Clinical Case Presentation

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Clinical Case Presentation
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• 68yr/m
• c/o fever altered sensorium
• PS for MP

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PS REPORT

• RBC Normocytic Normochromic
• WBC Count within normal limit with normal
  distribution
• PLATELETS Adequate
• PARASITES Present, long, sheathed
  microfilaria measuring 250 µm in length

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• MICROFILARIA

FOUND in Blood Mf.bancrofti, Mf malayi, Mf.loa,
Mf ozzadi, Mf timori
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HISTORY

• Demarquay -
• Found larval forms in hydrocele fluid in 1863
• Wucherer -
• Found them in chylous urine in 1866
• Lewis -
• Found them in human blood in 1872
• Bancroft -
• Found adult females in 1876

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GEOGRAPHICAL DISTRIBUTION

• Mostly confined to tropics
• Seen in West Indies, Puerto Rico, West Central
  Africa, South America, Japan, Southern China
• In India, reported in Rajasthan, Uttar Pradesh,
  Punjab Delhi

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HABITAT

• Lymphatic vessels lymph nodes of MAN ONLY

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MORPHOLOGY ADULT WORM

• Long, hair-like transparent
• Filiform in shape
• Head end terminates in a slightly rounded
  swelling
• Tail end is narrow abruptly pointed
• MALE
• 2.5 4 cm x 0.1 mm
• Tail end contains 2 spicules of unequal length
• Curved ventrally

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MORPHOLOGY ADULT WORM (CTD)

• FEMALE
• 8 10 cm x 0.2 0.3 mm
• Tail end is narrow abruptly pointed
• Ovi-viviparous
• Male female are coiled together are can only
  be seperated with difficulty
• Life span 5 10 year

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MORPHOLOGY EMBRYOS

• MICROFILARIAE
• 290 µm x 6 7 µm
• Found in lymphatic trunks circulating blood
• Very active
• Appear colourless transparent bodies with blunt
  heads pointed tails
• When stained with Romanowskys stains, they show
  the following
• Hyaline sheath
• Cuticula
• Somatic Cells or Nuclei
• Granules
• Genital cells (G-cells)
• Central (Internal) body of Manson

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MORPHOLOGY EMBRYOS (CTD)

• Hyaline Sheath
• Structureless sac
• Projects slightly beyond the extremities of the
  embryo. Best seen here
• Much longer than the larval body
• Larva much backwards forwards in it
• Represents chorionic envelope of the egg
• Cuticula
• Lined by subcuticular cells
• Seen only with vital stains

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MORPHOLOGY EMBRYOS (CTD)

• Somatic Cells Or Nuclei
• Appear as granules in the central axis of the
  body
• Extend from the head to the tail-end
• Do not extend to the tip of tail (distinguishing
  feature of Mf. Bancrofti)
• Ant end (cephalic space) is also devoid of
  granules
• Granules are broken at specific places serving as
  the landmarks for identification
• Nerve ring an oblique space
• Anterior V-spot rudimentary excretory system
• Posterior V-spot anus or cloaca

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MORPHOLOGY EMBRYOS (CTD)

• Genital cells (G-cells)
• Central (Internal) body of Manson
• extends from anterior V-spot to G-cell.
• Represents rudimentary alimentary canal
• Life span 70 days in human body
• Periodicity
• Appear in blood at night, mostly between 10 pm
  to 4 am

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LIFE CYCLE

• Definitive Host
• Man
• Intermediate Host
• Mosquito

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PATHOGENESIS

• Mode of Infection
• Inoculative method
• Transmitting agent
• Female mosquito Gulex,Aedes,Anopheles
• Infective form
• Third stage larvae
• Portal of Entry
• Skin
• Site of Localisation
• Lymphatic system of superior or inferior
  extremities
• Most commonly of the inguino-scrotal region
• Incubation Period
• 1 1 ½ yrs

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PATHOGENESIS (CTD)

• Pathogenic effects are due to adult worms
• Microfilariae do not produce any pathogenic
  effect, except in occult filariasis
• Causes lymphangitis by
• Mechanical irritation
• Liberation of metabolites
• Absorption of toxic products
• Bacterial infection

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PATHOGENESIS (CTD)

• Causes of lymphatic obstruction
• Mechanical blocking
• Obliterative Endolymphangitis
• Excessive fibrosis of the lymphatic vessels
• Fibrosis of the afferent lymph nodes
• Effects of Lymphatic Obstruction
• Lymph varix Varicosity of lymphatic vessels
• Elephantiasis Hypertrophy of the affected part

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PATHOGENESIS (CTD)

• Pathogenic Lesions due to Classical Filaria
• Inflammation
• Lymphadenitis lymphangitis
• Dilatation of lymphatics
• Lymphangiovarix
• Rupture of lymphangiovarix
• Lymphorrhagia lymph scrotum, lymphocele,
  lymphuria
• Hyperplasia of skin connective tissues
• Elephantiasis

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PATHOGENESIS (CTD)

• Secondary Bacterial infection
• With streptococcus pyogenes staphylococcus
  aureus
• Septic lymphangitis, abcesses septicaemia

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CLINICAL FEATURES

• Clinical Features of Classical Filariasis
• Asymptomatic filariasis
• Symptomatic
• Inflammatory phase
• Obstructive phases
• Inflammatory phase
• Characterized by lymphangitis lymphadenitis
• Lasts few days subsides spontaneously
• Recurs at irregular intervals

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CLINICAL FEATURES (CTD)

• Obstructive Phase
• Varicose lymph nodes, lymph scrotum, hydrocele,
  chyluria elephantiasis
• Take long time to develop

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CLINICAL FEATURES (CTD)

• Occult Filariasis (meyers- kouwenaar syndrome)
• Massive eosinophilia (30 80)
• Generalized lymph node enlargement
• Hepatosplenomegaly
• Pulmonary symptoms
• Absence of microfilaraemia (destroyed in tissues)

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CLINICAL FEATURES (CTD)

• Tropical Pulmonary Eosinophilia
• Manifestation of occult filariasis
• Low fever, loss of weight, paroxysmal cough,
  dyspnoea splenomegaly
• Diffuse miliary mottling in the lung fields

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CLASSICAL FILARIASIS OCCULT FILARIASIS
Cause Developing worms adults Microfilariae
Basic lesions Acute inflammation followed by an epitheloid granuloma surrounding the adult worm a fibrous scar An eosinophilic granuloma (allergic or hypersensitive reaction)
Organs Involved Lymphatic system (lymphatic vessels lymph nodes) Lymphatic system, lungs, liver spleen
Microfilaria Present in blood Present in affected tissues but not in blood
Therapeutic Response No response to any drug Responds to microfilarial drug diethylcarbamazine
Serological test Complement fixation test not so sensitive Complement fixation test highly sensitive

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DIAGNOSIS

• DIRECT EVIDENCE
• Microfilariae (a sheathed microfilaria having
  tail-tip free from nuclei)
• In peripheral blood
• In the chylous urine
• In the exudate of lymph varix
• In the hydrocele fluid
• Adult worms
• In the biopsied lymph node
• Calcified worm by X-ray

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DIAGNOSIS (CTD)

• INDIRECT EVIDENCE
• Allergic Tests
• Blood Examination
• Eosinophilia
• Intradermal test
• Immunological Test
• Complement Fixation test

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• B. malayi differs from W. bancrofti
• Smaller in size
• Lies folded with head close to tail
• Possesses secondary kinks, instead of smooth
  curves
• Double stylets at anterior end
• Nuclei are blurred
• Tail-tip is not free from nuclei
• There are 2 nuclei
• At the extreme tip of tail
• Midway between tip posterior column

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THANK YOU
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