Filariasis

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Filariasis
Life cycle of Wuchereria bancrofti, a parasite that causes filariasis
Classification and external resources
Specialty	Infectious disease
ICD-10	B74
ICD-9-CM	125.0-125.9
Patient UK	Filariasis
MeSH	D005368
[edit on Wikidata]

Filariasis (or philariasis) is a parasitic disease caused by an infection withroundworms of the Filarioidea type.^[1] These are spread by blood-feeding black flies and mosquitoes. This disease belongs to the group of diseases called helminthiasis.

Eight known filarial nematodes use humans as their definitive hosts. These are divided into 3 groups according to the niche within the body they occupy:

• Lymphatic filariasis is caused by the worms Wuchereria bancrofti, Brugia malayi, and Brugia timori. These worms occupy the lymphatic system, including the lymph nodes; in chronic cases, these worms lead to the disease elephantiasis.
• Subcutaneous filariasis is caused by Loa loa (the eye worm), Mansonella streptocerca, and Onchocerca volvulus. These worms occupy thesubcutaneous layer of the skin, in the fat layer. L. loa causes Loa loafilariasis, while O. volvulus causes river blindness.
• Serous cavity filariasis is caused by the worms Mansonella perstans andMansonella ozzardi, which occupy the serous cavity of the abdomen.

The adult worms, which usually stay in one tissue, release early larval forms known as microfilariae into the host's bloodstream. These circulating microfilariae can be taken up with a blood meal by the arthropod vector; in the vector, they develop into infective larvae that can be transmitted to a new host.

Individuals infected by filarial worms may be described as either "microfilaraemic" or "amicrofilaraemic", depending on whether microfilariae can be found in their peripheral blood. Filariasis is diagnosed in microfilaraemic cases primarily through direct observation of microfilariae in the peripheral blood. Occult filariasis is diagnosed in amicrofilaraemic cases based on clinical observations and, in some cases, by finding a circulating antigen in the blood.

Signs and symptoms

The most spectacular symptom of lymphatic filariasis is elephantiasis—edema with thickening of the skin and underlying tissues—which was the first disease discovered to be transmitted by mosquito bites.^[2] Elephantiasis results when the parasites lodge in the lymphatic system.

Elephantiasis affects mainly the lower extremities, while the ears, mucous membranes, and amputation stumps are affected less frequently. However, different species of filarial worms tend to affect different parts of the body; Wuchereria bancroftican affect the legs, arms, vulva, breasts, and scrotum (causing hydrocele formation), while Brugia timori rarely affects the genitals.^{[citation needed]} Those who develop the chronic stages of elephantiasis are usually amicrofilaraemic, and often have adverse immunological reactions to the microfilariae, as well as the adult worms.^[2]

The subcutaneous worms present with rashes, urticarial papules, and arthritis, as well as hyper- and hypopigmentationmacules. Onchocerca volvulus manifests itself in the eyes, causing "river blindness" (onchocerciasis), one of the leading causes of blindness in the world.^{[citation needed]} Serous cavity filariasis presents with symptoms similar to subcutaneous filariasis, in addition to abdominal pain, because these worms are also deep-tissue dwellers.

Cause

Human filarial nematode worms have complicated lifecycles, which primarily consists of five stages. After the male and female worms mate, the female gives birth to live microfilariae by the thousands. The microfilariae are taken up by thevector insect (intermediate host) during a blood meal. In the intermediate host, the microfilariae molt and develop into third-stage (infective) larvae. Upon taking another blood meal, the vector insect injects the infectious larvae into the dermis layer of the skin. After about one year, the larvae molt through two more stages, maturing into the adult worms.

Diagnosis

Filariasis is usually diagnosed by identifying microfilariae on Giemsa stained, thin and thick blood film smears, using the "gold standard" known as the finger prick test. The finger prick test draws blood from the capillaries of the finger tip; larger veins can be used for blood extraction, but strict windows of the time of day must be observed. Blood must be drawn at appropriate times, which reflect the feeding activities of the vector insects. Examples are W. bancrofti, whose vector is a mosquito; night is the preferred time for blood collection. Loa loa's vector is the deer fly; daytime collection is preferred. This method of diagnosis is only relevant to microfilariae that use the blood as transport from the lungs to the skin. Some filarial worms, such as M. streptocerca and O. volvulus, produce microfilarae that do not use the blood; they reside in the skin only. For these worms, diagnosis relies upon skin snips, and can be carried out at any time.

Concentration methods

Polymerase chain reaction (PCR) and antigenic assays, which detect circulating filarial antigens, are also available for making the diagnosis. The latter are particularly useful in amicrofilaraemic cases. Spot tests for antigen^[3] are far more sensitive, and allow the test to be done any time, rather in the late hours.Various concentration methods are applied: membrane filter, Knott's concentration method, and sedimentation technique.

Lymph node aspirate and chylus fluid may also yield microfilariae. Medical imaging, such as CT or MRI, may reveal "filarial dance sign" in chylus fluid; X-ray tests can show calcified adult worms in lymphatics. The DEC provocation test is performed to obtain satisfying numbers of parasites in daytime samples. Xenodiagnosis is now obsolete, and eosinophilia is a nonspecific primary sign.

Treatment

The recommended treatment for people outside the United States is albendazole (a broad-spectrum anthelmintic) combined with ivermectin. A combination of diethylcarbamazine and albendazole is also effective.^[4] All of these treatments are microfilaricides; they have no effect on the adult worms. Different trials were made to use the known drug at its maximum capacity in absence of new drugs. In a study from India, it was shown that a formulation of albendazole had better anti-filarial efficacy than albendazole itself.^[6]

In 2003, the common antibiotic doxycycline was suggested for treating elephantiasis.^[7] Filarial parasites have symbiotic bacteria in the genus Wolbachia, which live inside the worm and seem to play a major role in both its reproduction and the development of the disease. Clinical trials in June 2005 by the Liverpool School of Tropical Medicine reported an eight-week course almost completely eliminated microfilaraemia