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Suggest treatment for filariasis, severe itching, crawling sensations, bloating in legs

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Posted on Sat, 16 May 2015
Question: Hi, I tested positive for filariasis but since it was a low positive and recently have not been to an endemic area, doctor says it's not filariasis. However, I have been to endemic areas in the past and also have been around people from that area. My husband tested positive for Strongyloides which apparently cross reacts with filariasis. I have severe itchiness, crawling sensations, bloading in the legs and eyes and neck, my arms are numb when I wake up and I feel clogged up in the head and behind my chest. These symptoms come and go, but with each cycle seems to get worse. We took ivermectin which temporarily made the symptoms go away, but then after a few rounds, I started to feel clogged up in the head and neck, fainted and went to hospital. My Hearst shunk after ivermectin, but is starting to swell again. We also have chronic cough, dizziness and chills, and heaviness in chest that are worse at night. I was thinking if I should have a lymphogram. Would that show clogged areas? Or does it only happen if the worms are calcified?
doctor
Answered by Dr. Rakesh Madhyastha (9 hours later)
Brief Answer:
Need more info

Detailed Answer:
Hello

Thanks for the query

I understand your concern, it must be very debilitating to have such issues. However in order to help you I need a few more details

1. Did you ever have fever with chills and rigor ?
2. do you have any swelling of the limbs ?
3. what aggravates the uncomfortable feeling ?
4. were you investigated for anything other than filariasis ?
5. are the symptoms improving or worsening over time ?

please get back to me , I am awaiting your reply

regards
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Follow up: Dr. Rakesh Madhyastha (5 hours later)
Thank you for your concern.
1. My son had a 41celcius fever, my husband and I had a middle grade fever a few weeks before the skin eruptions. The chills happen almost every night like clockwork around 11pm and sweating happens early morning. The rigor was starting to happen long before skin eruption.
2. My feet look normal, but shoe size have gone up by two sizes. It swells early evening and feels normal in the morning. Sometimes I feel tightness around my calves as if i have long tight socks, but im not. Arms on the other hand are numb and swollen in the morning. It is hard to make a fist and feels tight. But later in the day finger tips get wrinkled.
3. I am not sure what aggrivates it other than night time is the worst. Chills, dry cough, dizzyness. I wake up often with heaviness in the chest, stiff arms, neck and shoulders, and really bad headaches.
4. Blood test mostly normal except low vitamin D. Cortisol test, normal. Stool & ova negative except for bacterial infection. CT of head and heart normal.
5. The skin eruptions (lesions etc.,) are not as prominent as it was in the beggining, but other symptoms are getting worse. Itchiness is severe in upper arms, feet, genitals, and nose area. Stiffness in the neck, shoulders, and in between shoulder blades can suddenly happen as if that area freezes and then hurts as if i had whiplash. At the same time when stiffness happens, my throat(from the inside) feels swollen as if it closing up. Genital area swells up (again feels like the inside, like i fell pressure building) This was happening before the skin eruptions too. Breasts shrunk after ivermectin, but starting to swell again.

Do you think a lymphogram could show blockage? Or a lymphocyntigram? I feel like there are places that feel stuck or clogged. Right at the base of my neck where collar bone meets and behind my chest

My son keeps having recurrent dry cough and fevers that go over 40 accompanied by stiffness in the legs. Cough suppressants do not work.
Looking back on it, i think i might have had it for a long time and seems like after birth strange things started to happen.
I am worried because ivermectin did not cure it. When we took ivermectin, we broke out in huge rashes in the areas that have been bothering us (while on it we felt lots of prickles in those areas too). .
doctor
Answered by Dr. Rakesh Madhyastha (3 hours later)
Brief Answer:
Follow up

Detailed Answer:
Hello

Thanks for getting back in such detail. Here are my suggestions to you

1. If you are allergic to ivermectin then the only other alternative would be doxy and you are on it. I see that you have already tried albendazole
2. The next step for diagnosis would be to get an Ultrasound of the lymphatics ( legs and hands) done, this will show active filarial worms in it
3. Lymphoscintigraphy is a more accurate mode for diagnosis however it carries the risk of damaging the vessels. Lymphangiography with contrast is not done anymore.

I recommend that you approach a pulmonologist for further evaluation of the chronic cough.

I hope I was of help, if you have any further queries please get back to me

Regards
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Rakesh Madhyastha (35 minutes later)
Thank you for your exellent advice. I have a few questions regarding the ultra sound. Since i will be going to a clinic from a non endemic area, im not sure if they know how to read the ultra sound accordingly. Is there a frequency of some sort? What are the techniques in finding the sign of worms. Will they see the adult worms? I would need some guidance so that i can let the technician know how to and what to look for. I do feel a tremendous pressure in my neck area that is progressivly getting worse. Where is the easiest place to see them?
I also wanted to know if eventually would be better to travel to an endemic area where i can be seen by a doctor there. Do you have any suggestions?
Lastly, what should my child take instead of doxycycline since he is too young to take it. Should it be ripampicin? If so, what would be the length of the course and the daily dosage? And how soon will westart to see results?
Thank you so much!
doctor
Answered by Dr. Rakesh Madhyastha (23 hours later)
Brief Answer:
Follow up

Detailed Answer:
Hello

Thanks for getting back, I am sorry for the short delay in my reply. I thought I should discuss with the radiologist of my hospital before getting back to you

Here are the suggestion after discussing with him

1. They will be able to see the adult worms.
2. Please ask the technician to see under high frequency doppler mode. Please make sure he checks the venous pressure, increased venous pressure is an indirect indicator
3. There is no easy place to see, one will have to go through the lymphatics
4. Travelling to the endemic area and meeting a doctor will help in treatment for sure
5. I recommend albendazole for your child, for 3 weeks. However I recommend that the diagnosis is confirmed before giving prolonged therapy. The results will be visible within 5 days of treatment

I hope I was of help, I am once again sorry for the delay

Regards
Above answer was peer-reviewed by : Dr. Vaishalee Punj
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Follow up: Dr. Rakesh Madhyastha (9 hours later)
Hello! Thank you very much for looking into it. I appreciate it so much. I tried to ask for an ultrasound, but Dr said it can't be seen and that my lymph nodes are not swollen. I believe it's possible to see it and wish to be looked at by someone who knows how to do it. Will your hospital be able to do this? We tried albendazole and it seem to have an effect but after we finished a course, it acted up again a little later. My undertsanding is that ivermectin and albendazole has an effect on the microfilariae, but not the adult worms. One of the article is below:
http://www.mdpi.com/1420-3049/13/9/2156/pdf

Here are my questions:
Do my symptoms fit with Filariasis.
If there are adult worms can they be extracted from the lymphatic system?
Can your hospital do an ultrasound scan for me?
If not do you know anyone in the US who will be open minded to do an ultra sound and has some experience with this?
I am mostly concernd with my child who was so healthy before this happened, and now he is constantly scratching, has fevers periodically, dermatitus, stiffness, and cough.

This is my last questions for this session since i paid for not the monthly fee. I would like to continue talking to you. Can i request you again?
Again, thank you so much for your advice. It has been very helpful
.
doctor
Answered by Dr. Rakesh Madhyastha (12 hours later)
Brief Answer:
Follow up

Detailed Answer:
Hello

Thanks for getting back to me

1.I have gone through the article, but I am not sure which part of it you wanted me to concentrate on. It is correct that ivermectin does not help in killing adult worms. For that you will need to be on doxycycline as DEC is now discontinued in most states of USA
2. Your symptoms does look like Filariasis. However it is an easily treatable disease, I have yet to see a patient who has not responded to multiple therapy
2. Lyphmoscintigraphy can help you localise the adult worms however I am afraid it cannot be excracted out. You will have to be treated with antibiotics
3. My hospital can do an ultrasound however we do not perform Lymphoscintigraphy. I am sorry I am not aware of the facilities in USA
4. I strongly recommend you to approach a doctor in a country you have been to, they will be knowing the epidemics of their area the best.


You can address the question directly to me in the future. I have found a nice article for you to go through

http://www.merckmanuals.com/professional/infectious_diseases/nematodes_roundworms/bancroftian_and_brugian_lymphatic_filariasis.html

Regards
Above answer was peer-reviewed by : Dr. Vaishalee Punj
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Follow up: Dr. Rakesh Madhyastha (38 hours later)
Hello Doctor! Thank you again for the information. I can not find someone who will perferom ultrasound here for that reason and even if I did, i don't think they have the ability to recognize it. Last year after my sypmtoms started, i felt discomfort (pressure, like getting clogged) in my neck and some movement there, ultrasound was performed and i remember the radiologist kept looking at one spot and mumbled to herself that "something was fluttering" and then she ignored it. Of course i would like to find someone here, but im starting to think i need to be seen by someone with real experience.
I started taking doxycycline two weeks ago and the frequency and intesity of the itchiness has gotten a little bit better. It is getting harder for me to make a fist, i feel the bloading is getting worse right now. On Doxycycline, how long does it take until i feel a big difference?
Can i arrange to be seen by a radiologist at your hospital? And if something is found, what is the next step?
Thank you in advance.
Regards,
doctor
Answered by Dr. Rakesh Madhyastha (19 hours later)
Brief Answer:
Follow up

Detailed Answer:
Hello

Thanks for getting back


With doxycycline we can expect results in 14-15 days.
Fluttering what the radiologist found could be something known as filarial dance.

You are always welcome to our institute, Ultrasound can be arranged. However XXXXXXX is not endemic for filariasis and I doubt their expertise in regards to Filariasis. A better institute for this would be CMC, Vellore.

If something is found the next step would be Lymphscinitgraphy to confirm to diagnosis. Treatment remains the same

Regards
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Rakesh Madhyastha (18 minutes later)
Thank you! I will be traveling by myself and would prefer coming to XXXXXXX If the radiologist at your hospital knows how to look for adult worms and that seems like a good idead to me. I know you mentioned lymphocintigraphy is not avaliable at your hospital, if worms are seen with ultrasound then will i be refered somewhere else for lymphocintigraphy? If so will it be near by/another place in Bungalore?
My right hand feels so tight, and i can barely make a fist. The air plane ride is going to be tough.
If i were to come do i need to make an appointment in advance? And will i be meeting you first?
Please let me know so i can start making arrangments.
Thank you so much!
doctor
Answered by Dr. Rakesh Madhyastha (13 hours later)
Brief Answer:
Follow up

Detailed Answer:
Hello

Thanks for getting back

I tried to get in touch with the head of the department of radiology but he was unavailable, its the weekend here. I can get back to you on Monday regarding this.

Regards
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Rakesh Madhyastha (2 days later)
Hello Dr!
I realized you can't reply unless i write again. I am going to try getting an uktrasound here. Hopfully it will work. Otherwise, i would still consider coming there. Will the radiology department at your hospital be willing to see me?
My legs get really bloated always around the same time. It starts around 6pm. My calves feel thicker too. Itching also starts around the same time, 6pm. Does that indicate which kind of filariasis it is? Wucheria or bancrofti? Do the other filarial worms manifest lymphatic obstruction also? (Such as onceocerca, loa loa).
I have also in the mean time trying some plant based extracts such as ajwain, and andrographis paniculata. Do you know anything about these and do they interfere with doxycycline?
Thank you in advance.
Regards,
doctor
Answered by Dr. Rakesh Madhyastha (10 hours later)
Brief Answer:
Follow up

Detailed Answer:
Hello

Good to hear from you again. I was just about to approach the IT staff to send you an email. It is true that I cannot reply to you unless I have a follow up.

I spoke to the head of the department of radiology, he said he can arrange for a Ultrasound scan. His thoughts were that it could be difficult to locate an adult worm especially because you have already received treatment and the ultrasound could end up only showing edema. Coming all the way could be end up with disappointing results.

We do not do Lymphscinitgraphy in our hospital, I have found out that XXXXXXX Health does lymphscinitigraphy in XXXXXXX

Thicker calves in the evening associated with mild itching can also be mean venous insufficiency, it is usually seen in patients who have jobs which require standing for a long time.
Filarial worms can cause lymphatic obstruction.

There is no data suggesting interaction between doxycycline and ajwain or adrographis paniculata.

Regards
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Rakesh Madhyastha (22 minutes later)
Thank you Dr. Madhyastha. So my thoughts are i will attempt an ultrasound here next week, and if they don't know how to look for it, i will come to your hospital. Please have them email me so that i know how to get in touch. I really appreciate your help. Im more worried about my child's health than anything and any diagnosis will allow him to get the proper treatment in th US since he and my husband have the same symptoms.
Thank you
.
doctor
Answered by Dr. Rakesh Madhyastha (13 hours later)
Brief Answer:
Follow up

Detailed Answer:
Thanks for getting back

You are always welcome in my institute and I will be happy to take an appointment for you. We have staff who take care of international patients and medical tourism. I will ask them to get in touch with you. But please do keep in mind that we might not be able to isolate the worms since you have already received treatment. I do not have your e mail address, I will have to take it from the technical team


Regards
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Rakesh Madhyastha (2 days later)
Hello. Thank you for your reply. My father and I are trying to coordinate travel plans. We are thinking of arriving on the night of april 28th or 29th and stay until the 7th of May. I wanted to make sure appoinments can be made (ultrasound for sure and possibly lymphocintigraphy at other hosptial, not sure how that would be coordinated) for during that time. Even if worms cen not be seen moving it will help futher medical investigations for me and also my husband and son in the US(both have not started antibitotics). I definitely want the ultrasound as it is the reason for me to travel over there. I really appreciate your help. Please let me knownif you can't get in touch with me via email. Thank you!
doctor
Answered by Dr. Rakesh Madhyastha (19 hours later)
Brief Answer:
Follow up

Detailed Answer:
Hello

I got your e mail id from the IT team. Is it YYYY@YYYY ?

I will ask our medical tourism team to get in touch with you, they will help you get an appointment for lymphscitigraphy from the other hospital if possible. It's a holiday today, they might send you an e mail tomorrow

regards
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Rakesh Madhyastha (1 hour later)
Yes, that's the correct email. Iwill wait for them to get in touch with me. Thank you so much!
doctor
Answered by Dr. Rakesh Madhyastha (6 hours later)
Brief Answer:
Follow up

Detailed Answer:
Hello

I have given your e mail id to the team. They will get back to you shortly

Regards
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Follow up: Dr. Rakesh Madhyastha (44 hours later)
Thank you. They have emailed me and now we are trying to coordinate appointments. Just to let you know i walked into a clinic that deals with bloating from lymphatic problems where they perform ultrasound. He said his eqipment isn't high tech enough to see so well, but he did take a look. He saw white lines that he said was abnormal in various places. He also looked at the same area at the base of my neck where the former technician i told you about (she saw something fluttering). He also said there is movement there which is clearly not my pulse or from breathing and said it was in a pretty shallow area. However, he said hhe's not qualified to say what it is. He did think that it could be filariasis.
I just wanted to let you know. Thank you very much
doctor
Answered by Dr. Rakesh Madhyastha (15 hours later)
Brief Answer:
Follow up

Detailed Answer:
Hello

Thanks for getting back, our ultrasound machines are also not very high tech. I am not sure if the will be able to identify filarial worms in the lymphatics. If you could just recheck with XXXXXXX regarding this it would be helpful for you.

Regards
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Rakesh Madhyastha (55 minutes later)
Hello! Thank you again. The place I went to is a very small clinic and he said his ultrasound machines is used for the purpose of seeing if there are any leakages from the lymphatic system. I would think that a hospital will have a machine that is higher quality than his. And also even with his machine he was able to see abnormalities and strange movements. He was not able to identify what they are as he has no experience with filariasis. I have emailed your hospital and ask the question.
Thank you again!
doctor
Answered by Dr. Rakesh Madhyastha (4 minutes later)
Brief Answer:
Follow up

Detailed Answer:
Hello

I have set your appointment with Dr XXXXXXX XXXXXXX he comes highly recommended. He should be able to do a good job

Regards
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Follow up: Dr. Rakesh Madhyastha (5 hours later)
Hello. Do we need to get vaccinations before we visit? We plan on only being in XXXXXXX Recommended vaccinations are HepA and Typhoid fever. Is that something to we need to worry in Bangalore? Are there other ones we should consider too?
Also we arrive on the night of April 29th. So I wanted to make sure my appointments are after that. May be the 1st of May if available.
Thank you again!
doctor
Answered by Dr. Rakesh Madhyastha (18 hours later)
Brief Answer:
Follow up

Detailed Answer:
Hello

Thanks for getting back

Vaccinations are not mandatory. It is true that Hep a and Typhoid are endemic in this region so I recommend that you take it. Please co ordinate with the international team for the appointments. He told me that he is trying to arrange for the lymphscintigraphy for you. Ultrsaound will be done, it wont be an issue as it will be done in our hospital itself

Regards
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Rakesh Madhyastha (2 days later)
Thank you very much. The appointments have been arranged on the 2nd of May. I am truly grateful for your help and can not express it enough. I hope we will meet there. I will continue to keep in touch with you should i have any questions.
Thank you.
doctor
Answered by Dr. Rakesh Madhyastha (13 minutes later)
Brief Answer:
Follow up

Detailed Answer:
Hello

Thanks for getting back. I am happy to be of help. I am on leave from 3rd of may for 4 days for my engagement. I will see you on 2nd may

Regards
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Follow up: Dr. Rakesh Madhyastha (5 days later)
Hello Dr XXXXXXX
Everything seems to be moving forward. I have emailed Mr Nagarjuna to ask about the appointments on May 2nd as I am not sure which hospital i am supposed to go to first.
I also wanted to let you know the antibody test which I was positive for does not specify which type of filariasis it is. So it could be lymphatic or may be other types that are subcutaneous etc., although they all seem to possibly cause lymphoedema. I have been taking doxycycline for a while, but I'm not sure it's working so well. The Dr. in US did mention the possibility of loasis at one point which if I'm correct more subcutaneous (but can affect lymphatic system as well?). Just wanted to let you know.
Thank you.
doctor
Answered by Dr. Rakesh Madhyastha (11 hours later)
Brief Answer:
Follow up

Detailed Answer:
Hello

Thanks for updating me. Loasis is a very rare disease and it is a remote possibility, it is better to think of common diseases first. Besides Loa loa causes visual difficulties which you do not have.

Regards
Above answer was peer-reviewed by : Dr. Raju A.T
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Follow up: Dr. Rakesh Madhyastha (1 hour later)
Hi thank you for replying. I forgot to mention that our eyes were one of the places where symptoms started to appear in the beggining of all of this. When the crawling is around the face, it is also often around the eyes, swelling, crawling and prickly sensations in the membraine/ fleshy area and sometimes on the surface of the eyes. This happens periodically. It was particulalry bad in the beggining to the point where it became very painfuland subsided a lot after ivermectin for a while. And now albendazole seems to keep it down but not completely. But i am aware that it is rare and i agree with you that other ones should be considered first. When i meet with you i can tell you more in detail of our symptoms. Thank you again and congratulations on your engagement!
doctor
Answered by Dr. Rakesh Madhyastha (26 hours later)
Brief Answer:
Follow up

Detailed Answer:
Hello

When you come here we can arrange for someone with infectious disease background to see you.
Dr XXXXXXX XXXXXXX is a professor and has a lot of experience in this. I am going to request him to see you

Regards
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Suggest treatment for filariasis, severe itching, crawling sensations, bloating in legs

Brief Answer: Need more info Detailed Answer: Hello Thanks for the query I understand your concern, it must be very debilitating to have such issues. However in order to help you I need a few more details 1. Did you ever have fever with chills and rigor ? 2. do you have any swelling of the limbs ? 3. what aggravates the uncomfortable feeling ? 4. were you investigated for anything other than filariasis ? 5. are the symptoms improving or worsening over time ? please get back to me , I am awaiting your reply regards