BANCROFTIANFILARIASISRumala MorelDepartment of ParasitologyPeradeniyaY3S2
South East Asia - ½ the global burden
1.Describe the geographical distribution in SL2.Describe the pathogenesis & clinical features3.Evaluate the laboratory met...
Distribution of Bancroftianfilariasis in Sri LankaConfined to urbanizedcoastal belt:3 provinces - 9.5 million(50% of SL po...
life span 7-16 yrsRevision of Life Cycle
Immunopathogenesis:as yet unclear, associated withlocation of adult worms in lymphaticsBasic lesionDilatation of lymphatic...
PATHOLOGYAdult worms induceendothelial cell proliferationlymphatic dilatationDeath of adult worms – antigen leakageformati...
Pathogenesis of lympoedemaAcute Dermatolymphangioadenitis[ADLA]LymphoedemaPitting [Grade 1]Non pitting [Grade 2]Elephantia...
Death of adult worm causesgranuloma formationObliterative peri/endolymphangitisin dilated lymphatics
Clinical – ACUTE FILARIASIS1. Acute Filarial Lymphangitis [AFL] Due to death of adult worms Mild Residual lymphoedema -...
•Clinical – CHRONIC FILARIASISLymphangiectasiaDue to adult wormslymphoedemaelephantiasisMales: hydrocoele11rybacterial& fu...
Non pitting[Grade 2]Pitting oedema[Grade 1]Lymphoedema
Elephantiasis[Grade 3]
Clinical manifestations of lymphoedemadepend on site of obstructionlympoedema –Grade 1- pittingGrade 2- non pittingGrade 3...
CLINICAL MANIFESTATIONS INMALE GENITALIA- acute funiculitis- acute epididymo – orchitis- hydrocoele-Scrotal elephantiasis,...
Tropical Pulmonary Eosinophilia - TPEOCCULT FILARIASIScommon in India, Sri LankaPathogenesis: immune destruction of mf in ...
X’ray- broncho vascular markings serum IgE levels (> 1000 kU/L)filarial Ag/Ab+peripheral blood mf - veandclinical res...
Bilaterally diffusemilliary nodulesTropical Pulmonary Eosinophilia- TPEOCCULT FILARIASISANTI-FILARIAL TREATMENTDiethylcarb...
Clinical manifestations in endemic areasmf +subclinicallymphangiectasiabut non reversible40% kidneydamagemf +/-AFD-filaria...
Laboratory Diagnosis of Filariasis:Direct- detection of microfilaria in bloodThick film- 10pm-2 am (20-60µl)wet mount/ sta...
Useful in occult filariasis - TPEIndirect immunofluorescent test- IFA/FAT ELISA (enzyme linked immunosorbent assay)Dis...
Now WHO recommends :-www. who.int. lymphatic_filariasis/epidemiologyAntigen detectionImmunochromatographic [ICT] cardtest...
Antigen detection strip (card) tests- RDTsSample origin(whole bloodserum/plasma)polyclonal Ab+ colloidal goldMabW bancroft...
A. Ultrasound scan – scrotum – filarial dance signB. Radionucleotide lymphoscintigraphy- assessment of lymphatic damageIma...
The Global Programme to EliminateLymphatic Filariasis (GPELF) - 2000--• Global Alliance to Eliminate Lymphatic Filariasis ...
RAGFIL: Rapid Assesment of Geographical distribution ofbancroftian FILariasis. - Map endemic foci of lymphaticfilariasis -...
Filariasis in Sri Lanka-1937-39: Brugia malayi predominant1947: Anti Filariasis Campaign1960’s: Brugian filariasis eradica...
Filariasis control in Sri LankabyAnti Filariasis CampaignVector control: prevent mosquito breedingclear drains, cess pits...
started in Oct/1999 in SLcovering endemic area-3 provinces.In 2004 - coverage 80% compliance 71% (WHO)Exclude infants & ...
Motivate & train pts & care givers on :-washingelevation preventing & treating entry lesions-topical antibiotics & anti...
Washing with soapProper footwear
1. Regarding lymphatic filariasisA. Adult worms block lymphaticsB. Wucheraria bancrofti microfilaria show nocturnal period...
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Filariasis clinical

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Filariasis clinical

  1. 1. BANCROFTIANFILARIASISRumala MorelDepartment of ParasitologyPeradeniyaY3S2
  2. 2. South East Asia - ½ the global burden
  3. 3. 1.Describe the geographical distribution in SL2.Describe the pathogenesis & clinical features3.Evaluate the laboratory methods of diagnosis4.Name the antifilarial drug(s) used in Sri Lanka5.State the principles underlying the prevention and control6.Describe the preventive and control measures used in theNational Filariasis Control Programme in Sri LankaOBJECTIVES - Bancroftian filariasis
  4. 4. Distribution of Bancroftianfilariasis in Sri LankaConfined to urbanizedcoastal belt:3 provinces - 9.5 million(50% of SL population)exposedinland foci:Gampaha,WarakapolaVeyangoda
  5. 5. life span 7-16 yrsRevision of Life Cycle
  6. 6. Immunopathogenesis:as yet unclear, associated withlocation of adult worms in lymphaticsBasic lesionDilatation of lymphatics = LymphangiectasiaGranuloma(host inflammatory reaction)Not due to blockage by adult worm
  7. 7. PATHOLOGYAdult worms induceendothelial cell proliferationlymphatic dilatationDeath of adult worms – antigen leakageformation of granulomatous nodulesactivation of host inflammatory responsesObliterative peri/endolymphangitis in dilatedlymphaticsEpisodes of ACUTE FILARIAL LYMPHANGITIS [AFL]Lymphangiectasia = dilated lymphaticsImpairs lymphatic functionPredisposes to bacterial & fungal infectionsACUTE DERMATOLYMPHANGIOADENITIS [ADLA]leads to CHRONIC LYMPHOEDEMA
  8. 8. Pathogenesis of lympoedemaAcute Dermatolymphangioadenitis[ADLA]LymphoedemaPitting [Grade 1]Non pitting [Grade 2]Elephantiasis [Grade 3]Obstruction &Dilatation of lymphaticsGranulomaDeath of adult wormsAcute Filarial Lymphangitis [AFL]11ry bacterial & fungal infectionsRepeated attacks ofADLANo mechanical blockage by worms
  9. 9. Death of adult worm causesgranuloma formationObliterative peri/endolymphangitisin dilated lymphatics
  10. 10. Clinical – ACUTE FILARIASIS1. Acute Filarial Lymphangitis [AFL] Due to death of adult worms Mild Residual lymphoedema - rare2. Acute Dermatolymphangioadenitis [ADLA] Due to 11ry bacterial infections in limbs withcompromised lymphatics 2-6 attacks / year Diffuse subcutaneous inflammation & oedemaMales - acute funiculitis- acute epididymo – orchitisExtra lymphatic disease - filarial monoarthritis - KJ- filarial fevers
  11. 11. •Clinical – CHRONIC FILARIASISLymphangiectasiaDue to adult wormslymphoedemaelephantiasisMales: hydrocoele11rybacterial& fungalinfections11ry bacterialinfectionsRecurrent ADLA&
  12. 12. Non pitting[Grade 2]Pitting oedema[Grade 1]Lymphoedema
  13. 13. Elephantiasis[Grade 3]
  14. 14. Clinical manifestations of lymphoedemadepend on site of obstructionlympoedema –Grade 1- pittingGrade 2- non pittingGrade 3- elephantiasislymph leakage into urinary tract-chyluria(obstruction in cisterna chyli)lymph leakage intoperitoneal cavitychylous peritonitisCommon siteslimbsgenitaliabreastKidney damage: proteinuria & /or haematuria
  15. 15. CLINICAL MANIFESTATIONS INMALE GENITALIA- acute funiculitis- acute epididymo – orchitis- hydrocoele-Scrotal elephantiasis,-lymph scrotum(skin vesicles)
  16. 16. Tropical Pulmonary Eosinophilia - TPEOCCULT FILARIASIScommon in India, Sri LankaPathogenesis: immune destruction of mf in lungsdue to host responseto human mf / mf of animal filariaEosinophilic granulocytes in lung
  17. 17. X’ray- broncho vascular markings serum IgE levels (> 1000 kU/L)filarial Ag/Ab+peripheral blood mf - veandclinical response to diethylcarbamazineDiagnostic criteria for TPEClinical Syndrome: cough, bronchospasm (worse at night)With eosinophila >3000/µl& history of exposure to lymphatic filariasisBilaterally diffusebronchopneumonia.Early treatment canprevent interstitialfibrosis
  18. 18. Bilaterally diffusemilliary nodulesTropical Pulmonary Eosinophilia- TPEOCCULT FILARIASISANTI-FILARIAL TREATMENTDiethylcarbamazine 6mg/kg tds3 weeks
  19. 19. Clinical manifestations in endemic areasmf +subclinicallymphangiectasiabut non reversible40% kidneydamagemf +/-AFD-filarial feverslymphangitislymphadenitisCFD-chronicobstructive mf -TPEAsymptomatic Symptomaticmf - veFilarial Ag +/-Ab +OccultfilariasisAFD = Acute Filarial DiseaseCFD = Chronic Filarial Disease
  20. 20. Laboratory Diagnosis of Filariasis:Direct- detection of microfilaria in bloodThick film- 10pm-2 am (20-60µl)wet mount/ stain GiemsaNot sensitive!Concentration-•Knott’s method (old)•Membrane filtration- pore size 5µmDetection of adults in biopsy- rareIndirect1. Circulating Filarial Antigen [CFA] - BEST daytime2. Filarial Specific Antibody – won’t differentiatefrom past infection
  21. 21. Useful in occult filariasis - TPEIndirect immunofluorescent test- IFA/FAT ELISA (enzyme linked immunosorbent assay)Disadvantage: Can’t diagnose acutelymphatic disease.Antibodies long lasting. May be past infection.Detection of filarialantibodies in serum
  22. 22. Now WHO recommends :-www. who.int. lymphatic_filariasis/epidemiologyAntigen detectionImmunochromatographic [ICT] cardtest high sensitivity [100% sensitive in mf +ves ] high specificity 100 μl of fingerprick blood drawn at any time, dayor night.simple, no equipment required quick results <15 min
  23. 23. Antigen detection strip (card) tests- RDTsSample origin(whole bloodserum/plasma)polyclonal Ab+ colloidal goldMabW bancroftiT Cabsorbent padtest controlImmunochromatographic [ICT] card testDetects specificcirculating W bancrofti Agin serum/whole bloodusing monoclonal antibody
  24. 24. A. Ultrasound scan – scrotum – filarial dance signB. Radionucleotide lymphoscintigraphy- assessment of lymphatic damageImaging techniques
  25. 25. The Global Programme to EliminateLymphatic Filariasis (GPELF) - 2000--• Global Alliance to Eliminate Lymphatic Filariasis - 2000– public-private partnership– WHO & national Ministries of Health,– Private drug companies donating albendazole & ivermectin(Mectizan®)– NGOs• 1 billion at risk population• > 120 million people are already infected• > 40 million incapacitated or disfigured
  26. 26. RAGFIL: Rapid Assesment of Geographical distribution ofbancroftian FILariasis. - Map endemic foci of lymphaticfilariasis - to decide on mass treatment programs.>60%
  27. 27. Filariasis in Sri Lanka-1937-39: Brugia malayi predominant1947: Anti Filariasis Campaign1960’s: Brugian filariasis eradicatedcontrol of larval breedingresidual action of DDT on adultstreatment with DECBancroftian filariasis is the ONLY lymphaticfilariasis in SL now
  28. 28. Filariasis control in Sri LankabyAnti Filariasis CampaignVector control: prevent mosquito breedingclear drains, cess pits, sealing of septic tankslarviciding with insecticides, larvivorous fish Selective treatment of mf + cases2-weeks diethylcarbamazine [DEC] (6 mg/kg) Mass Drug Administration- eradicate parasite bykilling mf and disrupting transmission - continued for 4-5 yearsMOST EFFECTIVEMorbidity control – disability management training
  29. 29. started in Oct/1999 in SLcovering endemic area-3 provinces.In 2004 - coverage 80% compliance 71% (WHO)Exclude infants & pregnant femalesPregnancy- treat 1 month after deliveryMf + and clinical filariasis treated with full course DECEffect on intestinal geohelminths– Gunawardena NK et al - Ceylon Med J. 2008 Mar;53(1):13-6Treat all persons in endemic areas withDiethylcabamazine [DEC] +albendazoleannuallyMass Drug Administration-
  30. 30. Motivate & train pts & care givers on :-washingelevation preventing & treating entry lesions-topical antibiotics & antifungals using proper footwearWHO morbidity control strategyCommunity Home Based CarebyFilariasis Morbidity Control Clinics
  31. 31. Washing with soapProper footwear
  32. 32. 1. Regarding lymphatic filariasisA. Adult worms block lymphaticsB. Wucheraria bancrofti microfilaria show nocturnal periodicityC. Immunochromatographic card test is used to detectcirculating filarial antigensD. Secondary bacterial infections are importantco-factors in pathogenesisE. Treatment is with diethylcarbamazine [DEC]True BCDEMCQ

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