Treatment of Elephantiasis
For lymphatic filariasis causing elephantiasis, the recommended treatment is diethylcarbamazine (DEC) 6 mg/kg/day divided into 3 doses for 14 days plus albendazole 400 mg as a single dose, but only after excluding onchocerciasis and loiasis co-infections, which can cause fatal complications. 1, 2
Critical Pre-Treatment Screening (Mandatory)
Before initiating any treatment, you must exclude life-threatening co-infections:
Screen for Onchocerciasis
- Obtain skin snips for microscopy and perform slit lamp examination 2, 3
- If unavailable, give a test dose of DEC 50 mg to detect co-infection (will precipitate mild Mazzotti reaction if onchocerciasis present) 3
- DEC is absolutely contraindicated in onchocerciasis due to risk of blindness, hypotension, pruritus, and severe reactions 3
Screen for Loiasis (if travel to Central/West Africa)
- Perform daytime blood microscopy (10 am to 2 pm) using 20 ml citrated blood 2, 3
- Determine microfilarial count if positive 2
- DEC can cause fatal encephalopathy in patients with high Loa loa loads (>1000 microfilariae/ml) 3
- If microfilarial count >1000/ml: Start prednisolone (after screening for strongyloidiasis), then give albendazole 200 mg twice daily for 21 days to reduce load before DEC 1, 3
Screen for Strongyloidiasis
Primary Treatment Regimens
Standard Regimen (First-Line)
- DEC 6 mg/kg/day divided into 3 doses for 14 days 1, 2, 4
- Plus albendazole 400 mg as a single dose 2, 5
- Plus doxycycline 200 mg daily for 6 weeks to target Wolbachia bacteria 2, 4
Alternative Regimen (in Onchocerciasis Co-Endemic Areas)
- Ivermectin 200 μg/kg as a single dose 2, 5
- Plus albendazole 400 mg as a single dose 2, 5
- This combination reduces blood microfilariae by 99% for a full year 5
Administration Details
- Take DEC with food to improve tolerability 4
- Take albendazole with or after food 2
- Take ivermectin with food as bioavailability increases 2.5 times with high-fat meals 2
- Avoid alcohol as it may worsen side effects 2
Special Populations
Pregnancy and Lactation
- Avoid DEC in pregnancy; seek expert consultation 2, 4
- Ivermectin can be used in second and third trimesters with no observed teratogenicity 2
- Ivermectin is likely compatible with breastfeeding as it is excreted in very low levels in breast milk 2
Children
- Children 12-24 months: Discuss with expert before treatment 2, 4
- Children >24 months: Standard dosing can be used 2
Monitoring During Treatment
- Give prednisolone alongside DEC when microfilaraemia is present to reduce inflammatory reactions 2
- Monitor for adverse reactions: fever, lymphadenitis, lymphangitis, and allergic reactions 2, 4
- Perform FBC/LFTs every 2 weeks for 3 months, then monthly if within normal range (for prolonged courses) 2
Management of Established Elephantiasis
Medical Management
- All cases with lymphoedema can be treated with DEC, irrespective of swelling size 6
- Most lymphoedema cases resolve within 1 year of DEC treatment 6
- Elephantiasis requires 2-4 years for most swelling to disappear 6
Factors Affecting Treatment Success
- Arm elephantiasis is easier to treat than leg elephantiasis 6
- Unilateral elephantiasis responds better than bilateral 6
- Duration <3-5 years responds better than longer duration 6
- Lower grade elephantiasis responds better than higher grade 6
Adjunctive Measures
- Prevent bacterial superinfection to halt or reverse lymphoedema and elephantiasis 5
- Consider increased diuretics (e.g., furosemide) for symptomatic relief in non-filarial cases 7
- Surgery may be needed for genital elephantiasis or severe cases not responding to medical therapy alone 8
Critical Pitfalls to Avoid
- Never initiate DEC or ivermectin without determining microfilarial count in patients with potential Loa loa exposure 3
- Never use DEC in patients with onchocerciasis due to risk of blindness 3
- Never use corticosteroids without screening for strongyloidiasis due to hyperinfection risk 1, 3
- Caution with azithromycin co-administration as it significantly increases serum ivermectin concentrations 2