INTRODUCTION

Lymphatic
filariasis,
also
known
as
elephantiasis, is causedby parasitic worms of the
Filarioidea type. Many cases of thedisease have no
symptoms. Some however, develop largeamounts of
swelling of the arms, legs, or genitals. The skinmay also
become thicker, and pain may occur. The changesto the
body can cause social and economic problems for
theaffected person.
The worms are spread by the bites of infected mosquitos.
Infections usuallyThere arethree types of worms that
cause the disease: Wuchereria bancrofti, Brugia
malayi,and Brugia timori. Wuchereriabancrofti is the most
common. The disease is diagnosed bylooking, under a
microscope, at blood collected during the night. The
blood should be in the form of a thick smear and stained
with Giemsa . Testing the blood for antibodies against the
diseasemay also be used.

HISTORY
Lymphatic filariasis is thought to have affected humans
for about 4000 years. Artifacts from ancient Egypt and the
Nok civilization in West Africa show possible
elephantiasis symptoms. The first clear reference to the
disease occurs in ancient Greek literature, wherein
scholars differentiated the often similar symptoms of
lymphatic filariasis from those of leprosy.
The first documentation of symptoms occurred in the 16th
century, when Jan Huyghen van Linschoten wrote about
the disease during the exploration of Goa. Similar
symptoms were reported by subsequent explorers in areas
of Asia and Africa, though an understanding of the this
did not begin to develop until centuries later.
In 1866, Timothy Lewis, building on the work of JeanNicolas Demarquay and Otto Henry Wucherer, made the

connection between microfilariae and elephantiasis,

establishing the course of research that would ultimately
explain the disease. In 1876, Joseph Bancroft discovered
the adult form of the worm. In 1877, the lifecycle
involving an arthropod vector was theorized by Patrick
Manson, who proceeded to demonstrate the presence of
the worms in mosquitoes. Manson incorrectly
hypothesized that the disease was transmitted through
skin.
University of Illinois at Chicago (UIC) inventors have
developed a novel vaccine for the prevention of lymphatic
filariasis. This vaccine has been shown to elicit strong,
protective immune responses in mouse models of
lymphatic filariasis infection.The immune response
elicited by this vaccine has been demonstrated to be
protective against both W. bancrofti and B. malayi
infection.
On September 20, 2007, geneticists mapped the genome
(genetic content) of Brugia malayi, the roundworm
which causes elephantiasis (lymphatic filariasis).
Determining the content of the genes might lead to
development of new drugs and vaccines.

DISTRIBUTION
Prevalent worldwide in the Tropics and Sub-tropical
regions of
Africa
Asia
Western Pacific
Parts of Central & South America

SIGNS AND SYMPTOMS

The most spectacular symptom of lymphatic filariasis is
"Elephantiasis"edema with thickening of the skin and
underlying tissues; this was the first disease discovered to
be transmitted by mosquito bites. Elephantiasis results
when the parasites lodge in the lymphatic system.
The skin condition the disease causes is called
"Elephantiasis tropica" (also known as "Elephantiasis
arabum")

Elephantiasis mainly affects the lower extremities; the

ears, mucous membranes, and amputation stumps are
affected less frequently. However, various species of
filarial worms tend to affect different parts of the body:
Wuchereria bancrofti can affect the arms, breasts,
legs, scrotum, and vulva (causing hydrocele formation),
while Brugia timori rarely affects the genitals. Those
who develop the chronic stages of Elephantiasis are
usually amicrofilaraemic and often have adverse
immunological reactions to the microfilariae as well as
the adult worms.
The subcutaneous worms present with skin rashes,
urticarial papules, and arthritis, as well as hyper- and
hypopigmentation macules. Onchocerca volvulus
manifests itself in the eyes, causing "river blindness"
(onchocerciasis), one of the leading causes of blindness in
the world.
Serous cavity filariasis presents with symptoms similar to
subcutaneous filariasis, in addition to abdominal pain,
because these worms are also deep-tissue dwellers.
Elephantiasis leads to marked swelling of the lower half
of the body.

CAUSES
Elephantiasis occurs in the presence of microscopic,
thread-like parasitic worms such as Wuchereria
bancrofti (the most common), Brugiamalayi, and
Brugia timori (also known as B. timori), all of which

are transmitted by bites from infected mosquitoes.

Infections usually begin when people are children. Three
types of worms cause the disease and damage the
lymphatic system:
The disease itself is a result of a complex interplay
between severalfactors: the worm, the symbiotic
Wolbachia bacteria within the worm,the hosts immune
response, and the numerous opportunistic infections and
disorders that arise. Consequently, it is common in
tropical regionsand Africa. The adult worms only live in
the human lymphatic system.[6]The parasite infects the
lymph nodes and blocks the flow of lymph through out
the body; this results in chronic edema, most often noted
in the lower torso (typically in the legs and genital).

Host Factors
Man Natural Host
Age All age (6 months) Max: 20-30 years
Sex Higher in men
Migration leading to extension of infection to nonendemic areas
Immunity may develop after long year of exposure
(Basis of immunity-not known).

Agent Factors

Social & Environmental Factors

Associated with Urbanization, Poverty,
Industrialization, Illiteracy and Poor sanitation.
Climate: is an important factor which influences:
1. The breeding of mosquito
2. Longevity (Optimum temperature 20-300C &
Humidity 70%)
3. The development of parasite in the vector
4. Sanitation, Town planning, Sewage & Drainage.

Mode of Transmission &

Incubation Period
Lymphatic Filariasis is transmitted by the bite of
infected mosquito which harbours L3 larva.
L1: 1-3 hours
L2: 3-4 days
L3: 5-6 days
Pre-patent period: (L3 to Mf) Not known
Clinical Incubation period: 8-16 months

Laboratory Diagnosis
1. Demonstration of microfilarae in the peripheral
blood
a. Thick blood smear: 2-3 drops of free flowing
blood by finger prick method, stained with JSB-II
b. Membrane filtration method: 1-2 ml intravenous
blood filtered through 3m pore size membrane
filter
c. DEC provocative test (2mg/Kg):After consuming
DEC, mf enters into the peripheral blood in day
time within 30 - 45 minutes.
2. Immuno Chromatographic Test (ICT): Antigen
detection assay can be done by Card test and through
ELISA. Circulating Filarial Antigen detection is regarded
as Gold Standard for diagnosing Wuchereria bancrofti
infection. Specificity is near complete, sensitivity is
greater than all other parasite detection assays, will detect
antigen in amicrofilaraemic as well as with clinical
manifestations like lymphoedema, elephantiasis.
3. Quantitative Blood Count (QBC):QBC will identify
the microfilariae and will help in studying the
morphology. Though quick it is not sensitive than blood
smear examination.

4. Ultrasonography: Ultrasonography using a 7.5 MHz

or 10 MHz probe can locate and visualize the movements
of living adult worms of W.b. in the scrotal lymphatics of
asymptomatic males with microfilaraemia. The constant
thrashing movements described as Filaria dance sign
can be visualized.
5. Lymphoscintigraphy: The structure and function of
the lymphatics of the involved limbs can be assessed by
lymphoscintigraphy after injecting radio-labelled albumin
or dextran in the web space of the toes. The structural
changes can be imaged using a Gamma camera.
Lymphatic dilation & obstruction can be directly
demonstrated even in early clinically asymptomatic stage
of the disease.
6. X-ray Diagnosis:X-ray are helpful in the diagnosis of
Tropical pulmonary eosinophilia.

Picture will show interstial thickening, diffused

nodular mottling.
7. Haematology : Increase in eosinophil count

Prevention
The World Health Organization recommends treating
entire groups of people who are at risk with a single
annual dose of two medicines, namely albendazole in
combination with either ivermectin or diethylcarbamazine
citrate. Transmission of the infection can be broken when
a single dose of these combined oral medicines is
consistently maintained annually for a duration of four to
six years.

The strategy for eliminating transmission of lymphatic

filariasis is mass distribution of medicines that kill the
microfilariae and stop transmission of the parasite by
mosquitoes in endemic communities. With consistent
treatment, and since the disease needs a human host, the
reduction of microfilariae means the disease will not be
transmitted, the adult worms will die out, and the cycle
will be broken. In sub-Saharan Africa, albendazole
(donated by GlaxoSmithKline) is being used with
ivermectin (donated by Merck & Co.) to treat the disease,
whereas elsewhere in the world, albendazole is used with
diethylcarbamazine. Using a combination of treatments
better reduces the number of microfilariae in blood.
Avoiding mosquito bites, such as by using insecticidetreated mosquito bed nets, also reduces the transmission
of lymphatic filariasis.
According to medical experts, the worldwide efforts to
eliminate lymphatic filariasis is on track to potentially
succeed by 2020. An estimated 6.6 million children have

been prevented from being infected, with another

estimated 9.5 million in whom the progress of the disease
has been stopped.
The efforts of the Global Programme to Eliminate LF
are estimated to have prevented 6.6 million new filariasis
cases from developing in children between 2000 and
2007, and to have stopped the progression of the disease
in another 9.5 million people who had already contracted
it. Dr. Mwele Malecela, who chairs the programme, said:
"We are on track to accomplish our goal of elimination by
2020." In 2010, the WHO published a detailed progress
report on the elimination campaign in which they assert
that of the 81 countries with endemic LF, 53 have
implemented mass drug administration, and 37 have
completed five or more rounds in some areas, though
urban areas remain problematic.

Lymphoedema Management
Basic Components and Benefits

Basic Components

1. Hygiene
2. Prevention & cure of entry lesions
3. Exercise
4. Elevation of foot
5. Use of proper footwares
Lymphoedema management helps
to eliminate the bad odour
to prevent & heal entry lesion
to help patients self-confident
to reduce the size of the lyphoedema
to prevent disability
to prevent economic loss

Treatment
Treatments for lymphatic filariasis differ depending on
the geographic location of the endemic area. In sub-

Saharan Africa, albendazole is being used with ivermectin

to treat the disease, whereas elsewhere in the world,
albendazole is used with diethylcarbamazine. Geotargeting treatments is part of a larger strategy to
eventually eliminate lymphatic filariasis by 2020.
Another form of effective treatment involves rigorous
cleaning of the affected areas of the body. Several studies
have shown that these daily cleaning routines can be an
effective way to limit the symptoms of lymphatic
filariasis. The efficacy of these treatments suggests that
many of the symptoms of elephantiasis are not directly
aresult of the lymphatic filariasis but rather the effect of
secondary infections.

Surgical Treatment
Hydrocele: Excision
Scrotal Elip: Surgical removal of Skin & Tissue,
preserving penis and testicles.
Lymphoedema (Elephantiasis): Excision of redundant
tissue, Excision of subcutaneous and fatty tissues,
postral drainage and physiotherapy

Lymphatic Filariasis Control

Programme
The current strategy of filariasis control (Elimination) is
based on:
1. Interruption of transmission

2. Control of Morbidity
Interruption of the transmission can be achieved through:
a. Chemotherapy
b. Vector control
An integrated programme is in place for the control of
lymphatic filariasis. Earlier, vector control was the main
method of control. There are three main reasons why
filariasis never causes explosive epidemics
1. The microfilariae does not multiply in the vector
2. Infective larvae do not multiply in man
3. Life cycle of the parasite is relatively long (>15 )
4. Case detection and treatment in low endemic areas
are suitable for preventing transmission and
controlling the disease.
5. In high endemic areas, Mass chemotherapy is the
approach.
6. DEC medicated salt is also a form of Mass treatment
using low dose of drug over a long period of time (12 gm /Kg of Salt).

Vector Control
Vector control involves anti larval measures, anti adult
measures, personal prophylaxis. An integrated method
using all the vector control measures alone will bring
about sustained vector control.
I. Anti larval measures:

1. Chemical control
a. Mosquito larvicidal oil
b. Pyrosene oil
c. Organo phosphorous compounds such as Temephos,
Fenthion,
2. Removal of pistia plants
3. Minor environmental measures
II. Anti adult measures:
Anti adult measures as indoor residual spay using
DDT, HCH and Dieldrin. Pyrethrum as a space spray is
also followed.
III. Personal Prophylaxis:
Reduction of man mosquito contact by using
mosquito nets, screening of houses, etc.

Prevention of filariasis

Drying the Leg

Exercise

Prevention & Cure of Entry

Lesions

Elevation of Foot

Elevation of Foot