Soil transmitted nematodes

Ascaris lumbricoides Trichuris trichiura

Ancylostoma duodenale Necator americanus

Strongyloides stercoralis

Soil-transmitted nematodes

Parasitic nematode of human importance

Disease Lymphatic filariasis : Agent Wucheraria bancrofti Vector-borne nematode Lymphatic disease Elephantiasis WHO elimination programme

 8 species of filariae parasitise humans Occur in a wide range of habitats - lymph glands, deep connective tissue, subcutaneous tissue or mesenteries Intermediate host or vector (insect) Adult worms parasites of vertebrate hosts which produce characteristic larvae known as microfilariae

Filarial nematodes

Filarial nematodes

3 of the species are primarily responsible for most cases of human filariasis (Two billion exposed and at least 200 million infected)

Wucheraria bancrofti (lymphatic) Brugia malayi (lymphatic) Onchocerca volvulus (subcutaneous)

Wucheraria bancrofti

Primary causative agent of lymphatic filariasis Overt bancroftian filariasis : 115 million cases worldwide (45.5 million India, 40 million subsaharan Africa) Widespread throughout the subtropics and tropics (for e.g. Central Africa, India, Thailand, Malaysia, Phillipines, Pacific Islands, Haiti, coastal Brazil)

Different stages of the Wucheraria life cycle

Onchocerca volvulus : Onchocerciasis

 Periodic form : mf in

small numbers in circulating blood during the day and peak density at night (10 pm to 2 to 4 pm)
Subperiodic form : mf

Microfilarial periodicity

peak between noon and 8 pm

Periodic form

mosquitoes feed at night ; subperiodic form mosquitoes feed during the day

Gold standard diagnosis using blood films has diminished relevance as mass drug distribution expands
Use of sentinel sites for ongoing night blood films

Diagnosis of Wucheraria

Frequently made on clinical grounds in endemic regions but demonstration of microfilariae in circulating blood is key Where more than one species of filarial infection occurs need well stained slides for morphological identification of microfilariae Filarial infections can occur without microfilaremia

Diagnosis : Wucheraria bancrofti

Conventional method examination of thick smear (stained)(counting chamber method) Concentration techniques (Nucleopore filtration or Knotts concentration) Detection of circulating filarial antigen rapid format card test/ immunochromatographic card test (ICT)

Serodiagnosis
PCR-based assays for DNA

Imaging studies (high frequency ultrasound, lymphoscintigraphy)

 mf usually in blood 210-320um in length Loose sheath which

Characteristics of mf of W. bancrofti

when stained with Giemsa is pale pinky blue and does not stain well
Nuclei are discrete

and tail ends taper evenly

No nuclei on the tip of

the tail

Symptomatology
Clinical manifestations vary considerably Asymptomatic microfilaraemics show microscopic

hematuria and/or proteinuria

Early signs : fever, lymphangitis (limbs, breasts,

scrotum), lymphadenitis (femoral, inguinal, axillary and epitrochlear nodes)

Orchitis, Lymphocoel, Hydrocoel
Elephantiasis

Tropical pulmonary eosinophilia (TPE)

Distinct syndrome in some individuals Paroxysmal cough and wheezing Weight loss, low grade fever, pronounced blood eosinophilia Total serum IgE and antifilarial Ab titres raised Responds well to treatment but in its absence progressive pulmonary damage

Elephantiasis
Relatively uncommon

and late complication of filariasis

Elephantiasis

(enlargement of limbs, scrotum, breasts or vulva with dermal hypertrophy & verrucous changes)
Impairment of

circulation means secondary bacterial & fungal infections are common

Early lymphedema

Advanced lymphedema

Hydrocoele Elephantiasis

 Inflammatory changes in

the lymphatics Repeated attacks of inflammation lead to dilation & thickening of the affected lymphatics (lymphedema) Chronic lymphedema : hyperplasia of connective tissue, infiltration of plasma cells, macrophages & eosinophils Eventual thickening & verrucous changes: elephantiasis

Pathology

 Intensity and type of

Immunology
Immunomodulatory

host immune response may reflect range of clinical manifestations

Immune response

molecules
Experimental animal

varies by stage of infection

models (B. malayi not W. bancrofti)

Treatment
Diethylcarbamazine (DEC) : an effective

microfilaricidal drug which can eliminate adult worms more slowly. Successfully administered in table salt (Mass treatment) Combination of DEC & Albendazole Combination of DEC & Ivermectin Elephantiasis : surgery, rigorous hygiene

Prevention and control

Transmission depends upon two issues

(availability of vectors and presence of a population of people to infect the vector)

Vector control : larvicides, residual spraying WHO programme to eliminate lymphatic filariasis (GPELF) : 2 prongs - stop spread of infection & reduce morbidity (mass treatment once yearly for 4-6 yrs, education and intensive local hygiene; GSK and Merck donation)

Case study : Mass drug administration in India

Mass treatment of 590 million people 1.4 billion doses of DEC and 0.51 billion of Albendazole 1.1 million drug distributors

Challenges : quality of DEC sometimes poor, blister-packaging, side-effects, treatment coverage variability (55-89% in better developed states versus 0-35% in less), monitoring and evaluation weak

Lymphatic filariasis elimination programme in India: progress and challenges

Kapa D. Ramaiah Parasitology Today (2008) vol 25 (1) 7-8