Chronic Elephantiasis
 A Case Report*

          Human filarial infections afflict over 150 million persons worldwide and are major causes of morbidity in many developing countries. ( 1 )  Filariasis is a group of infectious diseased caused by arthropodborne nematodes. ( 2 )  Several of these parasites are a major health problem in Asia, Africa, and South Pacific.  Wuchereria bancrofti, Brugia malayi, and Onchocerca volvulus are filarial worms that cause diseases in humans.  Wuchereria and Brugia species causes elephantiasis and hydroceles.  Onchocerca volvulus is the cause of river blindness and several skin diseases.  Filariasis caused by Wuchereria bancrofti affects some 250 million people in the tropics and subtropics.( 3 )

               Elephantiasis is a chronic filarial disease most commonly occurring in the tropics.  It is caused by infection of the lymphatic channels with the nematode Wuchereria bancrofti or Brugia malayi (Fig.1) . ( 4 )  Blockage of lymphatic drainage results in enlargement of the limb with permanent thickening and fibrosis of the subcutaneous tissues and skin.  This may result in grotesque enlargement of the affected extremity with hyperkeratotic, thickened, verrucous changes of the skin.( 5 )  Close follow-up and local wound care are critical in preventing infection episodes.  Maceration and ulceration are frequent problems with these patients.  Local wound care and pressure-off dressings are often needed to prevent maceration and ulceration.

              Elephantiasis is rare in the U.S.  American servicemen stationed in South Pacific during World War II  may have been exposed to infected larvae that caused them to develop the disease.  Treatment of Filariasis, at present, depends on antifilarial drugs such as dielthylcarbamazine and ivermectin.  Diethylcarbamazine has been the standard antifilarial treatment for elephantiasis patients.  Different dosing regimens have been tried, including daily and weekly treatment.  Ivermectin is a new antifilarial drug that can be given in a single oral dose and has comparable efficacy and side effects with those of diethylcarbamazine. ( 6 )  The most common side effects associated with ivermectin and Diethylcarbamazine include fever, headaches, lethargy, and myalgia. ( 6 ) Success of antifilarial drugs depends on early diagnosis, appropriate treatment, and patient compliance by taking the prescribed medication.

A Case Report

A 76-year-old male with a 43-year history of elephantiasis came to the Veterans Affairs Salt Lake City podiatry clinic complaining of a superficial ulcer on his distal lateral aspect of the left foot. (fig.2) .  He also complained of excessive lymph fluid draining into the bottom of his shoes. The patient was wearing enclosed postoperative shoes with a folded paper towel inside to collect lymphatic drainage from the feet.  He stated he developed elephantiasis after a mosquito bite while he was in the South Pacific during World War II (fig.3) .  The patient also stated that he had multiple admissions for lower extremity cellulitis in the past.  He denied any fever, chills, nausea, vomiting, or signs of cellulitis at this time.  His medical history is remarkable for congestive heart failure, scrotal edema, cardiomegaly, and numerous bouts of pneumonia.

Physical examination revealed a non-infected superficial ulceration on the distal lateral aspect of the left forefoot.  The patient had no signs of cellulitis or infection.  He had chronic enlargement of the legs and feet with a thickened, verrucous, pebbly appearance of the skin. (fig.4) .  The patient had large multiple fissures with maceration of the lower extremities.  He had a significant amount of lymphatic drainage accompanied by a pungent odor.  The patient’s toes had maceration and fissuring secondary to the chronic swelling from elephantiasis (fig.5) .

            Treatment consisted of silver sulfadiazine 1% antibiotic cream to the ulcer site with a pressure-off bandage.  Cleansing of lower extremities was performed with mild soap and saline.  Gentian violet 1% topical solution was applied Innerdigitally and to the fissure areas to prevent maceration.  Compression Unna boot therapy was tried to reduce edema in the lower extremities, but there was minimal improvement secondary to chronic lymphedema and severe fibrosis.  Felt padding was applied to postoperative shoes, but this intervention was later abandoned because the patient preferred paper towel rather then the felt padding for lymphatic drainage.  Open-toed postoperative shoes were tried, but the patient would only wear  his enclosed postoperative shoes.  The patient was treated for local wound care on a regular basis by the Veterans Affairs podiatry service until he died from congestive heart failure and pneumonia in May 1993.  

Summary

            The authors presented a rare case study of a patient with chronic elephantiasis involving the lower extremities.  The patient had contracted lymphatic filariasis while serving in the armed forces during World War II.  The patient was followed regularly for local wound care by the Veterans Affairs podiatry department.  However, he died from congestive heart failure and pneumonia in May of 1993. 

Acknowledgment
Marva Jensen, MEd,  for her contributions to this manuscript; Tod Peterson, the Veterans Affairs Salt Lake City media Center, for the photographs.  

References

1.      NANDURI, KAZURA J: Clinical and laboratory aspects of filariasis.  Clin Microbiol Rex 2:30, 1989

2.      OTTENSEN EA:”Filariases and Tropical Eosinophilia,” in Tropical and Geographical Medicine, ed by DS Warren, AF Mahmoud, McGraw Hill, New York, 1984  

3.   DIALLO S, AZIA MA NDIR O, ET AL: Dose-ranging study of ivermectin in treatment of filariasis due to Wuchereria bancrofti. Lancet e: 1030, 1987  

4.   Dorland’s Medical Dictionary, WB Saunders, Philadelphia, 1988  

5.      SAUNDERS LJ, SLOMSKY JM, BURGER-CAPLAN C: Elephantiasis nostras: an eight -year observation of progressive nonfilarial elephantiasis of the lower extremity. Curtis 42: 406, 1988  

6.   OTTESON EA, VIJAYASEKARAN V, WAMI K, ET AL: A controlled trial of ivermectin and diethycarbamazine in lymphatic filariasis.  New Eng J Med 322: 1113, 1990.  

*The views and opinions expressed in this study are those of the authors and do not expressly reflect the views of the Department of Veterans Affairs.
** Submitted during third year residency, Veterans Affairs/Doxey-Hatch Medical Center, Salt Lake City.  
***Chief of Podiatry, Veterans Affairs/Doxey-Hatch Medical Center: Clinical instructor, University of Utah, Salt Lake City,

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