Onchocerciasis

Onchocerciasis is a major cause of blindness in many African countries. About half a million people are blind or visually impaired due to the disease. Onchocerciasis also causes ugly skin disease with depigmentation and severe unrelenting itching. The disease is most closely associated with subSaharan Africa, but it is also prevalent in Yemen and Latin America.

Onchocerca volvulus
Onchocerca volvulus is mainly found in West Africa and
Central and South America. Onchocerciasis, also known as river blindness, is a major public health problem, especially in West Africa despite the fact that an eradication program has been established. It is one of the worlds most distressing diseases of helminth origin, often resulting in blindness. Onchocerca volvulus is transmitted by the species Simulium or black fly whose breeding habitat is by fast flowing rivers or streams, therefore there is a patchy distribution of the disease as it is specified to where water courses are. The adult worms are found in nodules superficial sites, but may invade other tissues. It is estimated that there are 18 million cases worldwide with 17.5 million being found in Africa. Nigeria is the most infected region. The rate of morbidity is high in relation to those with an infection.

Onchcercaisis in Africa

Community-directed treatment with ivermectin = CDTI

The burden of Onchocerca volvulus in Sudan APOC: African Program Onchocercaisis Control
- The southern focus is the largest, with nodule and blindness rates exceeding 80% and 12%

- In the northern focus, located between the fourth and fifth Nile cataracts, present with limited but severe skin reactions, low nodule rates (16%), low microfilarial loads in the skin and no ocular involvement.
- The characteristics of patients from the eastern focus, close to the border with Ethiopian border are similar to those in the north, although most onchocercal skin disease in this area comprises the severe localized pruritus known as sowda. M. M. Mukhtar; M. M. Khier; O. Z. Baraka; M. M. A. Homeida , 1998

Adults in onchocercomas

A female worm is capable of producing 1000-3000 microfilariae (juvenile worms, stage L1) per day.

Section of onchocercoma due to Onchocerca volvulus. Several female adult worms were surrounded with host fibrotic tissue.

O. Volvulus microfilaria

female: 60 cm long male: 2-3 cm long

Symptoms
Adult worms lodge in nodules under the skin, releasing large numbers of microfilariae into surrounding tissues. Immature worms move through the body and after dying, cause a variety of conditions including: serious visual impairment and blindness, skin rashes, lesions, intense itching and depigmentation of the skin, lymphadenitis (resulting in hanging groins and elephantiasis of the genitals) and general debilitation.

Vector The blackfly Simulium damnosum

The black fly

Fast flowing water

Life Cycle
The microfilariae are ingested by a Black fly during a blood meal, from where they are carried to the midgut where they penetrate the epithelium and migrate, via the hemocoele, to muscles. they undergo two molts, L1L3 and develop into infective L3 larvae which move to the mouth parts. Development is completed in 69 days. When the infected fly takes another blood meal the infective larvae are once again transmitted into another host (definitive host). The microfilariae are released from the mouth parts and transmitted directly into the hosts bloodstream. Molting takes place form L3 - L4 within 25 days and the larvae then migrate widely through the body under the skin and between muscles, ligaments and tendons. The final molt to L5 occurs at 1.52.5 months after transmission. Male worms are known to mature in about four months later. Female worms initiate the formation of the nodules and the males may join later. The sexually mature female worms release microfilariae which migrate out from the nodules into the skin and other tissues, most significantly into the eye.

Clinical Disease
Clinical manifestations are due to dead microfilariae in the epidermis. Light infections may be asymptomatic or cause pruritis. This leads to scratching which can result in infection. Lyphadenopathy may also be a feature of early infection. After months or years, onchodermatitis results in secondary stage of thickening due to intradermal edema and pachydermis. There is a loss of elastic fibers resulting in hanging groin, hernias and elephantiasis of the scrotum. There is finally atrophy of the skin resulting in loss of elasticity. There is mottled depigmentation of the skin. Ocular lesions are related to the intensity of the microfilariae in the skin. Ocular lesions include sclerosing keratitis, secondary glaucoma and cataract, coroidoretinitis and fluffy corneal opacities. The major complication of onchocerciasis is the development of lesions in the eye which may result in blindness or other distressing ocular diseases.

Nodules caused by the adult worms

Onchocerca volvulus: nodules (removed from under the skin of infected people) contain the adult worms shows nodules, skin changes and blindness, all manifestations of the disease.

Eye infections by the microfilaria larvae

Ocular lesions in an onchocerciasis (river blindness) victim blinded from sclerosing Keratitis.

Symptoms
Adult worms lodge in nodules under the skin, releasing large numbers of microfilariae into surrounding tissues. Immature worms move through the body and after dying, cause a variety of conditions including: serious visual impairment and blindness, skin rashes, lesions, intense itching and depigmentation of the skin, lymphadenitis (resulting in hanging groins and elephantiasis of the genitals) and general debilitation.

Laboratory Diagnosis
1. Analysis of Skin Snips Small amounts of skin are collected by using a needle to raise the skin and then to slice about 1 mg of skin to a depth of 0.5m. Snips are collected from several sites, usually the shoulders or the buttocks and sometimes the chest and calves. The snips are placed immediately in 0.5ml normal saline in a microtiter plate and left for 4 hours to allow the microfilariae to migrate out of the tissues. After four hours, the wells are examined using an inversion microscope. The microfilariae should still be moving and can be identified from the table below. The microfilariae can also be collected by filtration or centrifugation and the deposit containing microfilariae can be stained with Giemsa at pH 6.8.

2. Analysis of Biopsies
Biopsies of tissue nodules can be dabbed on to a slide to produce impression smears and then stained with Giemsa stain at pH 6.8 for the presence of microfilariae. Recent advances in diagnostic methods includes and ELISA-based antibody detection assay which utilizes a cocktail of recombinant antigens. The advantages of using this test is that it is highly sensitive (almost 100% in onchocerciasis foci). It is also highly specific (100%), it also uses finger prick blood. Therefore, reducing the painful procedure of gaining a skin snip.