A review of epidemiology of lymphatic filariasis in Nigeria.

Lymphatic filariasis is a neglected tropical disease that affects the lymphatic system of humans. The major etiologic agent is a nematode called Wuchereria bancrofti, but Brugia malayi and Brugia timoriare sometimes encountered as causative agents. Mosquitoes are the vectors while humans the definitive hosts respectively. The burden of the disease is heavier in Nigeria than in other endemic countries in Africa. This occurs with increasing morbidity and mortality at different locations within the country, the World Health Organization recommended treatments for lymphatic filariasis include the use of Albendazole (400mg) twice per year in co-endemic areas with loa loa, Ivermectin (200mcg/kg) in combination with Albendazole (400mg) in areas that are co-endemic with onchocerciasis, ivermectin (200mcg/kg) with diethylcarbamazine citrate (DEC) (6mg/kg) and albendazole (400mg) in areas without onchocerciasis. This paper covered a systematic review, meta-analysis, and scoping review on lymphatic filariasis in the respective geopolitical zones within the country. The literature used was obtained through online search engines including PubMed and Google Scholar with the heading "lymphatic filariasis in the name of the state", Nigeria. This review revealed an overall prevalence of 11.18% with regional spread of Northwest (1.59%), North Central and North East, (4.52%), South West (1.26%), and South-South with South East (3.81%) prevalence. The disease has been successfully eliminated in Argungu local government areas (LGAs) of Kebbi State, Plateau, and Nasarawa States respectively. Most clinical manifestations (31.12%) include hydrocele, lymphedema, elephantiasis, hernia, and dermatitis. Night blood samples are appropriate for microfilaria investigation. Sustained MDAs, the right testing methods, early treatment of infected cases, and vector control are useful for the elimination of lymphatic filariasis for morbidity management and disability prevention in the country. Regional control strategies, improved quality monitoring of surveys and intervention programs with proper records of morbidity and disability requiring intervention are important approaches for the timely elimination of the disease in Nigeria.

An Unusual Encounter: Microfilaria Incidentally Detected in the Bone Marrow Aspirate of a Chronic Kidney Disease Patient.

Lymphatic filariasis is endemic in a few states of India and is one of the most common public health concerns. Wuchereria bancrofti (W. bancrofti) is the most common parasite that causes lymphatic filariasis in India. Microfilariae have been commonly found in the peripheral blood and body fluid, as well as demonstrated in fine needle aspirates (FNA) and bronchial cytology. They have been rarely reported in bone marrow aspirates. Due to the nocturnal periodicity of W. bancrofti, it may be missed in peripheral blood during the day. Though peripheral eosinophilia is a presenting feature of filariasis, it may be absent in the majority of cases, as in this case. We report an incidental finding of W. bancrofti in the bone marrow aspirate of a 72-year-old male who had chronic kidney disease.

Development of a novel rodent model for dog heartworm microfilaremia using the severe-combined immunodeficiency mouse.

Dirofilaria immitis is a mosquito-borne parasitic nematode that causes fatal heartworm disease in canids. The microfilariae are essential for research, including drug screening and mosquito-parasite interactions. However, no reliable methods for maintaining microfilaria long-term are currently available. Therefore, we used severe combined immunodeficiency (SCID) mice to develop a reliable method for maintaining D. immitis microfilaria. SCID mice were injected intravenously with microfilariae isolated from a D. immitis-infected dog. Microfilariae were detected in blood collected from the tail vein 218 days post-inoculation (dpi) and via cardiac puncture 296 dpi. Microfilariae maintained in and extracted from SCID mice showed infectivity and matured into third-stage larvae (L3s) in the vector mosquito Aedes aegypti. L3s can develop into the fourth stage larvae in vitro. Microfilariae from SCID mice respond normally to ivermectin in vitro. The microfilariae in SCID mice displayed periodicity in the peripheral circulation. The SCID mouse model aided in the separation of microfilariae from cryopreserved specimens. The use of SCID mice enabled the isolation and sustained cultivation of microfilariae from clinical samples. These findings highlight the usefulness of the SCID mouse model for studying D. immitis microfilaremia in canine heartworm research.

Preliminary study on buffy coat smear and molecular detection of microfilaria in domestic chickens (Gallus gallus domesticus) raised in Southern Thailand.

Background and Aim: Filarial nematode typically produces a larval stage (microfilariae) in the bloodstream of vertebrate hosts, where microfilariae reside in the blood or subcutaneous tissues. Filarial nematodes cause human diseases, such as river blindness and elephantiasis, which are widely studied. However, in avian species, they are overlooked because they are nonpathogenic. In Thailand, microfilaria can be found in wild birds and domestic chickens. Recently, an increase in the number of blood samples submitted to veterinary diagnostic laboratories may have increased the number of microfilariae. Therefore, knowledge about filarial species and reliable detection methods are important. Therefore, this study aimed to investigate the efficacy of buffy coat smear and polymerase chain reaction (PCR)-based methods for the detection of microfilaria in domestic chickens. In addition, parasites were identified using the sequence of the cytochrome c oxidase subunit 1 (COX1) gene. Materials and Methods: Giemsa-stained buffy coat smears from a previous study were reanalyzed. These available buffy coat smears were prepared from 55 domestic chickens raised as backyard free-ranging in Southern Thailand. Fifty-seven frozen genomic DNA extracted from chicken blood were used to detect the presence of the COX1 gene in Onchocercidae nematodes. The nested PCR protocol for amplification of the OnchoCOI_R2-OnchoCOI_R2 fragment of the COX1 gene was applied from a previous report. Sequences of COX1 were analyzed to identify Onchocercidae nematodes and if they were single or mixed infections. We constructed Bayesian phylogenetics to identify parasites and assessment of the relationship between filarial nematodes in avian species and other vertebrate hosts. Results: Buffy coat smears from 15 samples revealed microfilaria. Of these 15 samples, only eight were positive for COX1 nested-PCR amplification. The other two buffy coat-negative samples were also positive for nested-PCR. Sequencing of these 11 nested PCR-positive samples revealed that almost all of them were Onchocercidae nematodes. Bayesian phylogenetic analysis showed that chicken Onchocercidae spp. were grouped with other avian filarial nematodes. However, all chickens Onchocercidae spp. showed a double peak in the sequencing chromatogram, indicating mixed filarial infection (species or haplotypes). Therefore, no chicken Onchocercidae sequence was deposited on National Center for Biotechnology Information, GenBank. Conclusion: Giemsa-stained buffy coat smear was a reliable method for the detection of chicken microfilaria in routine veterinary diagnostic laboratories. Development of a new PCR-based method is necessary. This method may provide greater sensitivity and specificity of detection. In addition, the PCR method allowed us to access the genetic characteristics of nematodes, which helped us maximize our knowledge of nematodes. Further investigations, such as the pathogenicity of filarial nematodes in chickens and their potential vectors, are required.

Association of haemato-biochemical indices and blood composite ratios with microfilaridermia in Onchocerciasis patients.

BACKGROUND: Onchocerciasis causes chronic systemic inflammation. Several studies have used markers such as haemato-biochemical indices to predict the occurrence of systemic inflammation. This study assessed the variability and predictability of haemato-biochemical indices and blood composite ratios (BCRs) in microfilariae positive (MF+) and microfilariae negative (MF-) subgroups of onchocercomata participants. METHODS: One hundred and five (105) MF + and 34 MF- participants were retrospectively recruited into the study. Screening for the presence of O. volvulus microfilariae was done from skin snips taken from the left and right iliac crests of participants using established and approved protocols. Haematological and biochemical indices were measured using standard laboratory automated analyzers. Blood composite ratios (BCRs) were calculated as ratios of the absolute parameters involved. RESULTS: A significantly increased total WBC, absolute eosinophil, eosinophil percent and absolute basophil were observed in the MF + participants compared to MF- participants. Reduced gamma-glutamyl transferase (GGT) with increased estimated glomerular filtration rate (eGFR) was significantly associated with MF + participants compared to MF- participants. BCRs were significantly higher for eosinophil-to-neutrophil ratio (ENR), eosinophil-to-monocyte ratio (EMR), eosinophil-to-basophil ratio (EBR) and eosinophil-to-lymphocyte ratio (ELR) in MF + participants compared to MF- participants. After multivariate adjustment, onchocercomata participants with increased eosinophil counts (aOR = 13.86, 95% CI [2.07-92.90], p = 0.007), ENR x10 (aOR = 1.42, 95% CI [1.05-1.93], p = 0.025), EMR (aOR = 2.64, 95% CI [1.25-5.60], p = 0.011), EBR (aOR = 1.07, 95% CI [1.01-1.10], p = 0.020) and ELR x10 (aOR = 1.69, 95% CI [1.14-2.51], p = 0.009) were more likely to have microfilaridermia. CONCLUSIONS: Elevated eosinophil counts with higher ENR, EMR, EBR and ELR levels are significantly associated with microfilaridermia in onchocercomata participants. Combining BCRs with eosinophil count significantly led to an improvement in the conventional model for predicting microfilaridermia.

Microfilaruria of Dirofilaria immitis in a dog from Italy.

Dirofilaria immitis is a mosquito-borne nematode-causing canine heartworm disease, with adult worms localized in the pulmonary arteries and right heart. In rare cases, ectopic migration might occur, and adults and blood circulating microfilariae can be found in unusual organs or fluids (e.g., eyes, abdominal cavity, bone marrow, and urine). A 17-year-old mixed-breed female dog was presented in a private veterinary clinic in Italy for hematuria and dysuria. Physical examination showed cardiac mitral murmur with marked respiratory distress and cyanotic mucous membranes after handling. Abdominal ultrasounds revealed a non-specific chronic cystopathy, while the echocardiography showed enlargement of the right heart associated with tricuspid insufficiency and mitral regurgitation, with the presence of an adult filariae in the right ventricular chamber. Circulating microfilariae were observed in the blood smear and molecularly identified as D. immitis. Unusual microfilaruria was detected in the urine sediment. Data presented raise awareness about the occurrence of microfilariae in unusual locations, such as the bladder, suggesting the need of a thorough clinical and laboratory assessment where D. immitis is endemic.

Geographic Distribution and Neuropathology of Elaeophora schneideri in Shiras Moose (Alces alces shirasi) in Idaho, USA.

Elaeophorosis, infection by the filarial worm Elaeophora schneideri, is a parasitic disease of wild ungulates in North America; however, our understanding of the relevance of E. schneideri to moose (Alces alces) morbidity and mortality is incomplete. Between March 2020 and July 2022, necropsy and histopathology were performed on 61 Shiras moose (Alces alces shirasi) in Idaho, US. Among the 41 adults (greater than 1 yr old), 21 moose were from northern Idaho, and 20 were from southeastern Idaho. Elaeophorosis was diagnosed in 24% (10 of 41). All 10 infected moose were from southeastern Idaho; none of the 21 moose from northern Idaho were infected. No juvenile moose (nine from northern and 11 from southeastern Idaho) were infected. Microfilariae were detected histologically in 9 of 10 infected moose, most consistently in brain tissue associated with lesions indicative of ischemic injury to the neuroparenchyma attributed to occlusion of arterioles and capillaries by microfilariae or fibrin thrombi, including edema, necrosis, and glial nodules. Microfilariae found in other tissues of the head, including the eye, tongue, and pinnae of some animals, as well as in lung, heart, liver, and kidney, typically were associated with inflammation. Three of the 10 infected moose had cropped ears attributed to elaeophorosis, and four exhibited abnormal behavior, which may have been due to neuropathology associated with E. schneideri microfilariae in the brain.

Presumed Onchocerciasis Chorioretinitis Spilling over into North America, Europe and Middle East.

BACKGROUND: Newer generation ophthalmologists practicing in the developed world are not very familiar with some tropical ocular diseases due to the absence of reports in the ophthalmic literature over the past thirty years. Because of world globalization or due to influx of immigrants from sub-Saharan Africa, exotic retinal diseases are being encountered more often in ophthalmology clinics. METHODS: A multicenter case series of chorioretinitis or optic neuritis with obscure etiology that used serial multimodal imaging. RESULTS: Four cases qualified with the diagnosis of presumed ocular onchocerciasis based on their residence near fast rivers in endemic areas, multimodal imaging, long term follow-up showing progressive disease and negative workup for other diseases. Characteristic findings include peripapillary choroiditis with optic neuritis or atrophy, subretinal tracts of the microfilaria, progressive RPE atrophy around heavily pigmented multifocal chorioretinal lesions of varying shapes, subretinal white or crystalline dots, and response to ivermectin. Typical skin findings are often absent in such patients with chorioretinitis rendering the diagnosis more challenging. CONCLUSIONS: Familiarity with the myriad ocular findings of onchocerciasis, and a high-degree of suspicion in subjects residing in endemic areas can help in the correct diagnosis and implementation of appropriate therapy. Onchocercal chorioretinitis is a slow, insidious, progressive, and prolonged polymorphous disease.

A case report on rare finding of microfilaria in pus sample of an ulcer over elephantiasis leg.

Skin ulcerations are a significant cause of morbidity and can be challenging to manage. Among the various causes of chronic non-healing ulcers, lymphedema is also considered a possible diagnosis in countries such as Nepal. Lymphatic filariasis has been a significant public health issue in endemic areas. Wuchereria bancrofti is a common nematode parasite that causes lymphatic filariasis. Excessive retention of lymphatic fluid in the interstitial compartment can cause localized tissue swelling, known as lymphedema, which is caused by impaired lymphatic drainage. Microfilariae can be detected in peripheral blood, body fluids, and needle aspirates. Microfilaria is not commonly found in ulcers on elephantiasis legs. We discuss here a case of 73-year-old women with elephantiasis legs with pus discharging ulcers in the thighs. Microscopic examination of pus discharge revealed microfilaria which highlights the importance of pus examination as diagnostic modality in endemic countries.

Prevalence of epilepsy in the onchocerciasis endemic middle belt of Ghana after 27 years of mass drug administration with ivermectin.

BACKGROUND: In onchocerciasis-endemic areas with high ongoing Onchocerca volvulus transmission, a high prevalence of epilepsy has been reported. This study aimed to determine the prevalence and clinical characteristics of epilepsy in the Bono Region of Ghana following 27 years of implementation of ivermectin mass drug administration (MDA). METHODS: Between October 2020 and August 2021, cross-sectional surveys were conducted in nine communities in the Tain District and Wenchi Municipality of the Bono Region of Ghana. In the first stage, a random door-to-door approach was used to screen the population for epilepsy using a pre-tested questionnaire. Persons suspected of having epilepsy were invited for a second-stage neurological examination for case verification. Community O. volvulus microfilarial infection status and Ov16 seropositivity were also determined. Ninety-five confidence intervals (95% CI) for prevalence values were calculated using the Wilson Score Interval. RESULTS: Of the 971 participants, 500 (51.5%) were females, and the median age (interquartile range) was 26 (15‒43) years. Fourteen participants (1.4%, 95% CI: 1.0‒2.0) were diagnosed as having epilepsy with generalized seizures being the most frequent seizure type (85.7%, 12/14). The overall microfilarial prevalence of O. volvulus was 10.3% (November 2020) and 9.9% (August 2021); the Ov16 seroprevalence was 22.2% (June 2021). Only 63.2% took ivermectin in the last round of MDA distribution in March 2021. CONCLUSIONS: The 1.4% prevalence of epilepsy in the Bono region is similar to the median epilepsy prevalence in sub-Saharan Africa. However, the persistent microfilarial prevalence and low ivermectin study coverage call for the Ghana Onchocerciasis Elimination Programme to step up its efforts to ensure that the gains achieved are consolidated and improved to achieve the elimination of onchocerciasis by 2030.

Chromatinless microfilaria.

Herein, we are presenting a case of chromatinless microfilaria in a patient with chyluria.

Eosinophil: An innate immune cell with anti-filarial vaccine and biomarker potential.

Background: Filarial infections continue to pose a great challenge in endemic countries. One of the central goals in the fight against human filarial infections is the development of strategies that will lead to the inhibition of microfilariae (mf) transmission. Keeping mf under a certain threshold within endemic populations will stop transmission and eliminate the infection. Method: A narrative review was carried out to identify the possibilities and limitations of exploring the use of eosinophil responses as an anti-filarial vaccine, and biomarker for the detection of filarial infections. An extensive literature search was performed in online scientific databases including PubMed Central, PubMed, BioMed Central, with the use of predefined search terms. Results: A better understanding of the parasite-host interactions will lead to the development of improved and better treatment or vaccine strategies that could eliminate filariasis as soon as possible. Highlighted in this review is the explorative use of eosinophil-producing CLC/Galectin-10 as a potential biomarker for filarial infections. Also discussed are some genes, and pathways involved in eosinophil recruitments that could be explored for anti-filarial vaccine development. Conclusion: In this short communication, we discuss how eosinophil-regulated genes, pathways, and networks could be critical in providing more information on how reliably a front-line immune player could be exploited for anti-filarial vaccine development and early infection biomarker.

Hematologic parameters and the effect of hemoparasites of wild anurans in Northern Sinaloa, Mexico.

BACKGROUND: Few hematologic profiles for free-ranging amphibians are available. Hematologic evaluation is a useful tool for determining the health of amphibian populations and providing further knowledge for conservation actions. OBJECTIVES: Hematologic variables and the presence and effect of hemoparasites in anuran species were evaluated in Northern Sinaloa, Mexico. METHODS: Blood samples were collected from wild anurans of eight species to perform blood cell counts, leukocyte differential counts, and serum protein concentrations using manual methods and refractometry. In addition, morphologic identification and quantification of the hemoparasites were performed on blood smears. RESULTS: Differences were observed by sex, age, and season for the hematologic values of Incilius alvarius (n = 23), Incilius mazatlanensis (n = 46), Rhinella horribilis (n = 64), Leptodactylus melanonotus (n = 46), Lithobates forreri (n = 135), Lithobates catesbeianus (n = 20), Smilisca fodiens (n = 42), and Scaphiopus couchii (n = 7). Intra- and extra-erythrocytic hemoparasites were found in 56.2% of amphibian hosts; the hemoparasite infection of R. horribilis and L. melanonotus was higher in the dry season, showing increases in erythroplastids and monocytes. For L. forreri, males were more infected than females, and increases in leukocytes were associated with infections of different types of hemoparasites species. CONCLUSIONS: Hematologic values, hemoparasite prevalence, and the response to hemoparasite infection vary among amphibian species, sex, and age, as well as on season and hemoparasite type. This highlights the importance of hematologic evaluations in wild amphibian populations to determine the subclinical effects of hemoparasite infections.

Incidental Finding of Microfilaria in Lymph Node Cytology: A Case Report.

Filariasis is a global public health problem. We routinely examine it in peripheral smears made from samples collected during the night. Though the prevalence is high, microfilariae are rarely found in cytology smears. A lymph node presenting as a filarial nodule is an unusual occurrence. Also, lymph node fine needle aspiration cytology (FNAC) with a finding of microfilariae is uncommon. We would like to report the case of incidental microfilariae finding in a patient who presented with a supraclavicular lymph node mass. The patient presented with a right supraclavicular lymph node mass of size 2 cm × 2 cm and severe fever during the night for six months. The USG-neck region revealed enlarged lymph nodes in the right supraclavicular region. She was provisionally diagnosed as a case of cervical lymph node swelling under evaluation. However, on ultrasound-guided FNAC of the lymph node, microfilariae were found incidentally. In cases where clinical presentations of filariasis are absent, FNAC may aid in the diagnosis of microfilariae in the lymph node.

Unbalanced Arginine pathway and altered maturation of pleural macrophages in Th2-deficient mice during Litomosoides sigmodontis filarial infection.

Filarial parasites are tissue dwelling worms transmitted by hematophagous vectors. Understanding the mechanisms regulating microfilariae (the parasite offspring) development is a prerequisite for controlling transmission in filarial infections. Th2 immune responses are key for building efficient anti-parasite responses but have been shown to also lead to detrimental tissue damage in the presence of microfilariae. Litomosoides sigmodontis, a rodent filaria residing in the pleural cavity was therefore used to characterize pleuropulmonary pathology and associated immune responses in wild-type and Th2 deficient mice. Wild-type and Th2-deficient mice (Il-4rα-/-/Il-5-/- ) were infected with L. sigmodontis and parasite outcome was analyzed during the patent phase (when microfilariae are in the general circulation). Pleuropulmonary manifestations were investigated and pleural and bronchoalveolar cells were characterized by RNA analysis, imaging and/or flow cytometry focusing on macrophages. Il-4rα-/-/Il-5-/- mice were hypermicrofilaremic and showed an enhanced filarial survival but also displayed a drastic reduction of microfilaria-driven pleural cavity pathologies. In parallel, pleural macrophages from Il-4rα-/-/Il-5-/- mice lacked expression of prototypical alternative activation markers RELMα and Chil3 and showed an altered balance of some markers of the arginine metabolic pathway. In addition, monocytes-derived F4/80intermediate macrophages from infected Il-4rα-/-/Il-5-/- mice failed to mature into resident F4/80high large macrophages. Altogether these data emphasize that the presence of both microfilariae and IL-4R/IL-5 signaling are critical in the development of the pathology and in the phenotype of macrophages. In Il-4rα-/-/Il-5-/- mice, the balance is in favor of parasite development while limiting the pathology associated with the host immune response.

Microfilaria causing nephrotic syndrome: Highlighting the importance of diethylcarbamazine provocation test for diagnosis.

Filarial parasite infestation not only affects the structure and function of lymphatic vessels but is also associated with extralymphatic pathology and disease. Incidence of renal involvement in microfilaria carriers has led to increased cognizance of extralymphatic presentation. Literature set forth clinical syndromes having extralymphatic manifestation of filaria. The diagnosis of filariasis is done by visualisation of microfilaria in peripheral blood smear, lymphatic tissue. Other modalities of diagnosis are Enzyme linked immunosorbent assay (ELISA), Immunochromatographic test. Diethyl carbamazine (DEC) provocation test usually is done to detect microfilaria in night blood smear due to the nocturnal periodicity of microfilaria. The drug DEC flushes the microfilaria into the peripheral circulation leading to high probability of detection. We present a case of a 59-year-old male who was diagnosed as nephrotic syndrome and after a DEC challenge we detected microfilaria in the peripheral smear confirming microfilaria-induced Nephrotic Syndrome after all other secondary conditions were excluded.

Breast filariasis presenting fibroadenoma like nodules: a rare diagnosis.

India has still not eradicated filariasis, which is still endemic throughout the country. This study focuses on the breast as a non-typical but not uncommon site of breast disease characterized by nematodes causing obstruction of lymphatic vessels caused by filariasis. The case described herein involves a 26-year-old married female who presented with a subcutaneous nodule in her left breast. Clinical interrogation of this case as part of the pathological diagnosis, phlebotomy was performed by venepuncture in order to examine peripheral blood smears under a microscope. Nonetheless, the peripheral blood smear did not show microfilariae of the disease. Furthermore, fine needle aspiration cytology was also performed to identify possible things for the study. It was diagnosed that the fine-needle aspiration cytology smears of various lesions indicate the lump carried microfilariae. Conclusively the lymphatic swelling was confirmed to be caused by Wuchereria bancrofti in fine-needle aspiration cytology examination without evidence in peripheral blood smears. It was shown that the subject had filariasis, and the patient responded well to daily treatment with diethylcarbamazine citrate for 42 days.

Clinicopathological study of parasitic lesions of the eye and ocular adnexa in a tertiary care ophthalmic center in South India.

Purpose: To study clinical and pathological features of parasitic lesions in the ocular adnexa in a tertiary care ophthalmic center in south India. Methods: 43 cases of ocular parasitosis were analysed clinically and correlated with the pathological findings (gross morphology and histopathology) over a period of five years (2015-2020). Results: Among the 43 cases, the age group ranged from 9 months to 78 years (mean age of 41.6 years). Female patients were more common than male patients, with a percentage of 63% (27) and 37% (16) respectively. Cystic lesion in the lid or orbit was seen in 23 cases (53.4%); solid mass lesions were seen in 17 cases (39.5%); subconjunctival worms in three cases; and subretinal parasite in one. Gross examination and histopathologic study showed Dirofilaria in 23 cases (53.5%), followed by Cysticercus in six cases (14%) and Microfilariae in four cases (9.3%). Exact species identification was not possible in ten cases (23.25%). Correlation between the type of lesion and type of inflammatory cells with the specific parasite was done. Conclusion: Our study showed that important clinicopathological correlations can be made from the parasitic lesions in the eye and adnexa, which can aid in definitive diagnosis and prompt identification of the parasite for patient management.

The impact of Loa loa microfilaraemia on research subject retention during a whole sporozoite malaria vaccine trial in Equatorial Guinea.

Loa loa microfilariae were found on thick blood smears (TBSs) from 8 of 300 (2.7%) residents of Bioko Island, Equatorial Guinea, during a Plasmodium falciparum sporozoite malaria vaccine clinical trial. Only one subject was found to have microfilaraemia on his first exam; parasites were not discovered in the other seven until subsequent TBSs were performed, at times many weeks into the study. All infected individuals were asymptomatic, and were offered treatment with diethylcarbamazine, per national guidelines. L. loa microfilaraemia complicated the enrolment or continued participation of these eight trial subjects, and only one was able to complete all study procedures. If ruling out loiasis is deemed to be important during clinical trials, tests that are more sensitive than TBSs should be performed.