INTRODUCTION

Lymphatic filariasis is caused by infection of humans with helminthic

parasites such as Wuchereria bancrofti or Brugia malayi or Brugia timori (1). These
parasites belong to the superfamily Filarioidea (2) and are widely prevalent in
tropical countries all over the world (1). It is believed that the pathology associated
with lymphatic filariasis in humans is caused by the immune response of the host to
developing and adult forms of filarial parasite present in the lymphatic system.

The infection is most common in subtropical and tropical regions of the

world. It is not very easy to have an exact estimate about the actual number of
people infected by these parasites (3). But of the estimated 120 million persons
reported to be infected in the whole world, more than 90% (108 million) are infected
with Wuchereria bancrofti parasite (4). Most of the infected persons live in Asian and
African countries, with the highest number living in China, India and
Indonesia(4).The vectors that transmit the parasite are Culex, Anopheles and Aedes
mosquito (3). There are only eight species of helminthic parasites known to infect
humans. They are borne by different vectors in different geographical locations
(Table-1.1). The parasite has a complex life cycle involving a maturation stage in the
arthropod vector, and a further period of development and reproduction in their
definitive host (5) (Fig-1.2). As mentioned earlier and shown in Table - 1.1 only
three species of parasites can cause Lymphatic filariasis in human. Our present
study focuses on cellular and humoral basis of protective immune response against
lymphatic filariasis in humans.

1.1
 TABLE NO: 1.1

HELMINTHIC PARASITES THAT INFECT HUMAN

SL. PARASITES VECTORS GEOGRAPHICAL DISEASES

NO. DISTRIBUTION CAUSED

1. Onchocerca Black fly Africa, Central Dermatitis ,Skin

volvulus Similium spp and South nodules, Blindness
America

2. Wuchereria Mosquito: World wide, Adeno-

bancrofti culex ,Aedes, 41'N to 28'C lymphangitis,
mansonia Elephantiasis
Anopheles spp

3. Brugia malayi Mosquito: Far east,India Adeno-

Mansonia to Japan lymphangitis,
Anopheles Elephantiasis
Aides spp

4. Brugia timori Mosquito: Lesser Sunda Adeno-

Anopheles Islands lymphangitis,
barbirostris Indonesia Elephantiasis

5.' Loa loa Tabanid flies Western and Calabar swelling

Crysops spp Central Africa

6. Mansonella Culicoides spp Central and Usually benign

aggardi South Africa

7. Dipetalonema Culicoides spp Africa, Central Usually benign

perstans and America

8. Dipetalonema Culocoides spp Western and Usually non-

streptocerca central Africa pathogenic

*The data has been taken from the book "Immunology ofparasitic infections" Ed.
Sydney Cohen & Kenneth S. Warren.

1.2
1.1 Aetiology

Wuchereria bancrofti parasite has been difficult to study as it can not be

cultured or maintained in laboratory animals. Thus, only limited amount of
parasite material have been available for study, and techniques for defining
species and differentiating substrains or subspecies have been slow to develop.
Even the biochemical nature of different stages of each parasite is not well
understood. Further for some of the less common filarial infections, it is not even
certain where the adult parasite resides, and there is very little information on
how the parasite migrates and mates during the long prepatent period of these
infection.

One of the most intriguing aspects of these filarial infections, especially

those caused by lymph dwelling parasites, is the extremely broad spectrum of
clinical presentation found among individuals in endemic regions. At one
extreme there are many individuals with no clinical manifestation or indication
of filarial infection at all, though one can demonstrate that these people are
exposed to infective larvae to the same extent as those with filariasis. A second
clinical presentation is also entirely asymptomatic but is characterised by the
presence of microfilariae circulating in the peripheral blood. Most common of the
symptomatic clinical syndromes is characterised by the recurrent episodes of
"filarial fevers" seen in many infected individuals (6).

1.2 Early History Of The Disease.

Helminths existed in the free-living forms on earth from the earliest times
of biological life. But they got into the higher animal forms of arthropods and
vertebrates subsequently. They adapted to their new mode of parasitic life in

1.3
due course of time. Filariasis was probably known from as early as 600-250 B.C in
Greece and Rome (7). But the aetiology of the disease, the mode of transmission
etc. became known only during the last one and quarter century. Microfilariae,
probably belonging to the species Wuchereria bancrofti, were seen for the first time
in the hydrocele fluid of a man by Demarquary in 1863 (8) and subsequently in
the chylous urine of a patient by Wucherer (9). In the human blood it was seen
for the first time in 1872 in India (10). Filariasis was first recorded in India, as
early as sixth century B.C, by the famous physician Susruta in his "SUSRUTA
SAMHITA". A detailed description of the disease by Madhavakar is found in his
"MADHAV NIDAN" (seventh century AD). It is reported that in the sun temple
at Konark in Orissa there is a stone carrying of a person with elephantiasis,
which dates back to 13th century AD (11). Clarke in 1709 referred to the swollen
legs of the people of Malabar suffering from elephantiasis and termed these as
"Cochin Legs"(12). In 1868 Wucherer found an unknown worm in Brazil which
was later identified as a filarial parasite (9). After Wucherer's discovery T. R.
Lewis, a British physician at Calcutta found filarial parasite in the peripheral
blood of a patient (10). Bancroft in 1877 found adult female worm (13).
Manson in 1884 demonstrated the development of microfilariae to the infective
larvae in the mosquito (14). A new species of filaria parasite was described in
1927 by Brag who named it as Filarial malayi (15). In 1956 the same parasite was
renamed as Brugia malayi by Buckley and Edeson (16).

1.3 Prevalence.
The filarial worm, Wuchereria bancrofti causing Bancroft's filariasis
(elephantiasis) in human, has a world wide distribution encompassing countries
in the tropics and subtropics, Africa, the near and far east (Fig. 1.1).

1.4
Fig-1.1 Distribution of lymphatic filariasis in the World.
1.5
It occurs predominantly in coastal areas and island with sustained high,
humidity and heat for long periods. At one time it was prevalent in Charleston,
South Carolina, but it is no longer present in the United States. In the Western
hemisphere, it is found in the West Indies and along the coast of South America,
from the coast of Brazil to that of Costa Rica. The parasite Brugia malayi is
common in areas in India, the East Indies and South East Asia (17). Brugia is
spread over lesser Sunda Island and South East Asia (18). The disease is endemic
in all states of India except Jammu and Kashmir, Himachal Pradesh, Punjab,
Haryana, Delhi, Rajasthan, Nagaland, Manipur, Tripura, Meghalaya, Sikkim,
Arunachal Pradesh and Dadra and Nagar Haveli. Endemic areas are found in
Uttar Pradesh, Bihar, Orissa, Tamil Nadu, Kerala and Gujrat (19). The disease is
widely prevalent all over Orissa with very high endemicity in the coastal areas of
Balasore, Jaipur, Bhadrak, Jagatsinghpur, Denkhanal, Cuttuck, Puri, Nayagarh,
Khurdha, Ganjam, Paralakhemunedi and with moderate endemicity in central
and northern Orissa (20).

1.4 Life Cycle of Wuchereria Bancrofti Parasite.

Man is the definitive host of W. bancrofti and Culex mosquito is the

intermediate host and act as a vector. The adult parasites are usually found in the
lymphatic system of man. Females are viviparous, following copulation they
produce microfilariae, which find their way into the blood stream. The life span
of the microfilariae is not accurately known and may vary from 6 weeks to 30
months. The adult parasites live for about 10 years or longer. In the mosquito
vector the life cycle begins with the ingestion of microfilariae by female mosquito
along with the blood meal. In the mosquito which act as vectors, the following
stages of development takes place (Fig. 1.2).
1.6
 c r of i la r ict e

Adults in lymphatics
Lymphatics

Circulation

ssquito bit© woynd

MicrplitpricJ in blood

3rd stag© larva

{infective stage)

Migrates to head
and pro basics

Sheds Srhoath ponttho

stomach wall
3rd stage larva
/
T h o r o ^i c mw sol ,e s

1.7
1. The first stage larva (Li)- ex-sheathing, the larva escapes first from the sheath
in which it is enclosed within 1 to 2 hours after getting into the stomach of the
mosquito.
2. The second stage larva (L2)- After ex-sheathing, the larva penetrates through
the stomach wall in 6 to 12 hours and migrates to the thoracic muscles where it
grows and develops. It shortens and becomes quite thick & resembles as sausage.
The second stage larva increases in length with the development of an
alimentary canal and is relatively inactive.
3. The third stage larva (L3)- is thin, long and very active. It may be found in any
part of the insect. When it migrates into the head and down the labium of the
mouth parts of the mosquito, it is ready to infect the new host. Under optimum
conditions of temperature and humidity, the duration of mosquito phase of the
life cycle (extrinsic incubation period) lasts for about 10 to 14 days (21).
4. The forth stage larva (L4)-The whole process of development from microfilaria
to the infective stage takes around two weeks under favourable conditions in the
mosquito. This duration is notably affected by temperature. The infective larvae
then migrate to the proboscis of the mosquito where they await transmission to
the definitive host. Inside the definitive host they migrate subcutaneously to the
lymphatic system where they undergo 3rd moult to become the 4th stage larvae.
Thirty to forty days after the entry of the 3rd stage larva, final moult occurs and
the parasite becomes a juvenile adult. In man, the pre-patent period, i.e., the time
taken from infection to the production of micro-filariae is about 11 months for W.
bancrofti and about 3 V2 months for B. malayi.

1.6 Different Forms of Filariasis.

People living in the endemic areas show a wide range of clinical

manifestations, which range from asymptomatic amicrofilaraemia to chronic

1.8
adenolymphangitis leading to lymphatic obstruction (22). Pathophysiologically,
the disease should be divided into two distinct clinical states. One is caused by
adult or developing adult worm and is commonly referred to as lymphatic
filariasis and the other is caused by hyper immune responsiveness of the human
host against microfilariae producing occult filariasis, including tropical
pulmonary eosinophilia (23,24).

1.5.1 Lymphatic Filariasis.

The cause of different types of pathology manifested by different

individuals in lymphatic filariasis is not very well understood. The general
pattern of the disease is a long prepatent period, leading to either asymptomatic
micro-filaraemia state or to acute and chronic clinical manifestation. The acute
stage is characterised by episodic lymphadenitis and lymphangitis, with or
without fever, which may be followed by obstructive lesions appearing decades
later. The episodic adenolymphangitis in chronic stage indicates active infection.

1.5.2 Brugian Filariasis.

The clinical manifestations of Brugian filariasis are usually more distinct

than those of Bancroftian filariasis. Lymphadenitis occurs most frequently in the.
inguinal region, (25-29) generally affecting the superficial node at a time. The
acute clinical phase with its complications may evolve quickly or may take
several weeks to few months to manifest. Lymphadenitis occurs at medial site of
the foot and leg, at the axilla, at medial sites of the arm and hand, occasionally at
atypical sites such as the breast.

1.9
1.5.3 Bancroftian Filariasis.

The lymphatics of the male genitalia are most often affected during the
acute stage, leading to funiculitis, epididymitis or orchitis (30-33). The visible
features of the infection are swelling, tenderness and pain, which are sometimes
excruciating. Fever and other constitutional symptoms may or may not be
present. Episodic inflammation is a prominent feature, and each attack may last
from few days to two weeks (34). Lymphadenitis and lymphangitis of the
extremities are less commonly observed in Bancroftian filariasis than in Brugian
filariasis. But lymphoedema and elephantiasis are more common in the former
than the latter type of filariasis, which affect the leg, arm, scrotum, vulva and
breast in order of decreasing frequency.

1.5.4 Occult Filariasis.

The term occult filariasis is used in humans, in which microfilariae are

produced and destroyed by the host immune response (35). The destruction of
the mirofilariae is thought to be responsible for the clinical syndrome. The
clinical features are enlargement of die lymph nodes, which can effectively be
treated. The inguinal lymph nodes are commonly affected but cervical, cubital
and other nodes may also be enlarged. Hyper eosinophilia of 20-90% is the most
common feature of occult filariasis, and is a pointer to title possible origin of the
syndrome (36).

1.6 Epidemiology.
Lymphatic filariasis in humans is caused by the developing and adult
forms of the filarial parasites present in the lymphatic system. Three parasites

1.10
belonging to two genera namely, Wuchereria bancrofti or Brugia malayi or Brugia
titnori are the causative agents (2). Studies of the distribution of filariasis reveal
that the infection is most common in subtropical and tropical regions of the
world (37). There is no reliable data on the numbers of people actually infected.
More than 90% (108 Million) of them are infected with Wuchereria bancrofti and
less than 10% are infected with (12 Million) Brugia malayi or Brugia timori parasite
(2). Wuchereria bancrofti, the predominant parasite, is an urban parasite and
is transmitted very efficiently by Culex quinquefasiciatus the mosquito
associated with poor urban sanitation, where as the rural forms are transmitted
by Anopheles and Aides. No animal reservoirs are known for Wuchereria bancrofti
(2). Brugia malayi seen mainly in south-east Asia, is a much more complex
parasite. In swamp forests of Malaysia, Thailand and some areas in Indonesia
they are widely distributed (38,39). Anopheles and Mansonia mosquitoes serve as
their vector and the range of animal reservoir hosts is much wider. Brugia timori
essentially a human parasite, are transmitted by Anopheles barbirostris have been
detected only in the Indonesian Islands of Timor, Flores, Rote and Alor (40).
Traditionally, the parasites that infect humans have been classified on the basis of
their microfilarial periodicity into periodic and sub periodic form (2).

1.7 The Disease Spectrum.

In the endemic area people are exposed to the parasites and manifest
different types of clinical features. They can be broadly divided into five
categories depending upon mostly the clinical manifestations and, some times,
by the host's immune response. The host's immune system responds to the
parasite antigens finally resulting in the clinical manifestation of the disease (5,
23).

1.11
1.7.1 Asymptomatic Amierofilaraemie State
(Endemic Normals)

Some people living in the endemic areas may not manifest any clinical and
parasitological symptoms of filariasis inspite of getting exposed to infective
larvae through repeated mosquito bite. But when tested immunologicaly using
filaria parasite antigen they show strong T- cell response (23).

1.7.2 Asymptomatic Microfilaremie (ASM) State.

Some people inhabiting in the endemic area although infected by the

parasite do not show any apparent clinical symptoms of filariasis, but they have
microfilaria (Fig. 1.3) circulating in their blood and serve as carriers. This is
termed as patent infection. The duration that is taken by the infective larva (L3) to
produce circulating microfilaria in the peripheral blood has not been established
accurately. This group of people act as excellent carriers of the parasite and are
responsible for it's transmission (41).

1.7.3 The Acute Manifestations.

These are the kind of persons who may show repeated filarial fever with
lymphadenitis and lymphangitis. They may show attacks of fever once or twice a
year. Occasionally lymphangitis may spread through medial part of arm through
hand. Infrequently it may be seen at breasts and popliteal lymph nodes as well.
All the persons suffering from acute infection do not show patent infection. In
case of males, the genitalia are frequently affected.

1.12
Fig. 1.3 The magnified picture (400X) of W. bancrofti microfilaria circulating in
the blood.

1.13
1.7.4 The Chronic Manifestations.

This is the worst kind of infective stage although this appears only after
10-15 years after the first filarial attack. Due to ignorance and poverty often the
initial attack of the disease is neglected which leads to complications latter. The
infective larvae develop into adult and cause blockade of the lymphatic system,
which result in elephantiasis, hydrocele (Fig. 1.4) or chyluria.

1.7.5 Tropical Pulmonary Eosinophilia (TPE).

This is seen only in case of few individuals who reside in the Wuchereria
bancrofti endemic area. This is caused by hyper immune responsiveness of the
human host against microfilarial antigen producing first nocturnal paroxysms of
asthmatic symptoms and later chronic interstitial lung diseases. The patients do
not show any microfilaria in their blood.

1.8 Pathology.

Adult Brugia and Wuchereria parasite usually reside in the afferent

lymphatics or in the cortical sinuses of lymph nodes. They first cause dilatation
of the lymphatic vessels, followed by hypertrophy of the vessel wall. This is
caused by proliferation of endothelial and connective tissue and is associated
with formation of polypoid protrusions in to the vessel lumen. The lymph
vessels appear to remain alive (42,43). However, as is the case with varicose
veins, the valves are dilated, lymphatics become incompetent and allow back
flow of lymph that accumulates in distal portions of the affected limb. Clinically
this results in lymphoedema (44). If the infection is eliminated at this stage by

1.14
Fig. 1.4 The picture shows a chronic filaria patient having both elephantiasis and
hydrocele.

1.15
treatment, or if the affected individual is removed from the endemic area,
both the pathological and clinical manifestations are reversible. The death of
adult worms is associated with additional pathological event (43). An area of
necrosis, resulting from both the dissolution of the worm and degeneration of
host cell in the inflammatory exudate occurs. This is followed by a
granulomatous reaction containing foreign body-type giant cells as well as
plasma cells and eosinophils, and the deposition of collagen around the
degenerating parasites whose remains often become calcified. While the affected
lymphatic becomes obstructed during this process, lymph flow is shunted via
collateral lymph vessels. Recanalization of the obstructed lymphatic often takes
place as granulomatous reaction (45,46).
All manifestations of chronic lymphatic filariasis (elephantiasis) of the limbs,
genitalia, breast and chyluria have a similar pathogenesis. It is the site of the
pathological changes that determines what area of the body will be affected
(47,48). Microfilariae appear to contribute very little to pathogenesis of classic
lymphatic filariasis. Epidemiological studies indicate that title number of
microfilariae per ml of blood in individuals with patent infections remains fairly
constant over a period of many years (49). In animals, and presumably in man,
microfilariae are constantly produced by fertilised female worms and are
continuously cleared in the lungs, liver and spleen (50). But this process usually
does not result in any detectable clinical manifestation. This is in marked contrast
to the situation in a minority of individuals who develop tropical pulmonary
eosinophilia (TPE). Only seldom does the presence of microfilariae in aberrant
sites (e.g., breast, subcutaneous tissue) elicit a granulomatous response that
manifests itself clinically (51). It is also possible that microfilariae do play a role
in inducing inflammation of the lymphatics. It is postulated that the different
disease manifestations of filariasis are caused by different type of immune
responses mounted by the hosts (Fig. 1.4). Most of the recognised pathology
associated with this stage of the parasite result from tissue reactions around
1.16
those parasites, which have been cleared from the blood. In microfilaremic
individuals where there is continuous production of microfilariae, clearance of
these worms presumably takes place constantly in lungs, liver and spleen but
this clearance dose not appear to be associated with any definable clinical
system. Occasionally aberrant microfilariae are found in the breast, subcutaneous
tissue, or other sites where they elicit granulomatous response, which evoke a
symptomatic clinical response (52,53).

1.8.1 Immunopathology.

It appears that the chances of developing clinical manifestations of

filariasis depend upon the intensity and duration of exposure to infective larvae.
Differences in the intensity of transmission can account for most of the variations
in prevalence rates of filarial disease and clinical manifestations in different
endemic areas where the same parasite species is transmitted by the same vector
(54).

A second generalisation on the clinical and pathological aspects of human

filariasis that can be drawn from studies on the clinical and pathological aspects
of human filariasis in native populations is that native populations of endemic
areas react quite differently to filarial worms than previously unexposed
individuals from a non-endemic area. An extreme example of this phenomenon
is the development of elephantiasis in adolescent transmigrants, something that
is seldom observed in their locally bom contemporaries (55, 56). It has also been
reported that antifilarial antibodies are often present in human cord blood (57).
Virtually nothing is known about the types of immune mechanism that
underline the pathogenesis of specific clinical and pathological manifestation of
lymphatic filariasis or about the nature of the parasite antigens that elicit these

1.17
reactions. It has been suggested that obstructive lesions are caused by delayed
type of hypersensitivity reactions to dead or dying adult parasites (58,59).

Immunologic data in human filariasis have been collected by many

investigators using techniques such as skin testing, various antibody assays,
detection of circulating parasite antigen, and in vitro methods of assessing
lymphocyte responsiveness. It is clear that these infections elicit immune
responses of all types. The distinctive feature of these responses, which should be
recognised before one, considers the specific immunopathology associated with
the disease is the "immunosuppressed" state that been most clearly demonstrated
in vitro studies of lymphocyte function (60, 61). It is seen that patients with
chronic infection respond poorly to filarial antigens but their responses to other
antigens and to mitogens remains normal. With respect to specific mechanism
involved in this immunosuperession data are much less complete. But both
studies in animal and humans indicate that the suppressive mechanism already
delineated, as modulators of the host response to parasitic schistosomes are
likely to play an important role in patients with chronic filariasis (62-66). Another
characteristic feature of this infection is the immunologic profile, which is due to
prolonged persistence of living parasites within the host. When antigens are shed
or secreted continuously by the parasites in the presence of antibodies immune
'i '

complexes are formed which can then induce very strong immunological
reactions. Recently several groups have demonstrated the fact that a large
percentage of patients with filariasis have circulating immune complexes in their
body fluid (67).

The third distinctive pathologic feature of filariasis is immune

hypersensitivity reaction, which is shared with other chronic helminthic
infection. Serum IgE levels are elevated enormously in the TPE cases and
1.18
eosinophils are prominent. Basophils and mast cells can be shown to be
sensitised with specific reaginic antibodies (68). It has become clear that chronic
filaria patients have higher titres of IgE antibodies directed against adult worm
antigens, but patients with tropical pulmonary eosinophilia show
hypersensitization to antigens derived from the mierofilarial stage of the parasite
(69). These observations have given strong support to the original speculations of
others (70) that tropical pulmonary eosinophilia is a form of "occult filariasis" in
which the absence of circulating microfilariae reflects an immunologic
hyperresponsiveness on the part of the host which results in effective clearance
of this stage of the parasite from the blood. Much of this clearance, is probably
mediated by IgG antibodies and effected preferentially by lungs. The asthmatic
symptoms are likely to be due to immune response against the microfilariae. It is
not clear what predisposes certain individuals to react to the parasite antigens in
such a hyperresponsive fashion which is in sharp contrast to the almost complete
lack of any pathological manifestation which follows mierofilarial clearance in
the majority of patients with other forms of filariasis.

1.9 Protective Immune Response in Lymphatic

Filariasis.

Lymphatic filariasis is caused by infection of human by deposition of third

stage larvae on the skin while mosquitoes take their blood meal. These larvae
after entering into the lymphatics develop into adult worms over several months.
Mature female worms subsequently produce microfilariae, which are released to
circulate in the body fluid. Experiments using animal models of filarial infection
suggest that vaccination is a feasible strategy to reduce microfilaremia.
Resistance manifested by 50-80% reduction in adult worm burdens and 90%
decrease in the level of microfilaremia have been elicited by active immunisation
1.19
of jirds (71) and other mammals with irradiated third stage larvae of Brugia
spp (72-74). Identification of parasite antigens that can induce the
immunopathologic conditions like elephantiasis, acute lymphangitis and tropical
pulmonary eosinophilia or which can cause partial resistance to infection by the
parasite, is necessary for development of safe and effective immunoprophylatic
measures (75). Very little is known regarding factors responsible for protective
immunity in human filariasis. Till today there is no direct evidence to suggest
that such immunity exist in human. Partial protective immunity to filarial larval
challenges has been induced in animals by immunisation with irradiated
infective third stage larvae (La). Which are alive but developmentally arrested by,
drug treatment early after infection, the so called chemotherapy abbreviated
infections. These methods of immunization presumably work by stimulating
exaggerated immune responses to larval antigens that differ from immune
responses seen in animals that have been infected with normal larvae. The
mechanism(s) responsible for this immunity are not known but experience with
the more extensively studied Schistosoma mansoni suggests that both humoral and
cell mediated immunity may be involved. High levels of antiparasite IgE (76) and
IgG4 antibodies (77) are produced in filariae patients, which is generally
accompanied by eosinophilia. The IgG4 and IgE antibodies are often directed at
the same antigenic determinants (78, 79). The ratio between these two isotypes
are a major factor in determining whether antigen triggers an IgE mediated
hypersensitivity response or whether excess IgG4 can act as an anti allergic
blocking antibody (80). Although production of IgG4 and IgE is often linked (81),
it has been found that reciprocal expression of the above two isotypes exists.
Asymptomatic microfilaraemic patients have much higher ratio of IgG4:IgE than
found in elephantiasis patients (82). There is some suggestion that IgE is a
protective antibody, but high levels of IgE may be involved in the inducing
pathogenic pathway (83).

1.20
 Since cytokines produced by CD4+ T cells control the synthesis of IgE and
IgG4 antibodies as well as the levels of eosinophilia and mastocytosis in humans,
a great deal of efforts have gone into understanding how various cytokines are
induced by parasite antigens in different individuals and how they contribute to
the synthesis of different isotype antibodies and generation of different clinical
states. T-cells from helminth infected individuals secrete higher quantity of IL-4
and IL-5 when stimulated non-specifically by mitogens in comparison to the T-
cells from uninfected individuals, indicating thereby that they may be similar to
mouse Th2 cells. But there is no evidence whether there are T-cells in filaria
patients, which upon stimulation by parasite antigen would secrete only IL-4 and
IL-5. Thus the filaria antigen specific Th2 cells are still elusive. One important
point that has emerged from many studies is that parasite antigens at low
concentration induce production of more IL-4 than IFN-y which is reversed when
higher concentration of parasite antigens are used [84]. The most difficult
obstacle in this type of study has been the non-availability of well-defined
parasite antigens in sufficient quantity. It has not been possible to grow any of
the different developmental stages of W.bancrofti parasite in vitro. No normal or
immunocompromised mice tested so far have been able to support the growth
and differentiation of W.bancrofti parasite [85]. Therefore, one has to either
depend upon limited W. bancrofti parasite materials that can be obtained from
infected individuals or use genetic engineering approach to obtain parasite
antigen. There has been some interesting studies using genetic engineered Brugia
malayi antigen [86]. But there is no study reported yet which uses W.bancrfti
parasite antigen for detail analysis of immune response of individuals belonging
to different clinical states. Identification of the immune evasion mechanisms used
by the parasite will enable us to make strategies for immune intervention in

1.21
human infection. We now know that there is antigen specific
immunesuppression in individuals who carry live parasite in their body.

Synthesis of antigen specific IgG4 antibodies has been shown to correlate

with the presence of live microfilariae in the body fluid or tissue. But even in the
endemic normal individuals, who do not have detectable microfilariae
circulating in their blood one can detect reasonably high litres of parasite antigen
specific IgG4 antibodies circulating in the blood. This may be happening due to
cryptic infection. To resolve all these questions and to understand the mechanism
of immune evasion one has to use animal models. Only in these models one can
combine the knowledge of the immune response with the duration of infection,
the presence of different developmental stages of the parasite with the dose and
the site of infection. Using animal models some very interesting information
have already been obtained. By using parasites of Brugia species belonging to a
particular developmental stage to infect mice the immune response elicited by
them has been studied. It has been found that the parasites from different
developmental stage induce proliferation of contrasting T-helper cell subsets in
three different strains of mice [87, 88]. While microfilaria injected

intraperitonially induce strong Thl response with production of IFN-y, and

IgG2a, IgG2b and IgG3 class of antibodies, the T helper subsets change with
continued immunization. In contrast to the microfilaria, adult worms and the
infective larvae (L3) induce proliferation of Th2 cells producing IL-4, and IgGl
and IgE class of antibodies. Therefore, during the span of infection in mice
presence of both infective larvae and the adult worm would predispose the

immune response to Th2 cell type. This would affect IFN-y response against the
mf when they would appear in the blood stream but what exactly happens in
humans is not known.

1.22
 In an endemic area a significant number of individuals inspite of life long
exposure to infective larvae through repeated mosquito bite do not show any
parasitological or clinical symptoms of filarial infection. Therefore, one would be
tempted to know whether such persons are truly infection free and immune or
have cryptic infection. Recent studies have shown that individuals with
circulating microfilariae who were believed earlier to have no clinical symptoms
do have appreciable hidden lymphatic damage and renal pathology [89]. It has
also been seen that localised microbial infections are contributing significantly to
the pathology of lymphatic symptoms in filariasis. Therefore, any study on
pathology of lymphatic filariasis have to clearly define its study population
taking into consideration the clinical status and presence of different
developmental stages of the parasite. In this regard defining the truly infection
free endemic normals pose a serious problem. In the absence of any longitudinal
observation of individuals to assess the presence of parasites in the body tissue,
and without looking for clinical symptoms and measuring the levels of parasite
specific antigens circulating in the blood, one can not say for sure whether an
endemic normal is truly infection free or not. There have been no studies where
individuals have been categorised into endemic normals after longitudinal
studies and proper clinical and parasitological analysis.

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