Elephantiasis and Tropical Pulmonary Eosipholia

 

Elephantiasis and Tropical Pulmonary Eosinophila.

PKGhatak,MD

Round worm infestation of people living along the coast of the Bay of Bengal causes  Filariasis. The common nematodes are Wuchereria bancrofti, Brugia malayi,and Brugia tremor. Elephantiasis is the result of Lymphatic channels obstruction by the adult nematodes producing gross deformation of the legs of the victims, resembling elephants' legs. Tropical Pulmonary Eosinophilia is produced by the type I hypersensitive reaction to microfilaria antigen which is released intermittently from the trapped microfilaria in the lung parenchyma.

Life story of the filaria worm:

All the nematodes have a similar life cycle. It consists of 5 stages, part of them in the humans and rest in mosquitoes. A wider variety of mosquitoes - Culex, Anopheles, and Aedes are vectors of human filariasis. The female mosquitoes are infected at the time of feeding on the blood of the infected patients. In the gut and thoracic muscles of the mosquitoes, the microfilaria molt twice and the 3^rd stage larvae are infective microfilariae which move to the salivary apparatus of the mosquitoes and wait for the opportunity to infect humans and carry on to complete two more moltings and take up permanent residence in in the lymphatic channels, lymph nodes, and spleen of victims as adults worms. The male and female worms unite and a female gives birth to thousands of larvae every day. These microfilaria come out at night and circulate in the systemic blood, hoping to be ingested by a mosquito and to continue the life cycle.

Elephantiasis:

120 million people in a wide area of the world, spanning from India, South Asian countries, Western Pacific islands, Tropical Africa, Brazil, Haiti, Dominican Republic and Guyana are at risk of filariasis.

The adult filaria worms preferentially reside in lymph nodes of the groin and neck. The female worms remain fertile for 5 years out of 9 years of their lives. Lymphatic obstruction produces repeated Staphylococcus and fungal infections and scarring. The lymph flow disruption causes the thickening of the skin, and the skin turns hard and lumpy, and the legs become enormous in size. In W. Bancrofti infection the skin of the perineum thickens and causes disfigurement and deformities of the genitalia. The lymph edema that develops from Brugia infection spares the perineum and external genitalia.

Obstruction of the thoracic duct produces bilateral pleural effusion, the fluid is turbid due to the presence of high fat content, specially after a fatty meal. Abdominal pain and Chylous ascites result from abdominal lymphatic obstruction.

Complications: Ulceration and abscess formation, sinus formation from chronic ulcers develop in patients who are not properly cared for. Depression and loss of employment are generally common.

Tropical Pulmonary Eosinophilia (TPE):

Tropical Pulmonary Eosinophilia is much more common in India and in the adjoining countries than Elephantiasis.

TPE is a hypersensitivity eosinophilic inflammation of the respiratory organs. Nocturnal cough, wheezing, fever, loss of weight, blood stained sputum and eosinophilia, at one time thought to be Psudopulmonary eosinophilic tuberculosis. Dr. Weingarten was the first to use the term Tropical Pulmonary Eosinophilia in 1943. The eosinophil count is generally over 3,000/ml. Serum IgE over 1000 mg/dl.

Chest x-ray shows interstitial infiltrates to reticular interstitial pulmonary fibrosis.

Pathology of TPE.

An eosinophils release basic and acidic proteins, Peroxide and neurotoxic chemical in the tissues around the larvae. This weakens the microfilaria and restricts their activities. Complement activation increases opsonization and destruction of microfilaria. The Thymic Lymphocytes type II activation produces IL-4 and IL-5, filaria specific IgM, IgG and IgE and eosinophils. IL -4 potentiates inflammation and Interferon-gamma suppresses inflammation.

Diagnosis of filariasis:

Old standard diagnostic test of direct visualization of microfilaria in the nocturnal blood samples are difficult to exercise and often negative, specially in Elephantiasis. Various methods of concentration of blood for easier detection of microfilaria are practically replaced by the PCR test to detect filarial antigen and indirect ELISA antibodies are more in use at present.

Aspiration of lymph nodes and detecting of microfilaria in the fluid occasionally provide positive results. Also in some cases, microfilaria are detected in ascites and pleural fluids.

Treatment of Elephantiasis:

Adult worms are difficult to remove even by surgery. Ulcerated skin and gross deformed skin segments are removed by surgery.

Treatment of TPE:

In India, where more TPE is seen than Elephantiasis, is customary to use steroids initially for a few days then Diethylcarbamazine is used for 21 days. The results are excellent. Recurrence of TPE is due to reinfection rather than failure of treatment.

Albendazole and Ivermectin are also used but on a limited scale and case by case basis.

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