eMedicine Specialties > Infectious Diseases > Parasitic Infections

Filariasis: Treatment & Medication

Author: Siddharth Wayangankar, MD, MPH, Resident Physician, Department of Internal Medicine, Oklahoma University Health Sciences Center
Coauthor(s): Michael Stuart Bronze, MD, Professor, Stewart G Wolf Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center; Rhett L Jackson, MD, Associate Professor and Vice Chair for Education, Department of Medicine, Associate Director, Internal Medicine Residency Program, University of Oklahoma College of Medicine; Assistant Chief, Medicine Service, Oklahoma City Veterans Affairs Hospital
Contributor Information and Disclosures

Updated: Nov 23, 2009

Treatment

Medical Care

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

  • 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.
    • Inpatient care may initially be required for ADL and chronic filariasis and includes antihistamines, steroids, pain relief, and intravenous antibiotics for secondary infections.
    • Bed rest, limb elevation, and compression bandages traditionally have been used for the management of chronic lymphedema.
    • Steroids can be used to soften and reduce the swelling of lymphedematous tissues.
    • Treatment of chronic filariasis does not change the prognosis, as irreversible fibrosis usually destroys lymphatic tissue. However, asymptomatic patients still typically undergo treatment to hopefully diminish progression of the disease, although the benefit of this is unclear.18
    • 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.
    • 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 on abrasions, keep nails clean, wear comfortable footwear, and exercise the affected limb to aid lymphatic flow.
  • Onchocerciasis: If DEC and suramin are used, inpatient care is recommended to monitor for reactions and complications of therapy.
  • 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. Doxycycline treatment typically kills or sterilizes the filarial nematode.
    • In an open-label, randomized trial, Coulibaly et al (2009) recruited patients with M perstans infection from 4 African villages in Mali. Patients were randomly assigned to receive doxycycline 200 mg PO qd for 6 weeks (n=106) or no treatment (n=110). At 6 months, patients co-infected with W bancrofti underwent a second randomization to receive a single dose of albendazole (400 mg) plus ivermectin (150 mcg/kg) or no treatment. At 12 months, 97% of patients who received doxycycline had no detectable blood levels of M perstans compared with 16% in the group who did not receive treatment (P <0.001). At 36 months, M perstans remained suppressed in 75% of patients who received doxycycline. This suggests that doxycycline is an effective therapy for M perstans infection.19

Surgical Care

  • 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.

Consultations

  • Infectious diseases specialist
  • Urologist
  • Ophthalmologist
  • General surgeon
  • Plastic surgeon

Diet

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

Activity

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

Medication

The goals of pharmacotherapy are to eradicate the infestation, to reduce morbidity, and to prevent complications.

Anthelmintics

Recent studies have validated the use of single-dose regimens of ivermectin and DEC or albendazole for large-scale control and elimination programs and to reduce W bancrofti microfilaremia, antigenemia, and clinical manifestations.


Ivermectin (Mectizan)

Potent microfilaricide and macrofilaricide for W bancrofti in multiple doses. Used alone or in combination with DEC. DOC except in Mansonella infections, where its effects are limited. Exerts its antiparasitic action by acting as a potent agonist at GABA receptors and potentiating the inhibitory signals sent to motor neurons, which paralyses the parasite. Because GABA is confined to the CNS in humans and because ivermectin does not cross the BBB, the drug has no paralytic action in humans.
In the United States, it is available by prescription, and, in endemic areas of the world, it is provided free by the Mectizan Donation Program.

Adult

150-200 mcg/kg/d PO as single dose; repeat q2-3mo

Pediatric

<5 years or <15 kilograms: Not recommended
>5 years: Administer as in adults

May interact with other ligand-gated chloride channels, such as those gated by GABA

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Treat mothers who intend to breastfeed only when risk of delayed treatment outweighs possible risks to the newborn caused by ivermectin excretion in milk; repeat courses of therapy may be required in patients who are immunocompromised; may cause nausea, vomiting, and mild CNS depression; may cause drowsiness; adverse effects include fever, headache, myalgia, sore throat, and cough


Diethylcarbamazine (Hetrazan)

Microfilaricide. The precise mechanism is not understood. Shown to induce immobilization of microfilariae by decreasing muscle activity because of hyperpolarization effects. Alteration of surface membrane also occurs, with enhanced destruction by the host's immune system. Evidence exists that DEC may enhance adhesion of granulocytes via antibody-dependent and independent mechanisms. Hypotheses also include interference by microfilarial intracellular processing and transport of specific macromolecules by DEC.
To decrease risk of adverse effects, low doses (approximately 2-3 mg/kg/d) usually are recommended for the first 3 d of treatment. Higher doses (9 mg/kg/d) are recommended for L loa from days 4-21.
Concurrent administration of corticosteroids should be considered with DEC treatment to minimize the allergic manifestations secondary to the disintegration of microfilariae, particularly O volvulus and L loa infections. To avoid adverse effects, doses for the treatment of onchocerciasis and loiasis start at 50 mg and are increased slowly in frequency and amount.

Adult

6 mg/kg PO qd for 12 d to 3 wk

Pediatric

Administer as in adults

Documented hypersensitivity; DEC provocation

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in individuals with potential heavy infections of lymphatic filarioids because a DEC dose of 2 mg/kg may provoke a febrile and inflammatory reaction secondary to worm death; antipyretics and steroids may decrease the risk of these symptoms; adjust in patients with renal failure


Suramin (Germanin, Antrypol, Naganinum, Naganol)

Antitrypanosome and antihelminthic. Currently the only drug in clinical use for onchocerciasis that is effective against adult worms, but use is restricted because of frequency of associated complications and intrinsic toxicity. WHO has advised that it should only be considered for the curative treatment of individuals in areas without transmission of onchocerciasis, in individuals leaving an endemic area, and in individuals with severe hyperreactive onchodermatitis whose symptoms are not adequately controlled with ivermectin. WHO also recommends that suramin should not be used to treat onchocerciasis in individuals who are elderly or infirm, in patients with severe liver or renal disease, in children <10 y, in totally blind persons (unless they require relief from intensely itchy lesions), in lightly to moderately infected people with no symptoms and whose eyes are not at risk, or in pregnant women (who should be treated after delivery).

Adult

66.7 mg/kg/d IV in 6 weekly doses

Pediatric

<10 years: Not recommended
>10 years: Administer as in adults

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Monitor CBC; perform coagulation tests; evaluate for neuropathy during therapy; caution in patients with hepatic and renal failure; urine should be tested before treatment starts and at weekly intervals during treatment, reduce dosage if moderate proteinuria develops and discontinue if it becomes severe or if casts appear; adverse effects include abdominal pain, mouth ulceration, and skin reactions (eg, urticaria, pruritus); later reactions include paraesthesia, polyneuropathy, hyperesthesia of the palms and soles, skin eruptions, fever, polyuria, increased thirst, elevated liver enzymes, photophobia, and lacrimation; occasional reports of adrenal insufficiency exist


Mebendazole (Vermox, Banworm)

Causes worm death by selectively and irreversibly blocking uptake of glucose and other nutrients in susceptible adult intestine where helminths dwell.

Adult

100 mg PO bid for 3 d; second course if patient not cured in 3 wk

Pediatric

Administer as in adults

Carbamazepine and phenytoin may decrease effects; cimetidine may increase levels

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Adjust dose in patients with hepatic impairment; it is poorly absorbed and requires multiple doses; adverse effects include nausea and diarrhea


Flubendazole (Fluvermal)

Benzimidazole carbamate antihelminthic that is an analogue of mebendazole.

Adult

100 mg PO bid for 3 d

Pediatric

Administer as in adults

Coadministration with carbamazepine may decrease efficacy; dexamethasone, cimetidine, and praziquantel may increase toxicity

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Ulceration at injection site may occur; adjust dose in patients with hepatic impairment


Albendazole (Albenza, Eskazole, Zentel)

Broad-spectrum antihelminthic. Decreases ATP production in worms, causing energy depletion, immobilization, and, finally, death.

Adult

400 mg PO single dose

Pediatric

Administer as in adults

Coadministration with carbamazepine may decrease efficacy; dexamethasone, cimetidine, and praziquantel may increase toxicity

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Mild-to-moderate elevations of liver enzymes reported, especially with high-dose regimens, but enzymes usually normalize upon discontinuation of treatment; rare reports exist of severe hepatic abnormalities associated with jaundice and histological hepatocellular damage, which may be irreversible; caution if patient is pregnant or may become pregnant

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References
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Further Reading

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Keywords

filariasis, bancroftian filariasis, elephantiasis, hanging groins, leopard skin, river blindness, sowda, loaiasis, loiasis, tropical pulmonary eosinophilia, TPE, adenolymphangitis, ADL

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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, Professor, Stewart G Wolf Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center
Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physician Executives, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Federation for Clinical Research, American Medical Association, American Society for Microbiology, Association of Professors of Medicine, Association of Program Directors in Internal Medicine, Infectious Diseases Society of America, Oklahoma State Medical Association, and Southern Society for Clinical Investigation
Disclosure: Nothing to disclose.

Rhett L Jackson, MD, Associate Professor and Vice Chair for Education, Department of Medicine, Associate 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 and American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

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

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

 
 
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