Tissue Nematodes

II MBBS

Dr Ekta Chourasia Microbiology

Classification Tissue Nematodes

Lymphatic Wuchereria bancrofti

Brugia malayi Brugia timori Subcutaneous Loa loa (african eye worm) Onchocerca volvulus (blinding filaria) Dracunculus medinensis (thread worm)
Loa loa

Conjunctiva

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Wuchereria bancrofti (Filarial worm)

Definitive host Intermediate host Infective form Mode of transmission Site of localization Geographical distribution
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Man Female Culex, Aedes or Anopheles mosquito Third stage larva Inoculation bite of mosquito Lymphatics / lymph nodes of man India, China, Far East, Africa, South & Central America
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Life cycle

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Clinical features

Infection - Wuchereriasis/ Lymphatic filarisis/ Bancroftian filariasis Pathogenic states are produced only by adult worm (living/ dead) classical filariasis Occult filariasis lesions produced by microfilaria Clinical states in classical filariasis can be classified as:
1. 2. 3. 4.

Asymptomatic ( in endemic areas) Inflammatory Obstructive Tropical pulmonary eosinophilia (occult filariasis)
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1. Inflammatory stage

Lymphadenitis LNs of groin & axilla Lymphangitis lymphatics of extremities, testicles & epididymis Filarial fever high grade fever with chills Fever subsides in 7-10 days but such inflammatory attack recurs every month Repeated attacks damage lymphatics chronic lymphoedema
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Causes of lymphangitis
a.

Mechanical irritation movement of adult parasite inside lymphatics Liberation of metabolites of growing larvae Secretion of toxic fluid by fertilized female worms

b. c.

d.

Absorption of toxic products liberated from dead worms

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2. Obstructive stage

Lymphatic obstruction occurs with the death of worms Causes of obstruction

Blocking of lumen by dead worms Excessive proliferation & thickening of walls of lymphatic vessels Fibrosis of lymphatic vessels

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3. Complications of Lymphatic Obstruction

Elephantiasis of organs like leg, scrotum, penis, vagina, breast, arm etc fibrotic thickening of skin & subcutaneous tissue Lymphangiovarix dilatation of afferent lymphatics. Rupture of Lymphangiovarix into urinary tract chyluria Hydrocele
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Lymphatic filariasis

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4. Tropical Pulmonary Eosinophilia

Hypersensitive reaction to microfilarial Ags. Microfilariae trapped in alveoli eosinophil rich intra alveolar infiltration C/F paroxysmal cough, wheezing, wt loss, low grade fever, LNpathy, eosinophilia. Excessive rise in antifilarial Ab titres & serum IgE levels. Drug of choice DEC Symptoms resolve in 3 to 7 days of therapy.
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Classical v/s Occult filariasis

Classical filariasis
Cause
Basic lesions

Occult filariasis
Microfilariae
An eosinophilic granuloma (hypersensitivity reaction)

Developing worms & adults

Acute inflammation followed by an epitheloid granuloma surrounding the adult worm & a fibrous scar Lymphatic system Present in Blood No response to any drug

Organs involved Microfilaria Therapeutic response

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Lymphatic system, lungs, liver & spleen Present in affected tissues not in blood Responds to microfilaricidal drug, DEC.

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Laboratory diagnosis

Specimen - blood collected at night, preferably capillary blood from ear lobes, chylous urine, hydrocele fluid, exudate from lymphangiovarix Microscopic examination wet mount or stained with giemsa: sheathed microfilaria with no nuclei at tail tip

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Laboratory diagnosis

Concentration techniques for capillary blood, venous blood (Knotts technique) DEC provocation test 100 mg of DEC orally, examine peripheral blood smear after 30 to 45 minutes Serology using non specific Ags
1. 2. 3.

Passive hemagglutination test Fluoresecent ab test ELISA

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Treatment

Prevention

DEC (Diethylcarbamazine) microfilaricidal: 6mg/ kg/day for 2-3 weeks Elevation of the affected limbs, use of elastic bandages & local foot care reduces symptoms of lymphatic obstruction

Destruction of mosquitoes Protection against mosquito bites

Treatment of carriers

Surgical treatment of hydrocele

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Brugia sps

Two species infect humans : B.malayi & B.timori

Causes lymphatic filariasis

Transmitted by Mansonia & Anopheles species of mosquitoes

Life cycle, pathogenesis, clinical features, diagnosis & treatment similar to W. bancrofti, with a following differences

Children commonly affected Rapid development of signs & symptoms Elephantiasis affect lower extremities Chyluria & hydrocele rare Microfilaria : sheathed with 2 widely spaced nuclei & blunt tip at tail end.

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Onchocerca volvulus
(Blinding filaria 2nd most common cause of infectious blindness)

Definitive host Intermediate host

Man Black flies (simulium)

Infective form
Mode of transmission

Larva
Inoculation

Site of localization
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Subcutaneous tissue, dermis & eye

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Clinical features

Incubation period - 10 to 12 months Eosinophilia and urticaria. Nodular and erythematous lesions (Onchocercomata) in the skin and subcutaneous tissue Photophobia, lacrimation, keratitis and blindness due to trapping of microfilaria in the cornea, choroid, iris and anterior chambers.
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Diagnosis & Treatment

Nodular biopsy adult worm Skin snip unsheathed microfilaria with no nuclei

Treatment Ivermectin, surgical removal, DEC in non ocular onchocercosis

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Loa loa

(African eye worm)

Definitive host
Intermediate host Infective form Mode of transmission Site of localization
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Man
Chrysops (deer fly) Larva Inoculation Subcutaneous & deep connective tissue
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Clinical features

Subcutaneous swelling Calabar or fugitive swelling, measuring 5 to 10 cm, marked by erythema and angioedema, usually in the extremities

Migrating worm in subconjunctival tissue

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Diagnosis & Treatment

Peripheral blood smear - Sheathed microfilaria with nuclei upto rounded tail tip Isolation of worms from the conjunctiva or subcutaneous biopsy Treatment - Ivermectin, surgical removal, DEC (effective against adult & microfilaria)

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Dracunculus medinensis
Adult worms Definitive host Intermediate host Infective form Mode of transmission Site of localization
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(Guinea Worm)

Male 2 to 4 cm Female 70 120 cms, viviparous Human Cyclops Larva inside Cyclops Ingestion of water contaminated with cyclops Subcutaneous tissue
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Clinical Features

Disease Dracunculosis Clinical features develop an year after infection following the migration of worm to the subcutaneous tissue of the leg Blister formation rupture of blister when in contact with water ulceration release of larvae by adult female worm Secondary bacterial infection of ulcer
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Diagnosis & Treatment

Detection of adult worm when it appears at the surface of skin Detection of larva in milky fluid released by worm on exposure to water Radiology calcified worm in deeper tissues Treatment
1.

2.

3.
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Thiabendazole/ Metronodazole symptomatic relief, easy removal of worm Gradual extraction of worm by winding of a few cms on a matchstick per day, over 3 to 4 weeks Surgical excision
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Prevention

Provision of safe water supply Education to discourage people from entering water source Filtering water through a double folded cloth

Boiling water before drinking

Discouraging the use of step wells
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