Tissue helminth

Sitti Wahyuni, MD, PhD wahyunim@indosat.net.id Department of Parasitology Medical Faculty Hasanuddin University

6/18/2012

S. Wahyuni, Parasitology Dept, Medical Faculty, Unhas

Species & disease

Filaria---- lymphatic filariasis Schistosome---- Bilharziasis Trichinella spiralis- Trichinellosis Toxocara & animal Ancylostoma---visceral & cutaneus larva migrans Onchocerca volvulus & Loa-loa ----cutaneus & subcutaneus filariasis Capillaria hepatica Capillariasis F Fasciolopsis i l i b buski ki
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Lymphatic Filariasis
a vector born disease of lymphatic system caused by: Wuchereria bancrofti Brugia malayi Brugia timori not lethal but can be seriously y debilitating g causing an economic burden on infected individuals
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Clinical manifestation

It is i an old ld disease. di
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But still found nowadays..

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S. Wahyuni, Parasitology Dept, Medical Faculty, Unhas

Epidemiology
affect 120 million people over 80 tropics & subtropics countries 44 million have visible signs of disease 76 million have preclinical infection WHO has considered as one of the six potentially eradicable diseases WHO: global elimination of filariasis by 2020
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S. Wahyuni, Parasitology Dept, Medical Faculty, Unhas

Prevalence in Indonesia
extensive surveys since 1970: prev. prev 0-70% Health Minister & UI (1983): mf prev. has declined to 0 0-19,6% 19 6% WHO (2000) stated: - endemic in 22 of 27 provinces -150 150 million people at risk of infection - the highest prev. in South East Asia
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Adult
creamy creamy-white,

minute, thread like nematodes with smoth cuticula tapering toward both end,& terminations are bluntly rounded head: slighty swollen, surmounted by 2 rings of small papillas , no buccal Mouth: unarmed, vestibule
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Adult
Live in lymph nodes Can stay alive for 15 years Vivipar & produce microfilaria Causes clinical manifestation (febrile, extremitas oedema, hidrochele & elephanthiasis Can only be seen if it circulate in hidrocele/incision of lymph y p nodes
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Microfilaria W h Wuchereria i bancrofti b fi

Body: gently curved Tail: tapered to a point Nuclear column: loosely packed, & nuclei can be visualized individually and do not extend to the tip of the tail. Sheath: slightly stained with hematoxylin.

Thick blood smears stained with hematoxylin

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S. Wahyuni, Parasitology Dept, Medical Faculty, Unhas

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Microfilaria W h Wuchereria i bancrofti b fi

collected by filtration with a Nucleopore membrane. The Th pores of f the th membrane are visible.

Thick blood smears stained with Giemsa can not demonstrate the sheath

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S. Wahyuni, Parasitology Dept, Medical Faculty, Unhas

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Microfilaria B Brugia i
Shape: more tightly coiled nuclear l column: l more tightly packed, individual nuclei can not be visualize Sheath: slightly stained with hematoxylin. y
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Thick blood smears stained with hematoxylin

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S. Wahyuni, Parasitology Dept, Medical Faculty, Unhas

Microfilaria B Brugia i

collected by the Knott (centrifugation) concentration technique, in 2% formalin wet preparation

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Host
Definitive: -humans: humans: W. W bancrofti and B. B timori -human & animals: B. malayi Intermediate: masquitos q - urban W.bancrofti: Culex quenquefasciatus - rural W.bancrofti: A. farauti & A. punctulatis - nocturnally B. malayi (Sulawesi): Anopheles barbirostris - sub-periodic sub periodic B.malayi B malayi (Sumatra & Kalimantan): Mansonia spp. - nocturnal B timori : A. barbirostris
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How to get infection?

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Breeding site

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Breeding site

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spect u of spectrum o clinical c ca a and d parasitological manifestations

endemic normals/asimptomatic amicrofilaraemics Microfilaraemics Chronic obstructive disease

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S. Wahyuni, Parasitology Dept, Medical Faculty, Unhas

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Acute l lymphangitis/lymphadenitis h i i /l h d ii
Often occur in chronic patients Caused C db by d dying i or d degenerating ti adult d lt worms Bacterial or fungal superinfections in limbs with compromised lymphatic dysfunction play a significant role

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S. Wahyuni, Parasitology Dept, Medical Faculty, Unhas

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Chronic obstructive
Bancroftion filariasis -main clinical manifestation: hydrocele
can be accompanied by lymphoedema -can (elephantiasis) of the whole arm/leg enlargement of vulve/breast -enlargement

Brugian filariasis - lymphoedema (elephantiasis) of leg below the

knee or arm below the elbow -hydrocele h d l h has seldom ld b been recorded d d
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Tropical p pulmonary p y eosinophilia p (TPE)

A relatively unusual manifestation of infection microfilariae are generally absent from the circulation i l i hypereosinophilia, elevation of anti-filarial antibodies (lgE) & pulmonary symptom such as bronchial asthma
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Diagnosis
Detection of microfilariae A ti Antigen detection d t ti assays Molecular Diagnosis USG detection of adult worms Antibody assays

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S. Wahyuni, Parasitology Dept, Medical Faculty, Unhas

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Detection of microfilariae
Classic diagnosis of lymphatic Still the golden standard The time accord to the periodicity Two methods: finger prick & whole blood filtration

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S. Wahyuni, Parasitology Dept, Medical Faculty, Unhas

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Finger prick method

The blood is obtained by pricking the finger with a lancet Collect 20 20-60 60 ul blood on a slide glass Stained with Giemsa's stain Screen presence of mf under a light microscope sensitivity of this assay is low Time collecting blood is inconvenient
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Whole blood filtration

1-10 ml blood filtrated to the filter The filters: stained and examined in the same manner as finger prick blood Distribution Di t ib ti of f mf fi in th the periphery i h non-random, d mf can be missed as they are subject to periodicity The time of blood collection is inconvenient Many people object to vena puncture Requires skilled personnel & proper precautions

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S. Wahyuni, Parasitology Dept, Medical Faculty, Unhas

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Antigen detection assays

Developed for detection CFA Based on a monoclonal raised against bovine Onchocerca g gibson, named Gib-13 -93% W. bancrofti mf(+) were found positive -Detect CFA in mf (-) subjects with acute symptoms -53% of asymptomatic mf(-) subjects Unfortunately, no CFA has been developed for detection of brugian filariasis
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Molecular Diagnosis g
Characterization of filaria species-specific DNA using PCR-based assays primers for both W.bancrofti & B malayi y have been designed successfully Positive only in the presence of circulating mf Problem for diagnosis of cryptic infections PCR is an expensive assay Requires well-equipped laboratories & personnel 6/18/2012 S. Wahyuni, Parasitology Dept, Medical Faculty, Unhas 29

USG detection of adult worms

can be observed in dilation of lymphatic vessels/scrotal area: 'filaria dance sign Can be used to investigate the macrofilaricidal effects Non-invasive N i i & portable t bl equipment i ti is available Restricted to the male population Not available for B.malayi y
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Antibody y assays y

Anti-filarial lgG4 : have high specificity & sensitivity iti it Anti-filarial lgG4 correlate strongly with the presence of mf Can discriminate active from p past infection

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S. Wahyuni, Parasitology Dept, Medical Faculty, Unhas

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Management

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general strategies t t i to t reduce d transmission t i i

Treat the infection person decrease human human-vector vector contact Reduce the population of mosquito vectors t by b i insecticides,polystyrene ti id l t b beads d or biocides

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Diethylcarbamazine citrate (DEC)

For the past 50 years has been the primary drug of choice Has excellent microfilaricidal properties Demonstrated the rapid decline of mf in th periphery the i h after ft t treatment t t Have macrofilaricidal potential, if prolonged treatment is supplied part of individuals seem resistant Ap Side effects are recorded
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Dosage g of DEC
Standard : 12-14 day y course of 6 mg/kg g g BW Meta-analysis of studies : a single dose/a year for several years equivalently reduce mf f levels l l New opplications : mass administration of DEC fortified salt Combination therapy ivermectin /albendozole can give 10% better results results. Have a long-term effects
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Current control programs i Indonesia in I d i

Health ministry recommend annual mass drug administration (MDA): DEC 6 mg/kg + albendazole 400 mg for at least 4-5 45 subsequent years. Has been shown to be effective in reducing mf prevalence of B.timori and intestinal helminth infections in Alor island island, East Nusa Tenggara from 26.8% to 3.8%
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