A hypersensitive reaction to lymphatic-dwelling parasites and characterised by chronic cough, wheezing and persistent eosinophilic count which may rea

bladder gives rise to clyluria (when the lymph vessel is draining the intestine) or lymphuria (when it is not) Chyluria occurs intermittently and is more pronounced after a heavy meal It is often symptomless, but may cause fatigue and weight loss due to loss of fat and protein 5 Tropical eosinophilic syndrome - A hypersensitive reaction to lymphatic-dwelling parasites and characterised by chronic cough, wheezing and persistent eosinophilic count which may reach more than 50,000/mm3 Increased specific serum IgE and characteristic histological lesions (Meyers-Kouwennar bodies) in lymph nodes, lungs, spleen and liver Microfilaria are usually absent in blood Diagnosis - (i) Microfilariae in peripheral blood - examined about midnight Microfilariae may be found in fluid obtained from varices, from hydrocele sac and sometimes ascitic and pleural accumulation and joint fluid or sediment of chyluria (ii) X-ray - for calcified filaria (iii) Gland biopsy - to identify adult worm (iv) Intradermal test - About 90% of patients with Wuchereria bancrofti infestation have a positive intradermal test with material prepared from filarial worm of lower animals (v) Complement fixation test- A positive reaction suggests present or past infection Management - 1 SPECIFIC - (a) Diethylcarbamazine produces rapid disappearance of microfilariae from blood stream Dose - 50 mg (G mg/kg) t d s for 4 days to maximum of -200 mg t d s for 2 weeks (Total dose 75 mg/kg body weight) or single dose of G mg/kg is as effective in the long term at killing microfilariae and adult worms Long-term reduction of microfilariae and transmission control - Annual 2-drug regimens of ivermectin (200 mg/kg) co-administered with either DEC (G mg/kg) or albendazole (400 mg) Side effects - Dizziness, nausea and vomiting Fever, bodyache, skin rashes and temporary exacerbation of symptoms may occur in the beginning of treatment as a result of toxic proteins released from dead organisms These allergic reactions do not indicate cessation of treatment and are relieved by corticosteroid drugs (b) Ivermectin - Single dose (150 mg/kg on empty stomach) may be used to clear microfilariae almost as effectively as multiple doses of DEC The drug however does not affect adult worms (c) Coumarin (5, G-benzo-a-pyrone) - 400 mg/day reduces oedema and many symptoms of filarial oedema and elephantiasis Few side effects 2 TREATMENT OF SECONDARY INFECTION - (a) Local, treatment - elevation of limb Calamine or lead lotion Antibiotic ointment if ulcers (b) Antibiotics (c) Eradication of septic focus 3 RELIEF OF LYMPHATIC OBSTRUCTION - (a) Surgical treatment for re-establishment of lymphatic drainage by venonodal shunt or (b) bandaging the limb tightly preferably after a period of rest, and elevation, massage, and exercise 4 PALLIATIVE TREATMENT - (a) Acute lymphangitis - Rest, elevation of limb, hot fomentations, infra-red rays or short wave diathermy Analgesics for relief of pain Broad spectrum antibiotics to control infection (b) Chyluria - Complete rest Omit fat from diet Saline purge Bladder Vvash if clots (c) Elephantiasis -Since bacterial and fungal infections trigger most episodes of adenolymphagitis in tissues with compromised lymphatic function, simple hygiene measures are useful - (a) Twice daily washing of affected parts with soap and water (b) Raising the limb at night (c) Working the foot up and down to promote lymph flow (d) Keeping the nails clean (e) Wearing shoes (f) Use of antiseptic or antibiotic creams to treat small wounds or abrasions Long-term low-dose DEC may also help to reverse chronic lymphoedema and elephantiasis For resistant case lymphonodo-venous shunt operation, followed by surgical removal of excess tissue INTESTINAL HELMINTHS Hookworm -Hookworms are nematodes belonging to the family Ancylostomidae Human infection is caused by Ancylostoma - duodenale and Necator americanus Transmission - may occur wherever faeces' are allowed to remain in contact with damp soil at a suitable temperature. LIFE-CYCLE - The adult worms attach themselves by their mouths to the intestinal mucosa and feed upon blood. The gravid male lays eggs which are passed in the stools. In suitable conditions a larval worm hatches in about 24 hours and takes a week to reach the stage infective to man. These infective larvae can penetrate human skin. Having entered the body the larval worms pass in the blood stream to the lung capillaries. They enter the alveoli, pass up the air passages and down the oesophagus to reach the jejunum where they attach to the mucosa and mature Clinical features Cause DIAGNOSIS - Detection of ova in stool, or of worms after treatment. Treatment - When Hb is less than 5 gm % it is advisable to raise it to about 8 gm. with iron therapy before expelling the worms. Mebendazole - 100 mg. b.d. for 3 days (all age groups) or Albendazole - One dose of 400 mg for all patients over 2 years of age or Pyrantel - 10 mg/kg (maximum 750 mg in adults) in a single dose for 3 days. Roundworm - (Ascaris lumbricoides) LIFE CYCLE -The eggs leave the body tin the faeces. At this stage they consist of unsegmented ova protected by a thick shell, which in suitable conditions will develop into larval worms in 2 or 3 weeks Man acquires the infection by swallowing the larvae, usually on contaminated food. The larvae hatch in