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Filariasis Treatment & Management


Author: Siddharth Wayangankar, MD, MPH; Chief Editor: Pranatharthi Haran Chandrasekar, MBBS, MD more...
Updated: Dec 10, 2015

Approach Considerations
The medical management of a filarial infection should be specific and based on the
microfilariae isolated or antigenemia detected.
Mass drug administration reduces the transmission of filarial infection and disease
morbidity by decreasing the burden of microfilaremia, resulting in suboptimal levels
for transmission by disease vectors.[44, 45, 46, 47, 48, 49]
For example, annual mass treatment with albendazole and ivermectin is employed to
interrupt the transmission of W bancrofti. Since this species has no alternative hosts,

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this approach could theoretically result in eventual eradication of bancroftian filariasis.


One study evaluated the effect of higher dose and increased frequency (twice yearly)
of albendazole-ivermectin therapy for W bancrofti and found that it resulted in
complete microfilarial clearance, as well as a more sustained clearance than that
resulting from standard-dose albendazole-ivermectin treatment.[50]
The effects of mass treatment on filariasis have reportedly been sustained for up to 6
years.[51, 52, 53, 54] No filariasis vaccine is currently available, but efforts to develop an
effective one are under way.[55]

Surgery
Lymphatic filariasis
Large hydroceles and scrotal elephantiasis can be managed with surgical excision.
Correcting gross limb elephantiasis with surgery is less successful and may
necessitate multiple procedures and skin grafting.
Onchocerciasis
Nodulectomy with local anesthetic is a common treatment to reduce skin and eye
complications.

Diet and activity


Fatty foods are restricted in individuals with proven chyluria that is associated with
lymphatic filariasis.
Individuals with chronic lymphatic filariasis are encouraged to mobilize (with
compression bandage support) the affected limb.

Prevention
Avoidance of bites from insect vectors is usually not feasible for residents of
endemic areas, but visitors to these regions should use insect repellent and mosquito
nets.

Consultations
To prevent inappropriate treatment, consult an infectious disease specialist in all
cases of suspected filariasis outside of endemic nations. Other possible
consultations include:
Urologist
Ophthalmologist
General surgeon
Plastic surgeon

Pharmacologic Therapy
Lymphatic filariasis
Patients with asymptomatic microfilaremia can be treated on an outpatient basis.
Supervision of oral DEC therapy and provocation with postadministration observation
is recommended for patient compliance with therapy and for the management of
febrile reactions in heavily infected patients.[31]
Inpatient care may initially be required for adenolymphangitis (ADL) and chronic
filariasis. Such care includes the use of antihistamines, steroids, pain relief, and
intravenous antibiotics for secondary infections.
Lymphedema
Steroids can be used to soften and reduce the swelling of lymphedematous tissues.
Mild to moderate filarial lymphedema has been shown to improve with a 6-week
course of doxycycline, independent of ongoing infection.[56]
Bed rest, limb elevation, and compression bandages traditionally have been used for
the management of chronic lymphedema.
Chronic filariasis
Treatment of chronic filariasis does not change the prognosis, as irreversible fibrosis
usually destroys lymphatic tissue. However, asymptomatic patients, hoping to diminish
progression of the disease, still typically undergo treatment, although the benefit of
this is unclear.[57]
Chyluria
In the treatment of chyluria, a special low-fat, high-protein diet supplemented with
medium-chain triglycerides may prove beneficial. In addition, the sclerosing action
conferred by diagnostic lymphangiography may plug the leak.
Secondary infection
Supportive care should include the prevention of secondary infection, especially in
patients with advanced disease. Individuals with chronic infections should wash the
affected area frequently, apply antiseptic creams to abrasions, keep their nails clean,
wear comfortable footwear, and exercise the affected limb to aid lymphatic flow.

Onchocerciasis
If DEC and suramin (currently the only drug in clinical use for onchocerciasis that is
effective against adult worms) are used, inpatient care is recommended to monitor for
reactions and complications of therapy.[28]

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Moxidectin is being investigated as an alternative to ivermectin for the treatment of


river blindness. This agent may shorten the number of annual treatments to 6.

Bancroftian filariasis
Ivermectin is now considered the drug of choice for the treatment of bancroftian
filariasis. In the United States, it can be obtained from the Centers for Disease
Control and Prevention (CDC); in endemic areas of the world, it is provided free by
the Mectizan Donation Program. The addition of albendazole seems to improve
response.[58, 59, 60, 61]
Six-week and 8-week courses of doxycycline have compared favorably with
ivermectin plus albendazole.[62] Doxycycline therapy may be more readily available
and may be better tolerated by some patients. It may also be capable of preventing or
reversing lymphatic pathology.[63]
In one study, a 3-week course of doxycycline followed by a single dose of DEC was
shown to be microfilaricidal.[63]
Findings have validated the use of single-dose regimens of ivermectin and DEC or
albendazole for large-scale control and eradication programs aimed at reducing
Wuchereria bancrofti microfilaremia, antigenemia, and clinical manifestations.[50, 64,
65, 66, 67]

M perstans infection
Because M perstans is resistant to standard antiparasitic treatment, doxycycline is
sometimes used to eradicate Wolbachia, an endosymbiont found in most filarial
species.[26, 68]
Doxycycline treatment typically kills or sterilizes the filarial nematode. In an open-label,
randomized trial, Coulibaly et al recruited patients with M perstans infection from 4
African villages in Mali. Patients were randomly assigned to receive 200 mg of
doxycycline orally every day for 6 weeks or no treatment.[69]
At 12 months, 97% of patients who received doxycycline had no detectable blood
levels of M perstans, compared with 16% of patients in the group that did not receive
treatment. At 36 months, M perstans remained suppressed in 75% of patients who
had received doxycycline.[69]

Long-Term Monitoring
Patient monitoring includes posttreatment follow-up for 12 months, with examination
of peripheral blood and skin snips for microfilariae.
Observe and monitor oral therapeutic plans with DEC because compliance with
therapy is poor and usually incomplete.
Patients with filariasis are, by default, at risk for other parasitic infections because
areas endemic for bancroftian filariasis are also endemic for other parasites. After
treatment, patients should be monitored for symptoms that are characteristic of
parasitic infections.
Medication

Contributor Information and Disclosures


Author
Siddharth Wayangankar, MD, MPH Resident Physician, Department of Internal Medicine, Oklahoma University
Health Sciences Center
Siddharth Wayangankar, MD, MPH is a member of the following medical societies: American College of Physicians
Disclosure: Nothing to disclose.
Coauthor(s)
Michael Stuart Bronze, MD David Ross Boyd Professor and Chairman, Department of Medicine, Stewart G Wolf
Endowed Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center;
Master of the American College of Physicians; Fellow, Infectious Diseases Society of America
Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical
Association, Oklahoma State Medical Association, Southern Society for Clinical Investigation, Association of
Professors of Medicine, American College of Physicians, Infectious Diseases Society of America
Disclosure: Nothing to disclose.
Rhett L Jackson, MD Associate Professor and Vice Chair for Education, Department of Medicine, Director,
Internal Medicine Residency Program, University of Oklahoma College of Medicine; Assistant Chief, Medicine
Service, Oklahoma City Veterans Affairs Hospital
Rhett L Jackson, MD is a member of the following medical societies: American College of Physicians-American
Society of Internal Medicine, American Medical Association
Disclosure: Nothing to disclose.
Chief Editor
Pranatharthi Haran Chandrasekar, MBBS, MD Professor, Chief of Infectious Disease, Program Director of
Infectious Disease Fellowship, Department of Internal Medicine, Wayne State University School of Medicine
Pranatharthi Haran Chandrasekar, MBBS, MD is a member of the following medical societies: American College of
Physicians, American Society for Microbiology, International Immunocompromised Host Society, Infectious
Diseases Society of America
Disclosure: Nothing to disclose.
Acknowledgements
Rosemary Johann-Liang, MD Medical Officer, Infectious Diseases and Pediatrics, Division of Special Pathogens

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and Immunological Drug Products, Center for Drug Evaluation and Research, Food and Drug Administration
Rosemary Johann-Liang, MD is a member of the following medical societies: American Academy of Pediatrics,
American Medical Association, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.
Thomas M Kerkering, MD Chief of Infectious Diseases, Virginia Tech Carilion School of Medicine
Thomas M Kerkering, MD is a member of the following medical societies: Alpha Omega Alpha, American College
of Physicians, American Public Health Association, American Society for Microbiology, American Society of
Tropical Medicine and Hygiene, Infectious Diseases Society of America, Medical Society of Virginia, and
Wilderness Medical Society
Disclosure: Nothing to disclose.
Charles S Levy, MD Associate Professor, Department of Medicine, Section of Infectious Disease, George
Washington University School of Medicine
Charles S Levy, MD is a member of the following medical societies: American College of Physicians, Infectious
Diseases Society of America, and Medical Society of the District of Columbia
Disclosure: Nothing to disclose.
Michael D Nissen, MBBS, FRACP, FRCPA Associate Professor in Biomolecular, Biomedical Science & Health,
Griffith University; Director of Infectious Diseases and Unit Head of Queensland Paediatric Infectious Laboratory,
Sir Albert Sakzewski Viral Research Centre, Royal Children's Hospital
Disclosure: Nothing to disclose.
Russell W Steele, MD Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical
Professor, Department of Pediatrics, Tulane University School of Medicine
Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American
Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases
Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric
Research, and Southern Medical Association
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College
of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Medscape Salary Employment
Robert W Tolan Jr, MD Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at
Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine
Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American
Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene,
Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for
Social Responsibility
Disclosure: Novartis Honoraria Speaking and teaching
John Charles Walker, MSc, PhD Head, Department of Parasitology, Center for Infectious Diseases and
Microbiology, Westmead Hospital, Westmead, Australia; Senior Lecturer, Department of Medicine, University of
Sydney, Australia
Disclosure: Nothing to disclose.
Martin Weisse, MD Program Director, Associate Professor, Department of Pediatrics, West Virginia University
Martin Weisse, MD is a member of the following medical societies: Ambulatory Pediatric Association, American
Academy of Pediatrics, and Pediatric Infectious Diseases Society
Disclosure: Nothing to disclose.
Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of
Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Nothing to disclose.

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