerable increase in the number of microfilariae excreted in the urine,
and they have been seen in the sputum of patients who reacted with respir-
atory distress and productive cough. Microfilariae have also been found
in the blood and cerebrospinal fluid following the administration of diethyl-
carbamazine.
Although Mazzottl's test is specific and sensitive, it yields a small pro-
portion of both false positives and false negatives. In addition, its inter-
pretation is to some extent subjective. It rs not, therefore, recommended
as a routine test in epidemiological studies. However, because of its
"mobilization" of microfilariae into the epidermis, cornea, urine, sputum,
lymphatic system, blood, and cerebrospinal fluid, the procedure is of
considerable interest in research.
In view of the severe reactions in some patients the dose of diethyl-
carbamazine used for this test, as well as for the start of treatment, must
be carefully considered. In some areas 25 mg is sufficient, and even 12.5 mg
is adequate for small heavily infected patients. The drug should not be
used indiscriminately, and particularly not in severely debilitated old persons,
pregnant women, and those suffering from acute conditions. Symptomatic
relief from the unpleasant effects of a Mazzotti reaction may be obtained
with a combination of acetyl salicylic acid and codeine. Corticosteroids
and antihistamines should be available to treat patients with severe reactions.

Microfilaruria

The recommended method of making urine examinations for the pre-

sence of the microfilariae of O. volvulus is the triple-concentration tech-
nique (16). The subject should be instructed to empty his bladder completely
into a spillproof polypropylene container with a snap-on lid. Containers
calibrated in millilitres are preferable. The volume of urine should be
recorded and tincture of thiomersal is added (about I ml per 100 ml of

2t
urine). The specimen is then transferred to a 150-ml funnel fitted with a
length of plastic tubing and a clamp.
The specimen is allowed to settle overnight and then l0 ml are withdrawn
from the sediment layer into a centrifuge tube. After centrifugation, 3-4 ml
of the sediment resulting are transferred to small storage vials. At con-
venience, these specimens are washed from the vials into 15-ml graduated
tubes and centrifuged again. All but 0.5 ml of the supernatant fluid is
drawn off. The sediment is mixed by shaking, and is then examined micro-
scopically for O. volvulas microfilariae. This method permits an estimation
to be made of the number of microfilariae in the specimen.
In field studies with limited manpower and equipment, the following
simple method of urine examination can be employed. Urine specimens
are shaken immediately before l0-ml samples are transferred to l5-ml
conical tubes and spun in a manually operated centrifuge for 3 min at about
I 500 rev/min. The supernatant fluid is decanted and 0.5 ml of the sediment
is examined microscopically for microfilariae.
The sensitivity of either method can be increased considerably by
examining the urine of patients who have received a small dose (12.5-25 mg)
of diethylcarbamazine. Studies by Roux & Picql and by Anderson &
Fuglsang (22) to compare the frequency of microfilaruria in a population
sample of a hyperendemic area before and after diethylcarbamazine treat-
ment have shown that the prevalence of microfilaruria can be boosted to
more than twice its original level.

I Roux, J. & Prcq, J. J. (1973) Microfiloruria and the administrotion of drethylctrbanruzina m

onchocerriasis cascs. Unpublished WHO document ONCHO/73.104. A limrted number of
copies of thrs document are available to persons officially or professionally rnterested in the
subject from the Drvrsion of Malarra and Other Parasitic Dtseases, World Health Organizatton,
l2l1 Ceneva, 27, Switzerland.

22
 OCULAR ONCHOCERCIASIS AND ITS DIAGNOSIS

General comments

The appearance and development of ocular lesions in onchocerciasis

depend on the duration and intensity of the infection. It seems probable
that they result from the local death of microfilariae. The age at which
ocular lesions appear, their severity, and the frequency of impaired vision
and blindness are closely related to the intensity of infection in the com-
munity. Males are normally more heavily infected than females of cor-
responding age, and ocular lesions therefore tend to appear at an earlier
age and to be more serious in males.
The same ocular lesions are found in all the major endemic areas of
Africa and Latin America. However, in African savanna villages sclerozing
keratitis and anterior uveitis are more frequent and severe than they are in
rainforest villages with comparable levels of endemicity. This may be
explained by the tendency for the anterior segment of the eye to contain
greater numbers of microfilariae in the savanna areas and by differences in
the parasite strains.
In hypoendemicl villages onchocercal punctate keratitis is found in all
age groups but permanent ocular lesions are uncommon. They develop only
in adults and are rarely gross. In mesoendemicl villages punctate keratitis
is common in young persons but is seen less often in the older age groups.
Permanent lesions are found in young adults and become progressively
more common and serious in older persons. Blindness and impaired vision
associated with both anterior and posterior segment lesions is an appreciable,
but not overwhelming, problem.
In hyperendemicr villages heavy invasion of the eye by microfllariae is
common in early childhood; permanent lesions may develop in youth and
may result in impaired vision and blindness at this age. By the time adult
life is attained lesions of the anterior and posterior segment of the eye are
common and usually coexist. These lesions progress, sometimes with acute
exacerbations, so that there is an increasing prevalence of impaired vision
and blindness in each decade. However, in elderly patients the intensity of
microfilarial infection tends to fall off, so that although the end result is
often a seriously damaged eye, the disease process remains quiescent and
microfilariae can no longer be demonstrated.
r Based on the prevalence rates in representatrve population samples:.- l0i;,, sporadrc cases;
lO-39%, hypoendemrc; 40-69%, mesoendemrc; > 70olo hyperendermrc.

23
Microfilariae in the eye

The cornea
Onchocerciasis can be diagnosed by the presence of microfilariae in the
cornea. With a good slitJamp at a magnification of x 25 it is possible for
the experienced observer to see living, often actively moving, microfilariae
(23). The microfilariae are frequently coiled up and are thus almost invisible
at lower magnifications. They are mainly peripheral and are seen most
easily by retroillumination in the reflected beam.
Dead microfilariae can be seen easily at a magnification of ,t 16, but
sometimes they show up only by retroillumination. The larvae often lie
perfectly straight but other postures-S-shaped, C-shaped, or angulated-
are also seen. They can be located at any depth in the stroma and, although
more common nearer the corneal periphery, they are often seen at the
centre.
In a heavily
infected savanna village in Cameroon, microfilariae were
seen I of the total population over the age of 5 years.
in the cornea of 6l
The corresponding prevalence in a heavily infected rainforest village in
Cameroon was 39 ft.

The anterior cltamber

Onchocerciasis can also be diagnosed by finding microfilariae in the
anterior chamber of the eye. Their characteristic wriggling movements are
easy to see in the slit lamp beam. The microfilariae usually follow the
thermal currents of the aqueous humour and may be seen anywhere in the
anterior chamber. During prolonged examinations with the slit lamp they
tend to sink and disappear into the lower angle. Digital massage of the eye
or bending the head down for about a minute both increase the numbers
of circulating microfilariae. Dead microfilariae have not been observed
free in the anterior chamber.
The frequency of invasion of the anterior chamber seems to be less
subject to geographic variation. In hyperendemic villages in Cameroon,
the prevalence was similar in both rainforest and savanna,i.e., 40-501 of
the total population over the age of 5 years. No doubt this proportion
would have been higher with repeated observations following massage and
head posturing. Microfilariae have been observed in the anterior chamber
in a 3-year-old child.
Living or dead microfilariae are sometimes found adhering by one
extremity to the anterior lens capsule. They have not been seen within the
lens in the living patient but the presence of a microfilaria in a cataractous
lens removed at operation has been described (24).

The retrolental space and vitreous

By means of the slit lamp beam, microfilariae are often seen in the retro-
lental space and in the vitreous. Owing to the magnification of the lens

24
they appear larger at these sites than do microfilariae in the cornea or
anterior chamber.

Con junctiva

Microfilariae may also be found in conjunctival biopsies, but we do not

recommend this procedure. A skin snip taken at the outer canthus provides
adequate information on the load of microfilariae in the vicinity of the eye.
and a slit lamp examination of the cornea and anterior chamber provides
more direct and important evidence of ocular involvement.

Keratitis

Punctole keratitis

Following the death of a microfilaria within the cornea, a reaction usually

starts to form within days or weeks at some point along the larval body
(F19. 72). The resulting opacities vary slightly in appearance according to
their depth in the cornea. In the anterior third of the stroma, a typical
lesion results. It is circular and has a whitish broken-up surface, a diameter
of about 0.5 mm, and an indistinct edge that does not show up in the
reflected beam. It has been likened to a snowflake (Fig. 73). This type of
opacity is particularly common in younger people and non-African expa-
triates, in whom it may be somewhat larger. The epithelium over these
opacities is intact, there is no staining with fluorescein, and corneal sensation
is unimpaired. Deeper in the stroma, a similar lesion results but the colour
is a dull grey and the surface more homogeneous. The diameter is up to
0.5 mm and the edges are indistinct. The lesions of punctate keratitis vary
in number from I to 50 or more. They are distributed most commonly
within 2-3 mm ol the Imbus, particularly in the nasal or temporal inter-
palpebral areas, but they may be seen anywhere in the cornea. The lesions
are usually bilateral. These opacities do not interfere appreciably with
vision and they disappear without trace.
Many descriptive terms have been given to these lesions, including
"cracked ice", "linear", "fluffy", "snowflake", "morula", "feathery", and
"nummular". It is recommended that wherever possible they should be
recorded as dead microfilariae surrounded by reaction, but that when the
larval body has been absorbed the term "fluffy"1 should be used.
Di.fibrential diagrosrs. Disc-shaped corneal opacities of unknown etiology
are common, particularly in the savanna areas. They have a diameter of
1.0-1.5 mm and are characterized by a sharp margin that shows up clearly
in the reflected slit Iamp beam. Such opacities are seen with equal frequency
in persons with and without onchocerciasis. Certain adenoviruses produce

'The term rn French rs "cotonneuse"

25
corneal lesions very similar to those of onchocerciasis, but these have not
been frequently diagnosed in tropical Africa. They tend to be centrally
located, there may be a slight epithelial roughening over them, and they
are not infrequently unilateral. Other discrete, but much larger, lesions
caused by viruses are also seen, but rarely. Small irregular superficial
scars resulting from trauma can resemble fluffy opacities.

Sclerozing keratitis

Sclerozing keratitis is an important cause of blindness and results from

the presence of large numbers of microfilariae in the cornea. The first
detectable change is a haziness of the anterior third of the stroma, showing
as a strikingly white segment involving the peripheral millimetre or so. It
starts typically in the 2-4 or 8-10 o'clock position (Fie.7q. A superficial
migration of pigment on to the cornea follows, and this is accompanied by
the ingrowth of thin superficial vessels. The underlying changes are thus
often obscured. A white area of stromal keratitis of variable extent is
usually seen in front of the pigmented zone ( Fig. 75). Thick, straight stromal
vessels may also be seen growing into the area ol active keratitis (Fig. 76).
Sclerozing keratitis usually progresses from the sides and below, and a
confluent lesion is commonly seen (referred to as "k6ratitesemilunaire" by
French writers) (Fig.77). The pupil area is often covered and total opacifi-
cation may result, but the central and upper areas frequently remain relatively
clear (Fig. 78 and 79). These clearer areas may contain many hundreds of
microfilariae, and the cornea is sometimes so saturated with them that any
reactions around individual larvae are swallowed up in the overwhelming
stromal response. Sclerozing keratitis, particularly when advanced, is fre-
quently accompanied by anterior uveitis. Degenerative changes including
plaques of calcification may occur in longstanding cases.
Dffirential diagnosis. Trachomal pannus, although frequently seen at
the lower limbus, is invariably more pronounced above. Pterygium, with
its corneal apex and wing-like extension to a conjunctival base, bears little
resemblance to sclerozing keratitis. Pronounced pigmentation at the limbus
together with a slight irregularity and heaping up of nasal and temporal
limbal tissue are common in Africans, both with and without onchocerciasis.
Bulbar involvement in vernal conjunctivitis is not particularly localized to
the lower cornea, and eversion of the upper lid will often reveal the additional
presence of the characteristic palpebral form. Keratoconjunctivitis may
leave small vascularized flanged limbal infiltrates in their wake, and these
can mimic sclerozing keratitis. The stromal haze of arcus senilis, if mainly
localized nasally or temporally, can look very like the earliest stages of
sclerozing keratitis. If there is total corneal opacification diagnosis is
usually conjectural. Microfilariae are then, of course, not visible. The
differential diagnosis at this stage includes trachoma, advanced glaucoma,
degenerations, and scarring from smallpox, measles, xerophthalmia, and
injuries.

26
Iridocyclitis

Like sclerozing keratitis, iridocyclitis is found particularly in the more

heavily infected patients. This lesion may present with varying degrees of
severity from mild torpid to severe plastic inflammation. There are few if
any features, particularly in the less severe inflammations, that distinguish
the anterior uveitis of onchocerciasis from that due to other causes. How-
ever, the association of uveitis with the presence of microfilariae in the eye,
together with other onchocercal lesions of the anterior and posterior
segments, indicates the likely etiology.

Milcl uveitis
Mild uveitis is often seen in a noninjected eye. Although flare and cells
are present in the anterior chamber keratic precipitates are fine, and few if
any synechiae form. Slight degrees of pupil distortion are common. Some-
times, the pupil is somewhat dilated and reacts poorly to direct light.

S e ve re p last ic infl antntat io n

Ciliary injection occurs in the active phase but it is often partially masked
by limbal pigment. Keratic precipitates of a nongranulomatous type and
deposits of pigment are found on the corneal endothelium. Exudate and
even fibrin strands may be seen in the anterior chamber and are often
deposited on the anterior lens capsule or in the base of the anterior chamber.
Deposits on the lens may leave a thin film that sometimes produces the
appearance of an exfoliation of the capsule. However, in intense infections
a thick felt of exudate may occlude the pupil; this is often pigmented and
may be vascularized by vessels from the iris. Whitish deposits in the base
of the anterior chamber ("pseudohypopyon") tend to be drawn upwards
and forwards on to the posterior surface of the cornea at the 6 o'clock
position. Moreover, the iris is sometimes drawn down into the mass,
producing a piriform distortion of the pupil.
Posterior synechiae are often marked and the pupil may be completely
secluded. Peripheral anterior synechiae are frequently found at the 6 o'clock
position but in some eyes they may be more extensive. The synechiae may
only be visible with a gonioscope, but sometimes extend far enough on to
the cornea to be seen directly with the slit Iamp beam. In other eyes, even
though the peripheral anterior synechiae are extensive they are masked by
sclerozing keratitis. In some intense infections a large sucker-like attach-
ment of the iris to the posterior surface of the cornea at the 6 o'clock
position is seen.

Secondary glaucoma

Severe iridocyclitis may lead to secondary glaucoma. The end result may
be hypotension, corneal degeneration, or even phthisis bulbi.

27
Iris atrophy
lris pigment atrophy is often seen in onchocercal patients, but is also
common as a senile change in noninfected persons. Some workers believe
that complete loss of the iris pigment frill associated with a smoothing over
of the iris crypts to produce an appearance suggestive of golden yellow
blotting paper is suggestive of onchocerciasis. A fine fibrin deposit may
form on a pupil margin that has been denuded of its pigment frill.

Cataract

Uncomplicated senile cataract is seen with equal flrequency in persons

with and without onchocerciasis. However, the overall prevalence of cataract
in all age groups is higher in populations in endemic areas. In infected
persons it is commonly associated with, and secondary to, anterior uveitis.

Choroidoretinal lesions

Choroidoretinal lesions are found in all areas where onchocerclasts ls

endemic, though they have yet to be reported from Yemen. They are usually
associated with anterior segment lesions, particularly of the anterior uvea (9).
Like the latter, they are often found in both eyes but usually the lesions
have progressed to different degrees and are not bilaterally symmetrical.
The lesions usually appear at the outer side ol the macula (Fig. 80) and
they are also commonly found encircling the optic disc. They may coalesce
to produce a large lesion at the posterior pole of the eye that surrounds
both the optic disc and macula (25). The macula appears to be capable of
resisting the disease process rather longer than the surrounding retina and,
except in severe cases, it olten retains a relatively normal appearance asso-
ciated with good visual acuity.
The following clinical signs should be looked for:
(l) True retinal oedema may be difficult to diagnose. The normal red
reflex is lost and the retina may appear to be raised and mottled. Some-
times, the nerve fibres radiating from the optic disc become abnormally
prominent and this appearance is often exaggerated in fundus photographs
(Fie.8l).
(2) The retinal pigment epithelium is disrupted and becomes irregular.
In more advanced lesions the retinal pigment has migrated, exposing the
choroidal vascular pattern, usually over areas with a clearly defined and
often scalloped edge. Occasionally, the retinal pigment may disappear
almost completely, but usually clumps of retinal pigment remain, often at
the edge of the denuded area or alongside retinal blood vessels. Two types
of retinal pigment are found: (a) dense black pigment that tends to form
clumps (Fig. 82), and (6) red-brown pigment spots (Fig. 83). Consecutive
optic atrophy is lrequently associated with extensive choroidoretinal lesions,

28
and the optic disc presents the typical waxy appearance. However, there is
often coincident inflammation of the optic nerve head, leading to typical
postneuritic optic atrophy.
(3) Choroidal pigment disturbance produces a granular appearance
between the choroidal vessels (Fig. 8a) and the more pronounced disturbance
shown in Fig. 80. Changes in the choroidal vessels lead to a progressive
alteration in their colour from red to orange, yellow, and eventually white.
(4) Fine yellowish dots are commonly seen lying deep in the retina in
patients with and without onchocerciasis. A particular type of punctate
lesion has been described in onchocercal patients and it is reported that it
increases or appears for the first time following diethylcarbamazine or
suramin therapy (26).
Differential diagnosis. When these lesions are early and isolated none
of them is pathognomonic of onchocerciasis. However, as the full picture
of a Hissette-Ridley type lesion develops, particularly when associated with
microfilariae in the eye and with evidence of inflammation in the cornea,
iris, or optic nerve, the diagnosis becomes increasingly evident.
Some diseases that should be considered in the differential diagnosis are
toxoplasmosis, histoplasmosis, diffuse choroiditis, degenerative lesions, and
abiotrophies such as primary retinal pigmentary degeneration (retinitis
pigmentosa) and Sorsby-type lesions.

Postneuritic optic atrophy

Postneuritic optic atrophy is common in heavy infections and normally

associated with lesions elsewhere in the eye. Scarring and pigment disturb-
ance at the disc margin are often striking. Dense sheathing may extend
along retinal vessels for several disc diameters beyond the optic disc and
the retinal arterioles are usually markedly narrowed. Fine sheathing of
the retinal vessels is common in normal eyes and is not of diagnostic
significance.
tt is likely that these lesions are preceded by episodes of papillitis or
neuroretinitis; however, this stage is rarely seen (Fig. 85). Congestion of
the nerve head without swelling (Fig. 8l) is more frequently encountered
and may be a sign of pathological significance.

Histopathology

Reports on histological material have been published by a number of

authors.r Microfilariae have now been reported in every tissue of the eye in
association with ocular lesions. The microfilariae have frequently been
found in perivascular spaces associated with round-cell inflammatory reac-
tions. Neumann & Gunders (37) have reported a case in which microfilarial

'See, lor example, relerences 5,24,26,28,29,30,31, 32, 33,34, 35, j6,37

29
debris and round-cell infiltration lvere found around the ciliary arteries
penetrating the sclera. Live microfilariae were present in the choroid and
retina. They concluded that the typical posterior pole lesions are caused by
microfilariae or their toxins reaching the choroid and retina by penetrating
the sclera alongside the posterior ciliary arteries and nerves.
Unfortunately, most eyes examined have been blind eyes, and in these
late cases scarring of the tissues has occurred. There is a need to obtain
eyes for histological examination at an early stage of the disease. This need
might be met by an ophthalmologist attached to a general hospital situated
in an area where onchocerciasis is endemic. It would be necessary to
arrange a close liaison between the ophthalmologist and both the local
medical staff and an ocular pathologist. It might then be possible to make
an ocular examination of patients prior to death from other causes,
enucleate eyes at autopsy, and later correlate the clinical and histological
findings.

30
 Annex I

ONCHOCERCIASIS SURVEY FORMSI

ONCHOCERCIASIS SURVEY FORM (Part 1)

Identilication
Country Canton, District, etc.: ..............
Village ........ Geographical coordinates
latitude north or south (degrees and minutes)
longitude east or west (degrees and minutes)
Family number.................. Individual identification number
Name...........
Age .... (for children under I year use OO for 0 - less than Sex
6 months OX lor 6 - 12 months)
Tribe . .. .. .. . .. .

Place of birth

Exaninatiott
Body height ............. cm Body weight kg
Cross deformity and obvious incapacitation:
0 normal
I blindness
2 loss of limbs
3 dwarfism
4 skeletonism
5 others:
I ............ . .

2.................
3...............
4 .. ......... . .. .. .

5 ............. ...
Nodules: Present (estimated total number ) Absent
(give distribution diagram if needed)
Other severe manifestations :
0 none
I hanging groin
2 hydrocele
3 elephantiasis: site .....
other oedema: specify
5 anasarca
6 ascites
7 hernia (specrfy

1 ...
2 ...
3 ...
4...
5 ...
Skin condition (list only maior changes)
1 ...............
2 ...............
3 . .. ..... ... .. ..
I Thcsc forms are only provisional and may be rcviscd latcr in thc light of ficld cxpcriene.

3l
Laboralor y e.raninat io ns
Skin snips: done not done
number of microfilariae l-T-fl (examples: l6lTltl, rcft I0l,lt Iololt
Urine: specimen available )es n no [--l
volume l-T-|--lml
haematuria present absent
chyluria present absent
albumen present absent
blood present absent
sediment
microfilariae of O. volvulur present absent
other microfilariae present absent
(Specify ...)
Schislosona hactnalobiunt eggs present E absent l---l
ONCHOCERCIASIS SURVEY FORM (Part 2)
( Eye exanination hy an ophthalmologist )

Micro/ilariae in llte anterior chantberl

Risht Left
0 microfilariae absent 0
I 14 microfilariae seen I
2 5-19 microfilanae seen 2
3 2049 microfilariae seen 3
4 50+ microfilariae seen 4
8 microfilariae not visible because of corneal opacities 8
9 not examined 9
Living nicrofilariae in the cornear
Right Lcft
0 microfilariae absent 0
I l-4 microfilariae seen I
2 5-19 microfilariae seen 2
3 2049 microfilariae seen 3
4 50-99 microfilariae seen 4
5 100+ microfilariae seen 5
8 microfilariae not visible because ol opacificatron 8
9 not examined 9

An1, "7"r0" microfilariae in the cornea with or rtilhout reqclio,t, including nticrofilarial
bod ies w i t hin opaci t ies I
Right LeIt
0 microfilariae absent 0
I l4 microfilariae seen I
2 5-19 microfilariae seen 2
3 204.9 microfilariae seen 3
4 50-99 microfilariae seen 4
5 l00T microfilariae seen 5
8 microfilariae not visible because of opacification 8
9 not examined 9

Fluffy opacities (coltonwool, snowfloke) in the corneal

Risht Left
0 absent 0
1 14 opacities I
2 5-19 opacities 2
3 20+ opacities 3
8 opacities not visible because of corneal opacification 8
9 not examined 9
rIn ficld rnvcstigations whcre counting of mrcrofilarrae or opacitics is rmpractrcablc, recordings may be
srmphfied as follows O = absent; I = few; 3 = numerous.

32
Olher torneal opacities (specily)
Rieht Left
0 absent 0
I present I
8 opacities not visible because ofcorneal opacification 8
9 not examined 9

Sclerozing keratitis
Risht Left
0 absent 0
I nasal or temporal encroachment I
2 confluent semilunar, pupil free 2
3 confluent, pupil covered 3
8 cornea unrecognizable from other causes 8
9 not examined 9

Trachotna
Right Lcft
0 corneal signs of trachoma absent 0
I Herbert's pits present and/or pannus encroaching less than 2 mm I
2 pannus encroaching more than 2 mm 2
-t entropion tnchiasis present, any degree 3
8 cornea unrecognizable from other causes 8
9 not examined 9

Pupil
Risht Lett
0 normal 0
I pupil drlated and poorly reacting I
2 posterior synechiae present, any extent up to seclusio puprllae 2
3 seclusio pupillae 3
8 not visible 8
9 not examined 9

h'itis
Right Left
0 absent 0
I acute intis, any degree I
2 torpid iritis, any degree 2
8 unrecordable because ol corneal opacification 8
9 not examined 9

Lens
Rieht Left
0 clear lens 0
I early cataract, fundus detarls mostly visible I
2 advanced cataract, fundus details largely obscured 2
3 mature cataract J
4 subluxation or dislocation 4
8 not visible because ofcorneal opacification 8
9 not examined 9

Vitreous
Risht Lelt
0 normal 0
I microfilariae on posterior lens surface I
2 microfi lariae in vitreous 2
3 both I and 2 3
8 not visible 8
9 not examined 9

JJ
Optic disc
Right Left
0 normal 0
I pahsh disc, (?) pathological condition I
2 primary optic atrophy 2
3 postneuritic optic atrophy 3
4 paprllitis 4
5 congestion of nerve head without swelling, (?) pathological 5
condition
6 glaucomatous cupping 6
8 not visible 8
9 not examined 9

Retinal vessels
Rieht Left
0 normal 0
I sheathing of arteries I
2 sheathing of verns 2
3 combination of 1 + 2 J
4 narrowing of arteries 4
5 combination of 1 * 4 5
6 combination of 2 -l 4 6
7 combination ol 3 * 4 7
8 not visible 8
9 not examined 9

Choroidoretinitis ( Ridley type)

Right Left
0 absent 0
I early disruption of retinal pigment I
2 as I but with exposure of choroid and clumping of retinal 2
pigment, any degree
8 not visible because of opaque media 8
9 not examined 9

Choro idore t init is ( d i s t r ibut ion )

Rieht Left
0 absent 0
I temporal to macula I
2 peripapillary 2
3 bothl*2 J
4 other locations 4
5 combrnation of I f 4 5
6 combination of 2 * 4 6
7 combrnation ol 3 * 4 7
8 not visible because of opaque media 8
9 not examined 9

Focal choroiditis ol toxoplasmic type

Risht Lcft
0 absent 0
I macular I
2 elsewhere 2
3 combination of I+2 3

Probable anolomical location of main cause of blindness or impaired vision

Risht Left
1 cornea I
2 lens 2
3 anterior uvea J
4 choroidoretinal 4
5 optic nerve 5
6 phthisis bulbi 6
7 other (specify) 7

34
 Annex 2

THE MEASUREMENT OF VISUAL ACUITY

Assessment of vision under field conditions is difficult. To be compre-

hensive it should include visual acuity, refraction, visual fields, colour vision,
and dark adaptation. When examining unsophisticated patients some of
these investigations are impossible, even when the best equipment is avail-
able. However, many cases of serious visual impairment caused by oncho-
cerciasis will be missed if only patients with impaired visual acuity are
examined ophthalmologically.
The measurement of visual acuity in the open air under field conditions
is not easy, but if attention is paid to the following factors it should be
possible to obtain useful information.
(l) The selection of testers who have the required temperament and skill.
(2) The effective occlusion of the opposite eye.
(3) The use of illiterate "E" or "C" tests, preferably with each size of
letter on a separate square card.
( ) The satisfactory and, as far as possible, constant illumination of the
test card.
(5) The shading of patients from glare.
Visual acuity could be measured more accurately, and other more
elaborate examinations would be possible, if a specially equipped van were
available to eye units. Such a van should include facilities for blackout,
air conditioning, the standard illumination of tests, refraction tests, etc.
Wherever the local terrain permits, it is strongly recommended that such
vans should be provided.

Ocular examination lbr visual acuityt

Right IrIt
0 616 0
I 6le I
2 6lt8 2
J 6160 3
4 counting fingers at 3 m, 3/60 4
5 counting fingers at I m, l/60 5
6 perception of light 6
7 no perception of light '7

8 not able to understand test 8

9 not examined 9

I Thc WHO Study Oroup on thc Prcvcntion of Blndncss (38) defincd visual impairment rn tems of vrsual
acuity with both cyes. Thc corrclation betwecn thc two rcales rs as follows:

35
Yrsron wtth the bell"r Coruesponding WHO
seeing eye, using Slud! Group category
the above scale oJ vtsual impairtnent
3 I
4 2
5 3
6 4
7 5

36
 Annex 3

RECOMMENDED DIAGNOSTIC FACILITIES FOR USE IN FIELD

STUDIES

Slit lamp (in special travelling case) with accessories

applanation tonometer
triple mirror contact lens
single mirror contact lens (gonioscope)
Direct ophthalmoscope
Binocular indirect ophthalmoscope with condensing lens
Loupe
E-test cards
Blackout curtains.
It is implicit in the appointment that an ophthalmologist recruited for
onchocerciasis surveys should have received preliminary training in the field.
If ophthalmological work is to be performed by general practitioners, it is
assumed that they will have had adequate training in both general ophthal-
mology and the problems of onchocerciasis. Some work can be delegated
to specially trained paramedical personnel. but only under medical super-
vision.

JI
 ACKNOWLEDGEMENTS

The World Health Organization wishes to express its appreciation to Dr H. Connor

lor providing the photographs for Fig. l-52, 58-60, and 62-'71 (distinguished by a Unrted
States Armed Forces Institute of Pathology number (AFIP)), and Dr J. Anderson for
providing all the colour photographs (Fig. 73 85). Fig. 61 is reproduced from worms in
disease; a manual of medical helminthology by Dr R. L. Muller by kind permission of
the publishers, Heinemann Medical Books, London. The photograph used for Fig. 23
was kindly made available by Dr H. Fuglsang.

38
 REFERENCES

(l) WHO Expert Committee on Onchocerciasis (1966) Wld Hlth Org. techn. Rep. Ser.,
No. 335
(2) Nnochiri, E. (1964) Observations on onchocercal lesions seen in autopsy specimens
in Western Nigeria, Ann. top. Med. Parasit.,58, 89-93
(3) Israel, M. S. (1959) The nodule in onchocerciasis, Trans. ro1,. Soc. trop. Med. Hy,g.,
53, 142-147
(4) Duke, B. O. L. (1970) Onchocerciasis : deep worm bundles close to hrp joints, T'arrs.
t'q,. Soc. trop. Med. Hyg.,64,791-792
(5) Hissette, J. (1932) M6moire sur l'Onchocerca volvulus "Leuckart" et ses manrfesta-
tions oculaires au Congo belge, Ann. Soc. belge Mid. trop., 12,433-529
(6) Lagraulet, J., Monjusiau, A. & Durand, B. ( I 964) Etude des localisatrons des nodules
dans l'onchocercose; leurs relations avec le lieu de piq0re des simulies, Mid. trop..
24, 566-572
(7) Anderson, J., Fuglsang, H. & Zubaidy, A. (1973) Onchocerciasis in yemen with
special reference to Sowda, Trans. roy. Soc. trop. Med Hyg.,6j,3C_3l
(8) Buck, A. A. et al. (1969) Onchocercrasis: some new epidemiologic and clnical
findings, Anter. J. trop. Med. Hyg.,18,217-230
(9) Quer6, M. A. et al. (I963) Etude statistique sur la fr6quence et la sp6cificit6 des compli-
catrons oculaires de I'onchocercose, Bull. Soc. mid. Afr. noire Langue frang., B, l-26
(10) Roberts, J. M. et al. (1967) Onchocerciasis in Kenya, 9, Il, and lg years afrer
elrmrnation of the vector, Bull. I4/ld Hlth Org., 37, 195-212
(ll) Figueroa, M. H. (1972) Enfermedad de Robles. como saler Ias microfilarras del
oncocercoma, Rey. Invest. Salud pilbl. (Mex.),32,9 l9
(12) Neafie, R. C. (1972) Morphology of Ont.hocerta.t'olt'ulu.s, Amer. J. ctin. path., S7,
574 586
(13) Gaspannr, G. (1962) "sowda" nuova malattra o forma inedita di onchocercosi?,
Arch. ital. Sci. med. trop.,43,635-646
(14) Nelson, G. s. (1958) Hanging groin and hernia, compLcations of onchocerciasrs,
Trans. ro)'. Soc. trop. Med. Hyg.,52,272-275
(15) connor, D. H. et al. (1970) onchocercrasis: onchocercal dermatitrs, lymphadenitis
and elephantiasis rn the Ubangi Territory, Hum. path., 1,553-579
(16) Buck, A. A. et al. (1971) Microfilaruria in onchocerciasis, Bull. Wtd Hlth Org.,45,
353-369
(17) Duke, B. o. L. (1962) A standard method olassessing mrcrofilarral densitres on
onchocerciasis surveys, Bull.
Vr'ld Hlth Org.,27,629-632
(18) Ptcq, J. J., Coz, J. & Jardel, J. P. (1971) Une m6thode d'6valuation des densit6s
mrcrofilarres d'o. volvulus Leuckart, 1893 chez des onchocerquiens: technique et
temps de lecture des biopsies cutan6es, Bull. llld Hhh Org.,45, 517-52O
(19) Meyers, W. M. et al. (1972) Human streptocerciasis, Anter. J. trop. Med.Hyg.,2l,
528-545
(20) Kershaw, W. E., Duke, B. O. L., & Budden, F. H. (1954) The distribution of micro-
filariae of O. yolvulus in the human skin, Brir. med. I.,2,724-729
(21) Mazzotti, L. (1948) Possibilidad de utilizar como medio dragnostico en la oncho-
cercosis, las reacciones alergicas consecutivas a Ia administracron de "Hetrazan",
Rev. Inst. Salubr. Enferm trop. (Me.r.),9,235,231-
(22) Anderson, J. & Fuglsang,H. (1973) variation in numbers of microfilariae of oncho-
cerca volvulus in the anterior chamber of the human eye, Trans. roy. soc. trop. Med.
Hye., 67, 544-548
(23) Anderson, J. & Fuglsang,H. (1973) Living microfilariae of onchocerca volvulus in
the cornea, Brit. J. Ophthal.,57,712

39
(24) Cordero-Moreno, R. (1973) Etrologic factors in tropical eye diseases. Anter. J.
Ophthal., 75, 349-364
(25) Rldley, H. (1945) Ocular onchot'erciasis, including an investigatiott in the Gold Coasr.
London, Pulman (monograph supplement to the Brit. J' Ophthal')
(26) Vedy, J., Sirol, J. & coulm, J. (1971) La r6tinopathie ponctu6e albescente oncho-
cerquienne, Bull. Soc. Poth. exot.,9,479486
(27) Giaquinto, M. (1934) Pr6sence de microfilaires d'Onchocerca (aecutiens dans Ie nerf
optique, Rif. med., 50, 858-861
(28) Biyant, J. (1935) Endemic retino-choroidrtis in the Anglo-Egyptian Sudan and its
poisible relationship to Onchocerca t'olvulus, Trans' roy' Sot" trop' Med' Hl's'' 28'
523-532
(29) Semadeni, B. (1943) Histologischer Befund bei einem Fall von zahlreichen Mikro-
filarien beider Atgen, Schweiz. med- Lltschr.' 73,75-7'7
(30) Clark, W. B. (1947) Ocular onchocerciasis in Guatemala: an investigation of 215
natives infected with Ont.hocerca volt'ulus, Trans. Amer. J. Ophthal. Soc., 45,461 501
natives infected with onchocerca volvulus, Trans. Amer. J. Ophthal. soc.,45,461-501
(31) Lavier, c. et al. (1956) Etude anatomo-pathologique d'un eil presentant une chorio-
retinite onchocerqulenne, Bull. Soc. Path. exot., 49, 434438
(32) Offret, c. et al. (1958) Etude histopathologique d'un ceil onchocerquien, Bull. Sot.
Ophtal. Paris,71, ll0 ll3
(33) D'Haussy, R. et al. (1958) Contribution ?r l'6tude des l6sions du fond de l'ceil dans
f 'onchocercose, Mid. trop., 18' 340-367
(34) Lagraulet, J. (1958) A propos de I'onchocercose oculatre en Am6rique et en Afrique,
Bull. Soc. frang. Ophtal.,7l,266 276
(35) Rodger, F. C. (1960) The pathogenesis and pathology of ocular onchocercrasis. lv
The pathology, Amer. l. Ophrhal.' 49,560-594
(36) paul, E. V. tZimmerman, L. E. (1970) Some observations on the ocular pathology
of onchocerctasis, Hunr. Path., l, 581-594
(37) Neumann, E. & cunders, A. E. (1973) Pathogenesis of the posterior segment lesion
ofocular onchocerciasrs, Anter. J. Ophthal.,75' 82-89
(38) WHO Study Group on the Prevention of Blindness (1973) Wld Hlth Org. te<'hn' Rep'
Ser., No. 518
(39) Mazzottr, L. (1959) Presencia de microfilarias de onchocerca tolvulus en el liquido
celalorraquideo de enfermos tratados con hetrazan, Rev. Ittst. Salubr. Enfarn. trop'
( Mex.) , 19, I 5
(40) Rodhain, J. & Cavfllov' W. (1935) Un cas de localisation profonde de"MicroJilaria
volvulus", Ann. Soc. belge Mdd. trop.,15,551-560
(41)Thomas,D.B..Anderson,R.l.&MacRae,A.A.(1973)Microfilariaeofonchocerca
volvulus tn a vaginal irrigation specimen' Anter. J' Parasit',59,941 942
(42) Fuglsang, H. & Anderson, J. (1973) The effect of diethylcarbamazine and suramin
on Oncltocerca yolt,ulus microfilariae in the urine-preliminary results, Lanrct, 2,
321-322
(43) Buck. A. A. (1973) Mrcrofilaruria in onchocerciasis in Africans, Z. Tropennted.
Parasir.,24, 336-339
(44) Dyce Sharp, N. A. (1926) Communtcations: contribution to the study of onchoterca
til,ulus Leuckart, with some observattons on its prevalence rn Nigeria, Trans' ro.r"
Soc. trop. Med. HYg.,19, 373-388
(45) Price,O. L.rtsotlTheoccurrenceof microfilariae of oncho(ert'at'olvulus inurineof
rnfected individuals, J. Parasit., 47, 572
(46) Oomen, A. P. (1969) Srudies on onchocerciosis and elephantiasis in Ethiopia, Haarlem.
De Erven F. Bohn N. V.
(411LberiaResearchInstrtute(1969)In: FourthSenti-qnnualReportoJtheBernhard-Notht
Inliruta lbr Maritime and Tropit'al Diseases, Hamburg
(48) Anteson, R. K. (1972) Studies in filariasis in Ghana. l. Preliminary survey of human
filarral inlections. concurrence of diurnal and non-periodic forms, Ghana nted. J..
1t.146-148

40
I L LU STRATI ON S
Fig. 1. AcoilednongravidadultfemaleO.volvulusinthewall ofanaorta. Theworm
lies in the media and has disrupted the smooth muscle an$ the elastic fibres; scartissue
has formed around the worm, thickening the overlyin! intima (Movat stain, x11'
AFrP 73-61 57)

r3

Fig.2. A patient resident in the Ubangi Territory of Zai{e with onchocercal nodules
over the elbows, iliac crests, trochanters, and the left knee. The papules on the arms
and thighs and the depigmentation of the penis are manifestations of onchocercal
dermatitis (AFl P 68-7638-3)

-43-
 iit
::i

Fig. 3. Several adult O. volvulus worms coiled within a nodule. The hyalinized scat
tissue surrounding the worms incarcerates them, preventing their migration (Movar
stain, x7.6; AFIP 69-3639)

,' ,, -.. .

r -l
-t. ik.-. .3'
E3
lM&f
\W)
: i-t-

#ry$f
'1.,
tf

Fig. 4. Mass of entangled and intertwined male and female O. volvulus worms remain-
ing after the host tissue has been digested away from a nodule ( x3.6; AFIP 69-9753)

Fig. 5. Fragments of degenerating adult O. volvulus worm within an abscess in the

centre of a nodule (Movat stain, x19; AFIP 69-501 8)
_44_
Fig.
i
s
6. A layer of acidophilic material, presumably
immune complex, forming
s

*$
around a worm (arrowed). Clusters of polymorphonuflear leucocytes are digesting
this material (Movat stain, x145; AFIP 69-5022)

ra'"
Fig.7. Degenerating microfilariae within a nodule; thes! microfilariae are surrounded
by epithelioid and giant cells (Movat stain, x485; AFIP 72 -1729O)

rs. qE b a t

r{}
t
q
#
ft& \
{.",
LJ

k rt
1
*.

Fig.8. Transverse section through the anterior end of an apult gravid female O. volvulus
worm, showing a small digestive tube and the vulva (arrovled) (haematoxylin and eosin,
x450; AFIP 69-5925)

-45-
 .'.

Fig. 9. Uneven pigmentation of the skin is an early change in onchocercal dermatitis.

As this figure shows, uneven pigmentation may be seen more clearly in overexposed
photographs (AFIP 68-1 0067-1 )

Fig. 10. ln early onchocercal dermatitis there is usually, as seen in this figure, slight
acanthosis with elongation of the rete ridges, uneven pigmentation of the basal layer,
inflammatory cell infiltrates mainly about the small dermal vessels, and a few micro-
filariae (arrowed) within the dermis (haematoxylin and eosin, x100; AFIP 67-3526)

-46-
 t *

k' i*t,

''|k l
,rk&1,,*** &
/r,
l rq
'a,

Fig. 1 1. The anteriorend of an O- volvulusmicrofilaria has a cephalic clearspace (seen

here) between 7 gm and 13 pm long; the anterior nuclei (arrowed) are situated side by
side (haematoxylin and eosin, x1080; AFIP 71-10O72)

# w
A

rw I
l! --
.',
!-
.,
.b
,

q
,
& '*;'',,
h ...&,

LF ry{
*.*
;
#
-;
l'
*

*
1r
Fig. 12. The posterior end of the O. volvulus microfila
t
is finely tapered and there is
a caudal clear space 9-18 pm long. The terminal nu form a single row (arrowed)
and are thin and elongated (haematoxylin and eosin, x 080; AFIP 71 -10073)

-47-
 t
,

Fig. 13. Collection of lymphocytes around the small dermal vessels, the first micro-
scopic change usually detected in early mild onchocercal dermatitis (haematoxylin and
eosin, x395; AFIP 69-4951 )

Fig. 14. Fibrosis of the dermis with the presence of large numbers of fibroblasts
(anowed), some of which are large and have pointed processes, is a prominentfeature
of onchocercal dermatitis (haematoxylin and eosin, x600; AFIP 69-4939)

-48_
Fig. 15. A band of scar tissue (arrowed) has replace the norma loose areolar
connective tissue of the dermal papillae (Movat stain, x 1 ; AFIP 69-

,' ,ls

T
.}

Fig. 16. A coiled microfilaria in the u pper dermis immediately beneath the basal lay3r
(haematoxylin and eosin, x350; AFIP 69-8688)

-49-
 < ) l-.'

t
\

Fig. 17. A female patient from the Ubangi region of Zaire with papular eruptions of
the upper trunk, arms, and neck; this is a less common manifestation of onchocercal
dermatitis (AFIP 68-7835-6)

c..

Fig. 18. The forearm of a patient from Guatemala with a papular eruption. The papules
are more widely separated than in the patient shown in Fig. 17 and some of them are
pustular and scaling (AFIP 72-17116)

-50
 W

&

Fig. 19. This male patient has severe onchocercal dermatitis with depigmentation of
the legs and secondary infection resulting from scratching (AFIP 68-8080-1 )

Fig.20. ThesamepatientasinFig. 19. Treatmentofboththeonchocercal dermatitis

and the secondary infection has produced rapid healing (AFIP 68-8080-2)

_ -sl _
Fig.21 . Section of a papule revealing an intra-epidermal abscess containing many
polymorphonuclear leucocytes, fibrin, and degenerating epithelial cells (haematoxylin
and eosin, x12; AFIP 69-5428)

F..!r

Fig. 22. A small intra-epidermal abscess containing a microfilaria. Two tangential

sections of a single microfilaria are visible; one part is entirely within the abscess (upper
arrow), the other part (lower arrow) traverses the wall of the abscess. The roof of the
abscess is the keratin layer (haematoxylin and eosin, x250; AFIP 72-17172)

<1
 {
w sr,
$.ii::i
-

auilr , f;

.J

--*l
Fig. 23. A boy from Yemen with the characteristic manifestations of sowda, i.e.,
involvement of a single extremity, darkened skin, a papular eruption, swelling of the
limb, and enlarged femoral nodes

, .:]

Fig.24. Papular eruption of sowda ("1.22; AFIP 72-17181)

53-
 [,

\\

*
Fig.25. Microfilariae are only rarely seen in biopsy specimens taken from patients
with sowda. This microfilaria is in the mid-dermis and has provoked no focal reaction.
Two cross-sections (arrowed) and a long tangential section of the microfilaria are
visible (Giemsa, x750; AFIP 72-4538)

,:.:"

-:
'.t

Fig. 26. The skin of this patient is oedematous and focally depigmented; his femoral
and inguinal nodes are enlarged. One inguinal node when removed revealed the
advanced changes of onchocercal lymphadenitis (AFIP 68-7912-1)

-54-
 :"'{4"
Fig. 27. section of skin from a boy revealing atrophy of the epidermis, diff use oedema
of the dermal collagen, many large fibroblasts, and large numbers of microfilariae
(haematoxylin and eosin, x145; AFIP 68-9448)

Fig. 28. "Lizard skin" characterized by scaling and altered pigmentation. An oncho-
cercal nodule is present on the leftside of the ihest (arrowedf (nrrp 69-9769)

-55-
 (-

Fig.29. "Lizard skin" is associated microscopically with the separation of the keratin
almost constant feature), atrophy of the epidermis, and chronic inflammation of the
(a"n
dermis (haematoxylin and eosin, x50; AFIP 73-6043)

.-*
Fig. 30.ln "lizard skin" there is also a reduction of the elastic fibres in the upper dermis.
Th-e elastic fibres (black) visible in this section are in the mid-dermis in the lower part
of the picture (Movat stain, x 115; AFIP 71-12155)

-56-
 |:

Fig.31. "Leopard skin", characterized by focal depigmentation, is most common on

the shin. Small foci of persistent pigment are visible around the pores and hairfollicles
(AFIP 72-17223)

Fig. 32. The depigmented areas are

depressed, reflecting atrophy and un-
derlying fibrosis (AFIP 68-10071-2)

-57-
Fig. 33. The skin of the lower thighs and knees hangs in loose redundant folds
(AFIP 72-4500-A)

Fig. 34. Reticulum (precollagen) is a prominent feature of onchocercal dermatitis.

ln this section the reticulum fibres, stained black, are distributed throughout the dermal
collagen and have a circular orientation around the small dermal vessels (reticulum
stain, x115; AFIP 67-3532)

-58-
Fig.35. The reduced elastica in the upperdermis is associated with the disorganization
of the elastica in the mid and lower dermis; knots or entanglements (arrowed) sometimes
form (Movat stain, x 130; AFIP 67 -7485)

Fig. 36. Lymph node from a patient with severe onchocercal dermatitis and elephan-
tiasis of the genitalia revealing fibrosis of the capsule and the trabeculae (large arrows).
The superficial and deep lymphatics are dilated (small anow) and the subcapsular
lymphatics contain histiocytes (haematoxylin and eosin, x12; AFlp 69-9521)

-59-
 .{
*

t.

*'
il .x
Fig.37. ln this section of a lymph node cross-sections of a degenerating microfilaria
are visible (arrowed) and are surrounded by eosinophilic leucocytes, plasma cells, and
a few lymphocytes (haematoxylin and eosin, x485; AFIP 69-8694)

-t*
....,a .t
t) ,tare 3r,' !
{b
;.\
_b

r{
it
.-,4
r; ,
'i&& 'N43
"r#

Fig. 38. A degenerating microfilaria (arrowed) surrounded by epithelioid cells, giant

cells, and fibrous tissue (Giemsa, x375; AFIP 69-8464)

-60-
 *

lse
Fig. 39. Femoral and inguinal lymph nodes removed from patients with sowda ate
large,soft,andwithoutgrossevidenceof scarringorfocal lesions(x!.21; AFlP72-4555)

Fig. 40. Section of lymph nodes from patients wilh sowda reveal follicular hypoplasia
(in contrast to the nodes of onchocercal lymphadenitis in African patients) and an
infiltrate of plasma cells and histiocytes (haematoxylin and eosin, x50; AFIP 73-4620)

-61 -
 ."*r
a

:-'-;fu
:. F,

Fig.41 . Hanging groin may be unilateral or bilateral and overlies a cluster of fibrotic
femoral or inguinal nodes (AFIP 70-3172)

I
&.
l

Fig. 42. A patient with unilateral hanging groin overlying femoral'lymph nodes
showing the advanced changes of onchocercal lymphadenitis (AFIP 68-1 0066-1 )

-62
 .l:,

Fig. 43. Elephantiasis of the genitalia and severe lymphoedema of the skin in a boy.
They are associated with advanced onchocercal lymphadenitis of the inguinal lymph
nodes (AFIP 68-7912-2)

t
I
t

Fig. 44. Enlarged scrotum in a patient with severe onchocercal dermatitis. The
enlargement had continued steadily over a period of several years and at the time of its
removal the scrotum weighed 18 kg (AFIP 68-8582)

-63-
 4'
.*
t
r
;
I

,
t
,L
Fig.45. A coiled microfilaria in a hepatic sinusoid; it has provoked no reaction (haema-
toxylin and eosin, x650; AFIP 73-4628)

t
(
Fig.46. Section through the capsule of the liver revealing numerous microfilariae
(arrowed) that have apparently caused the fibrous thickening of the capsule and an
inflammatory cell infiltrate (haematoxylin and eosin, x195; AFIP 72-17568)

-64-
 w

Fig. 47. A glomerulus containing many microfilariae of O. volvulus (arrowed). All

lie within the capillary tuft.
The glomerulus and the surrounding tissues also contain an
inflammatory cell infiltrate (haematoxylin and eosin. x305; AFIP 73-4627)

:d

Fig.48. Section of kidney with a microfilaria in a tubule (haematoxylin and eosin,

x675; AFIP 71-12149)

_65_
 \ a

a .r? .'.

a
.>
fi
/.
# t

t, *$
l
,CL

Fig. 49. Section of lu ng with a microf ilaria ol O. volvulus surrou nded by a few inf lam-
matory cells (haematoxylin and eosin, x675; AFIP 71-1215'l)

Fig.50. Section of a lymph node revealing marked interstitial fibrosis with bands of
fibrous tissue containing dilated lymphatics. The scar tissue tends to have a circular
arrangement around the blood vessels (arrowed); this is seen also in the skin (haemato-
xilin and eosin, x60; AFIP 70-9313)

-66-
 ;*^

. *{;
f..\

Fig. 51. Section of skin with dilated lymphatics in the upper dermis containing micro-
filariae of O. volvulus (haematoxylin and eosin, x 195; AFIP 70-7349)

Fig. 52. Vessel containing a microfilaria in a lymph node. The anterior and posterior
ends of the microfilaria (large and small arrows, respectively) are both visible (haemato-
xylin and eosin, x650; AFIP 70-11370)

-67 -
 !;t.55 ,,
,.
:t ,, ai la: !) t( s ,t 0r

Fig. 53. lnstruments for obtaining skin snips: Holth type (left) and Walsertype (centre
and right) sclerocorneal punches (diameter of punch approximately 2.3-2.5 mm)

Correct depth
for skin snip

wHo 30513
Fig. 54. ldeal depth of skin snip for the assessment of O. volvulus microfilariae

-68
 90

80

70
o

60

N
o50
I
E
.9 40
=

30

20 o
10

tyHo 40030
0
0 10 20 40 50 60 70 80 90 100 110 120

Emergence lime (min)

Fig. 55. Time distribution of O. volvulus Fig. 56. Recommended sites for skin
microfilariae emergence from skin snips biopsies in routine examinations lor
and corresponding cu mulative freq uencies O. volvulus microfilariae

( skin snips

/
wHo 40031 /t cn

Fig. 57. Schema for multiple skin snips from the same general site

-69-
Fig. 58. Section of skin through a papule revealing a coiled adult Dipetalonema
strcptocerca in the superficial dermis surrounded by an inflammatory cell exudate
(haematoxylin and eosin, x110; AFIP 73-1230)

#ry,
n
s \&M

Fig. 59. The microfilariae ol Dipetalonema strcptocerca have a short cephalic clear
space about 5 pm long and the anterior nuclei are staggered (arrowed); they are not
side by side or overlapping as the anterior nuclei of O. volvulus microfilariae (see Fig. 1 1 ),
Furthermore, the nuclei approaching the anterior end of the D. streptocerca microfilariae
form a single column; this is quite different from the arrangement of these nuclei in
O. volvulus microfilariae (haematoxylin and eosin, x1080; AFIP 71 -10075)

70_
 ffi WN
W;'

W WY
,xp 3r
,&
w
,A

7 ',.,,W

& r'!
Y
r
m
*d.4&,x r*" . *
w

Fig.60. ln the posterior end of a D. strcptocerca microfilaria the nuclei form a single
column. These nuclei are short and quadrate and go to the tip of the tail, leaving a
caudal clear space of only 1 pm (anowed); this is in contrast to the posterior end of
O.volvulus microfilariae (see Fig. 12) (AFIP 71-8341)

50!m

Drawr by D'f. L. Mull-"r, Londo. Schoo o{ Hv(rene and Troorcal Medrcrne

Fig. 61 . Microfilariae of O. volvulus (top) and D. stteptocerca (bottom)

7t
- -
 4- -<n .t *t I*i: tr

Fig. 62. Section of lymph node removed from a patient after a course of diethylcarba-
mazine; the capsule is oedematous and inflamed and there are abscesses in the sub-
capsular lymphoid tissue (arrowed) (haematoxylin and eosin, x45; AFIP 73-5695)

Fig. 63. Enlargement of the abscesses in Fig. 62 revealing large numbers of degener-
ating microfilariae surrounded by inflammatory cells including polymorphonuclear
neutrophils, histiocytes, and a few lymphocytes (Giemsa, "440; AFIP 73-5693)

-72-
Fis. 64. Extensive desquamation of the skin of the thigh after the patient was treated
with diethylcarbamazine (AFl P 7 2-17 247 )

i
\
C\

? ,i
a

\
sl
&

q'
aa-., .$.
'n{n*,*.
ix-_*
&*$* t
Fig.65. Biopsy specimen taken t hour after an initial dose of diethylcarbamazine
revealing numerous sections of a degenerating microfilaria in the dermis. Eosinophilic
leucocytes surround the microfilaria (haematoxylin and eosin, x575; AFIP 69-9527)

-73-
 .8 ;
'- .-i8$s-i:.i$'"
...*-
:$&; '''
*':. ,.rt d
I )
'rt
-! "f,r: -.r (F .*, "c
ti d! v
. 'lqp - ,;T.+ !& i''
I
^**d'
/,.s
d!$::: r
-. '
{ &,- -$si|I!}l'
f '!....\
$ alt

, t
.(d

]u
$,a 3
Fig. 66. Section of skin sample taken 3 days after the patient received diethylcarba-
mazine revealing fragments of a degenerating microfilaria (arrowed) surrounded by
eosinophilic leucocytes that have disintegrated releasing granules into the adjacent
tissues (haematoxylin and eosin, x525; AFIP 70-7347)

i rp
r !r.
; M

\
N n

Fig. 67. Skin specimen taken 24 hours after the patient was treated with diethylcarba-
mazine. The degenerating microfilaria is surrounded by histiocytes, epithelioid cells,
and giant cells (haematoxylin and eosin, x850; AFIP 69-4938)

-74-
 ..*

I
Fig. 68. The anterior ends of several microfilariae (arrowed) have penetrated the basal
Iayer and are beginning their migration into the epidermis. This specimen was obtained
5 hours and 20 minutes after the patient received an initial dose of diethylcarbamazine
(haematoxylin and eosin. x300; AFIP 73-5689)

rJr
t,

I
:.n'\
f .'f
,,.
-j'';
Fig.69. Aspecimen obtained Tdaysaftertheinitialdoseof diethylcarbamazinereveals
a clearing of the microfilariae from the dermis but occasional coiled microfilariae
(arrowed) are trapped within the keratin (haematoxylin and eosin, x 145; AFlp 68-9446)

_75_
 t
t,

\)

Fig.70. Skin specimen obtained 5 days after the initial dose of diethylcarbamazine
revealing a microfilaria migrating into the epidermis (arrowed). This migration has
caused inter-epidermal oedema and an intra-epidermal migration of polymorphonuclear
neutrophils (haematoxylin and eosin, x450; AFIP 72'3237)

Fig.71. Migrating microfilariae in this skin specimen have provoked the formation of
intra-epidermal abscesses. The specimen was obtained 48 hours after the initial dose
of diethylcarbamazine (haematoxylin and eosin, x 1 1 5; AFIP 73-5682)

(a)
lT Ttffffiffi
(b) (c) (d) (e) (f) (s) (h)
'.:t',2,i:
:z::;

(i)
!::.

(i)
wHo 40033

Fig.72. Schematic representation of reactions in the cornea forming around individual

deid microfilariae. (a) Microfilaria without reaction; (b)-(f) varying degrees of reaction;
(g) and (h) fully developed fluffy opacity within the body, almost absorbed in (h);
(l) and (i) resulting opacities.

-76-
 'il
.!i

{
t
.-"!

ily,q1qn*1,*1',

Fig. 73. Punctate keratitis Fig.74. Limbal haze of early sclerozing keratitis

\
\

,fn'
I ;
I

I t*&-, j *
I

Fig. 75. White area of stromal keratitis in front Fig. 76. Thick stromal vessels in the cornea
of pigmented zone containing over 1 000 microfilariae

-77 -
 {

Fig. 77. Confluent opacification

in sclerozing keratitis

f
til

a
J
. :G" .-. i '''

Fig.78. Advanced sclerozing

keratitis

3 i*iltts.
] ttril|!,
,r., t -

Fig. 79. Slit lamp photograph

showing corneal opacifications of
the lower half with only discrete
opacities above

-78-
Fig. 80. Extensive fundus lesion
temporal to macula

ire

Fig. 81. Congestion of the optic

disc and the prominent sweep of
nerve fibres

=-

F55 * E:
+ts-
: i'';.'
i*'
Fig. 82. Large clumps of retinal
pigment associated with extensive
ch oroidoretin itis
m*
-79-
 Fig. 83. Red-brown pigment spots
in inflammatory patch temporal to
the macula

'/
I

/
E

Fig, 84. Exposure of choroidal

pigment temporal to the macula

Fig. 85. Papillitis

-80-
 WHO publications may be obtained, direct or through booksellers, from

ALGERIA Soci6t6 Nationale d'Edition et de Diffusion. 3, bd Zirout Youcef, Arcrrns.

ARGENTINA Libreria de las Naciones, Cooperativa Ltda, Alsina 500, BupNos Arnrs Editorial
Sudamericana S.A., Humberto 1o 545, BurNos AInrs. -
AUSTRALIA Australian Government Publishing Service, Sales and Distribution, P.O. Box 84,
CANBERRA, A.C.T. 2600 (mail orders); AGPS Book Centre, ll3-115 London Circuit,
CANBERRA Ctrv; 347 Swanston St., MELBoURNT; Commonwealth Centre, l-3
St George's Terrace, Penru; Bank House, 315 George St., SyoNry- Hunter Publi-
cations, 58a Gipps Street, Cou-rNcwoop, Vic. 3066.
AUSTRIA Gerold & Co., I. Graben 31, VrrNNl l.
BELGIUM Office international de Librairie, 30 avenue Marnix, BRUssELs.
BRAZIL Biblioteca Regional de Medicina OMS/OPS, Unidad de Venta de Publicaciones, Caixa
Postal 20.381, Vila Clementino, 01000 Sio Pruro, S.P.
BURMA see lndJa, WHO Regional Office.
CANADA Information Canada Bookstore, l7lSlater Street, OrrAwA, Ontario KIA OS9
B3J 129; Edifice Aeterna-Vie, I182;
1683 Barrington Street, HALTFAX, Nova Scotia
ouest, rue Ste-Catherine, MoNrnrlr, ll0 (Qu6.); 221 Yotge Street, ToRoNro 205,
Ontario;657 Granville Street, VANcouvrn 2, B.C.; 393 Portage Avenue, WrNNlerc,
Manitoba.
CHINA China National Publications Import Corporation, P.O. Box 88, PEKrNc.
COLOMBIA Distrilibros Ltd, Pio Alfonso Garcia, Carrera 4a, Nos 36-119, CrnucrNr.
COSTA RICA Imprenta y Libreria Trejos S.A., Apartado 1313, SaN Jos6.
CYPRUS MAM, P.O. Box 1674, Nrcosrl.
DENMARK Ejnar Munksgaard, Ltd, Norregade 6, ConrNHacrN.
ECUADOR Libreria Cientifica S.A., P.O. Box 362, Luque 223, Guayaeurr-.
EGYPT Nabaa El Fikr Bookshop, 55 Saad Zaghloul Street, ALEXANDRTA.
FIJI The WHO Representative, P.O. Box 113, Suve.
FINLAND Akateeminen Kirjakauppa, Keskuskatu 2, HrlsrNxr 10.
FRANCE Librairie Arnette, 2, rue Casimir-Delavigne, PARrs 6".
GERMANY, Govi-Verlag GmbH, Beethovenplatz l-3, FnaNxrunr a. M. 6 W. E. Saarbach,
Postlach 1510, Follerstrasse 2, 5 ColocNr I -
- Alex. Horn. Spiegelgasse 9, 62
FEDERAL
REPUBLIC OF WTESBADEN-
GREECE G. C. Eleftheroudakis S.A., Librairie internationale, rue Nikis 4, ATHENS (T. 126\.
HAITI Max Bouchereau, Librairie "A la Caravelle", Boite postale 111-8, Ponr-au-PnrNcs.
HUNGARY Kultura, P.O.B. 149, BuDApEsr 62 Akad6miai K6nyvesbolt, Vdci utca 22, BuoaprsrV.
ICELAND
-
Snaebjorn Jonsson & Co., P.O. Box l l3l, Hafnarstraeti 9, Revxra.vx.
INDIA WHO Regional Office for South-East Asia, World Health House, Indraprastha
Estate, Ring Road, Nrw Drlur 1 Oxford Book & Stationery Co., Scindia House,
- l6 (Sub-agent).
New DelHr; 17 Park Street, Cllcurra
INDONESIA see India, WHO Regional Office.
IRAN Mesrob Grigorian, Naderi Avenue (Arbab-Guiv Building), TEHERAN.
IRELAND The Stationery Office, Dunr-rN.
ISRAEL Heiliger & Co., 3, Nathan Strauss Street, JERUsALEM.
ITALY Edizioni Minerva Medica, Corso Bramante 83-85, TuRtN; Via Lamarmora 3, Mrur.t.
JAPAN Maruzen Co, Ltd, P.O. Box 5050, ToKyo International, 100-31.
KENYA The Caxton Press Ltd, Head Office: Gathani House, Huddersfield Road, P.O. Box 1742,
Narnosr.
KHMER The WHO Representative, P.O. Box ll1, PHNoU-PrNu.
REPUBLIC
LAOS The WHO Representative, P.O. Box 343, VrrNrrlNr.
LEBANON Documenta ScientificaiRedico, P.O. Box 5641, Bsrnur.
LUXEMBOURG Librairie du Centre,49, bd Royal, Luxruaounc.
MALAYSIA The WHO Representative, P.O. Box 2550, Ku,ll,r. Luupun Jubilee (Book) Store
Ltd,97 Jalan Tuanku Abdul Rahman, P.O. Box 629, Kuara-Luupun. Parry's Book
Center, K.L. Hilton Hotel, Kuua. Lunpun.
MEXICO La Prensa M6dica Mexicana, Ediciones Cientificas, Paseo de las Facultades 26,
MExrco Crrv 20, D.F.
MONGOLIA see lr,dia, WHO Regional Office.
MOROCCO Editions La Porte, 281 avenue Mohammed V, R.ln,lr.

Price: Sw. fr. 72.-

Prices are subject to change without notice.
 WHO publications may be obtained, direct or through booksellers, from

NEPAL sae India, WHO Regional Office.

NETHERLANDS N.V. Martinus Nijhoff's Boekhandel en Uitgevers Maatschappij, Lange Voorhout 9,
THE H.acrrE.
NEW ZEALAND Government Printing Office, Government Bookshops at: Rutland Street, P.O. Box 5344,
Aucrl.rrNo; 130 Oxford Terrace, P.O. Box 1721, CHRrsrcHuncr; Alma Street,
P.O. Box 857, HnurlroN; Princes Street, P.O. Box 1104, Durr,rorN; Mulgrave Street,
Private Bag, WrrrrNcroN R. Hill & Son Ltd, Ideal House, Cnr. Gilles Avenue
-
& Eden St., Newmarket, AucruNn S.E. l.
NIGERIA University Bookshop Nigeria, Ltd, University of Ibadan, Ia,loa.N.
NORWAY Johan Grundt Tanum Bokhandel, Karl Johansgt. 43, Osr-o 1.
PAKISTAN Mirza Book Agency, 65 Shahrah Quaid-E. Azam, P.O. Box 729, Llnons 3.
PARAGUAY Agencia de Librerias Nizza S.A., Estrella No. 721, AsuNcr6N.
PERU Distribuidora Inca S.A., Apartado 3l15, Emilio Althaus 470, Lrrve.
PHILIPPINES World Health Organization, Regional Office for the Western Pacific, P.O. Box 2932,
MlNrr,r The Modern Book Company Inc., P.O. Box 632, 926 Rizal Avenue,
MaNra. -
POLAND Skladnica Ksiggarska, ul. Mazowiecka 9, W.r,rlstw ( except periodicals) Ruch,
ul. Wronia 23, WARsAw (periodicals only). -BKWZ
PORTUGAL Livraria Rodrigues, 186 Rua Aurea, LrssoN.
REPUBLIC OF The WHO Representative, Central P.O. Box 540, Sroul.
KOREA
REPUBLIC OF The WHO Representative, P.O. Box 242, SrrcoN.
VIET.NAM
SINGAPORE The WHO Representative, 144 Moulmein Road, G.P.O. Box 3457, SrNclpoxB l.
SOUTH AFRICA Van Schaik's Bookstore (Pty) Ltd, P.O. Box 724, PREroRrA.
SPAIN Comercial Atheneum S.A., Consejo de Ciento 130-136, BARcELoNA 15; General
Moscard6 29, Meouo 20 Libreria Diaz de Santos, Lagasca 95, M,lonlo 6.
SRI LANKA
-
see lndia, WHO Regional Office.
SWEDEN Aktiebolaget C.E. Fritzes Kungl. Hovbokhandel, Fredsgatan 2, SrocrHor.u 16.
SWITZERLAND Medizinischer Verlag Hans Huber, Liinggassstrasse 76,3012 BsnNs 9.
THAILAND see India, WHO Regional Office.
TUNISIA Soci6t6 Tunisienne de Diffusion, 5 avenue de Carthage, TuNrs.
TURKEY Librairie Hachette, 469 avenue de I'Ind6pendance, Isr,rNnur-.
UGANDA see address under Ksxyn.
UNITED H. M. Stationery Office; 49 High Holborn, LoNpoN WCIV 6HB; l3a Castle Street,
KINGDOM EotNsuncH EH2 3AR; I09 StMaryStreet,CARDrFFCFl IJW; 80Chichesterstrect,
Brrr,c.sr BTI 4JY; Brazennose Street, MANcHEsrrn M60 8AS; 258 Broad Street,
BtnMrNcg.ql"l Bt 2HE; 50 Fairfax Street, BRrsroL BSI 3DE. All mail orders should be
sent to P.O. Box. 569, London SEI 9NH.
UNITED REP. see address under Kr:^qyt.
OF TANZANIA
UNITED STATES Single and bulk copies of individual publications (No, subscriptiozsl.'Q Corporation,
OF AMERICA 49 Sheridan Avenue, Ar-n,c.Ny N.Y. 12210. Subscriptioni : Subscription orders,
accompanied by check made out to the Chemical Bank, New York, Account World
Health Organization, should be sent to the World Health Organization, P.O. Box 5284,
Church Street Station, Nrw Yonx, N.Y. 10249. Correspondence concerning subscrip-
tions should be forwarded to the lVorld Health Organization, Distribution and Sales
Service, 121 I GrNrv,c, 27, Switzerland. Publications are also available from the United
Nations Bookshop, NEw YoRK, N.Y. lOOlT ( retail only) .
USSR For readers in the USSR requiring Russian editions .' Komsomolskij prospekt 18,
Medicinskaja Kniga, Moscow For readers outside the USSR requiring Russian
-
editions : Kuzneckij most 18, MeZdunarodnaja Kniga, Moscow G-200.
VENEZUELA Editorial Interamericana de Venezuela C.A., Apartado 50785, C,lucls Libreria
del Este, Av. Francisco de Miranda 52, Edificio Galip6n, C,{n,c.cA.s. -
YUGOSLAVIA Jugoslovenska Knjiga, Terazije 27/II, Brrcuoe.

Orders from countries where sales agents have not yet been appointed may be addressed to:
World Health Organization, Distribution and Sales Service, l2ll Gercva27,
Switzerland, but must be paid for in pounds sterling, US dollars, or swiss francs.