Lymphatic Filariasis

DR NARENDRA KUMAR YADAV

MBBS, MD Community Medicine & Tropical Diseases
 Lymphatic Filariasis:

❖ Lymphatic filariasis, commonly known as elephantiasis.

 Lymphatic filariasis:
❖ Lymphatic filariasis is a parasitic disease caused by infection with three
closely related nematode (roundworms) worms: W. bancrofti, B. malayi
and B. timori.

❖ These species are responsible for two main types of LF:

Bancroftian Filariasis:(90%) Brugian Filariasis:

❖ Causative ❖ Wuchereria bancrofti ❖ Brugia malayi and Brugia timori

Agent:

❖ Vector: ❖ Culex Quinquefasciatus ❖ Mansonia

❖ (A/K/A: C. Fatigans)
 LIFE CYCLE:
❖ Definitive Host: Man

❖ Intermediate host: Mosquito

❖ The adult worms are usually found in lymphatic vessels of man.

❖ The females are viviparous and give birth to as many as 50,000 Mf

per day.

❖ The microfilariae circulate in peripheral blood and are available to

infect mosquito vectors when they come to feed.
..
❖ Adult worms rest in the lymphatic vessels and causes hidden
damage to the lymphatic system.

❖ Lymphatic damage, scaring and obstruction: Severe swelling of the

legs, arms, breasts, or genitals.
❖ Pain
❖ Severe disability
❖ Social stigma
❖ Adult worms rest in the lymphatic vessels and disrupt the normal function of
the lymphatic system. The worms can live for approximately 6–8 years and,
during their lifetime, produce millions of microfilariae (immature larvae) that
circulate in the blood.
❖ Mosquitoes are infected with microfilariae by ingesting blood when biting an
infected host. Microfilariae mature into infective larvae within the mosquito.
When infected mosquitoes bite people, mature parasite larvae are deposited
on the skin, from where they can enter the body. The larvae then migrate to
the lymphatic vessels where they develop into adult worms, thus continuing a
cycle of transmission.
 Epidemiology of Lymphatic filariasis:
❖ Filariasis is a global problem.
❖ Lymphatic filariasis is common in tropical and sub-tropical climates of
Africa, Asia, West pacific and parts of America, affecting over 73 countries.

❖Global: More than 1.4 billion people live in areas where there is a risk of

infection, of whom 120 million are infected and in need of treatment,

including 40 million people with overt disease.(WHO)

❖ This includes 15 million people with lymphoedema and 25 million men

with urogenital swelling principally scrotal hydrocele.
Epidemiological determinants of LF:
Agent factors: Host factors: Environmental and social factors:

❖ W. bancrofti ❖ Man is a natural ❖ CLIMATE: Between 22- 38 °C

(90%), host. ❖ DRAINAGE: LF is associated with bad

❖ AGE: LF affects all drainage.
❖ B. malayi
ages. ❖ TOWN PLANNING: Inadequate sewage
❖ B. timori.
❖ SEX: Male > disposal and lack of town planning.
Female ❖ Urbanization, industrialization,
❖ Illiteracy, Poverty,
❖ Poor sanitation.
 PERIODICITY: Cyclical pattern of Mf in the bloodstream
❖ The Mf of W. bancrofti and B. malayi have a nocturnal
periodicity, i.e., they appear in large numbers at night and
retreat from the blood stream during the day.

❖ The maximum density of Mf in blood is reported between 10

pm and 2 am.

❖ This is a biological adaptation to the nocturnal biting habits of the

vector mosquitoes.
 RESERVOIR OF INFECTION:
❖ In humans the source of infection: A person with circulating Mf in
peripheral blood.

❖ The minimum level of Mf which will permit infection of mosquitoes: A

man with 1 Mf/ 40 cu. mm of blood is infective to 2.6% of the
mosquitoes which fed on him.

❖ In filarial disease (late obstructive stages) Mf are not found in the

blood.
Mode of transmission of LF:
❖ All three infections (W. bancrofti, B. malayi and B. timori) are

transmitted to man through the bites of infective mosquitoes.

Lymphatic Filariasis:
❖ Incubation period of LF: 8 to 16 months.
 Clinical manifestations of LF:
❖ Only a small proportion of infected individuals exhibit clinical signs.
❖ The disease manifestations can be divided into 2 distinct clinical types :

A. LYMPHATIC FILARIASIS: Caused by B. OCCULT FILARIASIS:

A/K/A: Cryptic filariasis
the parasite in the lymphatic system:

❖ 1. Asymptomatic amicrofilaraemia ❖ Caused by a hypersensitivity reaction to filarial

antigens derived from Mf.
❖ 2. Asymptomatic microfilaraemia
❖ Classical clinical manifestations are not present.
❖ 3. Stage of acute manifestations
❖ Mf are not found in the blood.
❖ 4. Stage of chronic obstructive ❖ The best known example is: Tropical Pulmonary
lesions Eosinophilia(TPE).
LYMPHATIC FILARIASIS: Stages:
1. Asymptomatic amicrofilaraemia:
❖ Clinical manifestations of the disease: (-)
❖ Blood for Mf: (-)

2. Asymptomatic microfilaraemia:
❖ Asymptomatic

❖ Blood is positive for Mf.

❖ Important source of infection in the community.

❖ These carriers are usually detected by night blood examination.

 LYMPHATIC FILARIASIS: Stages: Cont..
3. Stage of acute manifestations:
❖ In the first months and years: Recurrent episodes of acute inflammation
in lymph glands and vessels.

❖ Fever

❖ Lymphangitis: Inflammation of lymphatic vessels.

❖ Lymphadenitis: Enlargement of one or more lymph nodes.

❖ Lymphoedema of the various parts of the body.

❖ Epididymo-orchitis in the male.

LYMPHATIC FILARIASIS: Stages: Cont..
4. Stage of chronic obstructive lesions:

❖ The chronic stage usually develops 10-15 years from the onset of the
first acute attack.

❖ This phase is due to damage, fibrosis and obstruction of lymphatic

vessels causing permanent structural changes.

❖ Elephantiasis may affect the legs, scrotum, arms, penis, vulva and
breasts, usually in that order of decreasing frequency.

❖ Lymphatic damage, fibrosis and obstruction: Severe swelling of the

legs, scrotum, arms, genitals , breasts.
 Diagnosis of lymphatic filariasis:
1. Blood smear (The thick film): Capillary blood and examined for Mf

❖ Ideal time of taking blood is: 8:30 pm- 12.00 midnight

2. Membrane filter concentration (MFC) methods: Blood is collected by
venipuncture and filtering large volumes of blood.

3. DEC provocation test (100 mg DEC oral):

❖ Mf can be induced to appear in blood in the daytime by administering DEC

100 mg orally.

❖ Mf begin to reach their peak within 15 minutes and begin to decrease 2

hours later.
Lymphoedema management:
TREATMENT FOR UNCOMPLICATED ADLA: TREATMENT FOR SEVERE ADLA:
(ADLA: Acute dermato-lymphangioadenitis)

❖ Analgesic (Paracetamol) ❖ iv Benzylpenicillin (Penicillin G) 5 million

❖ Oral Antibiotics (Amoxicillin/ erythromycin) x 8 days Unit x TDS X 8 days OR
❖ Elevation of the limb and exercise. ❖ im Procain benzylpenicillin 5 million units
❖ Clean the limb with antiseptic. x BID x 8days. OR
❖ Check for any wounds, cuts, abscesses and interdigital ❖ IV erythromycin 1gm x TDS
infection (especially between the toes): Antiseptic,
Antibiotic cream. ❖ Analgesic (Paracetamol)
❖ Home management: Plenty of water, wriggling the
toes, washing the limb, cooling the limb with cold water.
❖ Do not give any antifilarial medicine.
❖ Do not give antifilarial medicine.
 CONTROL MEASURES:
❖ The current strategy of filariasis control is based on :
1. Chemotherapy

2. Vector control
 CONTROL MEASURES:
1. Chemotherapy:
A. Mass drug administration (Mass Deworming) to control the infection:
❖ DEC + Albendazole. OR
❖ Ivermectin + Albendazole
Except: Children < 2 years , Pregnant women, seriously ill patients.

❖ Diethylcarbamazine (DEC)= 6 mg/kg body

❖ Mass drug administration (MDA) is given single dose annually for 4-6
years.
B. DEC-medicated salt: 1-4 g DEC/kg of salt and duration of treatment is 6-9 months.
CONTROL MEASURES:
2. Vector control (Mosquito Control):
A. Physical Methods:

❖ Source Reduction (Best): Elimination of breeding place.

❖ Use of mosquito nets
❖ Wearing of full sleeves shirts and full pants
❖ Use of mosquito repellent: creams, liquids, coils, mats Gambusia

B. Chemical Methods:

❖ Antiadult measures (Nerve/ Contact Poison): DDT, Pyrethrum, Malathion

❖ Antilarval measures: Paris Green (Stomach Poison)
C. Biological Methods: Gambusia, Lebister, Poecilia (All are Larvivorous Fishes)
• The strategy to interrupt transmission of the disease calls for mass
administration of a 2-drug regimen (ivermectin or DEC plus
.albendazole) administration as a single dose annually for 4-6 years.
• The current hypothesis is that reducing the prevalence of
microfilaraemia in humans to < 1 per cent will stop transmission.

• One provisional set of guidelines for stopping treatment would

require 2 5 annual rounds of MDA with coverage of 2 65 per cent of
the total population
MCQ
Q. The vector for transmission of Bancroftian filaria is:
• (a) Culex fatigans
• (b) Aedes aegypti
• (c) Mansonoides annulifers
• (d) Anopheles stephensi
• . Ans. (a) Culex fatigans
MCQ
• Q. DEC is used extensively in the chemotherapy of Filariasis. It is most
effective against:
• (a) Microfilariae
• (b) Adult worm
• (c) Infective stage larvae
• (d) All of the above
• . Ans. (a) Microfilariae
MCQ
• Q. The currently given regimen for Bancroftian filariasis is:
• (a) DEC – 6 mg/ Kg / day × 21 days
• (b) DEC – 6 mg/ Kg / day × 12 days
• (c) DEC – 100 mg/ day × 21 days
• (d) DEC – 100 mg/ day × 12 days
• 260. Ans. (b) DEC – 6 mg/kg/day x 12 days
MCQ
• Q. The Clinical incubation period of Filariasis is:
• (a) 10 to 20 days
• (b) 3 to 6 months
• (c) 6 to 12 months
• (d) 8 to 16 months
• Q. Ans. (d) 8 to 16 months