[Genital elephantiasis: reconstructive treatment of penoscrotal lymphoedema with a myocutaneous M. gracilis flap. Experiences from a District Hospital in Ethiopia]. / Genitale Elephantiasis: Rekonstruktive Behandlung des penoskrotalen Lymphödems durch myokutane M. gracilis-Lappenplastik. Erfahrungen aus einem District Hospital in Athiopien.

BACKGROUND: Genital elephantiasis is an illness leading to serious functional and aesthetic as well as psychosocial impairment. Since the 19th century there have been articles describing methods for surgical ablative treatment of penoscrotal lymphoedema. However, most of these methods ignore the creation a new drainage for the lymph. We now describe a new technique using a myocutaneous M. gracilis muscle flap for the reconstruction of the soft tissue damage resulting from radical excision, thus ensuring drainage of the lymph into the deep muscle compartment of the thigh. PATIENTS AND METHOD: In the District Hospital "Mettu-Karl Hospital" in the Ethiopian rain forest region of Illubabor, during a period of 6 months the described surgical procedure was applied to 9 patients suffering from severe forms of this grotesquely disfiguring disease. Two patients presented with combined penoscrotal oedema, while the other 7 patients were suffering from isolated scrotal lymphoedema alone. All patients benefited from reconstruction with a myocutaneous M. gracilis muscle flap after radical excision of the affected tissue. All patients were evaluated after 3 and 12 months postoperatively in the presence of a translator. RESULTS: All nine patients showed a functionally and aesthetically satisfying result after 3 months without postoperative occurrence of infection. The evaluation 12 months postoperatively showed no recurrence of genitoscrotal lymphoedema. All patients reported on having regained normal ability for sexual intercourse and no occurrence of urinary tract infections since the operation. Concerning fertility, no statements could be made. A significant improvement in the quality of life was observed by the regained ability to walk and work and consequently the reintegration of the patients into their socio-economic environment. CONCLUSION: Radical excision of the affected tissue followed by transferring a functioning lymphatic drainage into the deep muscle compartment of the ipsilateral thigh using a proximally based myocutaneous gracilis muscle flap treats genital lymphoedema without recurrence. Satisfying aesthetic and functional results are achieved. The described surgical technique is still successfully being performed by two Ethiopian surgeons trained in this procedure.

Onchocerca jakutensis filariasis in humans.

We identified Onchocerca jakutensis as the causative agent of an unusual human filariasis in a patient with lupus erythematosus. To our knowledge, this is the first case of human infection with O. jakutensis and the first human case of zoonotic onchocercosis involving >1 worm.

Evidence for macrofilaricidal activity of ivermectin against female Onchocerca volvulus: further analysis of a clinical trial in the Republic of Cameroon indicating two distinct killing mechanisms.

During a 3-year trial of the effects of ivermectin (Mectizan) on adult worms and microfilariae of Onchocerca volvulus in the Republic of Cameroon, comparison was made between the percentages of calcified and uncalcified moribund (M) and dead (D) adult female worms dying following (a) the standard dose (150 microg/kg) given annually; (b) high doses (400, then 800 microg/kg) given annually; and (c and d) these same doses given at 3-monthly intervals. In the killing of adult female O. volvulus worms, the relative rôles of (a) natural causes; (b) a presumed, direct, anthelminthic, macrofilaricidal action of ivermectin; and (c) a potentially fatal pleomorphic ovarian neoplasm (PN), of which the incidence is increased by ivermectin treatment, are herein further investigated and discussed. It is concluded that ivermectin per se has a considerable direct macrofilaricidal action against female worms and that this lethal effect is supplemented by the drug's ability in some worms to increase the incidence, and the spread throughout the body of the worm, of the potentially fatal PN ovarian tumour. In moribund and dead ivermectin-treated female worms that were heavily invaded by PN, it is probable that the neoplasm was chiefly responsible for their death, but the additional direct anthelminthic action of the drug, which by itself has been responsible for the death of many other female worms, cannot be excluded as having played a supplementary lethal rôle. Similar problems as to the exact means by which adult female worms are killed may arise now that ivermectin is used in Africa for the mass treatment of lymphatic filariasis; or if and when the macrofilaricidal actions on O. volvulus of other drugs, which are closely related to ivermectin, come to be investigated.

Onchocerca volvulus breast mass: case report from Cameroon and literature review.

Onchocerca volvulus is usually associated with subcutaneous and ocular infections. Infection of the breast is rare and there are only two previous case reports. We report a case of a thirteen-year-old Cameroonian female with a left breast mass, which had a microscopic evaluation consistent with O. volvulus.

A stochastic model for the aggregation of Onchocerca volvulus in nodules.

A model is presented which describes the aggregation of female Onchocerca volvulus in nodules and their distribution in the human population. The basic model is based on a single parameter, the formation probability q, which represents the probability with which incoming larvae form a new nodule. This parameter describes parasite behaviour which cannot easily be recognized in available data without modelling. The estimate for the average formation probability of muq = 0.39 suggests an attraction of the invading infective larvae to already existing nodules or resident worms with probability 0.61. No significant difference in muq was found between the forest and savanna parasite strains. The model can be used inversely to estimate the worm burden of persons from palpation data. The observed variance in the number of nodules per person requires the assumption of a variance-increasing mechanism which was implemented by heterogeneity within the host population (extended model with 2 parameters). Possible reasons for this heterogeneity are presented and its implications concerning the reproductive biology of the parasite are discussed.

[Deep onchocerciasis of the left thigh. An unusual case]. / Onchocercome profond de la cuisse gauche. A propos d'un cas isolé.

INTRODUCTION: Commonly onchocercoma has been presented as superficial and multiple nodules. When it's unique and deeply situated, its clinical diagnosis is difficult. An uncommon form of onchocercoma is reported. CASE REPORT: A 37 years old man presented a big tumor at the inferior third of the left thigh like lipoma or liposarcoma because of microcalcifications. The tumor was removed. It was a cyst containing a liquid like an "mango juice". The histological examination was performed. Degenerated microfilariae of Onchocerca volvulus was found. DISCUSSION: A big and deep onchocerma of the thigh is uncommon and diagnosis before operation is very difficult. Histological examination have eliminate filarial infections like Dracunculus medinensis and have given the right diagnosis. Radiological microcalcifications and absence of microfilariae at the parasilogical and ophthalmological examinations recall an "aged" onchocercoma. For this reason, we didn't realise a chemotherapy. CONCLUSION: This tumor in Sahel areas is very difficult to diagnose before operation. The histological examination is very important in this case. We don't use chemotherapy because this onchocercoma looks old without alive microfilariae.

Integrated control of Onchocerca volvulus infection in a hyperendemic zone in Sierra Leone.

A simplified integrated method of onchocerciasis control involving mass chemotherapy with ivermectin, nodulectomy and health education was carried out in south central Sierra Leone. The prevalence of Onchocerca volvulus in the village community ranged from a low of 7.4% among the International School children to a high of 97.0% in Gbessebu. There was a significant (3-4%) overall reduction in the rate of infection after one year of ivermectin treatment (G = 2565.97, df = 11, P < 0.001). In addition, ivermectin treatment had a significant effect on the college community (G = 1168.21, df = 5, P < 0.001) and from year to year (G = 187.29, df = 1, P < 0.001), though the effect indicates the reduction varied between communities. Mass ivermectin treatment significantly (G = 1 3.79, df = 1, P < 0.005) reduced the rate of infection among school children, while the prevalence and intensity of infection was reduced by nodulectomy. Health education involving the community gave us an entry point and allowed us to gain the maximum cooperation and participation from the communities.

Intramuscular onchocercoma. Case report.

Onchocerciasis is characterized by the presence of numerous microfilariae in the skin, formation of subcutaneous nodules and eye lesions that can lead to blindness. We present a case, rather uncommon in our environment, in which an incomplete life cycle of the parasite, led to a single intramuscular nodule. The clinical symptoms and histological features are described, together with the treatment, using Ivermectin.

Onchocercacidal effects of amocarzine (CGP 6140) in Latin America.

An open clinical trial of amocarzine was carried out in onchocerciasis patients in Ecuador and Guatemala. Administration after food was more effective than that during fasting. The most effective and best tolerated regimen, 3 mg/kg twice daily after food for 3 days (in 312 patients), killed 73% of 1477 female worms at nodulectomy 4 months after treatment. The mean microfilarial skin count was greatly reduced within a week (6-11% Of day 0 value on day 8) and it remained low at least 6 months (14-18% on day 180). Follow-up of a higher dose 3 day regimen taken while fasting showed microfilaridermia of 7-9% of the day 0 value 2 years after treatment.

Viability of adult Onchocerca volvulus after six 2-weekly doses of ivermectin.

Ivermectin is a safe, effective microfilaricide and microfilarial suppressant for Onchocerca volvulus; but in single doses of 100-200 micrograms/kg body weight it has no macrofilaricidal action. The present trial aimed to determine whether 6 doses of 100 micrograms/kg ivermectin, given at 2-week intervals, would kill the adult worms. Eighty-two nodules from 28 otherwise healthy adult male Liberian patients treated with this ivermectin schedule, and 102 nodules from a similar group of 25 control patients, were removed four months after the last dose of ivermectin. They were coded and assessed in a masked fashion either by routine histology or by examination of whole worms extracted from the nodules after collagenase digestion. The drug had no visible effect on adult male worms. More adult female worms were assessed as moribund or dead in the ivermectin-treated group than in the control group (for the collagenase digests P = 0.09; for the histological assessment P = 0.47). The data suggest that repeated dosage with ivermectin may lead to a slow attrition of some female worms and this possibility should be investigated in patients receiving regular doses every 3, 6 or 12 months as part of onchocerciasis control programmes.

Effects of nodulectomy in onchocerciasis in Ecuador.

Nodulectomies were performed in a hypoendemic area on the Rio Santiago and in a hyperendemic area on the River Cayapas. All palpable nodules were removed. In the hypoendemic area the nodulectomies had a positive effect in reducing the intensity of infections and they contributed in the control of the advancement of the disease. In the hyperendemic area also a positive effect was observed but new nodules developed rapidly.

Diagnosis and extirpation of nodules in human onchocerciasis.

The clinical search for onchocercal nodules, and their preferred sites on the body in different geographic areas are described and illustrated. The differential diagnosis of onchocercomata is discussed and figures on the frequency of false diagnoses are reported. The prevalence of adult Onchocerca volvulus in relation to the endemicity of infection, the age and sex of the patients, the localisation of nodules on the body, and the measures used to control onchocerciasis are discussed. Recommendations are made on the selection of patients for different medical studies. The technique of nodulectomy and the equipment needed are described.

The reduction in microfilariae loads in the skin and eye after nodulectomy in Ecuadorian onchocerciasis.

This study is concerned with the relationship between palpable onchocercal nodules and Onchocerca volvulus microfilarial loads in the skin. The number of microfilariae in clinically normal skin decreases as the distance from the nodule increases. Surgical removal of nodules reduces the microfilarial loads in 40 of 46 patients studied over a period of five months, with an average reduction of 65.4% of the prenodulectomy microfilarial load at the iliac crest. Complete elimination of detectable parasites was seen in some patients. Five individuals had increased microfilarial loads, all of which had developed new palpable nodules. Also, nodulectomy had a significant effect on ocular tissue, reducing the levels of parasites in the cornea and anterior chamber in 10 of 15 patients observed with no new nodules developing during the observation period. Both dermal and ocular clinical manifestations of onchocerciasis were reduced in a proportion of the patients. These parasitological and clinical findings provide evidence that nodulectomy is a beneficial procedure to O. volvulus infected patients in Ecuador by reducing both microfilarial loads and the degree of pathology.

Geographical distribution of the prevalence of nodules of Onchocerca volvulus in Guatemala over the last four decades.

In Guatemala a national nodulectomy campaign has been carried out since 1935 in three operational areas, namely the Eastern, Central and Western endemic zones. The prevalence of nodules was calculated in each 1 km grid square in these zones in each decade and plotted on mesh maps. A total of nine foci of high endemicity, three in each operational area, was found in the decade 1940-49. Nodule prevalence was concentric in each endemic focus; high in the centre and gradually falling towards periphery. The foci were found mainly on Tertiary or Quaternary-Tertiary volcanic rocks in the Eastern and Central zones, or on non-carbonate sedimentary rocks in the Western zone. Nodule carriers were found at altitudes from 220 to 2200 m above sea level. The altitude of the foci of high endemicity varied, being low in the Eastern zone, medium in the Central zone and high in the Western zone. The nodule prevalence declined from the decade 1940-49 to the decade 1970-79 in most of the grid squares. The Santa Rosa focus in the Eastern zone virtually disappeared before 1970. The extent of endemic area having a nodule prevalence of 1% or higher decreased from 2384 km2 in the decade 1940-49 to 1424 km2 in the decade 1970-79. The area recommended for vector control operation against Simulium ochraceum was estimated at 803 km2.

Effects of a single complete nodulectomy on nodule burden and microfilarial density two years later.

In hyperendemic onchocerciasis areas of the Liberian rain-forest it was possible to re-examine 210 microfilaria carriers two years after a first examination. At the first examination of these patients 143 had presented with palpable nodules, and 110 nodule carriers had been completely nodulectomized. Two-thirds of the operated patients had an average of one newly detected nodule two years later, and their microfilarial densities were slightly increased. In the remaining third of the operated patients no nodules could be palpated two years later, and the average microfilarial densities were slightly decreased. The 33 nodule carriers who had not undergone nodulectomy had, however, significantly higher numbers of nodules and microfilariae in the skin two years after the first examination. The possible benefit of a single, complete nodulectomy is discussed.