Lymphatic Filariasis / Elephantiasis Ali Bbdullah M. Al mareed الفيلاريا الليمفاوية / داء الفيل Ali Bbdullah M. Al mareed PhD student at KSU

وهو يصف المتلازمة التي تتضخم فيها الأرجل والذراعين والأعضاء التناسلية بصورة واضحة للعين إلى أحجام تشبه الأحجام في الفيل

مناطق وجود داء الفيل - الفيلاريا ويوجد المرض في أمريكا الجنوبية، وسط أفريقيا، وآسيا، وجزر المحيط الهادي، والكاريبي .

What is it ? Wuchereria bancrofti and Brugia malayi are filarial nematodes Spread by several species of night - feeding mosquitoes Causes lymphatic filariasis, also known as Elephantiasis Commonly and incorrectly referred to as “Elephantitis”

Definitive Host العائل النهائي Humans are the definitive host for the worms that cause lymphatic filariasis

Intermediate Host العائل المتوسط Anopheles Intermediate Host العائل المتوسط Aedes Transmitted by Culex, Aedes, and Anopheles species B.malayi is transmitted by Anopheles and Mansonia species. Culex Mansonia

Lymphatic Filariasis by the numbers Endemic in 83 countries 1.2 billion at risk More than 120 million people infected More than 25 million men suffer from genital symptoms More than 15 million people suffer from lymphoedema or elephantiasis of the leg

para-lab by l. wafa menawi Morphology I Adult: White and thread-like. Two rings of small papillae on the head. Female:5~10cm in length Male: 2.5~4cm and a curved tail with two copulatory spicules. para-lab by l. wafa menawi

para-lab by l. wafa menawi Morphology II Microfilaria: 177~296 µm in length, a sheath with free endings. Bluntly rounded anteriorly and tapers to a point posteriorly. A nerve ring with no nuclei at anterior 1/5 of the body. para-lab by l. wafa menawi Wuchereria bancrofti Brugia malayi

Characteristic of life cycle Host: Mosqutoes (intermediate host) Human (final host) Location: Lymphatics and lymph nodes Infective stage: Infective larvae Transmission stage: Microfilariae Diagnostic stage: Microfilariae

para-lab by l. wafa menawi Life cycle para-lab by l. wafa menawi

para-lab by l. wafa menawi Wuchereria Life Cycle para-lab by l. wafa menawi

أعراض الإصابة الحادة بداء الفيل هي: ارتفاع درجة الحرارة. ألم بالمنطقة أسفل الحوض وجود رعشة. وجود عرق. صداع وقيئ و آلام. تضخم بالغدد الليمفاوية.

قرح بالجلد. ألم بالعظام والمفاصل. شعور بالتعب. قد تحدث خطوط حمراء على الذراع أو الساق. قد تظهر خراريج Abscesses على الجلد أو بالغدد الليمفاوية.

Nocturnal periodicity Phenomen which the number of microfilariae in peripherial blood is very low density during daytime, but increase from evening to midnight and reach the greatest density at 10p.m to 2 a.m.May be related to cerebral activity and vasoactivity of pulmonary vessels.

para-lab by l. wafa menawi Larva deposited by mosquito bite Travel through dermis to lymphatic vessels Growth (approx 9 months) to mature worms(20-100mm long) Worms live 5-7 years (occasionally up to15 years) Mate->Microfilariae (1st stage larva) Females->release up to 10,000 microfilariae/day into bloodstream Microfilarie taken up by mosquito bite Develop into 2nd and 3rd stage larva over 10-14 days inside mosquito vector para-lab by l. wafa menawi

para-lab by l. wafa menawi Lymphatic System Network of vessels that collect fluid that leaks out of the blood into tissues (lymph) Redirects lymph back into the blood stream para-lab by l. wafa menawi

para-lab by l. wafa menawi Clinical Course Initially asymptomatic Symptoms develop with increasing numbers of worms Less than 1/3 of infected individuals have acute symptoms Clinical Course is 3 phases: Asymptomatic Microfilaremia Acute Adenolymphangitis (ADL) Chronic/Irreversible lymphedema Superimposed upon repeated episodes of ADL para-lab by l. wafa menawi 18

para-lab by l. wafa menawi Acute ADL Presents with sudden onset of fever and painful lymphadenopathy Retrograde Lymphangitis Inflammation spreads distally away from lymph node group Immune mediated response to dying worms Most common areas: Inguinal nodes and Lower extremities para-lab by l. wafa menawi 19

para-lab by l. wafa menawi Inflammation spontaneously resolve after 4-7 days but can recur frequently Recurrences usually 1-4 times/year with increasing severity of lymphedema Secondary bacterial infections in edematous(elephantatic) areas Filarial fever (fever w/o lymphangitis) Tropical Pulmonary Eosinophilia Hyperresponsiveness to microfilariae trapped in lungs Nocturnal Wheezing para-lab by l. wafa menawi

Chronic Manifestations Lymphedema Mostly LE and inguinal, but can affect UE and breast Initially pitting edema, with gradual hardening of tissues  hyperpigmentation & hyperkeratosis GenitaliaHydroceles para-lab by l. wafa menawi 21

Chronic Manifestations Renal involvement Chylurialymph discharge into urine Loss of fat and protein hypoproteinemia & anemia Hematuria, proteinuria from ?immune complex nephritis Secondary bacterial/fungal infections para-lab by l. wafa menawi

para-lab by l. wafa menawi Elephantiasis: accumulation of lymph in extremeties, fibrosis, and thickening of skin. para-lab by l. wafa menawi

Microfilariae are seen in blood smears and are DIAGNOSTIC para-lab by l. wafa menawi

Blood Smear - Microfilaria Note wavy microfilarial worm in the thick part of blood film. Dark blue structures are nuclei Tail end tapering (no nuclei) Sheath covering worm. para-lab by l. wafa menawi

Blood Smear - Microfilaria Note wavy microfilarial worm in the thick part of blood film. Head end of the worm – rounded (no nuclei) (Sheath is not clearly seen) para-lab by l. wafa menawi

Blood Smear - Microfilaria Note wavy microfilarial worm in the thick part of blood film. Dark blue structures are nuclei Tail end - tapering sheath (no nuclei) para-lab by l. wafa menawi

Hydrocele fluid – cell block. Note wavy microfilarial worms. Inflammatory cells – lymphocytes. Hemorrhagic fluid sediment para-lab by l. wafa menawi

Hydrocele fluid – cell block. Inflammatory cells – lymphocytes. RBC Microfilaria. para-lab by l. wafa menawi

Control As with malaria, the most effective method of controlling the spread of W.bancrofti and B.malayi is to avoid mosquito bites The CDC recommends that anyone in at-risk areas: Sleep under a bed net Wear long sleeves and trousers Wear insect repellent on exposed skin, especially at night

Vector control Covering water-storage containers and improving waste-water and solid-waste treatment systems can help by reducing the amount of standing water in which mosquitoes can lay eggs. Killing eggs (oviciding) and killing or disrupting larva (larviciding) in bodies of stagnant water can further reduce mosquito populations.

Treatment Treatment of filariasis involves two components: Getting rid of the microfilariae in people's blood Maintaining careful hygiene in infected persons to reduce the incidence and severity of secondary (e.g., bacterial) infections.

thank you for your attention AL mareed A.A PhD student at KSU