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Filariasis Treatment & Management

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

Approach Considerations

The medical management of a filarial infection should be specific and based on the microfilariae isolated or antigenemia detected.

Mass drug administration reduces the transmission of filarial infection and disease morbidity by decreasing the burden of microfilaremia, resulting in suboptimal levels for transmission by disease vectors.[44, 45, 46, 47, 48, 49]

For example, annual mass treatment with albendazole and ivermectin is employed to interrupt the transmission of W bancrofti. Since this species has no alternative hosts, this approach could theoretically result in eventual eradication of bancroftian filariasis.

One study evaluated the effect of higher dose and increased frequency (twice yearly) of albendazole-ivermectin therapy for W bancrofti and found that it resulted in complete microfilarial clearance, as well as a more sustained clearance than that resulting from standard-dose albendazole-ivermectin treatment.[50]

The effects of mass treatment on filariasis have reportedly been sustained for up to 6 years.[51, 52, 53, 54] No filariasis vaccine is currently available, but efforts to develop an effective one are under way.[55]

Surgery

Lymphatic filariasis

Large hydroceles and scrotal elephantiasis can be managed with surgical excision. Correcting gross limb elephantiasis with surgery is less successful and may necessitate multiple procedures and skin grafting.

Onchocerciasis

Nodulectomy with local anesthetic is a common treatment to reduce skin and eye complications.

Diet and activity

Fatty foods are restricted in individuals with proven chyluria that is associated with lymphatic filariasis.

Individuals with chronic lymphatic filariasis are encouraged to mobilize (with compression bandage support) the affected limb.

Prevention

Avoidance of bites from insect vectors is usually not feasible for residents of endemic areas, but visitors to these regions should use insect repellent and mosquito nets.

Consultations

To prevent inappropriate treatment, consult an infectious disease specialist in all cases of suspected filariasis outside of endemic nations. Other possible consultations include:

  • Urologist
  • Ophthalmologist
  • General surgeon
  • Plastic surgeon
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Pharmacologic Therapy

Lymphatic filariasis

Patients with asymptomatic microfilaremia can be treated on an outpatient basis. Supervision of oral DEC therapy and provocation with postadministration observation is recommended for patient compliance with therapy and for the management of febrile reactions in heavily infected patients.[31]

Inpatient care may initially be required for adenolymphangitis (ADL) and chronic filariasis. Such care includes the use of antihistamines, steroids, pain relief, and intravenous antibiotics for secondary infections.

Lymphedema

Steroids can be used to soften and reduce the swelling of lymphedematous tissues. Mild to moderate filarial lymphedema has been shown to improve with a 6-week course of doxycycline, independent of ongoing infection.[56]

Bed rest, limb elevation, and compression bandages traditionally have been used for the management of chronic lymphedema.

Chronic filariasis

Treatment of chronic filariasis does not change the prognosis, as irreversible fibrosis usually destroys lymphatic tissue. However, asymptomatic patients, hoping to diminish progression of the disease, still typically undergo treatment, although the benefit of this is unclear.[57]

Chyluria

In the treatment of chyluria, a special low-fat, high-protein diet supplemented with medium-chain triglycerides may prove beneficial. In addition, the sclerosing action conferred by diagnostic lymphangiography may plug the leak.

Secondary infection

Supportive care should include the prevention of secondary infection, especially in patients with advanced disease. Individuals with chronic infections should wash the affected area frequently, apply antiseptic creams to abrasions, keep their nails clean, wear comfortable footwear, and exercise the affected limb to aid lymphatic flow.

Onchocerciasis

If DEC and suramin (currently the only drug in clinical use for onchocerciasis that is effective against adult worms) are used, inpatient care is recommended to monitor for reactions and complications of therapy.[28]

Moxidectin is being investigated as an alternative to ivermectin for the treatment of river blindness. This agent may shorten the number of annual treatments to 6.

Bancroftian filariasis

Ivermectin is now considered the drug of choice for the treatment of bancroftian filariasis. In the United States, it can be obtained from the Centers for Disease Control and Prevention (CDC); in endemic areas of the world, it is provided free by the Mectizan Donation Program. The addition of albendazole seems to improve response.[58, 59, 60, 61]

Six-week and 8-week courses of doxycycline have compared favorably with ivermectin plus albendazole.[62] Doxycycline therapy may be more readily available and may be better tolerated by some patients. It may also be capable of preventing or reversing lymphatic pathology.[63]

In one study, a 3-week course of doxycycline followed by a single dose of DEC was shown to be microfilaricidal.[63]

Findings have validated the use of single-dose regimens of ivermectin and DEC or albendazole for large-scale control and eradication programs aimed at reducing Wuchereria bancrofti microfilaremia, antigenemia, and clinical manifestations.[50, 64, 65, 66, 67]

M perstans infection

Because M perstans is resistant to standard antiparasitic treatment, doxycycline is sometimes used to eradicate Wolbachia, an endosymbiont found in most filarial species.[26, 68]

Doxycycline treatment typically kills or sterilizes the filarial nematode. In an open-label, randomized trial, Coulibaly et al recruited patients with M perstans infection from 4 African villages in Mali. Patients were randomly assigned to receive 200 mg of doxycycline orally every day for 6 weeks or no treatment.[69]

At 12 months, 97% of patients who received doxycycline had no detectable blood levels of M perstans, compared with 16% of patients in the group that did not receive treatment. At 36 months, M perstans remained suppressed in 75% of patients who had received doxycycline.[69]

Long-Term Monitoring

Patient monitoring includes posttreatment follow-up for 12 months, with examination of peripheral blood and skin snips for microfilariae.

Observe and monitor oral therapeutic plans with DEC because compliance with therapy is poor and usually incomplete.

Patients with filariasis are, by default, at risk for other parasitic infections because areas endemic for bancroftian filariasis are also endemic for other parasites. After treatment, patients should be monitored for symptoms that are characteristic of parasitic infections.

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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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