A Woman from British Guyana with Recurrent Back Pain and Fever

Abstract

Diagnosis: Chyluria associated with infection due to Wuchereria bancrofti. This patient, who had lived most of her life in an area in which Wuchereria bancrofti infection was endemic, received a diagnosis of chyluria due to lymphatic filariasis. The diagnosis was confirmed by serological testing for filarial antibody and the presence of circulating filarial antigen. Lymphatic filariasis caused by infection with W. bancrofti and Brugia species affects >120 million people worldwide. The spectrum of disease associated with filariasis includes asymptomatic microfilaremia, acute lymphangitis, and chronic manifestations, such as lymphedema, elephantiasis, chyluria, or hydrocele. Chyluria is produced by the rupture of lymphatics into the renal collecting system with resultant reflux of intestinal chyle into the urine (figure 1). This occurs when filaria residing in the lymphatics incite a chronic inflammatory reaction with scarring that ultimately increases pressure in the renal lymphatics. Filarial nematodes contain endobacteria of the genus Wolbachia, which are phylogenetic relatives of Rickettsia, Ehrlichia, and Anaplasma species [ 1-5]. Wolbachia species have coevolved in an ndosymbiotic fashion to some filarias, such as Wuchereria bancrofti, Brugia species, and Onchocerca volvulus (but not Loa loa). W lbachia endosymbionts of these filarial nematodes are vital for larval development and for fertility and viability in the adult female worm. In addition, there is evidence that Wolbachia species contribute to the inflammatory process within the lymphatics by releasing cell wall components that interact with Toll-like receptors and induce a lipopolysaccharide-like immune response [2-7]. The de endency of the filaria on Wolbachia species has led to the novel therapeutic approach of treating filariasis with antiWolbachia agents [2-4]. Doxycycline, which is active against Wolbachia species, sterilizes the adult female and interrupts transmission of Onchocerca species for up to several months. Doxycycline also enhances ivermectin-induced blockage of microfilaremia [2, 9]. On the other hand, treatment of lymphatic