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REVIEW ARTICLES |
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| Year : 2005 | Volume
: 21
| Issue : 1 | Page : 24-26 |
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Medical treatment of filariasis and chyluria
MS Ansari
Department of Urology, SGPGIMS Lucknow, UP, India
Correspondence Address:
M S Ansari
Department of Urology,SGPGIMS Lucknow,UP
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0970-1591.19546
 Abstract | | |
The medical treatment of filariasis and chyluria is based on dietary modification, i.e. a diet excluding fat, supplemented by medium chain triglycerides (MCT) and high protein content. Drug therapy include administration of antifilarial drugs like diethylcarbamizine (DEC), ivermectin and albendazole. Annual mass drug administration of DEC combined with albendazole is recommended by the Global Programme to Eliminate Lymphatic Filariasis (GPELF) in endemic areas. DEC-medicated salt has been effectively used in various filarial endemic countries and as well as in certain parts of India. Vector control is a useful means in addition to chemotherapy in control of lymphatic filariasis.
Keywords: Chyluria; Diet; Diethylcarbamizine; Ivermectin and albendazole; Lymphatic filariasis
How to cite this article:
Ansari M S. Medical treatment of filariasis and chyluria. Indian J Urol 2005;21:24-6 |
Parasitic nematode worms, which produce filariasis in humans place approximately one billion people at risk in more than 75 countries. Filariasis is a significant health problem and more than 100 million people are infected with these diseases.[1] Repeated filarial attacks lead to obstruction of lymph flow resulting in rupture of dilated lymphatics in to urinary system. Prolonged chyluria results in loss of weight and subcutaneous fat, hypoprotenemia, lymphopenia and anaemia. Initially medical treatment should be tried in every case, which consists of dietary modification, antifilarial drugs, bed rest and high amount of fluid intake. [2],[3],[4],[5]
| Dietary modifications | |  |
Nutrition support has played a major role in the treatment of chyluria, both to prevent malnutrition and to minimize chyle production and its flow. Fat containing medium chain triglycerides (MCT; <12 C atoms) (found in coconut oil) can be taken as these are absorbed through portal system directly.[2] Obligatory oxidation of fatty acids in the liver after being transported there via the portal vein, leave almost no MCT derivative for incorporation in body fat or general circulation through other organs.[3] In cases of heavy chyluria parenteral administration of specialized products with MCT formulas, containing the fat as MCT along with albumin has also been prescribed. In cases of intractable chyluria total parenteral nutrition with total enteric rest is advised.[6] General dietary guidelines are given in [Table - 1].
| Medical treatment of filariasis | | |
Diethylcarbamazine (DEC) (Hetrazan, Benocide) rapidly kills microfilaria and can kill some, but not all adults of both Wuchereria and Brugia. DEC exerts no direct lethal effect on microfilarae but apparently modifies them so that they are eliminated by host's immune defense mechanism.[4] The standard dose is 6 mg/kg, which is to be given in three divided doses after food over a period of 10-14 days, which reduces microfilaremia levels by approximately 80-90% in several days. Initially lower dose (1-3 mg/kg) once a day should be started in order to decrease side effects of the drug in cases of heavy parasitic load. Drug reactions due to dying worm may commence after the start of the medical treatment. These reactions may be local or systemic. Systemic reactions include fever, headache, myalgia, vomiting, weakness and asthma; usually result from rapid destruction of microfilariae and perhaps adult worms, specially in heavily infected individuals. Local reactions include lymphadenitis, abscess formation and transient lymhadema. These symptoms develop within 2 days, often within 12 h, after initiation of the treatment and persist for 3-4 days. The drug is not recommended during pregnancy though no teratogenic effect so far has been reported. Side effects of DEC therapy may be reduced with spacing in between the two doses like single dose of 6 mg/g once weekly, twice monthly or once monthly. DEC treatment of micofillraemic patients and with acute symptoms eliminates the episodes of acute lymphatic inflammation that may prevent the development of obstructive lesions hence reducing the incidence of chyluria. The drug is rapidly excreted and nontoxic; can be repeated at 1 month following completion of the first course. Multiple courses of treatment may be required which may be repeated at 6 months interval. Peripheral eosinophilia often accompanies the infection with this parasite that should resolve with the response of the treatment. If peripheral eosinophilia and/or clinical symptoms persist after treatment, peripheral blood should be re-examined for microfilaremia/or circulating antigen.[5],[6]
The two other drugs which have used been in the treatment of filarial infestation are ivermecten and albendazole. Ivermectin kills microfilarae only and can be given as single dose of 400 mg/kg. All though ivermectin leads to rapid clearance of microfilarae, sustained reductions at six moths or longer after treatment are equivalent or better with single 6 mg/kg dose of DEC. This is consistent with DEC having a greater effect on adult worms. Ivermectin can also be used with DEC as single dose that gives more rapid clearance of microfilarae and recurrence is delayed. Side effects of ivermectin are similar to that of DEC with additional neurotoxicity. Albendazole 400 mg as single dose in combination with ivermectin is more effective in clearing microfilarae than ivermectin alone.[2]
Correction of anaemia
Correction of anaemia needs administration of hematenics along with multivitamins. Oral iron supplementation along with generous intake of green leafy vegetables and sticking to other dietary measures described above usually improve the haemoglobin level in these patients. Patients with gross haematuria (haematochyluria) warrant blood transfusion.
Supportive treatment
In addition to DEC therapy symptomatic treatment with antiinflammatory, analgesics and antipyretics along with bed rest should also be considered in case of acute attack and lymhadenitis. Use of abdominal binders during acute attacks of chyluria; elevation of affected limb, application of elastic bandage and special message help in the management of swollen lymphadematous limb. Patients with urinary retention secondary to chylous clot need cystoscopy and bladder wash. Bladder irrigation through a three way foley catheter may also be useful in cases of recurrent urinary retention.
| Therapeutic control at community level | | |
Therapy of a community in high prevalent area may consist of selective or mass treatment. In mass therapy DEC is administered to the total population barring children and pregnant women. In mass treatment parasitological diagnosis may be omitted in order to make the treatment cost effective. In selective treatment microfilarial carriers or patients with symptomatic disease are identified through various screening programmes. The drug may be administered in widely spaced doses (100 mg for adults and 50 mg for children once weekly, once monthly or bimonthly over a period of 1 year) or added to the table salt.[2],[4],[5] Annual mass drug administration (MDA) using diethylcarbamizine (DEC, 6 mg/kg) combined with albendazole (alb 400 mg) is recommended by the Global Programme to Eliminate Lymphatic Filariasis (GPELF).[7] WHO programme strategies focus on both transmission and morbidity control. For interruption of transmission it is recommended that the entire population at risk to be treated once yearly with single dose of two drug regimens, i.e. albendazole 400 mg plus ivermectin 150 mg/kg in African endemic countries and albendazole plus DEC 6 mg/kg in other parts of the world.[8]
Studies in India and abroad (China, Tazania) demonstrated the benefit of cooking salt fortified with DEC citrate for the control of lymphatic filariasis.[9] In India, DEC-medicated salt has been introduced on a commercial basis in certain parts of India, which is endemic for filariasis. Salt fortified with (0.25-0.33% w/w) DEC is administered with the food. After 1 year of treatment, the prevalence and intensity of microfilaremia were both reduced by more than 95%, while antigenemia levels were reduced by 60%.[9],[10]
| Vector control | | |
Vector control is a useful means in addition to chemotherapy in control of lymphatic filariasis. Effective control rapidly reduces the transmission thus reducing the prevalence of filariasis. The various preventive measures are; environmental control of breeding sites (elimination of stagnant water), larvicidal drugs and the spray of insecticides. Besides local hygiene, proper clothing, use of repellants and mosquito net are other important measures.
| References | | |
| 1. | Kinnamon KE, Engle RR, Poon BT, McCall JW, Dzimianski MT. A new class of anti-filariasis compounds: a preliminary look. Mil Med 1994;159:368-72.  [PUBMED] |
| 2. | Hashin S, Rohol HB, Babayan VK, Vanitallie TB. Treatment of chyluria and chylothorax with medium chain triglyceride. N Eng J Med 1964;270:756-61. |
| 3. | Geliebter A, Torby N, Bracco EF. Over feeding with medium-chain triglycerides diet results in diminished deposition of fat. Am J Clin Nut 1983;37:1-4. |
| 4. | Mc Mohan, Simonsen PE. In : JE Manson's tropical diseases. 2th Edn. WB Saunders: London 1334-6. |
| 5. | Ramaiah KD, Das PK, Vanamail P, Pani SP. The impact of six rounds of single-dose mass administration of diethylcarbamazine or ivermectin on the transmission of Wuchereria bancrofti by Culex quinquefasciatus and its implications for lymphatic filariasis elimination programmes. Trop Med Int Health 2003;8:1082-92. [PUBMED] [FULLTEXT] |
| 6. | Buttiker V, Fanconi S, Burger R. Chylothorax in children: guidelines for diagnosis and management. Chest 1999;116:682-7. [PUBMED] [FULLTEXT] |
| 7. | Tisch DJ, Michael E, Kazura JW. Mass chemotherapy options to control lymphatic filariasis: a systematic review. The Lancet 2005;5:514-23. [PUBMED] [FULLTEXT] |
| 8. | Meyrowitsch DW, Simonsen PE. Long-term effect of mass diethyl carbamazine chemotherapy on bancroftian filariasis: results at four year after start of treatment. Trans R Soc Trop Med Hyg 1998;92:98-103. [PUBMED] |
| 9. | Freeman AR, Lammie PJ, Houston R, LaPointe MD, Streit TG, Jooste PL, et al. A community-based trial for the control of lymphatic filariasis and iodine deficiency using salt fortified with diethylcarbamazine and iodine. Am J Trop Med Hyg 2001;65:865-71. [PUBMED] [FULLTEXT] |
| 10. | Panicker KN, Arunachalam N, Kumar NP, Prathibha J, Sabesan S. Efficacy of diethylcarbamazine-medicated salt for microfilaraemia of Brugia malayi. Natl Med J India 1997;10:275-6. [PUBMED] |
[Table - 1]
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