LIFECYCLE OF AGENTS OF FILARIASIS

Geographic VECTOR deposits L3 into bite Develop into adults that LIVE IN Adults produce that are And migrate to
Distribution wound microfilariae

FEMALES MALES
WUCHERERIA Tropical areas A. poecilus 80-100 mm x . 40 mm x .1 mm lymphatics 244-296um x 7.5- Sheathed  Lymph and blood
BANCROFTI Anopheles minimus var 24-.30 mm 10 um nocturnal activity (except S. Pacific
flavirostris: Mt. Prov., Sulu, creamy, white, long and filiform microfilariae)
Palawan tail pointed and clear
BRUGIA MALAYI Asia Aedes 43-55 mm x 13-23 mm x 70- lymphatics 177-230 um x 5-7 Sheathed lymph  blood
Mansonia 130-170 um 80 um um tail pointed with 2 nuclei streamperipheral blood
M. bonnae: freshwater
swamps
M. uniformis: rice fields
Night biters (5-11pm)
**cat-mosquito-man
LOA LOA Africa Chrysops 40-70 mm x . 30-34mm x . Subcutaneous tissue 250-300um x 6-8 Sheathed peripheral blood at day
African eye worm (day biting flies/ deer flies) 5mm 33-.43 mm um diurnal periodicity: lungs during
- day= peripheral blood. noncirculation phase
- Noncirculation phase=  also seen in spinal fluids,
lungs urine, sputum
tail blunt with nuclei
MANSONELLI Carribean, Central Culicoides 65-81mm x . unknown Subcutaneous tissue 250um x 6-7um Unsheathed and nonperiodic Blood stream
OZZARDI and South America (Midges) 21-.25mm Mesentery and visceral fat tail pointed and clear
Simulium (black flies)
MANSONELLA Africa and S. America Culicoides Body cavities (peritoneal, pleural, 200um x 6um Unsheathed and subperiodic Blood stream
PERSTANS (Midges) pericardium), connective tissues of tail blunt with nuclei
abdominal organs
MANSONELLA West and Central Culicoides Dermis, <1mm from skin surface Unsheathed and nonperiodic skin
STREPTOCERCA Africa (Midges) peripheral blood
ONCHOCERCIASIS Africa, M. East, C. and Simulium (black flies) wirelike, whitish, lie coiled within Subcutaneous and deeper tissues For ~9 years Unsheathed  peripheral blood, urine,
S. America fibrous tissue capsules Has lifespan ~2yrs sputum
skin and lymphatics of
connective tissue
 DISEASE CLINICAL PRESENTATION
WUCHERERIA Bancroftian filariasis  hydrocele and scrotal elephantiasis
BANCROFTI
BRUGIA MALAYI Malayan filariasis  Manifestations are caused by adult worms, living, dead, or degenerating
 Microfilariae cause less pathology but a/w TPE, granulomas of the skin, and allergic reactions following destruction by drugs

Asymptomatic stage
 Presence of thousands to millions of microfilariae in the peripheral blood and adult worms in the lymphatic system with no manifestations of filariasis
 Seen among those with a highly down regulated immune system
 May have hidden lymphatic pathology and kidney damage

Acute stage
 Early manifestations: Fever, inflammation of lymph glands (especially of the male genital organs, arms and legs)
 Recurrent attacks: Swelling and redness of the arms and legs accompanied by vomiting, headache
 S/sx reflect immunologic phenomenon caused by sensitization to the products of living or dead worms collectively called adenolymphangitis (ADL) or dermatolymphangitis (ADL) or
dermatolymphangioadenitis (DLA)

Chronic stage
 With repeated acute manifestations merge into a chronic proliferative overgrowth of fibrous tissue around the dead worms – lead to lymphatic obstruction, recurrent attacks of DLA and lymphedema,
elephantiasis, or hydrocoele
 Cellular reaction and edema are replaced by fibrous hyperplasia
 TPE (tropical pulmonary eosinophilia): occult filariasis
 Immunologic hyperresponsiveness to filarial infection characterized by nocturnal cough, wheezing, hypereosinophilia, elevated ESR, diffuse military lesions or increased vascular markings
 Chyluria- rupture of lymphatics in the kidney due to blockage of retroperitoneal lymph nodes
 Several reports of glomerulonephritis in bacroftian filariasis

 “Expatriate syndrome”: lymphadenitis and lymphangitis with allergic reactions such as hive, rashes and blood eosinophilia (infected after migration to endemic regions)
LOA LOA Loasis (same as onchocerciasis)
 often asymptomatic
 Episodic angioedema and sunconjunctival migration of an adult worm can occur
 Non painful migration through tissues
 Conjunctival edema; patches of localized subcutaneous edema (Calabar swellings)
 Eosinophilia
MANSONELLI OZZARDI  Asymptomatic
 Inguinal adenopathy has been reported
 Skin lesions, arthritis, fever, marked eosinophilia
 Pulmonary symptoms, adenopathy, hepatomegaly, and pruritus
MANSONELLA PERSTANS  Often asymptomatic, can be associated with angioedema, pruritus, fever, headaches, arthralgias, and neurologic manifestations
 Edema and inflammatory changes and granulomas form around dead filariae
 Eosinophilia
ONCHOCERCIASIS Onchocerciasi  Most worms become encapsulated -- nodules are produced
s  Onchocerciasis can cause pruritus, dermatitis, onchocercomata (subcutaneous nodules), and lymphadenopathies.  (skin nodules and progressive keratitis)
river blindness  The most serious manifestation consists of ocular lesions that can progress to blindness
 onchocercomas of the forearm skin, also called sowda, in a Sudanese man
 LABORATORY DIAGNOSIS OF FILARIASIS iv. Prepare a temporary wet mount by removing the filter and placing it on a glass slide, adding a drop of stain
A. Identification of adult worms or dye and a coverslip.
 from tissue samples: v. For permanent preparations, pass 2 to 3 ml of methanol through the filter while it is still in the holder;
o nodulectomies (onchocerciasis) remove filter and dry it on a glass slide; then stain it with Giemsa stain, horizontally (so that the filter does
o subcutaneous biopsies not wash off the slide); coverslip filter before examining.
o worm removal from the eye (loiasis)
B. Examination of blood samples to identify microfilariae  Comparison of microfilariae of W. bancrofti and B. malayi
 Blood sample can be a thick smear, stained with Giemsa or H&E  W. bancrofti B. malayi
 Finding of microfilariae in the blood as seen in wet or thick blood smears taken between 8 pm and 4am Mean length (µm) 290 222
(nocturnal periodicity – W. bancrofti) Cephalic space; breadth 1:1 2:1
 B. malayi microfilariae – subperiodic periodicity Sheath in Giemsa Unstained Pink
 For increased sensitivity, concentration techniques can be used:  Nuclei Regularly spaced, Irregularly spaced and
1. Knott's technique: Centrifugation of the blood sample lyzed in 2% formalin. Also used for low-intensity infection separately situated overlapping
2. Filtration through a Nucleopore® membrane.
Tail Single row of nuclei that Single row of nuclei that
 Examination of skin snips will identify microfilariae of Onchocerca volvulus and Mansonella streptocerca.  does not reach the tail’s reaches tail’s end
 Skin snips are obtained using a corneal-scleral punch, or a scalpel and needle.  ends
 Allow sample to incubate for 30 minutes to 2 hours in saline or culture medium, and then
Terminal nuclei None 2 nuclei which bulge the
examined for microfilariae that would have migrated from the tissue to the liquid phase of the specimen
cuticle, conspicuously
 DEC (diethylcarbamazine) provocative test stimulates microfilariae to come out to peripheral circulation
places
allowing blood smear collection even during daytime
Appearance in blood film Smoothly curved Kinky
C. Antibody detection - limited value
 Substantial antigenic cross reactivity exists between filaria and other helminths, and a positive serologic
test does not distinguish between past and current infection.
Periodicity: Fluctuation in numbers of microfilariae present in the peripheral blood during a 24 hour period
D. Antigen detection techniques to detect circulating filarial antigens (CFA)
1. Nocturnally periodic - species found in the blood ruing night-time hours but absent at other times
 useful in low and variable infection
e.g. W. bancrofti and B. malayi
 A rapid-format immunochromatographic test, applicable to Wuchereria bancrofti antigens, has been
2. Diurnally periodic: present only during certain daytime hours
recently evaluated in the field.
e.g. Loa loa
E. Molecular diagnosis using PCR
3. Nonperiodic or aperiodic: microfilariae that circulate in the blood throughout a 24 hour period without significant
 available for W. bancrofti and B. malayi. changes in their numbers
F. Ultrasonography, contrast lymphagiography and lymphscintigraphy e.g. Mansonia spp
 May demonstrate live worms in the lymphatics 4. Subperiodic: microfilariae normally present in the blood at all hours but whose density increases significantly during
 Contrast lymphangiography and lympscintigraphy using radiolabled albumin or dextran may either the night or day
demonstrate obstructed lymphatics There are two strains of B.malayi;
G. Special Procedures for Detecting Microfilariae (Blood microfilariae)  the nocturnal periodic strain which is widely distributed in Asia, the microfilariae being in their highest
1. Capillary (fingerstick) blood concentrations between the hours of 10pm and 2am, and
 Since microfilariae concentrate in the peripheral capillaries, thick and thin smears prepared from  the sub-periodic strain which is found in Malaysia, Indonesia and the Philippines where humans exhibit a
fingerstick blood are recommended. microfilaraemia all the time with the highest numbers being detected between noon and 8pm
2. Anticoagulated (EDTA) venous blood (1 ml) should be concentrated by one of the  following methods:
a. Centrifugation (Knott’s technique) – uses 2% formaldehyde Treatment
i. Prepare 2% formaldehyde (2 ml of 37% formaldehyde + 98 ml H2O).  Different drugs are recommended for the treatment of filariasis depending on the specific causal agent. 
ii. Mix 9 ml of this 2% formaldehyde with 1 ml of patient’s venous blood. 
 Diethylcarbamazine citrate (DEC) – drug of choice for bancroftian filariasis: 6 mkday orally for 12 days [given in
iii. Centrifuge at 500 × g for 10 minutes; discard supernatant.  Sediment is composed of WBCs and microfilariae
divided doses after meals]
(if present).
– Brugian filariasis – 3-6 mg per kg per day up to 36 to 72 mg/body weight
iv. Examine as temporary wet mounts.
 Ivermectin 200 to 400 ug/kg single oral dose – as effective as 12 days of DEC
v. Prepare thick and thin smears; allow to dry; dip in absolute methanol before Giemsa staining to enhance
staining of microfilariae.
Prevention and control
b. Filtration – uses membrane filter (Millipore® or Nucleopore® membrane filter)
 Goal for endemic communities: eliminate microfilariae in the blood to prevent transmission of disease by vectors
i. Place Millipore® or Nucleopore® membrane filter (5 µm pore) in filter holder with syringe attachment.
 Control of transmission:
ii. Mix 1 ml of venous blood (in EDTA) with 10 ml of 10% Teepol® 610 (Shell Co.); allow to stand for several
– Identification of endemic areas
minutes to allow lysis; transfer to a 10 ml Luer-Loc® syringe; attach the filter apparatus.
– Implementation of mass treatment programs using albendazole/DEC or DEC/ivermectin combination in
iii. Force the solution through the 5 µm pore filter, followed by several syringes of water to wash out the
areas where onchocercosis or loaiasis is prevalent
remaining blood, then 1 or 2 syringes full of air to clear excess fluid.
 Personal protective measures
 Vector control: dev’t sprays and polystyrene beads to seal latrines
 MORPHOLOGIC FEATURES OF MICROFILARIAE
WUCHERERIA BANCROFTI
 snake-like organisms  Central axis: shows dark staining nuclei; column of nuclei
 Enclosed in a hyaline sheath which is longer than the arranged in 2 or 3 rows and is distinctly conspicuous
microfilaria itself  Graceful appearance

 Thick blood smears stained with hematoxylin).    Microfilaria of Wuchereria bancrofti collected by filtration with a
 microfilaria is sheathed, body is gently curved, & tail is tapered to a Nucleopore® membrane. 
point.   The pores of the membrane are visible
 nuclear column (the cells that constitute the body of the microfilaria)
is loosely packed, the nuclei can be visualized individually and do not
extend to the tip of the tail
BRUGIA MALAYI
 Enclosed in a sheath and with angular curvatures with secondary kinks and 2 nuclei at the tail tip
 Column of nuclei is in 2 rows which are indistinct or confluent

[Thick blood smear (hematoxylin Via Knott’s technique  Tapered tail The tail of Brugia malayi showing
stain]: Note the clearly visible sheath that  subterminal and a terminal the sheath and the 2 distinct nuclei
Like W. bancrofti, this species has extends beyond the anterior and nuclei (seen as swellings at at the tip of the tail
a sheath (slightly stained in posterior ends of the microfilaria.  the level of the arrows),
hematoxylin). There are four sheathed species: separated by a gap without
unlikeWuchereria, the Wuchereria bancrofti, Brugia nuclei. 
microfilariae in this species are malayi, Brugia timori, and Loa loa.
more tightly coiled, and the
nuclear column is more tightly
packed, preventing the
visualization of individual cells.
Loa loa (right) and Mansonella perstans (left).  M.streptocerca
{thick blood smear stained with hematoxylin.}
 Mansonella perstans is smaller,  Loa loa is sheathed, with a  microfilaria is unsheathed, has a nearly straight body attitude
has no sheath relatively dense nuclear column;  tail is typically coiled into a “shepherd’s crook”
 blunt tail  tail tapers and is frequently  terminal nuclei extend as a single row to the end of the tail.
 nuclei extending to the end of coiled
the tail  nuclei extend to the end of the
tail
Mansonell ozzardi Onchocerca volvulus

(Giemsa stained)  from skin snip from a patient seen in Guatemala (Wet
 microfilaria is typically small, unsheathed preparation)
 slender, tapered tail that Is hooked ("buttonhook").  No sheath present;
 The nuclei do not extend to the end of the tail.  Tail is tapered and is sharply angled at the end