Ultrasonographic examination of the scrotal area was performed in 14 asymptomatic individuals with bancroftian filariasis and microfilaremia. While in seven subjects (50%) the ultrasonographic findings were normal, lymphatic dilation and tortuosity were observed in the other seven. In these vessels, structures with peculiar aleatory movements (filaria dance sign) were detected. A segment of the lymphatic tract containing these mobile intraluminal structures that was resected surgically from the left spermatic cord of one individual confirmed that these structures were living Wuchereria bancrofti adult worms (two females and one male). Our study demonstrates for the first time the feasibility of using a low-cost, widely available, noninvasive technique (ultrasonography) to detect and monitor living adult worms and lymphatic dilation in patients with bancroftian filariasis.

When ivermectin and diethylcarbamazine (DEC) are given simultaneously in a single dose to persons with Wuchereria bancrofti infection, the resulting suppression of microfilaraemia is more profound and sustained than when either drug is given alone. To assess whether this effect is a result of enhanced macrofilaricidal efficacy, we used ultrasound to monitor the adult worms in the scrotal area of men with W. bancrofti microfilaraemia. Twenty-one men were treated simultaneously with DEC (6 mg/kg) and either 200 micrograms/kg or 400 micrograms/kg of ivermectin (11 and 10 men, respectively). Ten other men received a single 200 micrograms/kg dose of ivermectin followed 5 d later by a 6 mg/kg dose of DEC (sequential treatment). All men became amicrofilaraemic after treatment and all except one remained so for one year. Cessation of adult worm movement, indicative of death of all the adult worms in a given 'nest', was observed in none of 30 nests in men who received simultaneous treatment and in 3 of the 19 nests (16%) in the men who received sequential treatment (P = 0.05). Scrotal nodules were detected in 5 of 21 men (24%) who received simultaneous treatment and in 8 men (80%) who received sequential treatment (P < 0.01). Thus, co-administration of ivermectin with DEC seems to interfere with the macrofilaricidal action of DEC. These findings have implications both for treatment of the individual patient and for community-based drug distribution programmes designed to interrupt transmission of W. bancrofti.

To determine the tolerance to diethylcarbamazine (DEC) treatment of patients with Bancroftian filariasis, 193 individuals (138 asymptomatic microfilaraemic, 30 amicrofilaraemic diseased patients and 25 asymptomatic amicrofilaraemic endemic residents) were enrolled in a prospective trial with different dose schedules, in a hospital and outpatient clinic setting in Brazil. Systemic adverse reactions, localized adverse reactions, and side effects, related to microfilariae, adult worms and the drug itself, were evaluated. Systemic reactions occurred irrespective of the DEC dose and schedule in about 40% of the microfilariae carriers, but not in amicrofilaraemic diseased patients or residents; they usually consisted of microscopic haematuria, followed by fever and malaise. Localized reactions were manifested by the appearance of inflammatory reactions, mainly in the scrotal area. Nodules containing degenerating adult worms developed mainly in the scrotal lymphatics of microfilaraemic patients, diseased amicrofilaraemic patients, and residents. Drowsiness, which increased with higher doses of DEC, was the most common side effect in both microfilaraemic and amicrofilaraemic individuals, followed by nausea and gastric upset. The results indicate that the occurrence of systemic and local adverse reactions was unrelated to either the dose of DEC or the pretreatment microfilarial density. The severity of systemic reactions was proportional to the microfilarial density. Side effects were dependent on the drug dosage irrespective of infection status.

The effectiveness of single oral doses of ivermectin (200 or 400 (μg/kg) and diethylcarbamazine (DEC, 6 mg/kg), preceded 4 d earlier by either placeb

Although morphology is generally limited to static images, the histopathological features of bancroftian lymphatic disease are presented here in a way that is as dynamic as possible and closely associated with the clinical, ultrasonographic and surgical characteristics. The protean spectrum of alterations seen in the host's lymphatic vessels is discussed, and the changes caused by the live and dead worms are highlighted, as independent events. Evidence of a remodelling process, in which the lymphatic endothelial cells appear to have a key role, is provided for the first time. Despite many new pieces of information, there remain many 'blank pages' in the natural history of bancroftian filariasis.