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Filariasis Workup

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

Approach Considerations

The traditional diagnostic method for filariasis is to demonstrate microfilariae in the peripheral blood or skin. For example, the microfilariae of all species that cause lymphatic filariasis and the microfilariae of L loa, M ozzardi, and M perstans are detected in blood.[8]

O volvulus and M streptocerca infections are diagnosed when microfilariae are detected in multiple skin snip specimens from different sites located on both sides of the body. In addition, microfilariae of O volvulus may be detected in the cornea or anterior chamber of the eye, using slit-lamp examination.

Urine examination and microscopy

Microfilariae may also be observed in chylous urine and hydrocele fluid. If lymphatic filariasis is suspected, urine should be examined macroscopically for chyluria and then concentrated to examine for microfilariae.

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Detection of Microfilariae in the Skin and Eye

Skin

O volvulus and M streptocerca infections are diagnosed when microfilariae are detected in multiple skin-snip specimens from different sites located on both sides of the body.

In suspected cases of African onchocerciasis, the recommended sites for skin snips are the gluteus and calf. For American onchocerciasis, the scapula and deltoid skin are preferred.

Mazzotti test

The Mazzotti test allows a presumptive diagnosis of cutaneous filariasis to be made when skin snips are negative for microfilariae. An intense pruritus is elicited within hours after a single small dose of DEC (50-100 mg). Steroids may be necessary to control this inflammatory reaction. The test must be used with caution in individuals who may be heavily infected, because a severe systemic reaction can be provoked. A DEC patch test that causes a localized skin reaction may be used in such patients.

Eye

Microfilariae of O volvulus may be detected in the cornea or anterior chamber of the eye using slit-lamp examination.

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Detection of Microfilariae in Blood

As mentioned, the microfilariae of all species that cause lymphatic filariasis and the microfilariae of L loa, M ozzardi, and M perstans are detected in blood. (See the image below.)

Filariasis. Microfilariae of Mansonella perstans i Filariasis. Microfilariae of Mansonella perstans in peripheral blood.

Capillary finger-prick or venous blood is used for thick blood films. Venous blood also can be concentrated or passed through a Nuclepore filter before being examined microscopically. The species of infection then can be determined by the microscopic appearance. W bancrofti and Brugia species have an acellular sheath. W bancrofti has no nuclei in its tail, whereas B malayi has terminal and subterminal nuclei. (See the image below.)

Filariasis. Appearance of microfilariae after conc Filariasis. Appearance of microfilariae after concentration of venous blood with a Nuclepore filter.

Microfilariae may periodically appear in the peripheral circulation. For the best chance of detection, the blood should be examined at different intervals over a 24-hour period. (See the image below.)

Filariasis. Microfilaria of Wuchereria bancrofti i Filariasis. Microfilaria of Wuchereria bancrofti in a peripheral blood smear.

Bancroftian and brugian filariasis tend to show nocturnal periodicity, so it is recommended that samples be collected between 10:00 pm and 2:00 am. Provocation of nocturnally periodic microfilariae may be achieved with a daytime dose of DEC at 1-2 mg/kg.

Microfilariae may be absent in the following cases:

  • Patients with ADL or late chronic lymphatic disease
  • Typically, patients with loiasis, unless the infection has been present for many years

Complete blood count

Eosinophilia is marked in all forms of patent filarial infection.

Serum immunoglobulin concentrations

Elevated serum IgE and IgG4 may be observed with active filarial disease. Testing based on polymerase chain reaction assay has been described.[37]

A multiplex bead assay to monitor serial levels of serum antibody during treatment has been proposed.[38]

Detection of filarial antigen

The presence of circulating filarial antigen in the peripheral blood, with or without microfilariae, is considered diagnostic of patent filarial infection and is also used to monitor the effectiveness of therapy. Commercial kits are available to test venous blood and can be quantitative (enzyme-linked immunoassay [ELISA]) Og4C3 monoclonal antibody–based assay) or qualitative (immunochromatographic).

The ELISA is one of the best predictors of worm burden[39] ; the other, although not as sensitive,[40] was once considered the test of choice in field surveys. However, results from this test remain positive for 3 years posttreatment; hence, immunochromatographic testing has been shown to be ineffective.[41]

Detection of filarial antibodies

The use of recombinant antigens for the diagnosis of onchocerciasis IgG4 antibodies (which are a marker of active infection) has improved the sensitivity and specificity of serologic assays.[42] The usual IgG and IgE lack specificity (species differentiation) and usually crossreact with antigens of Strongyloides. In addition, they do not differentiate between past and recent infections. Thus, diagnosis based on recombinant antigens is useful in expatriates but not in persons living in endemic regions.

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Imaging Studies

The following imaging studies can be used in the evaluation of filariasis:

  • Chest radiography - Diffuse pulmonary infiltrates are visible in patients with tropical pulmonary eosinophilia (TPE)
  • Ultrasonography - Can be used to demonstrate and monitor lymphatic obstruction of the inguinal and scrotal lymphatics
  • Lymphoscintigraphy [9]

Ultrasonography has also been used to demonstrate the presence of viable worms, which are seen to be in continuous motion (ie, "filarial dance" sign). This imaging characteristic has been used to monitor the effectiveness of treatment.[43] In addition, deep onchocercomas and vitreous changes in the eye can sometimes be detected with ultrasonography.

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Biopsy

It is recommended that biopsy specimens be obtained only in patients with cutaneous filariasis, as excising nodes may further impede lymphatic drainage in patients with lymphatic filariasis. Adult worms of O volvulus and L loa are found in the nodules and fibrotic tissue of the skin. L loa worms occasionally can be dissected from the conjunctiva of the eye or bridge of the nose as they migrate through subcutaneous tissue.

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Histologic Findings

Lymphatic filariasis

Affected lymph nodes demonstrate fibrosis and lymphatic obstruction with the creation of collateral channels. The skin of individuals with elephantiasis is characterized by hyperkeratosis, acanthosis, lymph and fatty tissue, loss of elastin fibers, and fibrosis. (See the image below.)

Filariasis. Adult worms of Wuchereria bancrofti in Filariasis. Adult worms of Wuchereria bancrofti in cross section isolated from a testicular lump.

Onchocerciasis

Two areas are evident in onchocercomas: (1) a central stromal and granulomatous, inflammatory region where the adult worms are found and (2) a peripheral, fibrous section. Microfilariae in the skin incite a low-grade inflammatory reaction with loss of elasticity and fibrotic scarring. (See the image below.)

Filariasis. Adult Onchocerca volvulus contained wi Filariasis. Adult Onchocerca volvulus contained within onchocercomas of the skin.
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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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