LYMPHATIC FILARIASIS

Tri Wulandari K.
LYMPHATIC FILARIASIS
Introduction
•- caused by dwelling tissue nematodes
•- transmitted by vector mosquito
•- cause of permanent disability
•- potentially eradicable disease
–no reservoir host (bancrofti); reservoir host
(malayi): Presbythis cristata, Macaca fascicularis,
Felis catus
–no amplification of the parasite within the
mosquito vector
Etiology
• Wuchereria bancrofti
• Brugia malayi (zoonotic)
• Brugia timori
CLASSIFICATION :
• Class Secernentea, Ordo Spirurida,
Superfamily Filaroidea, Family Filariidae,
Genus Wuchereria, Brugia
Prevalence
• Distribution of lymphatic filariasis
– in the world : 120 million people are infected in 81 country and 1.3
billion people in 72 countries are threaten
• 1/3 suffering chronic manifestation
• 1 M at risk of acquiring the infection
– in Indonesia : more prevalence in the islands besides Java and
Bali
GEOGRAPHIC DISTRIBUTION OF FILARIASIS
IN THE WORLD
Prevalence in Indonesia
GEOGRAPHIC DISTRIBUTION OF FILARIASIS
IN INDONESIA
ENDEMICITY OF FILARIASIS IN INDONESIA
VECTORS
• Vectors (73 Species of mosquitoes ):
- Night-biting Anopheles , Culex , Mansonia
- Daytime-biting Aedes polynesiensis
• No reservoir host (bancrofti)  endemicity
depend on both of infected human and
sufficient numbers of mif. in circulating
blood
Biologic aspect of lymphatic filaria
• Morphology of microfilaria diagnose
• Life cycle transmission control
• Periodisity blood sample
– nocturnally (22.00-02.00),
– subperiodic nocturnally,
– diurnally,
– subperiodic diurnally
– nonperiodic
• Sufficient number of microfilaria are need to
transmit the disease
microfilariae
macrofilariae

female male
Life cycle of lymphatic filariasis

Healthy human
mosquito
 Pathogenesis of elephantiasis
• Caused by the adult worm (macrofilaria) that located in the
vessel and lymph tissue obstruction.
• Process:
– Directly by adult worm
– Indirectly  inflammation reaction to adult worm
• Repeated attack  dilatation and thickening lymph
vessel  lymphedema  cronic: fibrosed, hyperplasia
connct. tissue , infiltration inflammation cells 
thickening and verrucous changes of the skin
(elephantiasis).
• Affected lymph tissue: axilla, inguinal, epitrochlear,
pelvic nodes, testis, epididymis , breast.
Clinical manifestation
• Acute stage (asymptom or symptom)
– systemic  repeated fever in 1-2 days, reduce at day 2-5 (filarial
fever)
– local  depend on the location of the adult worm: lymphadenitis,
lymphangitis (genital male: funiculitis, epidydimitis, orchitis,
swollen of scrotum; limbs)
• Chronic stage (lymphedema (early) and
elephantiasis)
– Depend on the species and location of the adult worm
 bancroftian : genital & limbs;  brugian : limbs
 note :
not all of the acute stage develop to become an elephantiasis
 – hydrocoele : lymph fluid in tunica vaginalis caused
by repeated inflamation  scrotal elephantiasis
– Chyluria : Lymph fluid in urine  caused by rupture of
unirary tract lymph. varices
– Stages of lymphedema
• Stage I : pitting oedema
• Stage II: non pitting oedema, not skin changes yet
• Stage III: non pitting oedema, verrucous changes of skin
• Stage IV: III + warty skin

• Occult filariasis
Human filariasis with immuno-hyperresponsive
reaction  >>mif. destructed  main symptom :
Hypereosinophilia,  IgE , mif. in the tissue-not in
the blood, respiratory interference.
Normal Urin Chilury before Chilury after
centrifugated centrifugated
Acute stage
• lymphedema,
inguinal
lymphadenopathy,
and hydrocele
 Chronic stage

Bancroftian filariasis Brugian filariasis

 Extreme elephantiasis of all four limbs and scrotum

courtesy Dr. John F. Kessel, adopted from

http://images.search.yahoo.com/search/images?_adv_prop=image&fr=yfp-t-501&va=elephantiasis&sz=all
Diagnose
Clinical manifestation
Laboratory
• Found microfilaria in the blood  periodicity
– Fresh blood
– Thick blood sample
– Consentration: membrane filtration
• Found macrofilaria in attached lymph nodes
– ultrasonography (filarial dance sign)
Newest methods
• Detection of antigent  ICT
(Immunochromatographic test)
• Detection of DNA in RBC & mosquito  PCR
 Differential Diagnose
• ADLA episodes from bacterial infections
• lymphedema due to congenital anomalies of the
lymphatics
• secondary lymphedema resulting from
malignancy of pelvic structures, irradiation or
surgical excision
• damage of the lymphatics due to podoconiosis
(due to the absorption of silica particles from the
soil)

ADLA: acute dermato-lymphangio-adenitis

 Specific Therapy
• Individual:
– DEC 6mg/ kg BW 3x/day for 12 days (standart dose)
– Side effect: fever, nousea, dizzy
• MDA:
– DEC (6mg/ kg BW) + Albendazole (400mg) yearly single
dose for 5-6 years (based on reproductive lifespan of
parasite)  successful for reduce the transmission
– DEC salt containing 0,2-0,4 % DEC for 2 years
DEC : diethylcarbamazine citrate
MDA : mass drug administration
SIDE EFFECT OF DRUG THERAPY
• CAUSED BY:
– Pharmacologic effect
– Response to the death of micro/macrofilaria
• Depend on the species and density of mf
• Malayi > Bancrofti
Manifestation of side effect
reaction
• Systemic (in the first day)
– Headache, dizzy, fever, nausea, vomit, anorexia,
malaise, muscle/ joint pain
• Local (if occur, is about 1-3 weeks after
treatment)
– Lymphadenitis, lymphangitis,
adenolymphangitis, funiculitis, epidydimitis,
orchitis, abscess, ulcer, lymphedema
Level Symptom

Light Fever, dizzy, headache, muscle/ joint pain, nausea,

vomit, anorexia

Moderate Diarrhea, eritheme, urticaria, lymphadenitis,

lymphangitis, adenoplymphangitis, subcutan nodule,
abscess, orchitis, orchalgia, epididymitis, funiculitis

Hard Asma brochiale, angioedema, icterus, colestasis,

epistaxis

Life threaten Anaphylactic shock, laryng spasme

Control Programme
WHO  GPE of LF (2020)
• Reduce or interrupt the transmission
– chemotherapy to reduce microfilaremia (MDA); vector control;
reducing contact vector-human
• Reduce the suffering
• To alleviate the pain from an acute attack/
infammatory episode :
– A cool compress around the affected organ/ medication
approaches: analgesic and antipiretic
– Elevate, exercise, skin care of the affective limbs
• Taking care the affected organ (elephantiasis):
– Antibiotics for secondary infection
– Washing with soap the affected organ (every day)
– To take care the wound
Caring of the elephantiasis patient on the affected limbs to prevent the secondary infection.
(adopted from http://tettystak.files.wordpress.com/2008/04/kaki-gajah-1.jpg)
Reference
• David, T.J and A.P. Williams , 2006. Markell
and Voge’s Medical Parasitology. 9th ed.
Saunders Elsevier. USA.
• Depkes RI, 2007. Pedoman Pengobatan
Dasar di Puskesmas. Jakarta.
• Kemenkes RI, 2010. Rencana nasional
Program Akselerasi Eliminasi Filariasis di
Indonesia. Jakarta.