History

Fact Explanation
Introduction Parasites are widespread throughout the developing world and are associated with a heavy burden of morbidity and mortality. Filariasis is a parasitic disease affecting humans and animals, and is caused by filariae (Wuchereria bancrofti [3,8] which is a nematode parasite of the order Filariidae that is transmitted by arthropod vectors (Culex mosquito ) [2,6] Disease is commonly seen in tropical and subtropical regions of the world. [1]
Asymptomatic microfilaremia Filariasis causes a spectrum of diseases including the asymptomatic microfilaria. [6] Culex mosquito is the vector for the transmission and the adult worms live in the lymphatic vessels of the definitive host. The microfilariae are released into the peripheral circulation. There are two catergories of microfilarimia, asymptomatic amicrofilaremia and patent infection (with or without microfilaremia). [4,5] Occasionally microfilaremia at the following sites is also reported: Bronchial aspirates, pericardial fluid, cervicovaginal smears, joint aspirates, and thyroid masses.[2]
Fever Lymphatic filariasis is characterized by recurrent attacks of fever due to the inflammation of lymph nodes (lymphadenitis), lymphatics (lymphangitis) [4] or due to recurrent infections associated with damaged lymphatics. [3]
Pain in the Inguinal or axillary regions [3] Inguinal, axillary and epitrochlear nodes [4] lymph nodes are commonly involved. [5]
Testicular and/or inguinal pain [3] Funiculitis, epididymitis [7] and/or orchitis [4] causing acute testis are seen among patients with filariasis.
Skin exfoliation Acute dermatotolymphangitis, is the development of a plaque-like lesion of cutaneous or sub-cutaneous inflammation. It is accompanied by ascending lymphangitis and regional lymphadenitis. [4]
Limb or genital swelling [3] The chronic sequelae of lymphatic filariasis develop years after initial infection. [4,7] The manifestations are hydrocele and swelling of the testis and / or lymphedema of the entire lower limb, the scrotum, the entire arm, the vulva, and the breast . [7]
Milky urine Chyluria is a complication of filariasis. [3,5] The chronic sequelae of lymphatic filariasis develop years after initial infection[4]
Paroxysmal cough and wheezing, weight loss, low-grade fever [4] These are the features of Tropical pulmonary eosinophilia (TPE). Tropical pulmonary eosinophilia (TPE) is a distinct syndrome that develops in some individuals infected with W. bancrofti and B. malayi [4] -that are usually nocturnal (and probably related to the nocturnal periodicity of microfilariae)[4]
Hematuria, froth in the urine (proteinuria) Renal abnormalities including proteinuria, haematuria, nephrotic syndrome and glomerulonephritis can occur with filariasis. Circulating immune complexes containing filarial antigens have been implicated in the renal damage[4]
Joint pain Lymphatic filariasis may also present as a mono-arthritis of the knee or ankle joint due to Circulating immune complexes containing filarial antigens.[4]
Impaired vision, and blindness Causative factor for the Onchocerciasis is the filarial nematode Onchocerca volvulus, that is which is transmitted by Simulium. [9] This particularly causes visual problems known as river blindness due to the invasion and death of microfilariae in the skin and eye. [9] Loa loa infestation of the the eye may cause adult worms to be seen in the eye. [10]
Itching Onchocerciasis causes characteristic pruritic plaques. [9] Loa loa infestation may also cause subcutaneous tissue lesions associated with itching. [10]
Sense of adult worm migration under the skin Adults worms of Loa loa may migrate beneathe the skin. [10]
References
  1. LIPNER EM, LAW MA, BARNETT E, KEYSTONE JS, VON SONNENBURG F, LOUTAN L, PREVOTS DR, KLION AD, NUTMAN TB, FOR THE GEOSENTINEL SURVEILLANCE NETWORK. Filariasis in Travelers Presenting to the GeoSentinel Surveillance Network PLoS Negl Trop Dis [online] , 1(3):e88 [viewed 24 September 2014] Available from: doi:10.1371/journal.pntd.0000088
  2. SHASTRY S. Detection of microfilaria on needle aspiration from breast mass: An uncommon finding Trop Parasitol [online] 2014, 4(1):58-59 [viewed 25 September 2014] Available from: doi:10.4103/2229-5070.129189
  3. OMUDU EA, OCHOGA JO. Clinical Epidemiology of Lymphatic Filariasis and Community Practices and Perceptions Amongst the Ado People of Benue State, Nigeria Afr J Infect Dis [online] 2011, 5(2):47-53 [viewed 25 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3497846
  4. BABU S, NUTMAN TB. Immunopathogenesis of lymphatic filarial disease Semin Immunopathol [online] 2012 Nov, 34(6):847-861 [viewed 24 September 2014] Available from: doi:10.1007/s00281-012-0346-4
  5. OTSUJI Y. History, Epidemiology and Control of Filariasis Trop Med Health [online] 2011 Mar, 39(1 Suppl 2):3-13 [viewed 28 September 2014] Available from: doi:10.2149/tmh.39-1-suppl_2-3
  6. MISHRA A, BHADORIYA RS. An Epidemiological Study of Filariasis in a Village of District Datia, MP Indian J Community Med [online] 2009 Jul, 34(3):202-205 [viewed 28 September 2014] Available from: doi:10.4103/0970-0218.55284
  7. AZAD K, ARORA R, GUPTA K, SHARMA U. Lymphatic filariasis: Aspiration of adult gravid female worm from a soft tissue swelling J Cytol [online] 2010 Oct, 27(4):156-157 [viewed 28 September 2014] Available from: doi:10.4103/0970-9371.73308
  8. SAMYKUTTY A, DAKSHINAMOORTHY G, KALYANASUNDARAM R. Multivalent Vaccine for Lymphatic Filariasis Procedia Vaccinol [online] 2010:12-18 [viewed 28 September 2014] Available from: doi:10.1016/j.provac.2010.11.003
  9. TAMAROZZI F, HALLIDAY A, GENTIL K, HOERAUF A, PEARLMAN E, TAYLOR MJ. Onchocerciasis: the Role of Wolbachia Bacterial Endosymbionts in Parasite Biology, Disease Pathogenesis, and Treatment Clin Microbiol Rev [online] 2011 Jul, 24(3):459-468 [viewed 29 September 2014] Available from: doi:10.1128/CMR.00057-10
  10. LUKIANA TUNA, MANDINA MADONE, SITUAKIBANZA NANITUMA H, MBULA MARCEL M, LEPIRA BOMPEKA F, ODIO WOBIN T, KAMGNO JOSEPH, BOUSSINESQ MICHEL. . Filaria J [online] 2006 December [viewed 29 September 2014] Available from: doi:10.1186/1475-2883-5-6

Examination

Fact Explanation
Febrile Inflammation of lymph nodes (lymphadenitis) and lymphatics (lymphangitis) may release pyrogens that causes fever. [1] Recurrent infections associated with damaged lymphatics may also cause the fever. [2]
Chronic swelling, and elephantiasis of the legs, arms, scrotum, vulva, and breasts. The chronic sequelae of lymphatic filariasis develop years after initial infection [1] In lymphatic filariasis, repeated episodes of inflammation and lymphedema [5] leads to lymphatic damage adding chronicity to the disease and graded as follows. Pitting edema which is reversible with limb elevation (Grade1) Nonpitting edema irreversible with the elevation of limb (Grade 2) Severe swelling with sclerosis and skin changes (Grade 3). [2]
Features of hydrocele: enlarged scrotum, transilumination of the content In men, scrotal hydrocele is the most common chronic clinical manifestation of bancroftian filariasis due to accumulation of edematous fluid in the cavity of the tunica vaginalis testis. [3] It is frequent in post-puberty. Mechanism of fluid accumulation is unknown. [1]
Skin changes: hyperpigmentation and hyperkeratosis with wart-like protuberances Endothelial and connective tissue proliferation with damaged or incompetent lymph valves will cause lymphatic dilatation, dysfunction leading to lymphedema. [4] Early pitting edema and later brawny edema with hardening of tissues can be followed by hyper-pigmentation and hyper-keratosis. [1]
Lymphatic discharge Dilated lymphatics are ruptured leading to discharge of lymph fluid, later this will cause entry of microorganisms into the lymphatics. [1]
Respiratory System -Scattered wheezes and crackles are heard in both lung fields Tropical pulmonary eosinophilia (TPE) is a syndrome that is frequent in patients infected with W. bancrofti and B. malayi [1]
Joint tenderness Circulating immune complexes containing filarial antigens causes arthritis present as a mono-arthritis of the knee or ankle joint .[1]
Periorbital swelling Lymphatic filariasis has been associated renal abnormalities including hematuria, proteinuria, nephrotic syndrome and glomerulonephritis. Circulating immune complexes containing filarial antigens have been implicated in the renal damage[1]
Visual impairment Ocular pathology is occur due to the invasion and death of microfilariae in the eye. This may be leading to blindness on certain occasions. [6] Corneal pathology includes “fluffy” or “snow-flake” opacities (punctate keratitis), and hyperpigmented (sclerosing keratitis). [6]
Pruritic plaques Pruritic hyperpigmented hyperkeratotic plaques, that are asymmetrically located are found as cutaneous manifestations in onchocerciasis. [6]
Features of loiasis Calabar swellings, eyeworms are seen in these patients. [7]
milky appearance of urine This is due to the chyluria occuring as a complication. [8]
References
  1. BABU S, NUTMAN TB. Immunopathogenesis of lymphatic filarial disease Semin Immunopathol [online] 2012 Nov, 34(6):847-861 [viewed 24 September 2014] Available from: doi:10.1007/s00281-012-0346-4
  2. OMUDU EA, OCHOGA JO. Clinical Epidemiology of Lymphatic Filariasis and Community Practices and Perceptions Amongst the Ado People of Benue State, Nigeria Afr J Infect Dis [online] 2011, 5(2):47-53 [viewed 25 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3497846
  3. AZAD K, ARORA R, GUPTA K, SHARMA U. Lymphatic filariasis: Aspiration of adult gravid female worm from a soft tissue swelling J Cytol [online] 2010 Oct, 27(4):156-157 [viewed 28 September 2014] Available from: doi:10.4103/0970-9371.73308
  4. MISHRA A, BHADORIYA RS. An Epidemiological Study of Filariasis in a Village of District Datia, MP Indian J Community Med [online] 2009 Jul, 34(3):202-205 [viewed 28 September 2014] Available from: doi:10.4103/0970-0218.55284
  5. OTSUJI Y. History, Epidemiology and Control of Filariasis Trop Med Health [online] 2011 Mar, 39(1 Suppl 2):3-13 [viewed 28 September 2014] Available from: doi:10.2149/tmh.39-1-suppl_2-3
  6. TAMAROZZI F, HALLIDAY A, GENTIL K, HOERAUF A, PEARLMAN E, TAYLOR MJ. Onchocerciasis: the Role of Wolbachia Bacterial Endosymbionts in Parasite Biology, Disease Pathogenesis, and Treatment Clin Microbiol Rev [online] 2011 Jul, 24(3):459-468 [viewed 29 September 2014] Available from: doi:10.1128/CMR.00057-10
  7. LUKIANA TUNA, MANDINA MADONE, SITUAKIBANZA NANITUMA H, MBULA MARCEL M, LEPIRA BOMPEKA F, ODIO WOBIN T, KAMGNO JOSEPH, BOUSSINESQ MICHEL. . Filaria J [online] 2006 December [viewed 29 September 2014] Available from: doi:10.1186/1475-2883-5-6
  8. GOYAL NK, GOEL A, SANKHWAR S, SINGH V, ALI W, NATU SM, SINGH BP, SINHA RJ, DALELA D. Factors affecting response to medical management in patients of filarial chyluria: A prospective study Indian J Urol [online] 2014, 30(1):23-27 [viewed 29 September 2014] Available from: doi:10.4103/0970-1591.124201

Differential Diagnoses

Fact Explanation
Congenital or hereditary lymphedema - Eg, Milroy syndrome Congenital lymphoedema (Milroy disease) is a rare autosomal dominant condition for which a major causative gene defect has recently been determined. [2] It causes a chronic swelling of limbs due to dysfunction of lymphatic vessels. [1] It is classified according to the age at onset, as early-onset lymphedema (primary congenital lymphedema or Milroy disease or late-onset lymphedema. [1] Congenital variety is seen from the birth. This may be associated with other syndromes like noonan's syndrome and turner's syndrome. [1]
Allergic bronchopulmonary aspergillosis Inhalation of aspergillus spores produces type 1 hypersensitivity reaction in the bronchial wall. [6] Aspergillosis has two main pathological types: superficial and deep. In superficial variety there is superficial invasion of aspergillus into the bronchial lining producing inflammation. There is productive cough with large amounts of thick green sputum and it might produce thick yellow mucus plugs. [4] Cough with mucous plugs, haemoptysis and shortness of breath are the common presenting features. [4] Recurrent wheezing, peripheral blood eosinophilia are the features of allergic aspergilosis that mimic in tropical pulmonary eosinophilia. [3] Oedema will not be there as in filariasis, There can be features of bronchiectasis in aspergillosis.
Chronic eosinophilic pneumonia It is a type of eosinophilic lung disease. There is an accumulation of eosinophils and lymphocytes in the alveoli and interstitium, with mild interstitial fibrosis. [8] Chest radiographic finding includes nonsegmental infiltration with peripheral predominance involving mainly the upper lobe when compared to topical pulmonary eosinophilia. [8] High-resolution CT scan demonstrates patchy consolidation with peripheral and upper lobe predominance, ground-glass opacities with crazy paving and bandlike subpleural opacities. [8]
Congenital hydrocele [5] This may present from the birth. Underlying cause is the patent processus vaginalis after birth that causes accumulation of the fluid inside the scrotum. Chronic hydrocele is the most common manifestation of bancroftian filariasis, an endemic disease. [5] They may not have the swelling of the other areas of the body. Thick blood films may be helpful in differentiating two conditions.
Systemic vasculitides eg:Churg-Strauss syndrome These are a complex group of disorders which, there can be a multi organ involvement. Fever, night sweats, malaise, weight loss, arthralgia, myalgia and normocytic normochromic anaemia, leucocytosis, thrombocytosis, and raised erthyrocyte sedimentation rate (ESR) and C reactive protein (CRP) like features are found due to the systemic inflammation that makes it different from the filariasis. [7] ANCA (antineutrophil cytoplasmic antibody) may be positive which is not present in filariasis. Rheumatoid vasculitis, vasculitis associated with systemic lupus erythematosus and Sjogren's syndrome, inflammatory bowel disease, sarcoidosis, Infectious diseases: hepatitis B and C, human immunodeficiency virus, mycobacteria, syphilis, haematological malignancies such as myeloproliferative and lymphoproliferative disorders, solid tumours and drugs may be the causative factors. [7]
Leprosy leprosy causes lesions of the skin and peripheral nerves. Enlargement of the superficial nerves such as great auricular, ulnar, median, radial cutaneous, superficial peroneal, sural, and posterior tibial may be palpable against the bony prominences, tenderness due to neuritis, sensory impairment over the skin lesions such as loss of sensation of temperature, touch, or pain are some features helps to differentiate it from the filariasis. [10] Nerve conduction will be reduced on conduction studies. The lepromin test (response is measured as induration (in mm) 4 weeks after injection), biopsy and histopathological examination of the test site may behelpful to make a diagnosis. [11]
Scrotal/Testicular trauma Anatomic location and mobility of the scrotum makes it vulnerable for the traumatic situations. They will give a history of direct trauma to the scrotum, as a sporting injury or other similar mechanism. [9] It is different from the filariasis, as it cause acute pain, and swelling of the testis and may be associated with scrotal wall abrasion or wall thickening. [9] High-resolution Doppler flow evaluation can be used to evaluate the scrotal abnormalities to assess the contents and vascular integrity. [9]
References
  1. IRRTHUM A, KARKKAINEN MJ, DEVRIENDT K, ALITALO K, VIKKULA M. Congenital Hereditary Lymphedema Caused by a Mutation That Inactivates VEGFR3 Tyrosine Kinase Am J Hum Genet [online] 2000 Aug, 67(2):295-301 [viewed 25 September 2014] Available from: doi:10.1086/303019
  2. BRICE G, CHILD A, EVANS A, BELL R, MANSOUR S, BURNAND K, SARFARAZI M, JEFFERY S, MORTIMER P. Milroy disease and the VEGFR-3 mutation phenotype J Med Genet [online] 2005 Feb, 42(2):98-102 [viewed 25 September 2014] Available from: doi:10.1136/jmg.2004.024802
  3. WARDLAW A, GEDDES DM. Allergic bronchopulmonary aspergillosis: a review. J R Soc Med [online] 1992 Dec, 85(12):747-751 [viewed 25 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1293764
  4. MANN B, PASHA MA. Allergic Primary Pulmonary Aspergillosis and Sch?nlein--Henoch Purpura Br Med J [online] 1959 Jan 31, 1(5117):282-283 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1992387
  5. NORõES J, DREYER G. A Mechanism for Chronic Filarial Hydrocele with Implications for Its Surgical Repair PLoS Negl Trop Dis [online] , 4(6):e695 [viewed 25 September 2014] Available from: doi:10.1371/journal.pntd.0000695
  6. CABRAL FC, MARCHIORI E, ZANETTI G, TAKAYASSU TC, MANO CM. Semi-invasive pulmonary aspergillosis in an immunosuppressed patient: a case report Cases J [online] :40 [viewed 15 September 2014] Available from: doi:10.1186/1757-1626-2-40
  7. SURESH E. Diagnostic approach to patients with suspected vasculitis Postgrad Med J [online] 2006 Aug, 82(970):483-488 [viewed 25 September 2014] Available from: doi:10.1136/pgmj.2005.042648
  8. SANO S, YAMAGAMI K, YOSHIOKA K. Chronic eosinophilic pneumonia: a case report and review of the literature Cases J [online] :7735 [viewed 25 September 2014] Available from: doi:10.4076/1757-1626-2-7735
  9. RAO MS, ARJUN K. Sonography of scrotal trauma Indian J Radiol Imaging [online] 2012, 22(4):293-297 [viewed 30 September 2014] Available from: doi:10.4103/0971-3026.111482
  10. KAR S, KRISHNAN A, SINGH N, SINGH R, PAWAR S. Nerve damage in leprosy: An electrophysiological evaluation of ulnar and median nerves in patients with clinical neural deficits: A pilot study Indian Dermatol Online J [online] 2013, 4(2):97-101 [viewed 30 September 2014] Available from: doi:10.4103/2229-5178.110625
  11. SCOLLARD DM, ADAMS LB, GILLIS TP, KRAHENBUHL JL, TRUMAN RW, WILLIAMS DL. The Continuing Challenges of Leprosy Clin Microbiol Rev [online] 2006 Apr, 19(2):338-381 [viewed 30 September 2014] Available from: doi:10.1128/CMR.19.2.338-381.2006

Investigations - for Diagnosis

Fact Explanation
Thick Blood films Microfilariae of all species causing lymphatic filariasis are detected in blood. [1,2]
Urine examination and microscopy Microfilariae may also be detected in chylous urine and hydrocele fluid. [2]
Full Blood count Marked Eosinophilia is seen in all forms of filarial infection. [1]
Serum immunoglobulin concentrations Elevated IgE and IgG4 levels will be observed in active disease. [1]
Antigen-detection assay This is done using serum,Urine and other body fluids.[1]
Antibody-detection assay The usual antibodies (IgG and IgE) lack specificity and usually cross react with antigens of Strongyloides. Also they do not differentiate past and recent infections. So the diagnosis based on recombinant antigens is only useful in expatriates while in persons in endemic regions which has no value. [1]
Chest X-ray Diffuse pulmonary infiltrates are visible on chest x-ray in patients with tropical pulmonary eosinophilia (TPE). [2]
Ultrasound scan Rarely ultrasonography may be used. It can use to assess thickening of the tissues in the swollen limbs. [4]
Lymphoscintigraphy Lymphoscintigraphy, is an radiological imaging study to use to assess the structural and functional changes in the lymphatics. Lymphatic dilatation, dermal back flow or obstruction to lymph flow in the edematous limbs can be demonstrated by this method.[4]
Biopsy and Histological examination Histological examination shows granulomatous reaction due to death of the adult worms. These granulomas are characterized by macrophages, plasma cells, eosinophils, neutrophils and lymphocytes. Macrophages later develop in to giant cells. There is endothelial and connective tissue proliferation with tortuosity of the lymphatics and damaged or incompetent lymph valves leading to lymphatic dilatation and subsequent lymphatic dysfunction. Later skin changes like hyper-pigmentation and hyper-keratosis with wart-like protuberances appears and on histological examination, reveal dilated loops of lymphatic vessels within nodular lesions. [3]
References
  1. Lymphatic filariasis: diagnosis and pathogenesis. WHO expert committee on filariasis. Bull World Health Organ [online] 1993, 71(2):135-141 [viewed 25 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2393467
  2. CHOUDHRI SH, WONG W, PLOURDE PJ, LERTZMAN M. Tropical pulmonary eosinophilia in a 63-year-old woman from Guyana. CMAJ [online] 1993 Jun 15, 148(12):2157-2159 [viewed 25 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1485295
  3. BABU S, NUTMAN TB. Immunopathogenesis of lymphatic filarial disease Semin Immunopathol [online] 2012 Nov, 34(6):847-861 [viewed 24 September 2014] Available from: doi:10.1007/s00281-012-0346-4

Investigations - Fitness for Management

Fact Explanation
Full blood count As a routine test before surgery to identify aneamia, as it should be corrected prior to surgery. [2]
Prothrombin time and International normalized ratio To detect any bleeding diathesis before surgery. [2]
Serum electrolytes and Creatinine These are particularly important in patients with co-morbities like diabetes mellitus or hypertension. [2]
Random blood sugar If patient is diabetic, blood sugar should be repeated on the day of surgery. [2]
Electrocardiogram Indicated prior to surgery particularly in patients who have a high risk for the cardiovascular problems such as diabetes mellitus, heart disease or hypertension. [2]
Chest X-ray Indicated in filariasis as patient may have Tropical pulmonary eosinophiolia.[1] Also generally it is indicated prior to surgery if patient having any pulmonary disease or malignancy. [2]
References
  1. CHOUDHRI SH, WONG W, PLOURDE PJ, LERTZMAN M. Tropical pulmonary eosinophilia in a 63-year-old woman from Guyana. CMAJ [online] 1993 Jun 15, 148(12):2157-2159 [viewed 25 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1485295
  2. ZAMBOURI A. Preoperative evaluation and preparation for anesthesia and surgery Hippokratia [online] 2007, 11(1):13-21 [viewed 30 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2464262

Investigations - Followup

Fact Explanation
Thick blood films Blood smears can be used to detect the microfilariae. [1] After DEC therapy patients should follow up about 10-15 years in tropical countries and should undergo selective DEC therapy with microfilarial density. [2]
References
  1. GRADY CA, BEAU DE ROCHARS M, DIRENY AN, ORELUS JN, WENDT J, RADDAY J, MATHIEU E, ROBERTS JM, STREIT TG, ADDISS DG, LAMMIE PJ. Endpoints for Lymphatic Filariasis Programs Emerg Infect Dis [online] 2007 Apr, 13(4):608-610 [viewed 25 September 2014] Available from: doi:10.3201/eid1304.061063
  2. KIM JS, NO BU, LEE WY. Brugian filariasis: 10-year follow-up study on the effectiveness of selective chemotherapy with diethylcarbamazine on Che Ju island, Republic of Korea Bull World Health Organ [online] 1987, 65(1):67-75 [viewed 30 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2490859

Investigations - Screening/Staging

Fact Explanation
Thick and thin blood smear Blood smears can be used to detect the microfilaria, but blood films may be innsensitive for monitoring microfilaremia on certain occasions.[1]
Ultrasonography Hydroceles are due to accumulation of edematous fluid in the cavity of the tunica vaginalis testis. Mechanism of fluid accumulation is unknown. [2] USS can be used to demonstrate and monitor lymphatic obstruction.
Staging of oedema Staging of oedema can be done clinically as follows. Stage 1is lymphangitis with pitting edema and total dissapearance on treatment that may recur. Stage 2 is uniform persistent pitting edema wtih clinical history of filriasis. Stage 3 is uniform non pitting fibrous persistent lymphaedema, and stage 4 is non pitting with complications like ulcers warts etc of long duration. [3] Pitting edema can also be assesses as follows. 2mm or less = 1 + Edema. 2-4mm = 2 + Edema. 4-6mm = 3 + Edema. 6-8mm = 4 + Edema.
References
  1. GRADY CA, BEAU DE ROCHARS M, DIRENY AN, ORELUS JN, WENDT J, RADDAY J, MATHIEU E, ROBERTS JM, STREIT TG, ADDISS DG, LAMMIE PJ. Endpoints for Lymphatic Filariasis Programs Emerg Infect Dis [online] 2007 Apr, 13(4):608-610 [viewed 25 September 2014] Available from: doi:10.3201/eid1304.061063
  2. OMUDU EA, OCHOGA JO. Clinical Epidemiology of Lymphatic Filariasis and Community Practices and Perceptions Amongst the Ado People of Benue State, Nigeria Afr J Infect Dis [online] 2011, 5(2):47-53 [viewed 25 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3497846
  3. MANOKARAN G. Surgical management of manifestations in filariasis Indian J Clin Biochem [online] 1997 Dec, 12(Suppl 1):22 [viewed 30 September 2014] Available from: doi:10.1007/BF02873048

Management - General Measures

Fact Explanation
Minimize complications of lymphoedema -hygiene -skin care (early detection, treatment, and prevention of entry lesions), -exercise -elevation of the affected limb -appropriate footwear Recognition of the importance of Acute dermatolymphangioadenitis in the progression of lymphoedema has led to basic recommendations for the treatment of lymphoedema in filariasis-endemic areas. The cornerstones of this treatment include hygiene, skin care.[2]
Prophylactic antibiotics [2] To minimize acute dermatolymphangioadenitis in the progression of lymphoedema.[2]
Diet control[3] Meals rich in fats are restricted in those who with proven chyluria associated with lymphatic filariasis [2]
Bed rest in chyluria[3] Medical management of chyluria with dietary modifications, anti-filarial drugs, bed rest and supportive measures gives reasonable success rate in excess of 70%, which is not affected by the disease duration, chronicity and primary versus recurrent nature of the disease[3]
Prevention of the disease Transmission of filariasis can be controlled with annual mass treatment with drugs that target microfilariae. [1]
compressive bandaging To reduce leg volume or circumference in response to basic lymphoedema management.[2]
References
  1. GRADY CA, BEAU DE ROCHARS M, DIRENY AN, ORELUS JN, WENDT J, RADDAY J, MATHIEU E, ROBERTS JM, STREIT TG, ADDISS DG, LAMMIE PJ. Endpoints for Lymphatic Filariasis Programs Emerg Infect Dis [online] 2007 Apr, 13(4):608-610 [viewed 25 September 2014] Available from: doi:10.3201/eid1304.061063
  2. ADDISS DG, BRADY MA. Morbidity management in the Global Programme to Eliminate Lymphatic Filariasis: a review of the scientific literature Filaria J [online] :2 [viewed 26 September 2014] Available from: doi:10.1186/1475-2883-6-2
  3. GOYAL NK, GOEL A, SANKHWAR S, SINGH V, ALI W, NATU SM, SINGH BP, SINHA RJ, DALELA D. Factors affecting response to medical management in patients of filarial chyluria: A prospective study Indian J Urol [online] 2014, 30(1):23-27 [viewed 26 September 2014] Available from: doi:10.4103/0970-1591.124201

Management - Specific Treatments

Fact Explanation
Pharmacological management with Diethylcarbamazine (DEC) Diethylcarbamazine (DEC) is a microfilaricide.Data on the impact of treatment with antifilarial drugs on filarial morbidity are inconsistent.[3] For most of these studies, the primary outcome of interest was microfilaraemia rather than clinical morbidity.[3] Parasitemic patients should receive DEC(6 mg/kg/day). A 1-day course appears to be as effective as the traditional 12-day regimen[5] In Tropical pulmonary eosinophilia Treatment consists of diethylcarbamazine (DEC) for at least three weeks.[4]
Pharmacological management with other anthelmintic drugs [3] Ivermectin, mebendazole, abendazole are some other antihilmintics used fro the treatment. Ivermectin is a potent microfilaricide anthelminthic drug. [5]
Steroid therapy Therapy for all filarial infections may be associated with allergic-like reactions resulting from degenerating filariae and Wolbachia, for which anti-histamines and corticosteroids may be useful.[5] These can also be used to soften and reduce the swelling of the lymphedematous tissues in mild to moderate filarial lymphedema. Steroids also have shown to have a beneficial in Tropical pulmonary eosinophilia.[4]
Doxycycline Prolonged courses of doxycycline (which kills and sterilizes adult worms as a result of anti-Wolbachia activity) may have a role.[5]
Surgical management of lymphoedema Correction of gross limb elephantiasis via surgery proven to be less successful and sometimes necessitate multiple procedures with skin grafting. But during later stages together with other measurements, it will help in controlling the disease.[1]
surgical management of hydrocele Surgery is the recommended intervention for hydrocele, and if done properly, it is regarded as curative.[3] Bilateral Nodovenal shunt with reduction is the treatment of choice[1]
Management of onchocerciasis This is usually with doxycycline given as a dose of 200mg/day for 4-6 weeks. New treatments such as those with antibiotics are gaining popular now. [6]
Management of chyluria Bed rest, use of abdominal binders to increase intra-abdominal pressure to stop lymph leakage, are initial steps in the management. Fat-restricted, high-protein diet with the addition of fats containing medium chain triglycerides (TGs) and high fluid intake are important dietary measures. Anti-filarial drugs may also improve the chyluria. [7]
References
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  7. GOYAL NK, GOEL A, SANKHWAR S, SINGH V, ALI W, NATU SM, SINGH BP, SINHA RJ, DALELA D. Factors affecting response to medical management in patients of filarial chyluria: A prospective study Indian J Urol [online] 2014, 30(1):23-27 [viewed 29 September 2014] Available from: doi:10.4103/0970-1591.124201