Sandbox Jyostna

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• Filariasis Return to Top

• Filariasis::* 1. Lymphatic filariasis- Wuchereria bancrofti, Brugia malayi Brugia timori::* 2. Cutaneous filariasis- Onchocercia volvulus, Loa loa

• Onchocerciasis Return to Top
  :* Onchoceria volvulus cutaneous filariasis (river blindness) treatmentGilbert, David (2014). The Sanford guide to antimicrobial therapy 2014. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808782.::* Preferred regimen: Ivermectin Single dose of 150mcg/kg po; repeat every 6-12 months until asymptomatic.  ::* Alternative regimen: If Ivermectin fails, consider Suramin.::: Note (1): Onchocercia and Loa loa may both be present. Check peripheral smear; if Loa loa microfilaria present, treat onchocercia first with Ivermectin before Diethylcarbamazine (DEC) for Loa loa.::: Note (2): Retreatment for microfilaremia often necessary q6-12 months as demonstrated by repeat blood smear or antigen testing.::: Note (3): Do not use Diethylcarbamazine (DEC) in Onchocerca volvulus due to increased risks of precipitating blindness.::* Treatment of endosymbiont Wolbachia (bacteria) may help clear infection:::* Preferred regimen: Doxycycline 100 mg qd or bid for 6-8 wks in lymphatic filariasis although effect may be more important for co-infecting pathogens such as Wuchereria or Onchocerca than loaloa.
• Loiasis Return to Top
  :* Loa loa cutaneous filariasis (eyeworm disease) treatmentGilbert, David (2014). The Sanford guide to antimicrobial therapy 2014. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808782.::* Preferred regimen: Diethylcarbamazine (DEC) escalation recommended to reduce reactions on day 1-50 mg, day 2-50 mg tid, day 3-100 mg tid, Days4-21, 8-10mg/kg/day in 3 divided dose::* Alternative regimen: Albendazole 200mg po bid for 21 days::: Note: If concomitant onchocercia Loa loa, treat oncho first. Ifover 5,000 microfilaria/mL of blood, Diethylcarbamazine (DEC) can cause encephalopathy. Might start with albendazole for few days with or without steroids, then Diethylcarbamazine (DEC).
• Wuchereria bancrofti Return to Top
  :* Wuchereria bancrofti lymphatic filariasis (elephantiasis) treatment::* Preferred regimen (1): Scaled dose Diethylcarbamazine (DEC) escalation recommended to reduce reactions on day 1-50 mg, day 2-50 mg tid, day 3-100 mg tid, Days 4-14, 2 mg/kg q8h for total of 72 mg over 14 days. (Diethylcarbamazine(DEC) 2 mg/kg PO tid for 12 days (may be accompanied by systemic reaction to dying worms,local reactions include lymphadenitis, transient lymphedema)).::: Note: Corticosteroids or antihistamines may be needed to treat allergic reactions that develop as a consequence of dying microfilariae.

• Preferred regimen (2): Albendazole 400 mg PO single dose regimen AND (Ivermectin 200 mcg/kg PO OR Diethylcarbamazine 6mg/kg) may reduce or suppress microfilariae; however, this will not affect adultworms.::: Note (1): Most symptoms with Wuchereria bancrofti are due to the adultworm.::: Note (2): Retreatment for microfilaremia often necessary q6-12 months as demonstrated by repeat blood smear or antigen testing.::: Note (3): Do not use Diethylcarbamazine (DEC) in Onchocerca volvulus due to increased risks of precipitating blindness.

Note (4): Skin snip technique is skin snips can be obtained using a corneal scleral punch, or more simply a scalpel and needle. The sample must be allowed to incubate for 30 minutes to 2 hrs in saline or culture medium, and then examined for microfilariae that would have migrated from the tissue to the liquid phase of the specimen. ::: Note (5): Site of infection:::: 5.1 General: filarial fever includes fever, chills, malaise during acute or recurrent episode.

5.2 Lymph:localized lymphadenitis, may be painful(red,warm) or painless, unilateral or bilateral groin swelling. May be due to adult worm or complicating bacterial infection.:::: 5.3 Derm:pruritus,dermatitis,subcutaneous nodules. :::: 5.4 Genital:scrotal or vulvar swelling/ hydrocele; may be able to visualize adult W.bancrofti worm by ultrasound. :::: 5.5 Extremities:unilateral or bilateral swelling, acute or chronic. May be extreme (classic elephantiasis) or mild. May be associated with recurrent bacterial cellulitis (abrupt onset of redness ,fever). :::: 5.6 Lungs:tropical pulmonary eosinophilia (miliary pattern on CXR, nocturnal paroxysmal cough, wheezing, accompanied by marked eosinophilia, responds to DEC, usually amicrofilaremic). :::: 5.7 Renal: chyluria, hematuria (rupture of dilated lymphatics into urinary excretory system). May see weightloss, hypoproteinemia, lymphopenia, anemia.

5.8 Musculoskeletal:acute monoarthritis (knee>ankle) which responds to DEC, tenosynovitis (rare), thrombophlebitis (rare).::: Note (6):::: Diagnosis 1.serological-antigen detection by commercially available card test ; IgG4 antibody (not filaria species specific and may cross react with other helminths);:::: Diagnosis 2.special maneuvers DEC provocative days test (induce microfilaremia with dose of DEC); polymerase chain reaction.:::: Diagnosis 3.skin snips (detect Onchocerca volvulus, Mansonella streptocerca). Ultrasonography can detect adult W.bancrofti worms in scrotal lymphatics.

• Treatment of endosymbiont Wolbachia (bacteria) may help clear infection:::* Preferred regimen: Doxycycline 100 mg qd or bid for 6-8 wks in lymphatic filariasis although effect may be more important for co-infecting pathogens such as Wuchereria or Onchocerca than loaloa.

• Brugia malayi Return to Top

• Brugia malayi, Brugia timori lymphatic filariasis (elephantiasis) treatment::* Preferred regimen (1): Scaled dose Diethylcarbamazine (DEC) escalation recommended to reduce reactions on day 1-50 mg, day 2-50 mg tid, day 3-100 mg tid, Days 4-14, 2 mg/kg q8h for total of 72 mg over 14 days. (Diethylcarbamazine(DEC) 2 mg/kg PO tid for 12 days (may be accompanied by systemic reaction to dying worms,local reactions include lymphadenitis, transient lymphedema)).::: Note: Corticosteroids or antihistamines may be needed to treat allergic reactions that develop as a consequence of dying microfilariae.

• Preferred regimen (2): Albendazole 400 mg PO single dose regimen AND (Ivermectin 200 mcg/kg PO OR Diethylcarbamazine 6mg/kg) may reduce or suppress microfilariae; however, this will not affect adultworms.::: Note :::: Diagnosis 1.serological-antigen detection by commercially available card test ; IgG4 antibody (not filaria species specific and may cross react with other helminths);:::: Diagnosis 2.special maneuvers DEC provocative days test (induce microfilaremia with dose of DEC); polymerase chain reaction.:::: Diagnosis 3.skin snips (detect Onchocerca volvulus, Mansonella streptocerca). Ultrasonography can detect adult W.bancrofti worms in scrotal lymphatics.

Echinococcusgranulosus(hydatid disease) (CID 37:1073, 2003; Ln 362:1295, 2003)Meta-analysis supports percutaneous aspiration-injection-reaspiration (PAIR) + albendazole. Before & after drainage: albendazole≥60 kg, 400mg po bid or <60 kg, 15mg/kg per day div. bid, with meals. Then: Puncture (P) & needle aspirate (A) cyst content. Instill (I) hypertonic saline (15–30%) or absolute alcohol, wait 20–30 min, then re-aspirate (R) with final irrigation. Continue albendazole x28 days Cure in 96% as comp to 90% pts with surgical resection

Echinococcus multilocularis(alveolar cyst disease) (COID 16:437, 2003) Albendazole efficacy not clearly demonstrated, can try in dosages used for hydatid disease. Wide surgical resection only reliable rx; technique evolving (AJM 18:195, 2005)