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Filariasis Clinical Presentation

  • Author: Siddharth Wayangankar, MD, MPH; Chief Editor: Pranatharthi Haran Chandrasekar, MBBS, MD  more...
 
Updated: Dec 10, 2015
 

History

Symptoms of filariasis are dependent on species and body type and can be acute or chronic in nature. Up to 70% of infected individuals remain asymptomatic. Symptoms usually do not manifest until adolescence or adulthood, when worm burden is usually the highest. Several variations have been observed.[32]

Because cases of filariasis in the industrialized world and the Western Hemisphere are uncommon, the diagnosis may initially be missed. To avoid this pitfall, obtain and document a travel history from patients with suspicious lesions.

Lymphatic filariasis

The clinical course of lymphatic filariasis is broadly divided into the following:

  • Asymptomatic microfilaremia - Patients with microfilaremia are generally asymptomatic, although those with heavy microfilarial loads may develop acute and chronic inflammatory granulomas secondary to splenic destruction; passage of cloudy, milklike urine may denote chyluria
  • Acute phases of adenolymphangitis (ADL)
  • Chronic, irreversible lymphedema

Lymphatic filariasis symptoms predominantly result from the presence of adult worms residing in the lymphatics. They include the following:

  • Fever
  • Inguinal or axillary lymphadenopathy
  • Testicular and/or inguinal pain
  • Skin exfoliation
  • Limb or genital swelling

The following acute syndromes have been described in filariasis:

  • Acute ADL
  • Filarial fever - Characterized by fever without associated adenitis
  • Tropical pulmonary eosinophilia (TPE)

Acute ADL

This refers to the sudden onset of febrile, painful lymphadenopathy. Pathologically, the lymph node is characterized by a retrograde lymphangitis, distinguishing it from bacterial lymphadenitis. Symptoms usually abate within 1 week, but recurrences are possible.[33]

Signs and symptoms of ADL include episodic attacks of fever associated with inflammation of the inguinal lymph nodes, testis, and spermatic cord, as well as with lymphedema. Skin exfoliation of the affected body part usually occurs with resolution of an episode.

Tropical pulmonary eosinophilia

TPE is a form of occult filariasis. Presenting symptoms include a dry, paroxysmal cough; wheezing; dyspnea; anorexia; malaise; and weight loss.

Symptoms of TPE are usually due to the inflammatory response to the infection. Characteristically, peripheral blood eosinophilia and abnormal findings on chest radiography are observed. TPE is usually related to W bancrofti or B malayi infection.

Onchocerciasis

This also is known as hanging groins, leopard skin, river blindness, or sowda. Symptoms result from the presence of microfilariae in the skin and include pruritus, subcutaneous lumps, lymphadenitis, and blindness.

Patients with onchocerciasis may report impaired visual acuity due to corneal fibrosis. Epilepsy has been associated with onchocerciasis in some studies.[34]

Loiasis

The symptoms of L loa infection are usually confined to subcutaneous swellings on the extremities, localized pain, pruritus, and urticaria.

Rare manifestations of infection include the following:

  • Arthritis
  • Breast calcification
  • Meningoencephalopathy
  • Endomyocardial fibrosis
  • Peripheral neuropathy
  • Pleural effusions
  • Retinopathy

M ozzardi, M perstans, and M streptocerca infection

Mansonella infections are usually asymptomatic. If symptoms are present, they may include fever, pruritus, skin lumps, lymphadenitis, and abdominal pain.

Dirofilaria infection

Symptoms of D immitis infection involve the respiratory system and include chest discomfort, cough, fever, and hemoptysis.

Symptoms of D repens infection usually include a lump in the subcutaneous tissue, submucosa, or eyelid.

Next

Physical Examination

Signs of filariasis present on examination are species-dependent and may be acute or chronic in nature.

Lymphatic filariasis

In lymphatic filariasis, repeated episodes of inflammation and lymphedema lead to lymphatic damage, chronic swelling, and elephantiasis of the legs, arms, scrotum, vulva, and breasts. (See the images below.)[2, 3, 4, 5, 6, 7]

Lymphatic filariasis resulting from Wuchereria ban Lymphatic filariasis resulting from Wuchereria bancrofti infection, which is causing limb lymphoedema, inguinal lymphadenopathy, and hydrocele. Photograph taken by Professor Bruce McMillan and donated by John Walker, MD.
Filariasis. Unilateral left lower leg elephantiasi Filariasis. Unilateral left lower leg elephantiasis secondary to Wuchereria bancrofti infection in a boy.
Filariasis. This is a close-up view of the unilate Filariasis. This is a close-up view of the unilateral lower leg elephantiasis shown in the previous image. Note the lymphedema and typical skin appearance of depigmentation and verrucosities (warty changes).
Filariasis. Lateral view of the right outer aspect Filariasis. Lateral view of the right outer aspect of a leg affected by gross elephantiasis secondary to Wuchereria bancrofti infection.
Filariasis. Inner aspect of the lower leg of the m Filariasis. Inner aspect of the lower leg of the male patient in the previous image, showing gross elephantiasis secondary to Wuchereria bancrofti infection.
Filariasis. Unilateral left hydrocele and testicul Filariasis. Unilateral left hydrocele and testicular enlargement secondary to Wuchereria bancrofti infection in a man who also was positive for microfilariae.
Filariasis. Bilateral hydrocele, testicular enlarg Filariasis. Bilateral hydrocele, testicular enlargement, and inguinal lymphadenopathy secondary to Wuchereria bancrofti infection in a man who also was microfilaremic.

The WHO has developed a system to grade the severity of edema, as follows[11] :

Grade 1 - Pitting edema reversible with limb elevation

Grade 2 - Nonpitting edema irreversible with limb elevation

Grade 3 - Severe swelling with sclerosis and skin changes

Hydrocele is the most common manifestation of chronic W bancrofti infection in males in endemic areas but is rare with B malayi and B timori infection.

Chyluria also may be present in chronically infected persons. Since large amounts of fat and protein are lost in the urine, these conditions can lead to nutritional deficiencies.

Tropical pulmonary eosinophilia

Scattered wheezes and crackles are heard in both lung fields. Lymphadenopathy and hepatomegaly may be present.

Onchocerciasis

The clinical triad of infection is as follows:

  • Dermatitis - Skin lesions include edema, pruritus, erythema, papules, scablike eruptions, altered pigmentation, and lichenification
  • Skin nodules (ie, onchocercomas) - Skin nodules tend to be common over bony prominences (see the image below)
    Filariasis. Onchocercomas of the forearm skin (sow Filariasis. Onchocercomas of the forearm skin (sowda) in a Sudanese man.
  • Ocular lesions - Eye lesions are usually related to the duration and severity of infection and are caused by an abnormal host immune response to microfilariae; loss of visual acuity may occur

Common eye findings in onchocerciasis include the following:

Loiasis

The diagnostic feature of loiasis is a Calabar swelling, ie, a large, transient area of localized, nonerythematous subcutaneous edema. This is most common around the joints.

Peripheral nerve involvement in loiasis has been described.[35] Microfilaremia tends to be asymptomatic. Occasionally, the worm is observed migrating through subconjunctival or other tissues.

M ozzardi, M perstans, and M streptocerca infection

Subcutaneous or conjunctival nodules and lymphadenopathy may be detected in symptomatic persons.

Dirofilaria infection

These infections are characterized as follows:

  • D repens infection - May result in painless subcutaneous, submucosal, or eyelid lumps
  • D immitis infection - Reduced localized air entry on chest auscultation may be detected
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Contributor Information and Disclosures
Author

Siddharth Wayangankar, MD, MPH Resident Physician, Department of Internal Medicine, Oklahoma University Health Sciences Center

Siddharth Wayangankar, MD, MPH is a member of the following medical societies: American College of Physicians

Disclosure: Nothing to disclose.

Coauthor(s)

Michael Stuart Bronze, MD David Ross Boyd Professor and Chairman, Department of Medicine, Stewart G Wolf Endowed Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center; Master of the American College of Physicians; Fellow, Infectious Diseases Society of America

Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, Oklahoma State Medical Association, Southern Society for Clinical Investigation, Association of Professors of Medicine, American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Rhett L Jackson, MD Associate Professor and Vice Chair for Education, Department of Medicine, Director, Internal Medicine Residency Program, University of Oklahoma College of Medicine; Assistant Chief, Medicine Service, Oklahoma City Veterans Affairs Hospital

Rhett L Jackson, MD is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine, American Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Pranatharthi Haran Chandrasekar, MBBS, MD Professor, Chief of Infectious Disease, Program Director of Infectious Disease Fellowship, Department of Internal Medicine, Wayne State University School of Medicine

Pranatharthi Haran Chandrasekar, MBBS, MD is a member of the following medical societies: American College of Physicians, American Society for Microbiology, International Immunocompromised Host Society, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Acknowledgements

Rosemary Johann-Liang, MD Medical Officer, Infectious Diseases and Pediatrics, Division of Special Pathogens and Immunological Drug Products, Center for Drug Evaluation and Research, Food and Drug Administration

Rosemary Johann-Liang, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Thomas M Kerkering, MD Chief of Infectious Diseases, Virginia Tech Carilion School of Medicine

Thomas M Kerkering, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Public Health Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Medical Society of Virginia, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Charles S Levy, MD Associate Professor, Department of Medicine, Section of Infectious Disease, George Washington University School of Medicine

Charles S Levy, MD is a member of the following medical societies: American College of Physicians, Infectious Diseases Society of America, and Medical Society of the District of Columbia

Disclosure: Nothing to disclose.

Michael D Nissen, MBBS, FRACP, FRCPA Associate Professor in Biomolecular, Biomedical Science & Health, Griffith University; Director of Infectious Diseases and Unit Head of Queensland Paediatric Infectious Laboratory, Sir Albert Sakzewski Viral Research Centre, Royal Children's Hospital

Disclosure: Nothing to disclose.

Russell W Steele, MD Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Robert W Tolan Jr, MD Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine

Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility

Disclosure: Novartis Honoraria Speaking and teaching

John Charles Walker, MSc, PhD Head, Department of Parasitology, Center for Infectious Diseases and Microbiology, Westmead Hospital, Westmead, Australia; Senior Lecturer, Department of Medicine, University of Sydney, Australia

Disclosure: Nothing to disclose.

Martin Weisse, MD Program Director, Associate Professor, Department of Pediatrics, West Virginia University

Martin Weisse, MD is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

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Filariasis. This figure displays the life cycle of Wuchereria bancrofti in humans and mosquito vectors (ie, Aedes, Anopheles, Culex, Mansonia species). Life cycles of other lymphatic nematodes (ie, Brugia malayi, Brugia timori) are identical, while the life cycles for other filariae differ in the body location of adult worms, the microfilariae present, and the arthropod intermediate hosts and vectors.
Filarial abscess scar on the left upper thigh in a young male who is positive for Wuchereria bancrofti microfilariae
Lymphatic filariasis resulting from Wuchereria bancrofti infection, which is causing limb lymphoedema, inguinal lymphadenopathy, and hydrocele. Photograph taken by Professor Bruce McMillan and donated by John Walker, MD.
Filariasis. Unilateral left lower leg elephantiasis secondary to Wuchereria bancrofti infection in a boy.
Filariasis. This is a close-up view of the unilateral lower leg elephantiasis shown in the previous image. Note the lymphedema and typical skin appearance of depigmentation and verrucosities (warty changes).
Filariasis. Lateral view of the right outer aspect of a leg affected by gross elephantiasis secondary to Wuchereria bancrofti infection.
Filariasis. Inner aspect of the lower leg of the male patient in the previous image, showing gross elephantiasis secondary to Wuchereria bancrofti infection.
Filariasis. Unilateral left hydrocele and testicular enlargement secondary to Wuchereria bancrofti infection in a man who also was positive for microfilariae.
Filariasis. Bilateral hydrocele, testicular enlargement, and inguinal lymphadenopathy secondary to Wuchereria bancrofti infection in a man who also was microfilaremic.
Filariasis. Adult worms of Wuchereria bancrofti in cross section isolated from a testicular lump.
Filariasis. Microfilaria of Wuchereria bancrofti in a peripheral blood smear.
Filariasis. Appearance of microfilariae after concentration of venous blood with a Nuclepore filter.
Filariasis. Onchocercomas of the forearm skin (sowda) in a Sudanese man.
Filariasis. Adult Onchocerca volvulus contained within onchocercomas of the skin.
Filariasis. Microfilariae of Loa loa detected in skin snips.
Filariasis. Microfilariae of Mansonella perstans in peripheral blood.
 
 
 
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