In this concluding part, doctors from AIIMS Delhi’s Dept of Surgical Disciplines tell ARCHANA JYOTI that Lymphedema, a build up of lymph fluid that causes swelling in a part of the body is not only due to cancer or cancer treatment. It can be also due to filarial parasites which is transmitted to humans through mosquito bites. The infection is usually acquired in childhood with painful and disfiguring visible manifestations appearing much later in life, often in the form of enlargement of body parts causing pain, severe disability, and associated stigma
What is Filariasis?
Dr Devender SINGH | DR Jyoti Sharma
Filariasis is a vector borne disease caused by small parasites which enters the body through a mosquito bite and reside in the lymphatic system or the subcutaneous tissues. Lymphatic filariasis impairs the lymphatic system and can lead to the abnormal enlargement of body parts like the arms, legs, and genitals. Acute infection may present as fever, redness and swelling of the affected limb or genitals, presence of painful red streaks over the limb, swollen and painful lymph nodes. Skin infections of the affected region are common. Repeated attacks result in severe swelling of the lower limbs and/or genitals with thickened ‘elephant-like’ skin, i.e; ‘elephantiasis’.
This may cause long term disability and disfigurement to the patient. In some cases, it can also affect the eyes and cause problems with vision. The treatment consists of medical therapy with Diethylcarbamazine (DEC) or Ivermectin, which kill these parasitic worms and alleviate the symptoms. Preventive measures mainly rely on mosquito control and protection from mosquito bites. Strategies include using mosquito repellents, wearing protective clothing, sleeping under mosquito nets and environmental measures to prevent mosquitoes from breeding. It is one of the most debilitating diseases.
Four States (UP, Odisha, Telangana, and Bihar) account for more than 60% Lymphedema cases, while four States (Odisha, Jharkhand, UP and Bihar,) account for over 80% Hydrocele cases.
Contribution of filariasis to lymphedema
Dr Yashwant Singh Rathore | Dr. Ravi
Earliest structural change in filarial infection is blockage of lymphatic channels by the nests of adult worms residing in lymphatic channels. Once this lymphatic damage progresses, stasis of lymph tends to occur in the dilated vessels due to incompetence of the unidirectional valves in them. Stagnation of lymph encourages growth of bacteria invading the region. Any interference with the skin integrity of the affected region like injuries, fungal or bacterial infections, fissuring of the skin, favour entry of pathogenic bacteria {mainly streptococci} into the tissues and are responsible for the acute attacks of dermato-lymphangio-adenitis commonly seen in filarial limbs. Lymphedema of extremities is a common chronic manifestation of filariasis, which on progression results in elephantiasis. Usually the lower limbs are involved, upper limbs, male genitalia and rarely breasts in the females may also be affected. Affected parts get swollen.
In advanced stages of lymphedema, the skin is thickened and thrown into folds, often with hypertrichosis, black pigmentation, nodules, warty growth, intertrigo in the webs of toes or chronic non-healing ulcers. Fungal infections in the interdigital region and in deep folds are a common finding in advanced lymphedema.
Investigations in Filaria and Lymphedema
DR GAGAN SONI | DR KAMAL KATARIA
The diagnosis of filariasis, a parasitic disease caused by worms, involves different methods to find evidence of the worms or their substances in the body. Clinical examinations to look for signs like swelling, enlarged body parts (like limbs or genitals), or other symptoms that suggest filarial infection. After that a blood smear examination is done and a small amount of blood is taken, usually at night when the worms are more likely to be in the blood. The blood is looked at under a microscope to check for the presence of young worms called microfilariae. Apart from this, antigen detection tests to look for specific substances produced by the worms in the patient's blood or urine. It can be done using a dipstick or card test, similar to a pregnancy test. It can also be done via the nucleic acid amplification by polymerase chain reaction. This method amplifies and detects the genetic material (DNA or RNA) of the worms in the blood sample. It can identify different types of filarial worms and is very accurate. Diagnosis can also be made by antibodies produced by the patient's immune system in response to the filarial infection. It can indicate whether the person has been infected in the past or currently.
The choice of which test to use depends on factors like the stage of infection, the type of worm involved, and available resources. Sometimes, a combination of tests may be needed to get an accurate diagnosis. Whereas, the diagnosis of lymphedema, a condition characterized by swelling due to impaired lymphatic drainage, involves a few key steps.
It's important to note that there is no definitive test for diagnosing lymphedema. The diagnosis is primarily based on the clinical assessment, medical history, and exclusion of other possible causes of swelling.
Drugs For Filariasis
The drug treatment for filariasis involves the use of medications to kill the worms causing the infection.
1. Diethylcarbamazine (DEC): This drug is effective against both microfilaria and adult worms. The typical dose is 6mg/kg given for 14 days.
2. Ivermectin: Ivermectin is another medication used to treat filariasis, often given in combination with DEC. This drug acts directly on the microfilaria and is used in single doses of 200 to 400ugm/ kg. The dosage varies depending on the person's weight and the specific treatment protocol. Typically, a single dose of ivermectin is given, and it may be repeated annually. Ivermectin was popularised during the COVID-19 pandemic for its treatment initially. But its usefulness was questioned later.
3. Albendazole: This anthelmintic drug is shown to destroy the adult filarial worms when given in doses of 400 mg twice daily for two weeks. When given in a single dose of 400 mg in combination with DEC or ivermectin, the destruction of microfilaria by these drugs becomes more pronounced. Albendazole is often used in combination with DEC or ivermectin for the treatment of filarial infections. The recommended dosage is usually a single tablet taken once a day, along with the other medications.
It's important to note that the exact dosages and treatment regimens may differ based on the type of filarial worm involved, the stage of infection, and other individual factors. It's crucial to complete the full course of medication as prescribed, even if the patient starts feeling better. This ensures that all the worms are effectively eliminated and reduces the risk of the infection returning.
Indications of surgery
The mainstay of treatment for filariasis is medical therapy. However, surgery may be required in advanced stages to manage the complications or improve the quality of life, says Dr Jyoti Sharma.
Some of the common indications are, severe swelling of the limbs (Advanced lymphedema): Surgery is offered to patients in whom the severe swelling causes difficulty in walking or performing daily activities. It is however secondary to conservative management that includes compression therapy and physiotherapy exercises. Also, fluid accumulation around the testicles (Hydrocele): Surgery is offered to patients with discomfort or complications due to hydrocele.
Repeated infections is another indication due to the presence of excess skin and multiple folds, these patients are prone to repeated skin infections leading to redness, pain, fever and development of abscess (pus) in the affected limb. Surgery helps to remove excess skin; however, it is generally kept as a last resort.
Treatment
Dr Devender Singh and Dr Richa Garg say that a multipronged approach is needed that focuses on preventing further transmission of the disease and alleviating the symptoms in infected individuals.
Here is an overview of the treatment methods used:
Medications: There are several medications available to treat filariasis. Diethylcarbamazine (DEC), Ivermectin and albendazole are commonly used. These medications work by killing the adult worms or preventing their reproduction. They are usually taken in combination for a prolonged period of time, often years, to ensure that all the worms are eliminated from the body.
Vector control: Since filarial worms are transmitted through mosquito bites, controlling the mosquito population is crucial in preventing the spread of the disease. This can be done by using insecticide-treated bed nets, applying insect repellents, and eliminating mosquito breeding sites, such as stagnant water.
Surgery: In cases where the disease has caused severe swelling and deformities, surgical intervention may be necessary. Lymphatico-venous anastomosis and lymph node transfer and debulking procedures are available which can help to reduce the size of the affected body parts and improve mobility and quality of life for individuals with advanced stages of the disease.
Hygiene: Good hygiene practices are essential in managing filariasis. This includes regularly washing and keeping the affected areas clean to prevent secondary infections. Affected individuals should also elevate their limbs whenever possible to reduce swelling and avoid prolonged standing or sitting.
Compression stockings: These specialized stockings apply pressure to the affected limb, reducing swelling and improving lymphatic flow
Health education and community involvement: Raising awareness about filariasis and its transmission methods is crucial in preventing new infections. Community participation in mosquito control programs and early detection and treatment of the disease can significantly reduce its prevalence.
It's important to note that filariasis is a complex disease, and treatment may vary depending on the stage and severity of the infection. Overall, a comprehensive approach that combines medication, vector control, hygiene practices, surgery when needed, and community involvement is essential for the effective prevention of the disease.
Role of Anaesthesiologist in management of lymphedema
Dr Sushmita Bairagi
Patients coming for lymphoedema surgery undergo a pre-anesthetic check-up before surgery where thorough general and physical examination is done, investigations checked and instructions for fasting given. Also, patients are asked to quit smoking and avoid taking aspirin or herbal medications before surgery. When patients are taken to the operation theatre, venous cannulation and attaching blood pressure cuffs in the affected limb are avoided. Regional anesthesia like spinal or epidural anesthesia is given in surgeries involving lymphoedema of lower limbs where a drug is injected into the back through a needle to numb the lower limbs and the patient is awake and pain free during surgery. Many patients prefer general anesthesia technique where patients are put to sleep throughout the surgery using drugs injected into the vein or inhaling some drug through mask and pain relief during and post-surgery is done using opioids and NSAIDS. Some surgeries require local anesthesia where injections given directly in surgical site to numb the pain which is accompanied with minimal sedation.
Filariasis pathways
Dr Catherine Halam | DR Ankita Singh Tiwari
A patient with long term filariasis can go ahead and develop certain conditions which can be mild to severe in nature. The skin in patients with filariasis can be hard in consistency due to chronic lymphatic obstruction. There is constant hardening of skin and swelling of the tissue underneath the skin can lead to accumulation of microbes in the finger webs, which is why we always ask patients with filariasis to maintain thorough skin hygiene. Filariasis can also lead to certain occult conditions meaning they are not very evident. The conditions are described below.
It can also lead to tropical pulmonary eosinophilia. The daughter worms (microfilariae) get trapped in the lungs. Our body has an inbuilt mechanism to any type of foreign body. So, when the daughter filariae gets trapped in lungs, the lungs produce reactions, and it becomes hyper responsive. In this process, the individual starts having wheezes, fever, and on blood tests there are raised eosinophilic counts (a component of blood). There can be involvement of joints in the form of filarial arthritis. Arthritis means inflammation of bony joints in the body. In this, the joints get swollen and painful due to filariasis. It is seen to be more common in children than adults. It can also cause a kidney reaction and the patient's urine output is decreased. Filariasis is known to affect both legs, also arms, but they may involve genitalia and breast too. In ladies, there can be breast abscess and in gents there can be swelling of private parts.
National Filaria Control Programme
Dr Geeta Prasad | Dr Puneeth Thalasta
As the Government aims to eliminate Lymphatic Filariasis by 2027, three years ahead of the global target, much hope is on the National Filaria Control Programme. It has five-pronged objectives including training of professional and ancillary personnel; reduction of the problem in un-surveyed areas; control in urban areas through recurrent anti-larval and anti-parasitic measures; Intensive monitoring at block level to be focused upon along with daily analyses of coverage and monitoring reports at all governance levels.
The strategies include vector control through anti-larval spray/application at weekly intervals with appropriate larvicides, biological control through larvivorous fishes, environmental engineering through source reduction and water management and anti-parasitic measures through diagnosis and treatment of microfilaria carriers and cases.
Single dose mass preventive dose of diethylcarbamazine once a year has been one of the strategies for its control. The anti-mosquito and anti-larval measures include one or two rounds of residual insecticide spray with DDT in areas which are known to be endemic for filariasis. Anti-larval measures with temephos in prescribed dosage in water storage tanks every week and application of Mineral Larvicidal oils on water surface are advised.