Benznidazol Nifurtimox Free radical formation upon metabolism Nifurtimox also for West African trypanosiomiasis (CNS stage) © by author ESCMID Online Lecture Library © by author ESCMID Online Lecture Library Aldert Bart & Tom van Gool Case history 34-year old Nigerian male Applicant for asylum, arrival in Netherlands: sept 2009 No medical history Former occupation: farmer Since 5 years: “Pepperish body” Worm-like movements in throat and stomach Itching skin, varying in duration and location Additional information:© by author No unprotected sex (never tested for HIV) ESCMIDNo movements Online in his eye Lecture Library No skin lesions No intoxications Stable weight Physical examination No abnormalities, notably: No lymfadenitis No scrotal abnormalities No skin lesions Additional tests Initial laboratory tests: all normal, notably: Haemoglobin 9.2 mmol/l, WBC 4.2 x 109/l, normal differentiation (no eosinophilia) Negative serology© for: byHIV, authorschistosomiasis and strongyloides QBC: no trypanosomiasis, but… ESCMID Online Lecture Library © by author ESCMID Online Lecture Library Filaria and filariasis heterogeneous group of nematodes (draadwormen) blood/tissue parasites vector borne transmission imported disease spectrum of diseases (eosinophilia!) serological cross© reactions by author ESCMID Online Lecture Library Filaria macrofilaria: adult worms, male or female take 1-2 year to develop, live up to >15 years 2-7 cm (Loa loa) to 50 cm (Onchocerca volvulus) in lymphatic system, subcutaneous, deep connective tissues or body cavities; may migrate microfilaria: larvae up to 1 year in host In blood, skin, urine,© lungs; by migrate author develop in vector (1-2 weeks) in infectious larvae ESCMID Online Lecture Library PERIODICITY nocturnal periodicity: largest number of microfilaria in the peripheral circulation occurs at night between 9 p.m. and 2 a.m. (W. bancrofti). diurnal periodicity: largest number of microfilaria found during daytime (Loa loa). aperiodic: (Mansonella perstans ). subperiodic or nocturnally subperiodic: microfilaria can be detected© by during author the day but at higher levels during late afternoon or at night (W. bancrofti, pacific region). ESCMID Online Lecture Library The basis of periodicity is unknown and when they are not in the peripheral blood, they are primarily in capillaries and blood vessels of the lungs. • Lymphatic filariasis – Wuchereria bancrofti – Brugia malayi – Brugia timori • Onchocerciasis (river blindness) – Onchocerca volvulus • Others: – Loa loa © by author – Mansonella perstans (formerly Dipetalonema perstans) – M. streptocerca ESCMID– M. ozzardi Online Lecture Library • Zoonoses: Dirofilaria Geographical Site of adult in Parasite Discase caused Vector distribution body Wuchereria lymphatic filariasis Africa, Asia, mosquitos lymphatics bancrofti (Bancroftian) South America, Pacific lymphatic filariasis Brugia malayi Asia mosquitos lymphatics (Malayan) loaiasis Calabar Central and West Loa loa Chrysops subcutaneous swelling Africa Onchocerca Onchocerciasis Africa and Central Simulium subcutaneous volvulus 'river blindness' America Tetrapetalonema Central and West abdominal or pleural none Culicoides perstans Africa, South America mesenteries Tetrapetalonema none West Africa Culicoides subcutaneous streptocerca Mansonella abdominal or pleural none South America Culicoides ozzardi © by author mesenteries The microfilariae of each species of filarial worms differ, and examination of microfilariaeESCMID is necessary Online to confirm the Lecture presence and identity Library of a particular parasitic infection. Genus and species of Geographic Location of Size in µm Sheath Head Tail Periodicity Vector Symptoms adult location distribution microfilaria length width Tropis and 1 subtropics Blood + Wuchereria bancrofti Tapered to point; Nocturnal, lymphatics Worldwide 230 - 300 7,5-10 Short no nuclei in end subperiodic Mosquitoes elephantiasis Tapered; terminal Southeast Asia, Brugia malayi Blood and subterminal Nocturnal, 2 West Pacific + lymphatics 170 - 260 5-6 Prolonged nuclei subperiodic Mosquitoes elephantiasis Tapered; nuclei West and Central Loa loa Blood irregularly spaced calabar swellings 3 Africa + subcutaneous 250 - 300 6-8 Short to end Diurnal Deer fly African eye worm Central and South Mansonella perstans America Tapered, bluntly Blood 4 body cavities, mesentery, - rounded; nuclei to Africa perirenal 150 - 210 4-5 Rounded end None Midge asymptomatic Mansonella ozzardi Central and South America, Blood 5 subcutaneous, possible - Long, slender tail; Carribean body cavity 175 - 240 3-5 Rounded no nuclei to end None Midge asymptomatic Central and South © by author river blindness America onchodermatitis Skin 6 Onchocerca volvulus - Short, Tapered to point; None or femoral lymph Africa subcutaneous 250 - 300 5-9 rounded no nuclei in end minimal Black fly nodes Tapered, bluntly West and Central Mansonella Skin rounded; nuclei to 7 Africa - streptocercaESCMID Online LectureRounded, end of tail. TailLibrary bent non pathogenic subcutaneous 150 - 240 2,5-3,5 slender in hook shape None Midge slight itching rash Lymphatic filariasis: elephantiasis 1.3 billion people at risk (20% world population) 30% India, 30% Africa, remainder Asia, Pacific, Americas Bangladesh, Congo, India, Indonesia, Madagascar, Nigeria, Philippines most highly - endemic countries 70-120 million persons© infected by author 25ESCMID million genital diseaseOnline (hydrocoele) Lecture Library 15 million lymphoedema/elephantiasis of the leg © by author ESCMID Online Lecture Library Adults in lymphatic system Microfilaria in blood transmission by mosquitoes 78-130 million infected worldwide Wuchereria bancrofti Brugia malayi © by author BrugiaESCMID timori Online Lecture Library © by author ESCMID Online Lecture Library Distribution of lymphatic filariases Adults in lymphatic system Microfilaria in blood transmission by mosquitoes 78 million infected worldwide Wuchereria bancrofti: periodic and non-periodic (islands of Eastern Pacific) Brugia malayi: periodic© by and author non-periodic (West Malaysia, S. Vietnam, Thailand, Philippines) BrugiaESCMID timori: IndonesiaOnline Lecture Library Bancroftian filariasis: I. Distribution and life cycle maturation (~1 year) lymph nodes, ~10 testis and days epididymis © by author ESCMID Online Lecture Library Adult male W. bancrofti ~4 cm females ~ 8–10 cm long © by author OnESCMID maturation, the Online infective larvaeLecture copulate Library and the adult filariae become localised in lymph glands (e.g. in the groin). © by author ESCMID Online Lecture Library Mosquito vectors: Culex, Mansonia, Aedes © by author ESCMID Online Lecture Library - Symptomless mf+ carriers - Amicrofilaremic patients adult (including - Lymphangitis endosymbiont Wolbachia) - Lymphadenopathy cause of disease through - Lymphadenitis inflammatory response © by author methylene-blue staining of Wolbachia endobacteria. (A, C). Wolbachia are ESCMID Online Lecture Libraryessential for growth, development, embryogenesis and survival of O. volvulus and lymphatic filaria - Symptomless mf+ carriers - Amicrofilaremic patients adult (including - Lymphangitis endosymbiont Wolbachia) - Lymphadenopathy cause of disease through - Lymphadenitis inflammatory response - Chronic Manifestations© by author in endemic areas : Hydrocoele ESCMIDOrchi-epididymitis Online Lecture Library Elephantiasis teenager from an Early elephantiasis due eastern Indian village Elephantiasis of the leg to Brugia malayi suffering from filarial and scrotum due to hydrocele. Wuchereria bancrofti in © by author Tahiti: requires radical surgery to remove the surplus tissue. ESCMID Online Lecture Library Severe socio-economic consequences of lymphatic filariasis: shunning, decreased income, … Elephantiasis of the scrotum © by author Urine containing lymph ESCMIDThe dilated lymph Online vessels rupture Lecture and Library discharge chyle into the urinary tract, thus producing the milky appearance known as chyluria. © by author ESCMID Online Lecture Library Control: mass drug administration 1. ONCHOCERCIASIS Onchocerca volvulus Transmitted by Simulium (fly) Adults in nodules, microfilaria in the dermis: tropical Africa (99%), South America, Yemen. Symptomatology Symptomless but© mf+ by author Cutaneous lesions: nodules or onchocercoma, pruritis, dermatitis with lichenification, lizard or elephant skin ESCMIDOcular lesions: Online blindness Lecture Library © by author ESCMID Online Lecture Library Geographical map of Onchocerca volvulus mainly a disease of riverine country © by author ESCMID Online Lecture Library © by author ESCMID Online Lecture Library Simulium or buffalo-fly with a humped back (larval stages in fast running water) © by author ESCMID Online Lecture Library Onchocercal scabies © by author ESCMID Online Lecture Library Subcutaneous nodule predominantely in the lower part of the body in Africa Macroscopic section of nodule © by author ESCMID Online Lecture Library Nodule opened to show tangled mass of adult worms. Female worms are very long and thin (50 X 0.5 cm). The males are shorter (2 cm). © by author ESCMID Online Lecture Library River blindness © by author ESCMID Online Lecture Library Control - 2. LOASIS Loa loa Transmission by Chrysops sp. Adults migrate, microfilaria in blood only in Central and West African rain forest. Symptomatology: Asymptomatic mf+ carriers Transient Calabar swellings© by author Almost constant pruritis Migration of adult under the skin and the conjunctiva Neurological,ESCMID