FILARIASIS & RELATED

INFECTIONS

Dr. SARTONO Sp PD
 Filariasis : infection caused by vector-borne tissue dwelling
nematodes called filariae.
 D.o. species , adult filaria may dwell in subcutaneous tissues ,
blood vessels, lymphatics, connective tissues & serous
membrane.
 Eight species infect humans , 4  responsible for serious
filarial infections i.e. Wuchereria Bancrofti , Brugia Malayi ,
Onchocerca volvulus , & Loa loa.
 Filarial parasites :
- about 170 million persons infected worldwide
- transmitted by specific species of mosquitoes or other
arthropods
- have a complex life cycle ( infective larva stages carried by
insects & adult worms , resides in lymphatics or
subcutaneous tissues of human ).
 Microfilariae ( the offspring ) :
- 200 – 250 μm long & 5-7 μm wide ( d.o. species )
- may / may not be enveloped in a loose sheeth
- circulate in the blood or migrate through the skin
- to complete the life cycle , microfilariae are ingested by
arthropod vector & over 1-2 weeks  new infective larvae
- adult worms live for many years ; microfilariae survive for
3 – 36 months
- Rickettsia-like endosymbiont Wolbachia  found intracellu
larly in all stages of Brugia, Wuchereria, Mansonella &
Onchocerca & is viewed as possible target for antifilarial
chemotherapy.
 Infection establised , with repeated, prolonged exposure to
infective larvae.
 Clinical manifestation develops slowy  induce chronic disease
with possible long-term debilitating effects.
 Based on nature, severity & timing , the clinical manifestation
of Px who are native to endemic areas ( undergo lifelong
exposure ) differs from those who are travellers or recently
moved to these areas.
 More acute & intense in newly exposed individuals.
 LYMPHATIC FILARIASIS
- Caused by W. Bancrofti , B. Malayi , B. Timori
- Adult parasites reside in lymphatic channels or lymph nodes
 may remain for 2 decades.

EPIDEMIOLOGY
 W. Bancrofti affects ± 115 million people , throughout the
tropics & subtropics, including Asia, the Pacific Islands, Africa,
South America & the Caribbean basin.
 Human  the only definitive host
 The subperiodic form is only in the Pasific Islands ;
elsewhere , W.bancrofti is nocturnally periodic.
( nocturnally periodic forms of microfilariae  scarce in
peripheral blood by day & increase at night ;
 subperiodic form present in peripheral blood at all times &
reach maximum level in the afternoon.
 Natural vectors for W.bancrofti :
- Culex fatigans in urban settings
- Anopheline or aedean in rural areas
 Brugian Filariasis ( B.malayi ),
- occurs primarily in China, India, Indonesia, Korea, Japan,
Malaysia & Philippines.
- two forms : * nocturnal in areas of coastal rice field
* subperiodic in forests
 B.malayi naturally infect cats & human
 B.timori exist only on islands of the Indonesian archiphelago
 PATHOLOGY
 Pathologic changes : due to inflamatory damage to lymphatics
, caused by adult worms & not by microfilariae.
 Adult worms in afferent lymphatics or sinuses 
lymphatic dilatation & thickening of vessel wall.
 Infiltration of plasma cells, eosinophils & macrophages in /
around infected vessels , with endothelial & connective tissue
proliferation  tortousity of lymphatics & damaged /
incompetent lymp valves  lymph edeema & chronic-stasis
changes with hard & brawny edeema in the overlying skin.
 These consequences due to :
- direct effect of the worms
- inflamatory response of the host to the parasite 
granulamateous & proliferative process  lymphatic
obstruction
 It’s thought -> lymphatic vessels remains patent as long as the
worm remains viable & the death of worm  granulomateous
reaction & fibrosis  lymphatic obstruction  compromised
lymphatic function ( despite collateralization ).

CLINICAL FEATURES
 Most common  asymptomatic / subclinical microfilaremia.
( hydrocele, acute adenolymphangitis / ADL, & chronic
lympangitis disease ).
 In endemic areas of W.bancrofti & B.malayi , infected
individuals  few overt clin. manifestations.
 Cinically asymptomatic, microfilaremia  subclinical disease 
mic. hematuria , and or proteinuria, dilated/tortous lymphatics
and scrotal lymphangiectasia in men.
 ADL , is characterised by :
- high fever
- lymphangitis & lymphadenitis
- transient local edeema
- enlarged regional lymph nodes
- indurated & inflamed lymphatic channels
- thrombophlebitis
- in Brugian filariasis, local abscess may form along lymphatic
tract  rupture to the surface
 Lympadenitis & lymphangitis can involve upper & lower
extremities in bancroftian & brugian filariasis ; but genital
lymphatics involvement is associated with W.bancrofti infection
( funiculitis, epididymitis, scrotal pain & tenderness ).
 In endemic areas  DLA ( Dermato Lymphangio Adenitis )->
syndrome :
- high fever
- chills
- myalgias
- headache
* edeemateous inflammatory plaques
* vesicle, ulcers, hyperpigmentation ( may be noted )
** DLA is often diagnosed as cellulitis.

 If lymphatic damage progress  transient lymphedema 

lymphatic obstruction  permanent changes  elephantiasis
 brawny edeema  subcutaneous tissues thickening &
hyperkeratosis.
 Skin fissuring & hyperplastic changes may develop 
superinfection of the poorly vascularized tissues.
 In bancroftian filariasis  genital involvement  hydroceles
 In advance stages  scrotal lymphedema & scrotal
elephantiasis.
 If retroperitoneal lymphatics obtruction occur  increased
renal lymphatic pressure  renal lymphatic rupture 
chyluria  usually intermittent & prominent in the morning
 In travellers or transmigrant , after a number of infected
vector’s bite , clinical manifestations develop over 3 – 6
months period.
 Lymphadenitis of epitrochlear, axillary, femoral, inguinal
lymph nodes  followed by retrogradely evolving
lymphangitis.
 DIAGNOSIS
 Dx can be made by detection of the parasites  difficult
 Adult worm in lymphatic vessels & nodes  inacessable
 Microfilariae can be found in :
- blood
- hydrocele fluid
- other body fluid ( rare )
 Microscopic examination of fluid may be :
- direct or ....... for greater sensitivity.....>
- concentration of parasites by a polycarbonate cylindrical
pore filter ( size 3 μm ) or by
- centrifugation of fluid fixed in 2% formalin
 Timing of blood collection  critical ( d.o. periodicity of micro
filariae
 Many infected ind’duals don’t have microfilariae  Dx difficult
 Assays for circulating antigen of W.bancrofti  Dx
microfilaremic & cryptic ( amicrofilaremic ) infection
 Commercially available tests :
- ELISA
- Rapid format immunochromatographic card test
- Both have sensitivities of 96-100 % & specificities approach
ing 100%
 PCR – based assay for DNA ( W.bancrofti & B.malayi )
 In suspected lymphatic filariasis , examination of
- scrotum or
- female breast , by high frequency ultrasound in conjunction
with Doppler techniques  identification of motile adult
worms within dilated lymphatics.
 Worms may be visualized  in lymphatics of the spermatic
cord ( in 80 % of infected men ).
 “ Filaria dance sign “ is a distinctive pattern of movement of
adult worms within lymphatic vessels.

 Radionuclide lymphoscintigraphic imaging of the limbs 

reveals widespread lymphatic abnormalities ( in both
asymptomatic microfilaremic persons or those with clinical
manifestation of lymphatic pathology.

 Eosinophilia & elevated serum IgE & antifilarial antibody 

support Dx of Lymphatic filariasis
 THERAPY
 DEC ( Diethylcarbamazine ), 6 mg/kg daily – 12 days
 Tx of choice for active lymphatic filariasis ( microfila
remia, antigen positivity, or adult worm on USG ).

 Alternative : Albendazol 400 mg bid for 21 days, although its

efficacy is less than DEC.

 8-week course of daily doxycyclin ( targeting the intracellular

Wolbachia endosymbiont ) has significant macrofilarial activity
as does a 7-day course of daily DEC / albendazol.

 Early Tx of asymptomatic Px is recommended to prevent

further lymphatic damage.
 ADL , supportive Tx ( analgesics & antipyretics ) is
recommended.
 Since lymphatic disease is associated with the presence of
adult worm  DEC is recommended for microfilaria-negative
adult – worm carrier.
 Chronic manifestation of lymphatic filariasis , Tx regimen
emphasize  hygiene, prevention of sec. bacterial infection, &
physiotherapy.
 Hydrocele can be drained repeatedly or managed surgically.
 Recommended course of DEC tx ( 12 days ; total dose 72 mg/
kg ) remain standard for many years.
 Data indicate that single dose DEC tx with 6 mg/kg may be
equally efficacious.
 Side effects of DEC : - fever
- chills
- arthralgia
- headaches
- nausea & vomiting

PREVENTION & CONTROL

 Avoidance of mosquito bites usually is not feasible for resident
of endemic areas
 Visitors should use insect repellent & mosquito net.
 Community-based intervention  filariasis as public health
problem
 Anti microfilarial chemotherapy :
- Albendazol with either DEC or Ivermectin  suppress
microfilaremia
- This combinations have secondary effects on GI helminths

 Alternative approach  the use of salt fortified with DEC 

reduces microfilarial density with no adverse effect.
 TROPICAL PULMONARY EOSINOPHILIA
 a syndrome , develops in some individuals infected with
lymphatic filariasis.
 Males to females ratio : 4 : 1
 Reported from India, Pakistan, Srilangka, Brazil, Guyana and
Southeast Asia.

CLINICAL FEATURE
- Paroxismal cough & wheezing ( usually nocturnal )
- weight loss
- low-grade fever
- adenopathy
- blood eosinophilia ( > 3000/μL )
 X-ray : may be normal , but generally ......
- increased bronchovascular marking
- diffuse milliary lesions or mottled opacity may be
present in middle & lower field

 Pulmonary function test : restrictive or

obstructive defect in half

 Elevated total IgE levels ( 10.000 – 100.000 ng/mL )

 Elevated antifilarial antibody titer