Filaria

PRESENTED
BY
DEEPA DHUNGANA
B.SC.MLT 3RD YR
LACHS/JFIHS
 Contents
 Introduction
 Classification
 History
 Geographical distribution
 Habitat
 Morphology
 Life cycle
 Pathogenesis
 Clinical manifestation
 Laboratory diagnosis
 Treatment
 prophylaxis
 Introduction

Filarial nematodes belong to the super family

Filarioidea.

Adults worms are thread like nematodes & they have

a simple mouth which is circular or slightly
elongated dorsiventrally & surrounded by papillae.

They live in lymphatics, subcutaneous tissues,

connective tissues, muscles and body cavities of host.
Female adult worms are viviparous i.e. lay larvae not
eggs. They multiply sexually by producing larvae (1st
stage) which are called microfilariae.

Humans are the key definitive hosts of the filarial

worms.

Filarial worms are transmitted through the bite of

arthropod hosts.
The disease produce by the filarial worm depends on
the tissues inhabited by the adult worms &
microfilariae.
 Chyluria
 Lymphatics filariasis
 Occult filariasis
Periodicity

The biological property of microfilariae to be

present in the peripheral blood circulation during a
particular period in the day or night.
 Classification

According to the habitat of the adul worm, human

filarial infection are classified as
s
1) Lymphatics filariasis 2)Subcutaneous filariasis
- Wuchereria bancrofti - Loa loa
-Brugia malayi - Onchocerca volvulus
-Brugia timori - Mansonella streptocerca
3)Serous cavity filariasis
-Mansonella perstans
- Mansonella ozzadi

 Microfilariae of these filarial worms can be grouped

on the presence or absence of sheath as sheathed or
unsheathed microfilariae.
 Wuchereria bancrofti

Common name is Bancroftᶦs filarial worm.

History
Demarquay (1963) first described the microfilariae
in the hydrocele fluid.

Later Wucherer (1866)in Brazil described the

microfilariae in the chylous urine & lewis (1872)
found them in the human peripheral blood.
Bancroft (1876-77) first demonstrated the adult
females& Sibthorpe (1888) first found the adult
males.

Manson (1878) first demonstrated the culex

mosquitoes as the intermediate hosts & also
described the nocturnal periodicity of the
microfilariae in the peripheral blood.
Geographical distribution
Wuchereria bancrofti is mainly confined to the
tropics & sub tropics.

In India, it is distributed along the sea coast & also

along the the banks of big river.
Habitat
Adult filarial worms are found in the lymphatic vessels
especially in the lymph nodes of the humans & other
vertebrates.

Microfilariae are found in the peripheral blood.

Occasionally, these are also found in the chylous ,urine

or in hydrocele fluid.
 Morphology

Adult, microfilaria(1st stage larvae) & third stage larvae are

the important morphological forms of W. bancrofti.

1) Adult worms
 Size; male : 2.5-4 cm length x0.1 mm thick
female;8-10cm length x 0.2-0.3mm thick

 Are transparent, long ,hair like structures.

 Often creamy white in colour.

 Are filiform in shape & both ends are tapering.

 Tail end of male is curved ventrally & contains two spicules

of unequal length, while that of female is straight.

 Males and females remain coiled together & it is difficult to

separate them.

 Female is viviparous.

 The life span of adult worms is several years(5-10 yrs).

Microfilariae
The first stage larva is called microfilaria & are found
in the peripheral blood & often in the hydrocele fluid
& chylous urine.

Are colourless & transparent with blunt heads &

pointed tails in unstained specimen.

The embryo measures about 290μmin length & 6-7

μm in breadth.
When dead & stained with Romanowsky stain, the
embryo shows following pecularities.

1)Covered by hyaline sheath

The larva moves backward &forward within this
this sheath which projects at both the ends of the
microfilariae.

2)Cuticula lined by subcuticular cells.(seen only with

vital stains)
3)Somatic cells or nuclei
-Appears as granules in the central axis of the body &
extend from the head to the tail end.

- Granules do not extend up to the tip of the tail &

serves as distinguishing features of bancrofti.

- Cephalic space devoid of granules at anterior end is

as long as it is broad.
4)Granules are broken at definite places serving as the
landmark for identification of the species & include nerve
ring , excretory pore, excretory cells, gulls & anal pores.

5)A few G cells (so called genital cells)

 The larval forms do not undergo any further development

in human body unless they are taken up by their
appropriate intermediate host(mosquito).

 Its life span in human body is 70 days.

Infective form
Third stage larva (L3) is the infective form of the
filarial worm for humans.

Is found only in mosquito vectors.

Is elongated, filariform & measures1,500μm to

2,000 μm in length & 18 μm to 23 μm in breadth.
 Life cycle

W. bancrofti passes its life cycle in two hosts ; i.e

definitive host & intermediate host.

Definitive host
-man

Intermediate host
- mosquito (Culex, Anopheles & Aedes species)
 Stage in the development of microfilaria in the mosquito

Sheathed microfilariae ingested by mosquito during

its blood meal gather round the anterior end of the
stomach.

They cast of their sheaths quickly, penetrate the

gutwall within an hour or two & migrate to the
thoracic muscles where they rest & begin to grow.
In next 2 days, the slender, snake like organism
changes to a thick,short, sausage shaped form with a
short spiky tail, measuring 124 - 250μm in length by
10-17 μm in breadth (1st stage larva which posses a
rudimentary digestive tract )

In 3-7 days, larva grows rapidly ,moults once or twice

& at the end of these stage it measures 225-330 μm in
length by 15-30 μm in breadth (2nd stage larva)
On the 10 or 11th day, the metamorphosis becomes
complete; the tail atrophies to a mere stump & the
digestive system, body cavity & genital organs are
now fully developed.

This is the 3rd stage larva which measures 1,500 to

2,000 μm in length by 18 to 23 μm by breadth & 3
sub terminal caudal papillae (B. malayi has 2).
 At this stage ,it is infective to man and entres the proboscis
sheath of mosquito on or about the 14th day.

 1 Microfilaria give rise to 1 infective larva in the proboscis

sheath.

Note
The time taken for the complete development of microfilaria
in the mosquito varies from 10-20 days or more , depending
however on the atmospheric tempr , humidity & also to a
certain extent an the species of the mosquito.
 Entrance into man & development into adult worms

When the infected mosquito bites a human being,

the 3rd stage larvae are not directly injected into the
blood stream like malarial parasite but are deposited
on the skin near the site of puncture.

Later attracted by the warmth of the skin ,the larvae

either enters through the puncture wound or
penetrate through the skin on their own.
 3rd stage larvae after penetrating the skin , reach
lymphatics channels, settle down at some spot(inguinal,
scrotal or abdominal lymphatics) & begin to grow into
adult forms.

 In course of time, probably after a period of 5-18

months they become sexually mature.

 The male fertilizes the female & gravid females give

birth to larvae.
A new generation of microfilariae is emitted which
passes either through the thoracic duct or the right
lymphatic duct, to the venous system & pulmonary
capillaries & then to the peripheral circulation , thus
completing the cycle.

These microfilariae circulate in the blood for 6

months to 2 years & if not taken up by the mosquito
 Pathogenesis

 The pathogenic effects seen in Wuchereriasis (Bancrofts

filariasis) are produced by the adult Wuchereria, living or
dead.

 Living microfilariae circulating in the blood are not known to

produce any pathogenic effects except in soccult filariasis.

 Lesion in occult filariasis is caused by micro filariae & is

found not only in the lymph node but also in lungs, liver &
spleen.
There is massive eosinophilia,generalised lymph
node enlargement hepatospleno megaly, pulmonary
symptoms & absence of microfilariae.

The injurious influence excited by the adult worm &

developing larva on its host is an inflammatory
reaction of the lymphatic system, lymphangitis
which forms the basic lesion in the classical filariasis.
Feature Classical filariasis Occult filariasis

Developing worms & adults Microfilariae

cause

Acute inflammation An eosinophilic granuloma

Basic lesion followed by an epitheloid (allergic or hypersensitivity
granuloma surrounding rxn)
adult worm & afibrous scar

Lymphatic system Lymphatic system , lungs,

Organs involved (lymphatic vessel & lymph liver & spleen
nodes)

Present in blood Absent in blood but

Microfilariae present in affected tissues

Therapeutic No response to any drug Respond to

response diethylcarbamazine.

Serological test Complement fixation test Complement fixation test

not so sensitive highly sensitive
The metabolites of growing larvae in highly reacting
individuals may give rise to allergic manifestations
such as urticaria, fugitive swellings (raised painful,
tender, red areas of the skin at the extremities) &
lymphoedema.
Causes of lymphatic obstruction

Mehanical blocking of lumen by dead worms

which act as embolus.

Obliterative endolymphangitis; Endothelial

proliferation & inflammatory thickening of the walls
of lymphatic vessels
Excessive fibrosis of the lymphatic vessels caused by
the recurrent & repeated attacks of lymphangitis.

Fibrosis of afferent lymph nodes draining a

particular area.
Effect of lymphatic obstruction
Two types of condition are produced
1)Lymph varix
variosity of lymphatic vessels

2)Elephantiasis
hypertrophy of affected part
Tropical pulmonary
eosinophilia(TPE)
 Also called eosinophilic lung or Weingartens syndrome.

 This is a manifestation of occult filariasis & is characterized

by low fever,loss of weight, paroxysmal cough with scanty
sputum, dyspnoea& splenomegaly.

 Associated with a high level of serum IgE & filarial Abs.

Chest radiography shows increased broncho vascular
markings or diffuse miliary “mottling” in the lung
fields.

Microfilariae may be demonstrated in tissues

obtained by lung biopsy,although it is difficult to
identify the species in the tissue secretions.

This condition responds to diethyl carbamazin

(DEC) that acts on microfilariae.
 Pathogenic lesions in classical filariasis

1)Inflammation
periodic attacks of fever with lymphangitis which
are due to the result of sensitisation to metabolites of
the worm located elsewhere.

2)Dialation of lymphatics

3)Rupture of lymphagiovarix(small blood vessels may

rupture into the dialated lymphatics)
4)Obstruction in the chyle bearing vessels, thoracic
ducts ( chylorrhagia)

5) Hyperplasia of skin & connective tissue leading to

elephantiasis of various parts.

6) Secondary bacterial infection ( with S. pyogen or

S.aureus) such as septic lymphangitis, abscesses &
septicaemia.
Lymphangitis
The parts usually involved are the lymphatics of the
testicle & epididymis, the lymphatics of spermatic
cord, abdominal lymphatics & the lymphatics of
upper & lower extremities.

Favourite site for the adults of W. bancrofti however

is the globus major of epididymis.
The visible lymphatic trunks appears as red
congested streaks in the superjacentskin.

On palpitation, they are found to be painful &

appears as cord like swellings.

An acute abdominal symptoms may arise as a result

of involvement of retroperitoneal lymphatics.
Causes of lymphangitis
Mechanical irritation inside the lymphatic system
caused by the movement of adult worm.

Absorption of toxic products liberated from dead

worms undergoing disintegration
Liberation of metabolites of growing larva in highly
reacting individuals & secretion of some toxic fluid
by the fertilised females at the time of parturition.

Bacterial infection (by streptococci )

Lymphadenitis
Inflammation of regional lymph nodes is a frequent
accompainmentor may precede an attack of
lymphangitis.

These are usually found in the groin & sometimes in

the axilla.
They appear as soft, more or less lobulated masses &
are often associated with other Wuchererial
manifestations.

The skin over the swelling is not adherent & unless

acutely inflammed, the swelling is not painful and
tender.
Filarial fever
Accompained by the rise of temperature ranging
from 103-104F which may continue for several days
(usually 3-5 days).

The fever is associated with a localising sign of

inflammation of the lymphatic vessel where the adult
worm lies.
sThe temperature comes down by the crisis with
profuse sweating.

Examination of blood often shows a transient

leucocytosis with an increased neutrophils or may
also reveal the presence of microfilariae.
Hydrocele
Most common feature.

Caused by the obstruction of the lymph vessel, the

spermatic cord & exduation from the inflammed
testes & epididymis.

Hydrocele fluid is typically amber in colour.

It consist of mesothelial cells,old blood clots,
fibrin ,cholesterol crystals & calcium particles.

Microfilariae of W. bancrofti may be found in the

fluid.

Adults worms can be demonstrated in the cord &

epididymal tissues.
Elephantiasis
Caused by the complex immune reaction of long
duration & repeated super infections over many years.

Hypertrophy & hyperplasia, seen in elephantiasis are

the result of excessive protein in the lymph exudate
stimulating the connective tissue to excessive growth.
Elephantiasis of legs result from the obstruction of
inguinal or iliac lymph nodes whereas of scrotum
results from obstruction of superficial inguinal
lymph nodes.

In it ,the overlaying skin of leg or scrotum becomes

thickened , fissured & warty.
s
The swelling at first is pitting but later becomes non
pitting.
The elephantoid mass consists of the fat in the
fibrous tissue.

Ulceration & secondary infections with bacteria or

fungi may occur.

Microfilariae usually are not demonstrated in the

peripheral blood.
Granuloma of female breast
 Caused by the adult worms present in the lymphatics of
breast or axilla.

 Characterized by the presence of a firm solitary mass in

the breast.

 Microscopically, they show eosinophils, histocytes & giant

cells in & around the degenerated microfilariae.
Chyluria
 Escape of chyle through urine due to rupture of
varicose chyle vessels through the mucous membrane
of the urinary tract.

 In it ,urine is milk white in colour & contains fat

particles , albumin & fibrinogen.

 Microscopical examination of sediment may reveal the

microfilariae, a few RBCs & lymphocytes.
 Clinical manifestation

Asymptomatic filariasis
These are cases of light infections.

Symptomatic filariasis
These can be divided into two phase.
-Inflammatory phase
-obstructive phase
Inflammatory phase
Characterised by lymphangitis & lymphadenitis.

Lasts for a few days, then subsides spontaneously &

recurs at irregular intervals for a period of weeks or
months.
Obstructive phase
Characterised by varicose lymph nodes, lymph
scrotum, hydrocele, chyluria& elephantiasis of
various parts.

The lesion results from progressive lymphatic

obstruction causing interference of lymph drainage.
These are found in sites where inflammatory rxn
have occurred previously.

The obstructive lesion takes a longtime to

develop ;may be 20 yrs.

The obstructive phase is punctuated by acute

inflammatory rxn.
 Laboratory diagnosis

Specimens
Peripheral blood is the specimen of choice.

Other lesser important specimens are chylous urine

& hydrocele fluid.
A)Blood microscopy
2 or 3 drops of peripheral blood are collected by
finger prick.

Blood is collected during the hours when a large no.

of microfilariae are found in the peripheral blood
circulation.
Nocturnal periodic W. bancrofti
Between 10PM & 4AM in night.

Subperiodic nocturnal periodic W. bancrofti

Between 8 PM & 10PM during night.

Subperiodic diurnal W. bancrofti

Between 2PM & 6PM in the afternoon.
 Microfilariae can be demonstratedin the blood by
following methods;

1. Direct wet mount

 2-3 drops of blood collected in a clean glass slide is
covered by coverslip & examined microscopically.

 Live microfilariae are identified by their characteristic

serpentine movement in blood.
2. Stained thick blood film smear
For demonstration of microfilariae, thick blood
smear stained with Giemsa or Leishman is the most
commonly used.

Presence of sheath but absence of the nuclei in the

tail of the microfilariae is diagnostic.
3.Concentration of blood
To increase the recovery of microfilariae, Knott
method & membrane filteration conc method using
nucleopore membrane filter or milipore membrane
filter are used.
B) DEC provocation test

This is a test in which diethyl carbamazine

(DEC) is given orally to stimulate nocturnal
periodic microfilariae to circulate in the
peripheral blood during the daytime.

It is recommended when night blood collection

is difficult or unacceptable to the population.
In this test, DEC is given orally at a dose of
2-8mg/kg body weight.

After 30min, the capillary blood is collected by finger

prick for demonstration of microfilariae by direct
wet mount or staining the blood smear.

The test is contraindicated in areas where Loa loa &

Onchocerca volvous infection are also found.
This method can frequently demonstrate the
circulating microfilariae in the blood.

Microfilariae are not found in the peripheral blood in

 Occult filariasis such as TPE.
 Chronic filariasis with cases of lymphatic obstruction
& obstructive lymphangitis.
C) Urine microscopy
Microfilariae can be demonstrated in the chylous
urine.

Usually 10-20ml of 1st early morning urine is

collected for examination & demonstration of
microfilariae by microscopy.
D) Microscopy of hydrocele fluid
& lymph node aspiration
Ether is used for hydrocele fluid to dissolve fat
globules .

Same method of examination is done as in urine

microscopy.
E) Immuno diagnosis
1.Serological test

a) Demonstration of circulating antibody

By indirect haemagglutination assay(IHA), indirect

fluorescent Ab test (IFA),enzyme linked immunosorbent
assay(ELISA), radio immuno assay (RIA) , luminescence
immuno assay ,etc
Disadvantage
Shows cross reactivity with sera from other filarial
& helminthic infection.

Are unable to distinguish between past & current

infection as the filarial Abs persist longer in the
circulationeven after clinical cure.
b) Demonstration of circulating antigen
 Circulating filarial Ags in the serum are present only during
recent or current infection.

 The Ag disappears from the circulation with clinical cure so

is absent in past infection.

 Therefore , is useful to distinguish between recent & past

infection.
Two monoclonal Ab based ELISA that detect
circulating filarial Ag in serum are available.

ELISA employing monoclonal Ab AD12 detect a

200KD Ag of adult W. bancrofti in the serum.

Other ELISA employing monoclonal Ab Og 4C3

detects adult W. bancrofti as well as micro filariae Ag
in serum.
ICT filariasis card test is a new & rapid filarial Ag
test that detects soluble W. bancrofti Ag in the serum
of infected humans.

Advantage
Blood can be collected during daytime for the
demonstration of Ag.
2. Cellular assay
Filarial skin test
Invitro lymphocyte responses to filarial Ags.

Disadvantage
 Assay is not specific.
F) Molecular methods
 PCR detect as low as 1pg of filarial DNA, which is nearly
1% of the DNA in one microfilariae,in patients blood.

 PCR is positive only when circulating microfilariae are

found in peripheral blood.

 Hence they are negative in case of chronic filariasis.

G) Imaging methods

1. X ray
Chest x ray shows diffuse pulmonary infiltrates in
patients with TPE.

X ray examination can detect dead & calcified worm.

2.Ultrasound
 Scrotal area is the only non invasive method for detection
of live adult worms in the affected lymph nodes.

 The live adult worms are identified by a distinctive

pattern of their movement known as filarial dance sign.

 Lymphatic obstruction of the inguinal & scrotal

lymphatics can be demonstrated.
H) Other test

 Biopsy of enlarged lymph nodes (adult worm)

Blood test (eosinophilia)

 Treatment

Diethyl carbamazine
1st day – 50mg after food
2nd day - 50mg three times daily
3rd day - 100mg three times daily
4-21th day - 5mg /kg/day in three divided doses

Ivermectin
Single oral dose of drug 150μg/kg body weight
 Prophylaxis

Destruction of mosquito.

Reducing rate of infection amongst insect vector.

 Treatment of carriers using hetrazan.

Protection against mosquito bites.

Feature W. bancrofti B.malayi

Length Larger (290μm x 7μm ) Smaller (230 μm x 6 μm )

Appearance Sweeping curve Kinky with secondary

curves

Cephalic space Length & breadth equal Twice long as well as

broad

Anterior end Single stylet present Double stylet present

Nuclear column Discrete nuclei 2 distinct nuclei ; one

terminal & sub terminal

Sheath Faintly stained Well stained

 Reference

Parasitology; KD Chatterjee ;13th edition

Textbook of medical parasitology; Subash Chandra

Parija; 2nd edition

Medical parasitology ; C P Baveja

Images ; internet source

Thank you !!