The efficacies of affected-limb care with penicillin, diethylcarbamazine, the combination of both drugs or antibiotic ointment, in the prevention of acute adenolymphangitis during bancroftian filariasis

Abstract

Repeated attacks of adenolymphangitis (ADL) contribute significantly to the progression of chronic lymphoedema in lymphatic filariasis. They are a cause of stigma and, since they may prevent work and require treatment for which payment must be made, of economic loss. The aim of the present study was to improve the treatment of ADL attacks, which is currently mostly empirical. In a double-blind, placebo-controlled, clinical study, 150 subjects who had each suffered at least two ADL attacks in the preceding year were enrolled and randomly allocated to a programme of self-care of the affected limb (after an intensive training programme) and one of five treatments for 12 months. The subjects were supplied with tablets and ointment so that they could take oral penicillin (800 mg/day), oral diethylcarbamazine (DEC; 1 mg/kg.day) or both of these drugs (at the same doses), or apply framycetin ointment to the affected limb, or just take placebo tablets and apply placebo (zinc-oxide) ointment. Placebo tablets and placebo ointment were used so that neither the subjects nor those assessing the responses to treatment were aware of the treatment arm to which each subject had been assigned. The subjects were requested to continue with the affected-limb care after they had stopped taking the tablets and applying the cream, and were followed-up for 24 months from the first treatment.Overall, the mean incidence of ADL attacks decreased from 2.7 episodes/person-year in the pre-treatment year to just 0.38 episode/person-year during the treatment year (P< 0.01). The greatest reduction in incidence was seen in the 58 subjects who received penicillin (with or without DEC). Even in the placebo group, however, the incidence of ADL in the treatment year was significantly lower than that seen in the pre-treatment year, indicating that affected-limb care on its own helps to prevent some attacks. In all groups except the placebo, the incidence of ADL attacks in the year post-treatment exceeded that seen in the treatment year, indicating that chemoprophylaxis needs to be continued for more than a year if such attacks are to be prevented. In most (84%) of the attacks recorded, titres of anti-streptococcal antibodies were seen to be elevated (compared with those recorded during convalescence),indicating that streptococci have a role in the aetiology of ADL. It is recommended that a combination of penicillin prophylaxis and affected-limb care be incorporated into filariasis-control programmes, to decrease morbidity.

A Longitudinal Analysis of the Effect of Mass Drug Administration on Acute Inflammatory Episodes and Disease Progression in Lymphedema Patients in Léogane, Haiti

“…51 The improvement of lymphedema observed in this cohort during this 13-year period clearly coincided with results of the lymphedema management study during 1995-1998. Consistent with other literature is the significant decrease in ADL episodes 14,16,17,20 and the decrease in foot and ankle circumference observed during the lymphedema management program. 20 In addition, the improvement in quality of life associated with lymphedema management programs is consistent with previous findings.…”

“…The failure to find an impact of DEC on ADL episodes is consistent with the findings of Beye and others, 33 but is inconsistent with other studies assessing DEC. 14,20,[24][25][26]28,32,36 Similarly, the failure to find an improvement in lymphedema after receiving DEC is consistent with some studies, [32][33][34] but inconsistent with several reports examining this question; although these studies used varied DEC dosages over varied treatment schedules. 20,[24][25][26][27][28][29][30]50 However, because of numerous differences in methods between studies, comparison with this study is difficult.…”

“…12 Clinical and histopathologic studies suggest that lymphedema management can decrease the number of ADL episodes 9,[13][14][15][16][17][18][19] and halt or, in some cases, partially reverse disease progression. 14,[16][17][18]20 Although there are several studies demonstrating improvement in lymphedema in patients who adhere to a lymphedema management regimen, the literature exploring the effect of mass drug administration with DEC, either alone or in combination with albendazole, on filarial morbidity is inconclusive. Recent clinical research using ultrasonography and lymphoscintigraphy has documented the reversal of early lymph-vessel damage in Brugia malayi-infected children after MDA with DEC in India.…”

Feasibility and Effectiveness of Basic Lymphedema Management in Leogane, Haiti, an Area Endemic for Bancroftian Filariasis

“…Recent studies indicate that, in addition to being a critical risk factor for progression of lymphedema [4]–[8], [13], [14], ADLA episodes are strongly associated with poor quality of life [10], [22]–[28]. Thus, reducing ADLA frequency is arguably the most important objective of lymphedema management in resource-poor countries.…”

“…These inflammatory episodes, characterized by intense pain, swelling, fever, and chills, accelerate damage to the peripheral lymphatic channels in the skin, which leads to worsened lymphatic dysfunction, fibrosis, and increased risk of further ADLA episodes. Clinical studies suggest that basic lymphedema management – including hygiene, skin care, elevation of the limb, and range-of-motion exercises – can halt, or perhaps even partially reverse, this progression [9]–[14]. The current prospective study was done to test, under field conditions, the feasibility and effectiveness of basic lymphedema management as a public health intervention in a resource-poor setting.…”