Filaria

Parasitology Department
Medical Faculty of USU
What is Filaria?
Threadlike worm

Filaria is devided 3;
based on their habitat
such as:
1. Lymphatic Filaria
2. Cutaneous Filaria
3. Body Cavity Filaria

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Lymphatic Filaria

Consist of:
Wuchereria bancrofti
Brugia malayi
Brugia timori

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EPIDEMIOLOGY

Endemic Countries

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 Papua,Maluku,
Jenis Kegiatan Sumatera Kalimantan Jawa Sulawesi Bali- NTB Indonesia
NTT
Jumlah Kab/Kota 139 55 116 70 18 73 471
Kab/Kota endemis 139 55 26 40 - 61 321
Kab/Kota Non endemis - - 25 - - - 25
Blm ditetapkan endemisitasnya 0 0 65 30 18 12 125

P2P: Filaria: Departemen kesehatan; laporan januari 2010

Wuchereria bancrofti

This worm is responsible for 90% of lymphatic filariasis

in the worldwide.

Vivipar;

Infective stage: Larvae st.3

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W. bancrofti
Morphology Cephalic space

Microfilaria:
Sheath (+)
Body
Cephalic space: Length = wide nuclei
(1:1)
Body Nuclei : Discrete (Regular)
Body curve: Smooth
Tail: No nuclei at the tip of the
tail

Tip of the tail

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W. bancrofti
Morphology

Adult worm:
Long-slender w/ smooth cuticle and bluntly rounded ends
The head is slightly swollen and bears two circles of well
defined papillae
The mouth is small and lack of buccal capsule
Males: 40mm long and 100m wide
Females: 6cm-10cm long and 300m wide

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W.bancrofti
Clinical Manifestations

Acute filariasis

Chronic filariasis

Atypical presentation

Asymptomatic carrier

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 W.bancrofti
Acute Manifestations

Characterised by recurrent attacks of fever associated with inflammation

of lymph nodes (adenitis) and /or lymph vessels (adenolymphangitis,
ADL)

Involvement of genitalia lymphatic in male funiculitis,

epididymitis or orchitis

Lasting for 4-5 days

Repeated episode important in the progression of disease

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 W.bancrofti
Acute Manifestations

Acute Filarial Lymphangitis

Cord-like structure with retrograde lymphangitis: painful,
red and tenderness
Systemic reaction mild, distal oedema rare
Recurrent at same site common

ADL with secondary bacterial infection

Most common form of ADL
Associated with fever, chills, myalgia and headache
Cellulitis and oedematous, subside after each attack
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W.bancrofti
Acute Manifestations

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W.bancrofti
Chronic manifestation

Major signs
Hydrocoele
Swelling of scrotum due to
collection of lymph fluid
Chyluria
Lymphoedema
elephantiasis

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W.bancrofti
Chronic manifestation

Major signs
Hydrocoele
Chyluria
Rupture of lymphatic lining
the bladder leading to
passage of lymph in the urine
May resolve spontaneously
Lymphocytes in urine
Lymphoedema
elephantiasis

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 W.bancrofti
Chronic manifestation

Major signs
Hydrocoele
Chyluria
Lymphoedema
Swelling due to collection of lymph
fluid in soft tissue
Pitting oedema, may or may not be
reversible
Thickened skin
elephantiasis

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W.bancrofti
Chronic manifestation

Major signs
Hydrocoele
Chyluria
Lymphoedema
Elephantiasis
Irreversible, non-pitting oedema with
fibrotic and verrucous skin changes
(thickening, folding, hyperkeratosis,
pigmentation, ulceration)
Skin & soft tissue infection common

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 Grading of lymphedema

Grade 1: reversible
pitting oedema

Grade 2: irreversible
pitting/non-pitting
oedema. Skin is
normal

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Grading of lymphedema

Grade 3: irreversible non-

pitting oedema. Skin is
thickened

Grade 4: non-pitting oedema

with fibrotic and verrucous
skin changes (elephantiasis)

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W.bancrofti
Chronic manifestation

Rarely develop before 15

Only a small proportion of filarial-infected population

affected

Immigrants tend to develop chronic manifestation more

often and sooner than indigenous people

Occurrence of major signs differ between places

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 Produk dari cacing dewasa
Parasit dewasa yang berada di
menyebabkan dilatasi pembuluh
pembuluh limfe
limfe

Antigen mengaktifkan sel T (

Disfungsi katup
dominan Th2)

Pelepasan sitokin Aliran limfe retrograde

Ekspansi klonal
Stimulasi sumsum Supresi fungsi Th1 limfedema
sel B
tulang

kecenderungan infeksi >>> Infeksi sekunder

Produksi IgE >>> eosinofilia

Eukasinoid Infeksi sekunder oleh bakteri

Peningkatan proses
proinflamasi atau jamur
inflamasi

Reaksi inflamasi Ekstravasasi cairan limfa ke

Reaksi granulomatosa untuk
berlanjut interstisial
membunuh parasit

edema
Kematian parasit

Berlangsung kronis
Meningkatkan reaksi inflamasi &
pembentukan granuloma

Perubahan kulit (fibrosis,

Proses penyembuhan meninggalkan pembuluh yang dilatasi, dindingnya verukosa, penebalan)
menebal, fibrosis, dan kerusakan struktur
elephantiasis
infeksi sekunder
Aliran limfe retrogarade
 ADLA PATHWAY AFL PATHWAY

Live adult worm in Dead adult worm in

lymphatic vessel lymphatic vessel

Induce granuloma
Secrete toxins formation

Lymphangiectasia Obstruction of lymph flow

(dilated lymphatic)
MICROBES
ENTER VIA AFL
LESIONS
ADLA (OEDEMA)
Rarely causes residual
lymphoedema: may be common
Common cause of filarial cause of filarial hydrocele
lymphoedema/ elephantiasis
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 Atypical presentation:
Tropical Pulmonary Eosinophilia (TPE)

Clinical
Cough, dyspnea, wheezing asthma-like.
Paroxysmal nocturnal cough
Diffuse mottling in chest x-ray

Laboratory
Hyper-eosinophilia
Increased eosinophilia
Elevated anti-filarial antibodies
Mf almost always absent

Clinical course
Rapid regression with DEC

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 Mechanism TPE

Microfilaria enzym (filarial gamma-glutaryl

transpeptidase) can induce TH2 (IL5) to
produce eosinophilia granule such as; EDN
(Eosinophil derived neurotoxin), ECP (Eos
Cationic protein) and MBP 2( major basic
protein)- damage lung epithelium - can
manifest airway hyper-responsive (AHR)
asthma like syndrome
Current opinion in pulmonary medicine, 2007, 13: 428-433
Asymptomatic Microfilaraemic

Microfilaraemic carrier

No sign and symptom of infection

Source of infection to others

Evidence of sub-clinical infections:-

40% with sub-clinical hematuria/proteinuria: low grade
renal damage. Complete reversal after clearing Mf
Lymphoscintigraphy: markedly dilated, tortuous
lymphatics and abnormal lymph flow
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The Endemic Normal

Residence in filarial endemic areas

Amicrofilaraemic
asymptomatic

May be infected and produce disease

Changing definition: depending on availability of improved diagnostic

methods: percentage dependence on sensitivity of diagnostic method used

Rationale for mass chemotherapy in elimination programme

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Diagnostic Methods

Microscopy for microfilaria

Serological methods
Antibody derection
Antigen detection assays

Imaging studies

Molecular techniques

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Microscopy for microfilariae

Specific but not sensitive dependence on

Timing of sampling - periodicity
DEC provocation low dose DEC prior to survey
Volume of blood
Increasing the volume of blood, increases the sensitivity concentration
techniques (Nucleopore membrane/Knotts concentration)
Infectious status
Pre-patent period
Dead parasite
Unisexual infection

Stained blood film - Giemsa

acridine orange staining (QBC)

Morphological characteristics

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Volume of blood: standardisation

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Serological Methods

Antigens derived from whole parasite difficulty in

standardization

Various format ELISA allows automation and batch

processing

Major difficulties poor specificity, differentiation between

exposed and diseased; past and current, active infection

IgG4 ELISA showed considerable sensitivity & specificity.

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Remarkable advances in the diagnosis of bancroftian
filariasis

Monoclonal antibody-based assay (AD12 and Og4C3)

Capture-ELISA test: detection of circulating filarial antigens

Sensitive, specific, correlating with worm burdens

Commercially available: ICT test card

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Imaging Studies

Combination of ultrasound and Dopplers technique

Direct visualisation of adult worm of W. bancrofti in worm

nest(constant location) in scrotum and breast tissue.

Distinctive pattern of movement, the filarial dance sign

Useful in monitoring success of treatment in individual patient

Not shown yet for Brugia malayi.

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Molecular techniques

Identification of repetitive non-coding sequences of B. malayi

and W. bancrofti

Combination of PCR and ELISA: ELISA based detection of PCR

products

Highly sensitive and specific.

Useful for speciation of parasite materials removed at surgery

where morphological diagnosis is not possible

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Brugia malayi

Morphology:
Adult worm:
Males:
13.5-20.5 mm long and 70-80 m wide
Tail is curved ventrally and Spicules are unequal and dissimilar
Females:
80-100 mm long and 240-300 m wide
Fingerlike tail cover with minute cuticular bosses

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 Ceph.
Morphology space

Microfilaria: Body nuclei

Sheath (+) stained; pinkish-red

Cephalic space:
length : wide = 2:1
Sub-terminal
Body nuclei: overlapping; irregular nukleus
Body curve: wrinkled
Terminal
Presence of sub-terminal and nukleus
terminal nucleus

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 Brugia timori

Overlapping body
nuclei
Sheath does not
stain pinkish but
(bluish)
Cephalic space
elongated, ratio 1:3
Presence of sub-
terminal and
terminal nucleus

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PENGOBATAN
Dietyl Carbamazyn Citrat (DEC): 6 mg/Kg BB/ hari selama12 hari.
Pemberian dapat diberikan dibagi 3 dosis/hari: sesudah makan.
Obat ini dapat membunuh mikrofilaria, cacing dewasa pada
pengobatan jangka panjang.
Untuk membunuh mikrofilaria dapat menggunakan dosis di atas;
tetapi untuk membunuh cacing dewasa harus diulang beberapa
kali siklusnya.
Untuk program eliminasi filariasis melalui pengobatan masal di
daerah endemis (prevalensi 1%), menggunakan kombinasi DEC 6
mg/kgBB dan albendazole400mg yang diberikan setiap tahun
selama 5-10 tahun pada penduduk di atas 2 tahun
Ivermectin : dosis tunggal 400g/kgBB (setiap 6 bulan sekali) atau
kombinasi dengan DEC (1 thn sekali).
Antibiotik dan antimikotik jika dijumpai infeksi sekunder

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 Pengobatan akan memberikan kesembuhan
pada penderita mikrofilaremia, stadium akut,
lymphedema std 1-2, chyluria dan std dini
elephantiasis.
Bila sudah sampai stadium hydrochele dan
elephantiasis lanjut maka diperlukan
PROGNOSIS4 pembedahan.
Pengobatan DEC pada filariasis akan
membunuh parasit sehingga keluar Wolbachia
(bakteri) menyebabkan efek samping
pengobatan.
Sehingga menambahkan antibiotik tetrasiklin
dan doksisiklin dapat membunuh Wolbachia.

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 Bersifat respons terhadap kematian parasit;
terdapat dua reaksi:
Reaksi sistemik: demam, berupa sakit kepala,
sakit pada berbagai tubuh, sendi-sendi,
pusing, anoreksisa, lemah, hematuria transien,
reaksi alergi, muntah, serangan asma; Hal ini
terjadi beberapa jam setelah pemberian DEC (<
EFEK SAMPING
3 hari).
PENGOBATAN4
Reaksi Lokal: limfadenitis, abses, ulserasi,
transien, lymphedema, hidrokel, funikulitis dan
epididimitis.
Efek samping bancroftian filariasis lebih ringan
daripada brugian filariasis; hal ini disebabkan
kemampuan DEC membunuh filaria lbh lambat
pada W.bancrofti

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