Extralymphatic disease due to bancroftian filariasis

An Unusual Encounter: Microfilaria Incidentally Detected in the Bone Marrow Aspirate of a Chronic Kidney Disease Patient

Lymphatic filariasis is endemic in a few states of India and is one of the most common public health concerns. Wuchereria bancrofti (W. bancrofti) is the most common parasite that causes lymphatic filariasis in India. Microfilariae have been commonly found in the peripheral blood and body fluid, as well as demonstrated in fine needle aspirates (FNA) and bronchial cytology. They have been rarely reported in bone marrow aspirates. Due to the nocturnal periodicity of W. bancrofti, it may be missed in peripheral blood during the day. Though peripheral eosinophilia is a presenting feature of filariasis, it may be absent in the majority of cases, as in this case. We report an incidental finding of W. bancrofti in the bone marrow aspirate of a 72-year-old male who had chronic kidney disease.

Immunomodulation of streptozotocin induced Type 1 diabetes mellitus in mouse model by Macrophage migration inhibitory factor-2 (MIF-2) homologue of human lymphatic filarial parasite, Wuchereria bancrofti

Helminth parasites modulate the host immune system to ensure a long-lasting asymptomatic form of infection generally, mediated by the secretion of immunomodulatory molecules and one such molecule is a homologue of human host cytokine, Macrophage migratory Inhibitory Factor (hMIF). In this study, we sought to understand the role of homologue of hMIF from the lymphatic filarial parasite, Wuchereria bancrofti (Wba-MIF2), in the immunomodulation of the Streptozotocin (STZ)-induced Type1 Diabetes Mellitus (T1DM) animal model. Full-length recombinant Wba-MIF2 was expressed and found to have both oxidoreductase and tautomerase activities. Wba-MIF2 recombinant protein was treated to STZ induced T1DM animals, and after 5 weeks pro-inflammatory (IL-1, IL-2, IL-6, TNF-α, IFN-γ) and anti-inflammatory (IL-4, IL-10) cytokines and gene expressions were determined in sera samples and spleen respectively. Pro-inflammatory and anti-inflammatory cytokine levels were significantly (p<0.05) up-regulated and down-regulated respectively, in the STZ-T1DM animals, as compared to treated groups. Histopathology showed macrophage infiltration and greater damage of islets of beta cells in the pancreatic tissue of STZ-T1DM animals, than Wba-MIF2 treated STZ-T1DM animals. The present study clearly showed the potential of Wba-MIF2 as an immunomodulatory molecule, which could modulate the host immune system in the STZ-T1DM mice model from a pro-inflammatory to anti-inflammatory milieu.

A Rare Co-existent Case of Splenic Microfilariasis and Pancreatic Solid Pseudopapillary Epithelial Neoplasm - A Double Jeopardy!

Filariasis is a major public health concern in tropical and subtropical countries like India with Wuchereria bancrofti accounting for 90% of lymphatic filariasis. Rarely observed are extra lymphatic manifestations caused by interaction of immune system with microfilaria and their diffusible products. Among various organs involved, splenic involvement is a rare extra lymphatic manifestation of filariasis and can masquerade clinicoradiologically as metastasis when associated with a known malignancy or as a primary malignancy like lymphoma. Hereby, we present an unusual case of coincidence of splenic filariasis with pancreatic solid pseudopapillary epithelial neoplasm in a 20-year-old woman associated with peripheral blood eosinophilia.

Cerebral filariasis infection with Litomosoides in Molossus barnesi (Chiroptera: Molossidae) in the Brazilian eastern Amazon, with comments on Molossinema wimsatti Georgi, Georgi, Jiang and Fronguillo, 1987

During bacterial and viral pathogen investigation of 30 specimens of bats captured in periurban forest areas in the city of Belém, Pará, Brazil, a case of cerebral filariasis was observed. In the course of histopathological examination, adult filariae were found in pseudocystic cavities brain of Molossus barnesi (Molossidae) and classified morphologically as Litomosoides by the shape of the spicules-left spicule with a handle longer than the blade; right spicule curved, with a sclerotized heel supporting a dorsal notch; the area rugosa constituted by a ventral band of small longitudinal crests; tail rounded in males; long esophagus with a slightly glandular distal portion; and a muscular bent vagina. All the specimens lack a stoma (buccal capsule). We compared our filarioids with the description of specimens of Molossinema wimsatti. Morphological characteristics of M. wimsatti resemble the genus Litomosoides. Thus, we believe that M. wimsatti is a synonym of L. molossi Esslinger, 1973, and filarioid specimens from material reported by Lichtenfels et al. (Trans Am Micros Soc 100:216-219, 1981) and from de Souto et al. (J. Helminthol 1195:e65, 2021) most probably correspond to Litomosoides. We suggest that the reduction of the buccal capsule may be attributable to the ectopic location. No evidence of tissue responses by the host was observed. This is the first record of Litomosoides infecting brain tissue of Molossus barnesi from Brazil, representing a record of a new host species. More specimens of bats should be examined in order to find filarioids in the brain and verify its taxonomic position using molecular techniques.

Filariasis Diagnosed by Real-Time Ultrasound Scanning as Filarial Dance Sign - A Case Report

Introduction

Lymphatic filariasis (LF) is a vector-borne illness caused due to Wuchereria bancrofti. Genital abnormalities may result from chronic inflammation of the lymphatic vessels and obstruction of the afferent vessels in Bancroftian filariasis. Doxycycline, albendazole, diethylcarbamazine, and ivermectin are among the treatments available.

Case

A 16-year male presented to our OPD with a complaint of left inguinal swelling for the past 6 Months. Examination of the swelling revealed a left-sided inguinal swelling of 5 × 4 cm with intact overlying skin. A provisional diagnosis of inguinal lymph varix was made, and real-time ultrasound scanning along with FNAC was performed. Swelling resolved after conservative management.

Discussion

Ultrasonography can easily observe adult worms due to their size and fast movements. Using pulsed-wave doppler mode, the characteristic movement profile of adult worms in pulsed-wave doppler mode can be distinguished from other movements (e.g., blood in venous vessels).

Conclusion

Ultrasound is the imaging modality of choice to detect filarial worms/microfilaria in the lymphatic system, which produces the classic twirling of microfilaria in the lymphatic system, known as the "filarial dance sign".

The role of helminths in the development of non-communicable diseases

Non-communicable diseases (NCDs) like cardiovascular disease, chronic respiratory diseases, cancers, diabetes, and neuropsychiatric diseases cause significant global morbidity and mortality which disproportionately affect those living in low resource regions including low- and middle-income countries (LMICs). In order to reduce NCD morbidity and mortality in LMIC it is imperative to understand risk factors associated with the development of NCDs. Certain infections are known risk factors for many NCDs. Several parasitic helminth infections, which occur most commonly in LMICs, have been identified as potential drivers of NCDs in parasite-endemic regions. Though understudied, the impact of helminth infections on the development of NCDs is likely related to helminth-specific factors, including species, developmental stage and disease burden. Mechanical and chemical damage induced by the helminth in combination with pathologic host immune responses contribute to the long-term inflammation that increases risk for NCD development. Robust studies from animal models and human clinical trials are needed to understand the immunologic mechanisms of helminth-induced NCDs. Understanding the complex connection between helminths and NCDs will aid in targeted public health programs to reduce helminth-induced NCDs and reduce the high rates of morbidity that affects millions of people living in parasite-endemic, LMICs globally.

Neglected tropical rheumatic diseases

The complexities of dealing with rheumatic diseases in tropical countries are diverse and likely due to limited health care infrastructure, lack of diagnostic and therapeutic facilities, impact of dominant prevailing diseases, and the challenges of differentiating from infectious and non-infectious disease mimics. Several tropical diseases present with musculoskeletal and rheumatic manifestations and often pose a diagnostic dilemma to rheumatologists. The diagnosis is often delayed or the disease is misdiagnosed, leading to poor patient outcomes. Endemic tropical diseases like tuberculosis and leprosy have myriad rheumatic presentations and remain important differentials to consider in patients with rheumatic manifestations. Infection with human immunodeficiency virus is a great masquerade and can mimic manifestations of multiple diseases. The role of viral infections in triggering and perpetuating autoimmunity is well known and chikungunya arthritis is a classic example of the same. This review highlights the rheumatic manifestations of tropical diseases and aims to create awareness among the caregivers. Key Points • It is crucial to be aware and identify infectious diseases presenting with rheumatic manifestations in the tropics. • Presentations akin to classic rheumatic syndromes such as rheumatoid arthritis, spondyloarthritis, systemic lupus erythematosus and vasculitis are common.

Prevalence of Methicillin-Resistant Staphylococcus Species Among Filarial Lymphedema Patients in Ahanta West District of Ghana

Background

Filarial pathologies such as lymphedema may be associated with complications such as chronic non-healing wounds. Nonetheless, the role of bacterial population colonizing the lymphedematous legs has been posited to worsen the conditions of those living with the infection. These bacteria are usually composed of staphylococcal species partly because they are commensals. Thus, this present study sought to type the methicillin-resistant Staphylococcus aureus (MRSA) prevalence among individuals presenting with filarial lymphedema, particularly as MRSA tends to affect treatments options.

Methods

We recruited individuals (n = 321) with stages I–VII of lymphedema in a cross-sectional study in the Ahanta West district of the Western Region of Ghana. Swabs from lymphedematous limb ulcers, pus, and cutaneous surfaces were cultured using standard culture-based techniques. The culture isolates were later identified using Matrix-assisted Laser Desorption/Ionization Time of Flight (MALDI-TOF) mass spectrometry.

Results

A total of 192 Staphylococci species were isolated, with an overall prevalence of 39.7% (95% CI: 35%–44%; N = 483). S. hominis was the most prevalent species (23.95%), followed by S. haemolyticus (20.83%), S. epidermidis (15.10%), S. aureus (10.41%), and S. saprophyticus (9.32%). The remaining 20.34% were distributed among S. wanneri, S. sciuri, S. pasteuri, S. xylosus, S. simulans, S. cohnii, S. caprae, S. lugdunensis, and S. capitis. MRSA, containing mecA gene, was detected in 21 out of 31 Staphylococci isolates tested, with an overall prevalence of 68% (95% CI: 51%–84%). In addition, a virulent gene, Panton–Valentine leukocidin (PVL), which is usually associated with S. aureus, was detected in 20/31 (64.5%) S. aureus in the study.

Conclusion

These results suggest that MRSA species may pose a challenge to the treatment of filarial lymphedema with antibiotics particularly, as doxycycline is currently being piloted in some endemic areas to treat the infection. Thus, intensive antimicrobial resistance surveillance should be conducted in endemic areas by health authorities to forestall the dilemma of multidrug resistance not only against lymphatic filariasis (LF) infection but other diseases.

The Crucial Questions on Synovial Biopsy: When, Why, Who, What, Where, and How?

In the majority of joint diseases, changes in the organization of the synovial architecture appear early. Synovial tissue analysis might provide useful information for the diagnosis, especially in atypical and rare joint disorders, and might have a value in case of undifferentiated inflammatory arthritis, by improving disease classification. After patient selection, it is crucial to address the dialogue between the clinician and the pathologist for adequately handling the sample, allowing identifying histological patterns depending on the clinical suspicion. Moreover, synovial tissue analysis gives insight into disease progression helping patient stratification, by working as an actionable and mechanistic biomarker. Finally, it contributes to an understanding of joint disease pathogenesis holding promise for identifying new synovial biomarkers and developing new therapeutic strategies. All of the indications mentioned above are not so far from being investigated in everyday clinical practice in tertiary referral hospitals, thanks to the great feasibility and safety of old and more recent techniques such as ultrasound-guided needle biopsy and needle arthroscopy. Thus, even in rheumatology clinical practice, pathobiology might be a key component in the management and treatment decision-making process. This review aims to examine some essential and crucial points regarding why, when, where, and how to perform a synovial biopsy in clinical practice and research settings and what information you might expect after a proper patient selection.

Membranoproliferative glomerulonephritis: A rare presentation of occult filariasis

Parasitic infections do not usually present with rapidly progressive renal failure but can provoke glomerular lesions which are mostly proliferative. In filarial infection, glomerular involvement is usually mild and transient, and presentation with renal failure is rare. We report occult filariasis presenting as rapidly progressive renal failure due to immune-complex mediated membranoproliferative glomerulonephritis. Our patient responded to treatment with diethylcarbamazine and a short course of steroid. This case highlights the importance of thorough workup to identify the cause and consideration of filariasis in an endemic area.

Filariasis presenting with bicytopenia, progressive splenomegaly and acute renal failure: An unusual case report

Extra-lymphatic manifestation of filariasis, especially as acute renal failure, is uncommon and may be clinically unsuspected. We document the case of a 60 year old elderly male who presented with bilateral pedal oedema, fatigue and abdominal distension. Investigations revealed severe anaemia, splenomegaly and acute renal failure. Bone marrow aspiration was performed to evaluate the clinical suspicion of malignancy. Out of eight smears examined, microfilaria (Brugia malayi) were identified in two. This presentation was devoid of peripheral eosinophilia. The patient was commenced on a regimen of diethylcarbamazine, on which he made a good recovery. The incidence of extra-lymphatic filariasis is largely unknown and sparsely reported. Such a presentation should be kept in mind by both clinicians and pathologists as it is potentially treatable.

Acidic Calcium-Independent Phospholipase A2 Regulates Eosinophil-Mediated Pathology during Filarial Manifestation of Tropical Pulmonary Eosinophilia

Eosinophils mediate pathological manifestations during tropical pulmonary eosinophilia (TPE), a potentially fatal complication of lymphatic filariasis, by mechanisms that are incompletely understood. Using two-dimensional gel electrophoresis, mass spectrometry, flow cytometry, and pharmacological and functional studies, we identified acidic calcium-independent phospholipase A2 (aiPLA2) as the master regulator of TPE pathogenesis. FACS-sorted lung eosinophils from TPE mice exhibited aiPLA2-dependent activation characterized by heavy calcium influx, F-actin polymerization, increased degranulation, and heightened reactive oxygen species generation. Interestingly, aiPLA2 also promoted alternative activation in lung macrophages and regulated the release of inflammatory intermediates from them. Treatment of TPE mice with MJ33, a nontoxic pharmacological inhibitor of aiPLA2, lowered eosinophil counts in the bronchoalveolar lavage fluid, reduced eosinophil peroxidase and β-hexosaminidase activity, increased airway width, improved lung endothelial barrier, and lowered the production of inflammatory lipid intermediates, which significantly improved the pathological condition of the lungs. Importantly, ex vivo reconstitution of arachidonic acid to eosinophils from MJ33-treated TPE mice increased eosinophil degranulation and inflammatory lipid intermediates underlining the pivotal role of aiPLA2 in arachidonic acid metabolism. Mechanistically, phosphorylation of JNK-1 regulated phospholipase activity of aiPLA2, whereas IgG cross-linking mediated pathological activation of eosinophils. Taken together, ours is the first study, to our knowledge, to report hitherto undocumented role of aiPLA2 in regulating TPE pathogenesis.

Burden of lymphatic filariasis morbidity in an area of low endemicity in Brazil

The Global Programme to Eliminate Lymphatic Filariasis has two main components: interrupting transmission of lymphatic filariasis (LF) and managing morbidity and preventing disability. However, interventions to prevent and manage LF-related disabilities in endemic communities have been of limited extent. The aim of this study was to describe the prevalence of morbidity and its correlation with filarial infection, thereby filling a gap that existed regarding the data on morbidity in Brazil. Presence of Wuchereria bancrofti microfilaria was investigated using the thick smear technique. Information on parasitosis-related clinical manifestations was obtained using a questionnaire applied by community health agents with previous training and capacitation to know about and identify the disease. To analyze correlations, Pearson's correlation coefficient was used with the corresponding statistical significance test. 23,673 individuals were investigated: 323 presented microfilaremia (1.36%) and 741 (3.13%) had clinical complaints that were attributable to LF. Acute dermatolymphangioadenitis (ADLA) was the most prevalent condition (2.2%). Lymphedema, ADLA and chyluria were more commonly reported among female patients. There were positive associations between all the clinical complaints reported and filarial infection. Hydrocele presented the most strongly positive association (r=0.699; p<0.001). The present study showed that there is an association between clinical condition reported and the rate of infection among people living in an area of low endemicity for LF. It contributes data that might provide support for healthcare systems and thus optimize disease management, through incorporating surveillance measures directed towards preventing disability and reducing the psychosocial and economic impact of the disease on poor populations living in areas endemic for LF.

Sudden Death Due to Coronary Blockade by Microfilaremia: An Autopsy Report

Extralymphatic filarial disease has varied clinical manifestations and is largely underestimated worldwide. We report an autopsy case of extralymphatic filarial disease with coronary and pulmonary circulations being involved and causing sudden death. Such an isolated event is, perhaps, rare and has not been reported so far to the best of our knowledge. Microfilaremia on autopsy may be easily missed or overlooked due to unawareness. The present report emphasizes the importance of extensive careful scrutiny of autopsy sections.

Filarial hydropneumothorax: a strange journey

Filarial infection can have varied manifestations, but hydropneumothorax at presentation has not yet been reported. A 28-year-old man presented to our hospital with heaviness of the left chest for the past 10 days, which was preceded by a sudden, short stabbing pain in the left chest after straining. Chest X-ray revealed left-sided hydropneumothorax. A peripheral blood picture revealed significant eosinophilia. A pleural fluid report also showed eosinophilia and a few motile microfilaria of Wuchereria bancrofti. Microfilaria was also documented in peripheral blood. There was no evidence of other organ system involvement. The patient was diagnosed with 'Filarial Hydropneumothorax'. After treatment with a temporary chest drain and oral diethylcarbamazine citrate, there was dramatic relief of symptoms and radiological improvement. The patient has been symptom free with no features of recurrence through 8 months of follow-up.

Disseminated microfilaremia associated with lung cyst and empyema: an autopsy report

Clinical manifestations of extralymphatic disease caused by filariasis are varied and range from symptoms due to tropical pulmonary eosinophilia to hematuria, proteinuria, splenomegaly, and rarely arthritis. Disseminated microfilaremia in association with loculated lung cyst and empyema is of rare occurrence and to the best of our knowledge has not been documented in the literature so far. We report here a case of disseminated microfilaremia due to Wuchereria bancrofti infection accompanied by a lung cyst and empyema in a 21-year-old Indian man.

[Systemic granulomatosis of infectious origin]

PURPOSE

Granulomatous diseases are defined by specific histological features, following the local recruitment of macrophages and lymphocytes. Many infections can lead to the development of granuloma.

CURRENT KNOWLEDGE AND KEY POINTS

Microorganisms responsible for granuloma include mainly mycobacteria, many viral and fungal species, as well as schistosoma in endemic areas. Nevertheless, almost all microorganisms can lead to granuloma, especially if their clearance needs macrophages pathway. New immunosuppressive drugs such as tumor necrosis factor antagonists are associated with a high risk of infectious granulomatous complications. All patients with granuloma must be carefully screened to find a potential underlying infection, since an immunosuppressive therapy could be otherwise considered. We here review the general diagnostic process with a specific glance to the main organs.

FUTURE PROSPECTS AND PROJECTS

Without clinical or epidemiological clue, diagnosis can be very tedious. New molecular tools now assist classical microbiological and histological techniques. Their specificity and sensitivity have recently been better characterized, and their use will probably increase in the near future for the diagnosis of infectious granuloma. They may also lead to discover new infectious aetiologies of granulomatous diseases formerly considered as idiopathic. We describe here the main microorganisms that can be responsible for granuloma, with a specific focus on the use of new diagnostic tools.

Antigen-specific immune complexes in urine of patients with lymphatic filariasis

Lymphatic filarial subjects with disease manifestations exhibit significantly elevated levels of immune complexes (ICs) in their circulation. The objective of the study was to explore the possible excretion of filaria-specific soluble ICs in urine of subjects with lymphatic filariasis. Paired urine (overnight) and serum samples were analyzed for complement activating filarial antigen containing immune complexes by enzyme-linked immunosorbent assay (ELISA). Antigen-specific ICs were detected in urine samples of 34% of subjects with filarial disease manifestations while the frequency of occurrence was low in microfilaremic subjects. The titer of urine ICs is significantly high in subjects with chronic filariasis as compared to microfilaria (mf) carriers. The occurrence of filaria-specific ICs in urine and their passage through the filtering structures of the kidney is suggestive of the focal or diffuse damage in those subjects. Detection of ICs in urine may provide a noninvasive means of assessing the extent of renal damage in patients with lymphatic filariasis.

Morbidity management in the Global Programme to Eliminate Lymphatic Filariasis: a review of the scientific literature

The Global Programme to Eliminate Lymphatic Filariasis (GPELF) has two major goals: to interrupt transmission of the parasite and to provide care for those who suffer the devastating clinical manifestations of the disease (morbidity control). This latter goal addresses three filariasis-related conditions: acute inflammatory episodes; lymphoedema; and hydrocele. Research during the last decade has confirmed the importance of bacteria as a cause of acute inflammatory episodes in filariasis-endemic areas, known as acute dermatolymphangioadenitis (ADLA). Current lymphoedema management strategies are based on the central role of ADLA as a trigger for lymphoedema progression. Simple intervention packages are in use that have resulted in dramatic reductions in ADLA rates, a lower prevalence of chronic inflammatory cells in the dermis and subdermis, and improvement in quality of life. During the past decade, the socioeconomic impact of ADLA and lymphoedema in filariasis-endemic areas has received increasing attention. Numerous operational research questions remain to be answered regarding how best to optimize, scale up, monitor, and evaluate lymphoedema management programmes. Of the clinical manifestations targeted by the GPELF, hydrocele has been the focus of the least attention. Basic information is lacking on the effectiveness and complications of hydrocele surgery and risk of post-operative hydrocele recurrence in filariasis-endemic areas. Data on the impact of mass administration of antifilarial drugs on filarial morbidity are inconsistent. Several studies report reductions in acute inflammatory episodes, lymphoedema, and/or hydrocele following mass drug administration, but other studies report no such association. Assessing the public health impact of mass treatment with antifilarial drugs is important for programme advocacy and morbidity control strategies. Thus, although our knowledge of filariasis-related morbidity and its treatment has expanded in recent years, much work remains to be done to address the needs of more than 40 million persons who suffer worldwide from these conditions.

Reconsidering the underestimated burden caused by neglected tropical diseases

It is generally acknowledged that the burden caused by neglected tropical diseases needs to be reassessed. Not only are there several important diseases unaccounted for, but new information suggests they have a more substantial impact on health than initially thought. Looking at the tropical diseases as a group makes sense: they tend to cluster in the same poor populations and, to make progress with their control, they will have to be dealt with in an integrated manner. Measuring the effect of such integrated control is likely to reveal the real impact of tropical diseases on human health and wellbeing.

Lymphatic filariasis: new insights into an old disease

Lymphatic filariasis has afflicted people in the tropical areas of the world for thousands of years but even up to comparatively recent times it has been poorly understood and its importance under recognised. In the last 2 decades or so there has been a flurry of activity in filariasis research, which has provided new insights into the global problem of filariasis, the pathogenesis of filarial disease, diagnosis and control.

Pathogenesis of lymphatic disease in bancroftian filariasis: a clinical perspective

The pathogenesis of lymphatic filariasis has been a matter of debate for many decades. Here, Gerusa Dreyer and colleagues propose a dynamic model of bancroftian filariasis, integrating clinical, parasitological, surgical, therapeutic, ultrasonographic and histopathological data. This model has profound implications for filariasis control programs and the management of the individual patient.