sign in sign up
<<
Home , Tropical eosinophilia

THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 3, NO. I 7

Occult filarial

P. CHATURVEDI, A. GA WDI, S. DEY

INTRODUCTION occult , mf may actually be found after more care- Bancroftian filariasis is an ancient known to man- ful blood examination despite their low density. III The kind since Be 600. In 1863, the filarial parasite was first clinical features of occult filariasis are different from those discovered by Demarquay in the hydrocoele fluid of of the classical disease and resemble many non-filarial patients in Cuba. In 1866, Wucherer demonstrated micro- from which they are sometimes difficult to distin- filariae (mf) in the chylous urine of Brazilians. In India, guish. Occult filarial manifestations may help explain the Lewis in 1872 identified mf in the blood of patients with aetiology of many clinical syndromes which were earlier filariasis. Bancroft discovered the adult female worm in not completely understood. For example, splenic granulo- 1876 and Browne the adult male in 1888.1 matous inflammatory reactions to mf of W. bancrofti have Lymphatic filariasis has been reported from almost all been discovered only on . II Following are some of tropical and subtropical countries in the world. It is the clinical manifestations of occult filarial infestation. endemic in South, Central and North America, the West Indies, Africa, Asia and Australia. Of the 2677 million TROPICAL PULMONARY people living in countries where the disease is endemic, This is perhaps the best example of occult filariasis. It was 905 million are estimated to be at risk of and first formally described by Frirnodt-Moller and Barton in 90 million are carriers of mf. ~ Filariasis is a disease 194012 although in 1939 Meyer and Kouwcnaar11 had characterized by a wide spectrum of clinical manifesta- demonstrated mf in the inguinal lymph nodes of individuals tions (Fig. I). The so-called 'occult' manifestations such with eosinophilia and . Five years later Van der Sar as tropical pulmonary eosinophilia (TPE),.1 glornerulo- and Hartz!" demonstrated mf in the lymph nodes and pathies." nerve palsies.! endomyocardial fibrosis (EMF),~ of their patients. Ottensen et al.' and Jayawardene arthritis." and filarial infections of the breast? are often and Wijayaratnam 15 showed that TPE was a disease seen in populations living in endemic areas. caused by human filarial parasites and not by animal The term occult filariasis is commonly used to designate filarial parasites as was then believed. TPE also has filarial infections in which mf are not found in the extrapulmonary manifestations. There are ethnic differ- peripheral blood although they may be seen in tissues. K.Y ences in its prevalence. It is more commonly seen on the However, it has now been shown that in some cases with Indian subcontinent although Bancroftian filariasis is endemic in many parts of the world. It can occur at any ASYMPTOMATIC, NO DETECTABLE age and has been reported even in infants. 16 The disease can MICROFILARAEMIA have an acute or an insidious onset. Its clinical manifesta- tions are usually , , chest pain, breathlessness, malaise and occasional abdominal pain. Examination - ASYMPTOMATIC, MICROFILARAEMIC of the chest reveals rhonchi and crepitations. Sometimes lymphadenitis, splenomegaly and hepatomegaly may also be observed. The natural course is marked by recurrences BANCROFTIAN _ FILARIAL FILARIASIS and relapses. Long-standing untreated cases progress to pulmonary fibrosis and respiratory insufficiency. 17 These patients have blood eosinophilia, raised erythro- - LYMPHA TIC OBSTRUCTION cyte sedimentation rates and there may be evidence of diffuse miliary lesions or increased bronchovascular markings in the chest X-rays especially of children. 1M T_ OCCULT OR CRYPTIC Microfilariae are not demonstrable in the blood smears but can be found in the lungs. liver and lymph nodes on a FIG 1. Clinical manifestations:' thorough examination.'? There is impairment of lung function with occurrence of both obstructive and restrictive defects.P It responds to treatment with Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha 442102, Maharashtra, India (DEC) which is yet another indication of its filarial origin. P. CHATURVEDI, A. GAWDI, S. DEY Department of Paediatrics Various immunological methods using homologous Correspondence to P. CHATURVEDI, Vivekanand Block, and heterologous have been employed for the KHS Campus, PO Sevagram, Wardha 442102, Maharashtra, India diagnosis of the disease. Using an indirect fluorescent © The National Medical Journal of India 1990 8 THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 3, NO. I test, Ismail and Wijayaratnam found filarial and Sen29 in a study of chylous arthritis (which they in only 57% of their patients and concluded believed to be of filarial origin) found lymphangiectasia, that the cause for TPE in antibody negative patients could stasis and varicosities in the popliteal lymphatics with be non-filarial (unpublished data). However, a compari- short blind channels leading to the joint suggesting son of the W. bancrofti mf excretory-secretory lymphatic fistulization into the synovial sac. The condi- (mfES Ag) with W. bancroft; larval (L3) excretory-secretory tion responds well to DEC but poorly to salicylates." antigen (L3 ES Ag) showed an antibody positivity rate of only 54% with mf ES Ag and a 96% positivity rate with GLOMERULOPA THIES L3 ES Ag, suggesting that L3 ES Ag was more specific Glomerulonephritis associated with lymphatic filariasis in the diagnosis of TPE. 21 was reported by Chugh et al. in 1978.4 Chaturvedi et al.29 In TPE and other occult filarial manifestations, specific also found that 2 of 5 children they had seen with filariasis antifilarial IgE antibody titres to mf antigens from W. and acute glomerulonephritis had filarial antibodies. bancrofti, B. malayi and D. immitis are increased. But in Renal biopsies in these patients showed diffuse mesangial filarial TPE, IgE antibodies are more highly sensitized proliferative glomerulonephritis with C3 deposition on and respond more to mf antigens than the IgE antibodies the basement membrane. The condition responds well to of other filarial manifestations.! Microfilariae, which are DEC therapy. 33 The production of typical lesions of destroyed in the lungs through an IgG mediated response, glomerulonephritis in cats infected with Brugia pahangi'" provoke hypersensitivity and lead to an increase in IgE is in keeping with this hypothesis. The demonstration of levels. 22.23This points to the existence of a type I reaction. filarial antigens and specific filarial antibodies in the The occurrence of an additional type III reaction is indi- immune complexes deposited in the glomeruli would cated by an increase in IgG, IgM and IgA 24and the presence provide definitive evidence for a filarial aetiology. of immunoglobulins in the lungs." Although TPE may occasionally present atypically, the diagnosis is seldom ENDOMYOCARDIAL FIBROSIS difficult. However, other occult filarial syndromes such as Endomyocardial fibrosis is a rare disease seen in the filarial arthritis are often not as easy to detect. equatorial belts. The incrimination of filarial infection in its causation is based largely on circumstantial evi- FILARIAL ARTHRITIS dence.v-" The geographic distribution of the disease in This is a form of arthritis which usually affects the knee areas endemic for filariasis, the detection of antibodies to joints and is fairly common in endemic areas. Though Loa loa in patients with EMF, 37 certain clinical features it had been recognized as a possible manifestation of resembling filarial infection and the occurrence of Bancroftian filariasis twenty years ago,2l>-2Hno detailed eosinophilia and EMF with Loeffler's syndrome." have investigations were done until 1973, when Ismail and led to the hypothesis of EMF being filarial in origin. Nagaratnam" using mf of W. bancrofti in a tluorescent Further, Harinath in 198739 found filarial antibodies in antibody test found that 90% of their patients with filarial 8 of the 10 patients with EMF. further supporting the arthritis tested positive for filarial antibodies. Chaturvedi theory that EMF may be of filarial origin. et al.1Y found that 80% of children with arthritis, where no other diagnosis could be made, had filarial antibodies. FILARIAL GRANULOMAS IN THE BREAST The need to differentiate filarial arthritis from other This manifestation is particularly prevalent in India and diseases, especially rheumatoid arthritis, is important as Sri Lanka where W. bancrofti is the predominant species. the treatment of both conditions is entirely different. It has not been reported from areas endemic for Brugian Filarial arthritis may be caused by species other than filariasis. Filarial granulomas present as hard breast W. bancrofti.~32 lumps attached to the overlying skin and are at times It is usually monoarticular but two-joint involvement difficult to distinguish from malignant tumours.t" A his- also occurs. Only large joints are affected and the occur- tological examination can confirm the diagnosis by the rence of the symptoms in small joints rules out the diagnosis finding of an eosinophilic granulomatous reaction around of filarial arthritis. The condition runs a short, benign the filarial parasites which are in varying stages of degenera- course and the majority of patients do not have fever but tion. Both adult worms and mf have been found in the a painless swelling of one or more joints (usually the granulomas.v':" Filarial antibodies have been demonstrated knee). Sometimes the affected joint may be painful. warm in these patients and the condition responds to DEC and tender with restriction of movement. 2 The symptoms therapy which, in many instances, can lead to complete may recur, often in the same joint but occasionally in disappearance of the lump, some other joint and may be mistaken for rheumatoid Finally a variety of manifestations such as thrombo- arthritis.s-" phlebitis, tenosynovitis and nerve palsies found in endemic These patients show normal or moderately elevated areas, sometimes coexisting with filariasis, have been eosinophil counts and erythrocyte sedimentation rates; suggested to be of filarial origin without much convincing X-rays of the involved joints show soft tissue swelling but evidence.? no bony abnormalities. Microfilariae in night blood smears may be seen in some instances. The antistreptolysin 0 SUMMARY titre is generally normal. 6 Classical filariasis presenting with lymphangitis, lymph- The of the disease is still obscure. Das oedema, chyluria or elephantiasis with microfilaraemia is CHATURVEDI, GAWDI, DEY: OCCULT FILARIASIS 9 well documented. In occult filariasis, microfilariae are not 20 Kamat SR. Pimparkar BD. Store SO. Warrier NVU. Fakey vc. found in the blood but may be seen in the tissues. Earlier, Study of clinical, radiological and pulmonary function patterns of occult filariasis was synonymous with tropical pulmonary response to treatment in pulmonary eosinophilia. Indian} Chest Dis 1970;12:91-100. eosinophilia but other manifestations such as glomerulo- 21 Malhotra A. Harinath Be. Comparative efficiency of Wuchereria pathies, endomyocardial fibrosis, arthritis and filarial bancrofti microfilarial and larval excretory-secretory antigens in infections of the breast are now well recognized. The ELISA for the diagnosis of tropical eosinophilia and Bancroftian occult manifestations are generally microfilaraemic and filariasis. Indian} Exp BioI 1984;22:520-2. the clinical manifestations are sometimes impossible to 22 Ezeoke A. Perara ABV. Hobbs JR. Serum IgE elevation with tropical eosinophilia. Clin Allergy 1973;3:33--5. distinguish from well known clinical entities. The diagnosis 23 Neva FA, Kaplan AP. Pacheco G. et al. Tropical eosinophilia. A of these occult manifestations can be confirmed by the human model of parasitic with observation on ELISA test using specific antigens. Therefore, in endemic serum IgE levels before and after treatment. I Allergy Clin areas, a high index of suspicion is necessary to establish a Immuno/1975;55:422-9. diagnosis because specific therapy against microfilariae is 24 Samuel AM. Udwadia FE. Parab PB. Balani PH. Ganatra RD. Cell mediated and humoral immune response in tropical eosinophilia. effective and easily available. Indian} Med Res 1978;68:444-9. 25 Udwadia FE. Pulmonary eosinophilic syndrome with special reference to the tropics and asthma. In: Ahuja MMS (ed.) Progress in clinical REFERENCES medicine in India. Second Series. New DelhiArnold Heinemann. 1978:453--75. Sasa M. Human Filariasis. A Global Survey of Epidemiology and 26 Napier LE. The principles and practice of tropical medicine. Control. Tokyo:University of Tokyo Press. 1976:334-508. New York:Macmillan. 1946:654-92. 2 Fourth report of a WHO expert committee on lymphatic filariasis. 27 Manson-Baht PH. Manson's tropical diseases. London:Cassel. Filariasis. WHO Tech Rep Ser 1984;702: 1-112. 1966:684. 3 Ottesen EA. Neva FA. Paranjape RS. Tripathy SP. Thiruvengadam 28 Das GC. Sen SB. Chylous ascites. Br Med} 1961l;2:27-9. KV, Beaven MA. Specific allergic sensitization of filarial antigens 29 Chaturvedi P. Gawdi A, Harinath BC. Reddy MVS. Confirmation in tropical eosinophilia syndrome. Lancet 1979;1:1158-61. of filarial aetiology of monoarthritis and other conditions in children 4 Chugh KS. Singhal PC. Tewari SC. Nath IVS. Datta BN. Acute of endemic area for Bancroftian filariasis. Abstract Book. 19th Inter- glomerulonephritis associated with filariasis. Am} Trop Med Hyg national Congress of Paediatrics. Paris. 1989:93. 1978;27:630-1. 30 Jaffres R. Sirnitzis Le Flobic AM. Chastel e. Arthrite filarienne a 5 Rao CK. Kumar S. Role of filariasis in endomyocardial fibrosis. Loa loa avec microfilaires dans Ie liquide articulaire. Rev Rhum Mal } Commun Dis 1982; 14:91-5. Osteoartic 1983;50:145-7. 6 Ismail MM, Nagaratnam N. Arthritis. possibly due to filariasis. 31 Doury P, Salion P. Charmot G. Les epanchements articulaires a Trans R Soc Trop Med Hyg 1973:67:405-9. eosinophiles. A propos d'une observation. Sem Hop Paris 1983; 7 Chandrasoma PT. Mendis KN. Kumararatne OS. Microfilarial 59: 1683--5. granuloma of the breast in a patient with tropical pulmonary 32 Langer HE. Bialek R. Mielke H. Klose J. Human with eosinophilia. Am} Trop Med Hyg 1977;26:570-1. reactive arthntis=-case report and review of literature. Klin 8 Joe LK. Occult filariasis: Its relationship with tropical pulmonary Wochenschr 1987;65:746-51. eosinophilia. Am} Trop Med Hyg 1962;11:646-52. 33 Yap HK. Woo KT. Yeo PP. Chiang GS. Singh M. Lim CH. The 9 Beaver pe. Filariasis without microfilaremia. Am} Trop Med Hyg nephrotic syndrome associated with filariasis. Ann Acad Mtd 1970;19: 181-9. Singapore 1982;1I:~3. 10 Partono F. The spectrum of lymphatic filariasis. In: Filariasis. Ciba 34 Au ACS, Denham DA, Draper CC, Mackenzie e. The Foundation Symposium 127. Wiley Interscience Publication 1987:25. of glomerulonephritis in feline filariasis. Trans R Soc Trop Med Hyg II Dhayagude RG. Amin BM. Microfilarial granulomata of the 1980;74:674-5. . Am} PathoI1942;18:351'-{)1. 35 Gerbaux A, Dubost C. Maurice P, et al. Endomyocardite fribreuse 12 Frirnodt-Moller C. Barton RM. A pseudo-tuberculous condition observee au cours de la filariose. A propos d'un cas traite chirurgicale- associated with eosinophilia. Indian Med Gaz 1940;75:607-13. ment. Ann Med Interne 1973;124:471-82. 13 Meyers FM. Kouwenaar W. Over hypereosinophilia en over 36 Walloopillai NJ, Korale DP. A case of tropical eosinophilia with unmerk waardigen vorrn van filariasis. Geneesk Tidschr Nedlnd constrictive cardiomyopathyJ Colombo Gen Hosp 1973;4:24-9. 1939;79:853--73. 37 Carlisle R, Ogunba EO, McFarlane H, Onayemi OA, Oyeleye YO. 14 Van der Sar A. Hartz H. The syndrome, Tropical eosinophilia and Immunoglobulins and antibody to Loa loa in Nigerians with microfilaria. Am} TTOp Med 1945;25:83--96. endomyocardial fibrosis and other heart diseases. Br Heart} 1972; 15 Jayewardene LG. Wijayaratnam Y. The fluorescent antibody test 34:678-80. in the serological diagnosis of the causative organism of tropical 38 Vakil RJ. Cardiovascular involvement in tropical eosinophilia. eosinophilia and filariasis.v Helminrho/1968;42:57-{,4. Br Heart} 1961 ;23:578-86. 16 Indrabai K, Sastry VN, Subrahmanyam MVG. Tropical 39 Harinath Be. Immunodiagnosis of Bancroftian filariasis. In: eosinophilia in pediatric age group. Indian Paediatr 1976;13:773--7. Filariasis, Ciba Foundation Symposium 127. Wiley Interscience. 17 Udwadia FE. Tropical eosinophilia-A correlation of clinical, 1987:216. histopathologic and lung function studies. Dis Chest 1967;52:531-8. 40 Chandrasoma PT, Mendis KN. Filarial infection of the breast. 18 Ball JD. Tropical pulmonary eosinophilia. Trans R Sac Trop Med Am} Trop Med Hyg 1978;27:770-3. Hyg 1950;44:237-58. 41 Saxena H, Singh SN, Samuel KC, Ajwani KD. Nodular breast lesion 19 Joshi VV, Udwadia FE, Gadgil RK. Etiology of tropical caused by filarial worms: Report of three cases. Am} Trop Med Hyg eosinophilia. Am} Trop Med Hyg 1%9;18:231-40. 1975;24:894-6.