A real-time PCR for quantification of parasite burden and its correlations with clinical characteristics and anti-rKRP42 IgG level in cutaneous leishmaniasis in Sri Lanka

In visceral and mucocutaneous leishmaniasis, humoral immune response can reflect disease severity and parasite burden. Cutaneous leishmaniasis (CL) in Sri Lanka is caused by a usually visceralizing parasite, Leishmania donovani. We assessed the parasite burden (relative quantity-RQ) in 190 CL patients using quantitative real-time PCR (qPCR-with primers designed for this study) and smear microscopy, then correlated it with clinical parameters and IgG response. RQ of parasite DNA was determined with human-specific glyceraldehyde 3-phosphate dehydrogenase (GAPDH) as the internal control. The qPCR sensitivity was tested with serially diluted DNA from cultured L. donovani parasites. Smears were assigned a score based on number of parasites per high power field. Data from previous studies were used for comparison and correlation; nested Internal Transcribed Spacer 1 (ITS1) PCR as reference standard (RS) and IgG antibody titers to the Leishmania rKRp42 antigen as the immune response. The qPCR amplified and quantified 86.8% of the samples while demonstrating a fair and significant agreement with ITS1-PCR and microscopy. Parasite burden by qPCR and microscopy were highly correlated (r = 0.76; p = 0.01) but showed no correlation with the IgG response (r = 0.056; p = 0.48). Corresponding mean RQs of IgG titers grouped by percentiles, showed no significant difference (p = 0.93). Mean RQ was higher in early lesions (p = 0.04), decreased with lesion size (p = 0.12) and slightly higher among papules, nodules and wet ulcers (p = 0.72). Our study established qPCR's efficacy in quantifying parasite burden in Sri Lankan CL lesions but no significant correlation was observed between the parasite burden and host IgG response to the Leishmania rKRP42 antigen.

Development of a Highly Sensitive Nested PCR and Its Application for the Diagnosis of Cutaneous Leishmaniasis in Sri Lanka

The recent surge in cutaneous leishmaniasis (CL) in Sri Lanka has rendered clinical diagnosis difficult; thus, laboratory confirmation is indispensable. A modified (two novel inner primers to detect CL caused by Leishmania donovani) nested Internal Transcribed Spacer-1 (ITS1) PCR-Restriction Fragment Length Polymorphism (RFLP) method was developed and tested. The sensitivity of the modified nested PCR was tested using serial dilutions (103 to 10−2) of the DNA extract of a cultured L. donovani DD8 strain. Patients (n = 194) from Southern Sri Lanka were examined clinically, microscopically (Slit Skin Smear-SSS) and using the modified nested PCR. The modified nested PCR detected 2.55 fg of parasite DNA compared to ITS1 PCR (25 fg) and detected more cases than SSS (94.3% vs. 77.3%; p < 0.01). The RFLP pattern was L. donovani in all cases. The modified nested PCR performed well in clinically doubtful lesions (95% by PCR vs. 60% by SSS; p < 0.01), ulcerated nodules (91% vs. 71.8%; p < 0.01) and plaques (100% vs. 66.7%; p < 0.01). SSS demonstrated sensitivity (80.9%), specificity (81.8%), PPV (98.7%) and NPV (20.5%) against modified PCR. Low parasite loads and atypical lesions can be diagnosed by the proposed method with higher accuracy.

Lymphoedema and its management in cases of lymphatic filariasis: the current situation in three suburbs of Matara, Sri Lanka, before the introduction of a morbidity-control programme

Using in-depth interviews, information on the current state of lymphoedema management was collected from 101 cases of lymphatic filariasis with lymphoedema in three suburbs of Matara. The interviews were conducted prior to the introduction of a programme of community home-based care (CHBC) that incorporates modern lymphoedema-management strategies. Thirty-two of the interviewees had severe lymphoedema (of grade III or above). The male interviewees had significantly more entry lesions than the female. Most of the subjects had suffered from episodes of limb pain with fever, although the incidence of these episodes appeared unrelated to the severity of the lymphoedema. The frequency of the episodes of limb-pain/fever in the 12 months prior to the interviews appeared unrelated either to the level of daily hygiene, which was generally poor, or to the frequency of bathing. Many (65%) of the subjects paid no attention to limb care when bathing, and 44% did not use footwear. Over 80% made no effort to keep their afflicted limbs elevated, and 95% did not exercise. Most of the female interviewees felt shameful of their condition and were, in consequence, less likely to attend government clinics, for treatment, than the male interviewees. The drug treatment that the interviewees had received was often inadequate, and most had stopped seeking treatment because they had not perceived any significant treatment-attributable improvement in their condition. Modern lymphoedema-management strategies (based on regular washing, careful drying, and treatment, with antifungal, antibiotic or emollient creams, of the affected limbs, limb elevation, exercise, and use of footwear) had not reached the study communities and the local physicians were not aware of them. When dermatology life-quality indexes (DLQI) were calculated for the interviewees, the 26 most impaired subjects gave scores of 5-15 (mean=8.6). The DLQI for these subjects will be regularly re-evaluated, as a measure of the effectiveness of the CHBC programme that has now begun.

Prevalence and levels of filaria-specific urinary IgG4 among children less than five years of age and the association of antibody positivity between children and their mothers

An enzyme-linked immunosorbent assay (ELISA) to detect filaria-specific urinary IgG4 was tested in samples from 203 children less than five years old and their parents (165 mothers and 127 fathers) in Sri Lanka. There were four IgG4-positive children within 58 days after birth, suggesting the transfer of the antibody from mothers. No positive children were found between days 65 and 417. After day 1,000, the number of the positive individuals and the level of IgG4 increased quickly. The children of urinary IgG4-positive parents showed a higher IgG4 positive rate than those of negative parents. The children of positive mothers had a higher prevalence than those of negative mothers, whereas, the positivity of the fathers was not associated with that of their children. Collecting urine samples was easy to perform and well accepted because of its non-invasiveness. The ELISA will be useful for monitoring filarial infections in very young children, who are a sentinel population for evaluating the intensity of filariasis transmission and effectiveness of control measures.

Human infection with Wuchereria bancrofti in Matara, Sri Lanka: the use, in parallel, of an ELISA to detect filaria-specific IgG4 in urine and of ICT card tests to detect filarial antigen in whole blood

The ICT card test to detect circulating filarial antigen and an ELISA that detects filaria-specific urinary IgG(4) were each used to screen 473 subjects from a community in Sri Lanka where Wuchereria bancrofti is endemic. When the ICT test was used as the gold standard, the ELISA was found to have a sensitivity of 91.2%. However, far more of the subjects were found ELISA-positive than ICT-positive (76.5% v. 31.1%). The youngest children studied (aged 1-10 years) were similar to the adult subjects in terms of the prevalence of antigenaemia (33.8%) and the prevalence (72.1%) and concentration of filaria-specific IgG(4) in their urine. Therefore, especially as urine samples are easier, less painful and safer to collect than blood samples, the ELISA may be particularly useful to screen very young and school-age children, to estimate current levels of transmission in a particular area.

Prevalence and intensity of Wuchereria bancrofti antigenaemia in Sri Lanka by Og4C3 ELISA using filter paper-absorbed whole blood

In Sri Lanka 2741 people from Matara, an endemic area for Wuchereria bancrofti, were examined in 1996/97 for microfilariae by 60-microL blood smear and for circulating filarial antigens by Og4C3 ELISA using filter paper-absorbed whole blood. The overall prevalence of microfilaraemia was 3.4%, and that of antigenaemia 14.4%. The prevalence of antigen-positive and microfilaria-negative people was 11.3%. Analysed by age-group, antigenaemia prevalence was similar in all groups, and the average number of antigen units was already very high in the age-group < 10 years, indicating that the infection started in early childhood. Among those who were antigen positive, the microfilaria prevalence was lower in females than in males. Diethylcarbamazine treatment eliminated microfilariae in 78% of the positives. However, 17 months after the treatment, antigenaemia was still positive in 76% of those who were parasitologically cured.

Sensitive and specific enzyme-linked immunosorbent assay for the diagnosis of Wuchereria bancrofti infection in urine samples

We developed an enzyme-linked immunosorbent assay (ELISA) that detects filaria-specific immunoglobulin G4 antibodies in unconcentrated urine. The ELISA was positive in 87 of 91 (95.6%) urine samples collected from people with Wuchereria bancrofti microfilariae, antigen, or both. Of 298 urine samples collected in Thailand, Lao People's Democratic Republic, and Japan, where no human filariasis is known, 295 (99.0%) were negative by ELISA. Various intestinal nematode and fluke infections did not interfere with the ELISA. Urine samples with sodium azide could be kept at 37 degrees C for 4 weeks, and the time of urine collection did not influence ELISA results. This ELISA can be used to identify endemic foci of filariasis.

An analysis of the safety of the single dose, two drug regimens used in programmes to eliminate lymphatic filariasis

This review of the safety of the co-administration regimens to be used in programmes to eliminate lymphatic filariasis (albendazole + ivermectin or albendazole + diethylcarbamazine [DEC]) is based on 17 studies conducted in Sri Lanka, India, Haiti, Ghana, Tanzania, Kenya, Ecuador, the Philippines, Gabon, Papua New Guinea, and Bangladesh. The total data set comprises 90,635 subject exposures and includes individuals of all ages and both genders. Results are presented for hospital-based studies, laboratory studies, active surveillance of microfilaria-positive and microfilaria-negative individuals, and passive monitoring in both community-based studies and mass treatment programmes of individuals treated with albendazole (n = 1538), ivermectin (9822), DEC (576), albendazole + ivermectin (7470), albendazole + DEC (69,020), or placebo (1144). The most rigorous monitoring, which includes haematological and biochemical laboratory parameters pre- and post-treatment, provides no evidence that consistent changes are induced by any treatment; the majority of abnormalities appear to be sporadic, and the addition of albendazole to either ivermectin or DEC does not increase the frequency of abnormalities. Both DEC and ivermectin show, as expected, an adverse event profile compatible with the destruction of microfilariae. The addition of albendazole to either single-drug treatment regimen does not appear to increase the frequency or intensity of events seen with these microfilaricidal drugs when used alone. Direct observations indicated that the level of adverse events, both frequency and intensity, was correlated with the level of microfilaraemia. In non microfilaraemic individuals, who form 80-90% of the 'at risk' populations to be treated in most national public health programmes to eliminate lymphatic filariasis (LF), the event profile with the compounds alone or in combination does not differ significantly from that of placebo. Data on the use of ivermectin + albendazole in areas either of double infection (onchocerciasis and LF), or of loiais (with or without concurrent LF) are still inadequate and further studies are needed. Additional data are also recommended for populations infected with Brugia malayi, since most data thus far derive from populations infected with Wuchereria bancrofti.

Epidemiology of bancroftian filariasis in three suburban areas of Matara, Sri Lanka

The epidemiological parameters of bancroftian filariasis were investigated in three suburbs of Matara, within the south-western coastal belt of Sri Lanka where the disease is endemic. The overall prevalence of microfilaraemia and the geometric mean density of the microfilaraemias observed were 4.4% and 20.6 microfilariae/60 microl fingerprick blood, respectively. Prevalence was significantly lower in the female subjects than in the male, and in males aged < 20 years than in older males. Overall, 9.5% of the subjects had the clinical manifestations of bancroftian filariasis (6.4% had filarial fever, 3.0% had elephantiasis and/or oedema, and 6.2% had hydrocele). The prevalence of elephantiasis/oedema was generally higher among the female subjects (4.2%) than among the male (1.4%), and an age-prevalence plot for this manifestation showed a linear increase in prevalence after the age of 40 years. Hydrocele also became commoner with increasing age, but this increase in prevalence began at the lower age of 20 years. More than 60% of the cases of elephantiasis/oedema but only 26.3% of the subjects found to have hydroceles experienced filarial fever attacks. The cases of fever and elephantiasis/oedema (but not those of microfilaraemia or hydrocele) were aggregated within households. However, the children whose mothers were microfilaraemic were much more likely to be microfilaraemic themselves (8.7%) than the children who had amicrofilaraemic mothers (2.8%), microfilaraemic fathers (0.0%) or amicrofilaraemic fathers (2.7%). The results of entomological surveys indicated that transmission of Wuchereria bancrofti occurred throughout the year in the study community.

Wuchereria bancrofti antigenaemia in Sri Lanka

The prevalence of Wuchereria bancrofti antigenaemia determined in 353 subjects in Matara, Sri Lanka by Og4C3 ELISA was 20.7%. Positive rates obtained with the same subjects by 1 ml Nuclepore filtration and 60 microl thick blood smear were 11.3% and 7.9%, respectively. Antigen levels were positively associated with microfilaria counts. Two-thirds of antigen-positive and microfilaria-negative (Ag+/Mf-) individuals were > 25-year-old, but younger age groups (< or = 25-year-old) tended to have proportionally more Ag+/Mf- cases. Possible origins of the Ag+/Mf- status are discussed.

The use of whole blood absorbed on filter paper to detect Wuchereria bancrofti circulating antigen

The Og4C3 enzyme-linked immunosorbent assay (ELISA) to detect circulating Wuchereria bancrofti antigen uses 50 microL of serum. In this study, a whole blood sample absorbed on filter paper was tested as a substitute for serum. Serum samples were obtained from 60 Sri Lankan subjects by venepuncture and finger-prick blood samples from the same individuals were directly absorbed on filter paper. Og4C3 ELISAs using serum and filter paper blood were compared. Despite the fact that the estimated amount of serum available for the ELISA with filter paper blood was only one-fifth of that available when serum was used, the 2 ELISAs gave almost identical results. Of the 39 positive serum samples, 38 were detected using filter paper blood. Employing the ELISA using filter paper blood, 619 people in Matara, Sri Lanka, were examined for antigenaemia. The positivity rate was 22.5%, 3.1 times higher than the rate of microfilaraemia detected by examination of 60 microL blood films.

Efficacy of a single dose treatment of Wuchereria bancrofti microfilaria carriers with diethylcarbamazine in Matara, Sri Lanka

OBJECTIVE

To test the efficacy of diethylcarbamazine DEC single dose regimen of 6 mg/kg body weight (bw) on a sample of Wuchereria bancrofti microfilaria (mf) carriers in Matara.

DESIGN

6 mg/kg bw DEC dose in 50 mg tablets given under direct observation to the subjects at 23.00 hours after pre-treatment blood collection for mf counts. Post-treatment mf counts were at 1, 2 weeks and 1, 3, 6, 12 months.

SUBJECTS

31 asymptomatic mf carriers, 14 males, age range 6 to 62 years.

RESULTS

Treatment resulted in 89 to 97% success rate, 19 to 28% cure rates and 74 to 80% reduction in mf density. There was no difference statistically in the success rate and cure rate at 6 and 12 months. The effect of DEC treatment at 6 and 12 months compared by sex, age group and pre-treatment mf level showed no difference. 64.5% of the carriers treated had at least one mild adverse reaction. Rates of the common reactions were 41.9% fever, 22.6% headache and 16.1% joint pains.

CONCLUSION

A new mass treatment program has been initiated by the national Antifilariasis Campaign using the single dose DEC 6 mg/kg bw regimen. The satisfactory reduction in mf density at 6 and 12 months following DEC single dose treatment we observed provides support for this program.

Microfilarial periodicity of Wuchereria bancrofti and man landing periodicity of the vector Culex quinquefasciatus say in Matara, Sri Lanka

OBJECTIVE

To compare the microfilarial periodicity of Wuchereria bancrofti, with the man landing periodicity of the vector Culex quinquefasciatus in Matara, Sri Lanka.

DESIGN

Periodicity was estimated using a statistical method. 60 microliters finger prick (FP) blood was smeared from a single subject every 2 hours for 24 hours of the day to make 12 samples. Smears were stained with Giemsa and the microfilariae (mff) counted. Man landing catches of mosquitoes were made inside a bedroom of a house in the same area on a sleeping volunteer during the night, between 18.00 and 06.00 hours. Each hourly catch was placed in separate paper cups. Hourly C. quinquefasciatus taken were counted.

SUBJECTS

10 asymptomatic microfilaria (mf) carriers.

RESULTS

The individual mf peaks in the 10 carriers varied from 22.00 to 04.00 hours. Using the statistical method the parameter k showing the mf peak hour was 1.19 estimating the peak mf density at 01.11 hours. The influence of different times of blood collection on false negatives among the very low density carriers was estimated by the periodicity curve. It would be desirable to collect blood during the estimated time interval when the mf count was 80% of the peak count, between 21.55 and 04.27 hours in Matara. The results of 25 all-night mosquito landing catches gave a peak activity hours of k as 7.78, corresponding to 01.47 hours.

CONCLUSION

The close agreement in the peak hours of mf density and vector activity suggests a perfect adaptation between parasite and vector for optimum transmission.

Human dirofilariasis caused by Dirofilaria (Nochtiella) repens in Sri Lanka

Human dirofilariasis due to Dirofilaria (Nochtiella) repens is a common zoonotic infection in Sri Lanka. Todate 70 cases are on record, and they include 3 expatriates from Russia, England and Korea, who were undoubtedly infected in Sri Lanka. Around 30-60% of dogs are infected with D. repens in various parts of the country and the mosquito vectors are Aedes aegypti, Armigeres subalbatus, Mansonia uniformis and M. annulifera. Unlike in other countries of the old world infection is most common in children under the age of 9 years, the youngest being 4 months old and the scrotum, penis and perianal regions of male children appear to be frequent sites for the worms. Dirofilaria (Dirofilaria) immitis is not present in Sri Lanka though it is present in neighbouring countries like India, and Malaysia.

The value of external morphology in the identification of larval anisakid nematodes: a scanning electron microscope study

We studied larval nematodes of four genera of the Anisakidae using a scanning electron microscope (SEM). The anterior and posterior extremities and cuticular structures of the 3rd-stage larvae (L3) of Anisakis type I, Pseudoterranova decipiens, Contracaecum type B and Hysterothylacium were examined. The 4th-stage larvae (L4) of Anisakis type I, P. decipiens, recovered after infection into laboratory rats, and the L3 and L4 of Anisakis type I larvae from human were also examined in the same way. There were generic differences in the shape and size of the lip bulges, external papillary structures, the appearance of the boring tooth, the width and depth of the grooves and ridges of the cuticle and the caudal structures of the L3. In Anisakis type I and P. decipiens L3, changes were seen in the anterior extremity, cuticle and posterior extremity after molting to the L4. Similar changes can be expected in larvae infecting man. The L4 of Anisakis type I from rat and man were similar, while the L4 of Anisakis type I and P. decipiens showed differences. These ultrastructural differences might be of value in the identification of fragments recovered during endoscopy in man.