LYMPHEDEMA
LYMPHATIC FILARIASIS
This
page has been updated. For the most
current version, please see:
Lymphatic
Filariasis
http://www.lymphedemapeople.com/wiki/doku.php?id=lymphatic_filariasis
Lymphedema Filariasis
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Discussion:
Lymphatic
Filariasis is the leading type of lymphedema worldwide, affecting an
estimated
120 million people. It is an endemic conditions located in the tropical
regions
of the world. These areas include SE Asia, the Indian
sub-continent,
Africa, and areas of South America.
Cause:
Infestation
or infection by a microscopic threat like parasitic worm.
The three main worms include Wuchereria bancrofti , Brugia malayi , and
B.
timori. The infections is spread through mosquito
bites. However,
there are five other species that may be involved, these include The
other five
species are Loa loa, Mansonella perstans, M. streptocerca, M. ozzardi,
and
Brugia timori.
The
worm larvae (microfilaria) may be injected by an infected
mosquito
directly into the blood. The microfilaria then reproduce and spread
throughout
the bloodstream, eventually traveling to the lymph system where they
grow into
adults. What makes this condition frustrating difficult to
diagnosis and
treat early is that the symptoms of infection may not show up for years.
Symptoms:
The symptom
of infection swelling of an arm, leg or genital areas.
Complications:
It is not the actual infection that can be life
threatening, but the
complications that occur as a result of the lymphedema. The
most
serious complication is massive infection (cellulitis,
lymphangitis).
Other complications include fibrosis (hardening) of the affected
tissue, severe
pain, gross disfigurement, sexual dysfunction. Long term
fibrosis or
tissue hardening can also cause venous thrombosis (blood
clot).
Diagnosis:
Suspicion
of lymphatic filiarisis of course, may be made upon the appearance
of the lymphedema. However, to prevent this it is imperative
to diagnosis
filariare infection before it gets to this stage.
This is usually
done through microscopic examination of blood samples.
However, there are
other diagnostic tools available. These include antigen
detection,
molecular diagnosis (polymerase chain reaction), identification of
adult worms
through tissue samples, and antibody detection.
Treatment:
Treatment
generally has a dual focus. First, you must eliminate the
infection that caused the lymphedema and then you must subsequently
treat the
lymphedema itself.
Treatment
for the parasitic infection include the administration of drugs such as
diethylcarbamazine (DEC), albendazole and ivermectin.
Treatment
for the lymphedema includes decongestive therapy on the affected limbs,
surgical
procedures on genital lymphedema and treatment of the numerous
complications.
Prevention:
The real
goal goal however, is in the prevention of this condition. A
massive global alliance including the World Health Organization,
medical
professional and pharmacy companies (SmithKline Beecham and Merck and
Co.) is
se
Seeking to eliminate this disease through preventative
therapy.
Through
studies being conducted in the affected regions, it has been found that
preventative doses of the above medicines can actually prevent the
initial
infection. Other modalities include extensive community
education, and
intensive improvement in local hygiene.
---------------------
Key facts
More than 1.3 billion people in 81 countries worldwide are threatened by lymphatic filariasis, commonly known as elephantiasis.
Over 120 million people are currently infected, with about 40 million disfigured and incapacitated by the disease.
Lymphatic
filariasis can result in an altered lymphatic system and the abnormal
enlargement of body parts, causing pain and severe disability.
Acute episodes of local inflammation involving the skin, lymph nodes and lymphatic vessels often accompany chronic lymphoedema.
To
interrupt transmission WHO recommends an annual mass drug
administration of single doses of two medicines to all eligible people
in endemic areas.
---------------------
For
Further Information
Excerpt
from Hydrocele, Filarial - Filariasis
Synonyms, Key Words, and Related Terms: scrotal lymphedema, filarial
worms,
filaria, filariae, Filaria bancrofti, F bancrofti, Wuchereria
bancrofti, W
bancrofti, Brugia malayi, B malayi, Filaria malaya, F malaya, Culex
pipiens, C
pipiens, parasitic disease, parasitemia, parasite infection,
filariasis,
mosquito bite, lymphatic filariasis, nematode, roundworm, round worm,
lymphangiectasia, filarial infestation, scrotal filarial infestation,
skin
sclerosis, elephantiasis, tropical eosinophilia, eosinophilic
interstitial
pneumonitis, chyluria
http://www.emedicine.com/med/byname/hydrocele-filarial.htm
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Lymphatic
filariasis - World Health Organization
|
This page provides links to descriptions of activities,
reports, news and events, as well as contacts and cooperating partners
in the various WHO programmes and offices working on this topic. Also
shown are links to related web sites and topics.
MeSH scope note: Infections with nematodes of the
superfamily FILARIOIDEA. The presence of living
worms in the body is mainly asymptomatic but the death of adult worms
leads to granulomatous inflammation and permanent fibrosis. Organisms
of the genus Elaeophora infect wild elk and domestic sheep causing
ischaemic necrosis of the brain, blindness, and dermatosis of the face.
RELATED
SITES
FACT
SHEETS
- Lymphatic
filariasis
RELATED
LINKS
- Eliminating
lymphatic filiariasis
- http://apps.who.int/tdr/svc/diseases
|
 |
http://www.who.int/mediacentre/factsheets/fs102/en/
|
Lymphatic filariasis
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Lymphatic Filariasis, known as Elephantiasis, puts at
risk more than a billion people in more than 80 countries. Over 120
million have already been affected by it, over 40 million of them are
seriously incapacitated and disfigured by the disease. One-third of the
people infected with the disease live in India, one third are in Africa
and most of the remainder are in South Asia, the Pacific and the
Americas. In tropical and subtropical areas where lymphatic filariasis
is well-established, the prevalence of infection is continuing to
increase. A primary cause of this increase is the rapid and unplanned
growth of cities, which creates numerous breeding sites for the
mosquitoes that transmit the disease.
In its most obvious manifestations, lymphatic filariasis
causes enlargement of the entire leg or arm, the genitals, vulva and
breasts. In endemic communities, 10-50% of men and up to 10% of women
can be affected. The psychological and social stigma associated with
these aspects of the disease are immense. In addition, even more common
than the overt abnormalities is hidden, internal damage to the kidneys
and lymphatic system caused by the filariae.
Cause
The thread-like, parasitic filarial worms Wuchereria
bancrofti and Brugia malayi that cause
lymphatic filariasis live almost exclusively in humans. These worms
lodge in the lymphatic system, the network of nodes and vessels that
maintain the delicate fluid balance between the tissues and blood and
are an essential component for the body's immune defence system. They
live for 4-6 years, producing millions of immature microfilariae
(minute larvae) that circulate in the blood.
Transmission
The disease is transmitted by mosquitoes that bite
infected humans and pick up the microfilariae that develop, inside the
mosquito, into the infective stage in a process that usually takes 7-21
days. The larvae then migrate to the mosquitoes' biting mouth-parts,
ready to enter the punctured skin following the mosquito bite, thus
completing the cycle.
Signs
and symptoms
The development of the disease itself in humans is still
something of an enigma to scientists. Though the infection is generally
acquired early in childhood, the disease may take years to manifest
itself.
Indeed, many people never acquire outward clinical
manifestations of their infections. Even though there may be no
clinical symptoms, studies have now disclosed that such victims,
outwardly healthy, actually have hidden lymphatic pathology and kidney
damage as well. The asymptomatic form of infection is most often
characterized by the presence in the blood of thousands or millions of
larval parasites (microfilariae) and adult worms located in the
lymphatic system.
The worst symptoms of the chronic disease generally
appear in adults, and in men more often than in women. In endemic
communities, some 10-50% of men suffer from genital damage, especially
hydrocoele (fluid-filled balloon-like enlargement of the sacs around
the testes) and elephantiasis of the penis and scrotum. Elephantiasis
of the entire leg, the entire arm, the vulva, or the breast - swelling
up to several times normal size - can affect up to 10% of men and women
in these communities.
Acute episodes of local inflammation involving skin,
lymph nodes and lymphatic vessels often accompany the chronic
lymphoedema or elephantiasis. Some of these are caused by the body's
immune response to the parasite, but most are the result of bacterial
infection of skin where normal defences have been partially lost due to
underlying lymphatic damage. Careful cleansing can be extremely helpful
in healing the infected surface areas and in both slowing and, even
more remarkably, reversing much of the overt damage that has occurred
already.
In endemic areas, chronic and acute manifestations of
filariasis tend to develop more often and sooner in refugees or
newcomers than in local populations continually exposed to infection.
Lymphoedema may develop within six months and elephantiasis as quickly
as a year after arrival.
Diagnosis
Until very recently, diagnosing lymphatic filariasis had
been extremely difficult, since parasites had to be detected
microscopically in the blood, and in most parts of the world, the
parasites have a "nocturnal periodicity" that restricts their
appearance in the blood to only the hours around midnight. The new
development of a very sensitive, very specific simple "card test" to
detect circulating parasite antigens without the need for laboratory
facilities and using only finger-prick blood droplets taken anytime of
the day has completely transformed the approach to diagnosis. With this
and other new diagnostic tools, it will now be possible both to improve
our understanding of where the infection actually occurs and to monitor
more easily the effectiveness of treatment and control programmes.
Treatment
Communities where filariasis is endemic.
The primary goal of treating the affected community is to eliminate
microfilariae from the blood of infected individuals so that
transmission of the infection by the mosquito can be interrupted.
Recent studies have shown that single doses of diethylcarbamazine (DEC)
have the same long-term (1-year) effect in decreasing microfilaraemia
as the formerly-recommended 12-day regimens of DEC and, even more
importantly, that the use of single doses of 2 drugs administered
concurrently (optimally albendazole with DEC or ivermectin) is 99%
effective in removing microfilariae from the blood for a full year
after treatment. It is this level of treatment effectiveness that has
made feasible the new efforts to eliminate lymphatic filariasis.
Treating the individual. Both
albendazole and DEC have been shown to be effective in killing the
adult-stage filarial parasites (necessary for complete cure of
infection), but ideal treatment regimens still need to be defined. It
is clear that this anti-parasite treatment can result in improvement of
patients' elephantiasis and hydrocoele (especially in the early stages
of disease), but the most significant treatment advance to alleviate
the suffering of those with elephantiasis has come from recognizing
that much of the progression in pathology results from bacterial and
fungal "superinfection" of tissues with compromised lymphatic function
caused by earlier filarial infection. Thus, rigorous hygiene to the
affected limbs, with accompanying adjunctive measures to minimize
infection and promote lymph flow, results both in a dramatic reduction
in frequency of acute episodes of inflammation ("filarial fevers") and
in an astonishing degree of improvement of the elephantiasis itself.
WHO's
strategy to eliminate lymphatic filariasis
The strategy of the Global Programme to Eliminate
Lymphatic Filariasis has two components: firstly, to stop the spread of
infection (i.e. interrupt transmission), and secondly, to alleviate the
suffering of affected individuals (i.e. morbidity control).
To interrupt transmission, districts in which lymphatic
filariasis is endemic must be identified, and then community-wide
("mass treatment") programmes implemented to treat the entire at-risk
population. In most countries, the programme will be based on
once-yearly administration of single doses of two drugs given together:
albendazole plus either diethylcarbamazine (DEC) or ivermectin, the
latter in areas where either onchocerciasis or loiasis may also be
endemic; this yearly, single-dose treatment must be carried out for 4-6
years. An alternative community-wide regimen with equal effectiveness
is the use of common table/ cooking salt fortified with DEC in the
endemic region for a period of one year.
To alleviate the suffering caused by the disease, it
will be necessary to implement community education programmes to raise
awareness in affected patients. This would promote the benefits of
intensive local hygiene and the possible improvement, both in the
damage that has already occurred, and in preventing the debilitating
and painful, acute episodes of inflammation.
The generous pledge in 1998 by the global healthcare
company SmithKline Beecham to collaborate with the World Health
Organization in its elimination efforts included the donation of
numerous resources (but especially albendazole, one of the mainstay
drugs in the elimination strategy), free of charge, for as long as
necessary to ensure success of the elimination programme. This
donation, coupled with the recent decision by Merck and Co., Inc., to
expand its ongoing Mectizan® (ivermectin)
Donation Programme to include treatment of lymphatic filariasis where
appropriate, and the creation of additional partnerships with other
private, public and international organizations, including the World
Bank, have all further strengthened the prospects for success of these
elimination efforts.
Economic
and social impact
Because of its prevalence often in remote rural areas,
on the one hand, and in disfavoured periurban and urban areas, on the
other, lymphatic filariasis is primarily a disease of the poor. In
recent years, lymphatic filariasis has steadily increased because of
the expansion of slum areas and poverty, especially in Africa and the
Indian sub-continent. As many filariasis patients are physically
incapacitated, it is also a disease that prevents patients from having
a normal working life. The fight to eliminate lymphatic filariasis is
also a fight against poverty.
Lymphatic filariasis exerts a heavy social burden that
is especially severe because of the specific attributes of the disease,
particularly since chronic complications are often hidden and are
considered shameful. For men, genital damage is a severe handicap
leading to physical limitations and social stigmatization. For women,
shame and taboos are also associated with the disease. When affected by
lymphoedema, they are considered undesirable and when their lower limbs
and genital parts are enlarged they are severely stigmatized; marriage,
in many situations an essential source of security, is often impossible.
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Lymphatic
abnormalities in human filariasis as depicted by
lymphangioscintigraphy
Source
Department of Surgery, University of Arizona, Tucson.
Abstract
BACKGROUND:
Investigation
into filarial lymphedema has been hampered by the lack of a simple,
safe, and easily repeated test to image the peripheral lymphatic system. Recent refinements in radionuclide lymphangioscintigraphy have
established this noninvasive technique as the initial procedure of
choice for visualizing lymphatics. Accordingly, we applied lymphangioscintigraphy to patients with filariasis and, for purposes of interpretation, compared the findings with those in patients with non-filarial lymphedema.
METHODS:
Thirty-three patients with classic symptoms or signs consistent with acute or chronic filariasis underwentlymphangioscintigraphy, and the findings were compared with those in five patients without lymphatic dysfunction and in 50 other patients with primary or secondary lymphedema without exposure to filariasis.
RESULTS:
As in patients with nonfilarial lymphedema, scintigraphic abnormalities in the 33 patients with filariasisincluded
delayed or absent tracer transport of the radiotracer (25 patients),
tortuous and bizarre deep lymphatics (seven patients), dermal diffusion
(15 patients), retrograde tracer flow (six patients), and faint or
absent regional nodal visualization (14 patients). Even in patients
with long-standing filarial lymphedema, peripheral trunks were often
visualized (at least in part), and regional nodes and more central
lymphatics sometimes filled after light exercise. In some of the latter
patients, however, discrete lymphatic trunks were not detected.
CONCLUSION:
Lymphangioscintigraphy is a simple, safe, reliable, noninvasive method with which to examine the peripheral lymphatic system, including truncal and nodal abnormalities, in endemic populations with occult and overtlymphatic filariasis.
http://archinte.ama-assn.org/cgi/content/abstract/153/6/737
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Lymphatic Filariasis
(Elephantiasis)
Lymphatic
Filariasis (Elephantiasis)
Lymphatic filariasis, also
known as elephantiasis, is best known from dramatic photos of people
with grossly enlarged or swollen arms and legs. The disease is caused
by parasitic worms, including Wuchereria bancrofti,
Brugia malayi, and B. timori,
all transmitted by mosquitoes. Lymphatic filariasis currently affects
120 million people worldwide, and 40 million of these people have
serious disease.
When an infected female mosquito bites a person, she may
inject the worm larvae, called microfilariae, into the blood. The
microfilariae reproduce and spread throughout the bloodstream, where
they can live for many years. Often disease symptoms do not appear
until years after infection. As the parasites accumulate in the blood
vessels, they can restrict circulation and cause fluid to build up in
surrounding tissues. The most common, visible signs of infection are
excessively enlarged arms, legs, genitalia, and breasts.
Medicines to treat lymphatic filariasis are most effective
when used soon after infection, but they do have some toxic side
effects. In addition, the disease is difficult to detect early.
Therefore, improved treatments and laboratory tests are needed. A
vaccine is not yet available.
NIAID Research
Mosquito Studies
Several researchers study the interactions between filarial
parasites and their mosquito hosts. Bruce
Christensen, Ph.D., from the University of Wisconsin at
Madison, studies how mosquitoes defend themselves from infections by
encapsulating the microfilaria and producing toxic proteins that defend
the insect against the invading parasite. Dennis
Knudson, D.Phil., of Colorado State University, leads a study
to decipher the genetic blueprint of mosquitoes in order to understand
the molecular basis for how mosquitoes carry filarial parasites. He and
his collaborator,
David Severson, Ph.D.
, of Notre Dame University, are using genetic and physical mapping
tools with their model vector-parasite system, the Aedes
aegypti mosquito and the human filarial parasite Brugia
malayi, to identify the genes that allow certain mosquitoes
to transmit filarial parasites
Because the geographic distributions of filariasis and
dengue overlap, Jeff
Vaughan, Ph.D., from the University of North Dakota,
investigates how filariasis can enhance the transmission of dengue
virus by mosquitoes.
Understanding
the Parasite
Tufts University's Juliet
Fuhrman, Ph.D., seeks to understand how filarial parasites
survive within mosquitoes, with the goal of developing novel ways to
manipulate the parasite's life cycle and block disease transmission.
James Kazura, M.D. , of Case Western Reserve
University studies the genetics of W. bancrofti
and analyzes the immune response to this parasite in infected
individuals. He supervises a research laboratory in Papua New Guinea
that looks at how exposure to the parasite affects susceptibility to
disease.
Vaccine
Research
Thomas
Nutman, M.D., of NIAID's Laboratory of Parasitic Diseases
searches for proteins from W. bancrofti that
stimulate an immune response in people. This research focuses on
finding potential molecules that can be used in a vaccine and in
improved diagnostic tests.
Additional
Links:
http://www.niaid.nih.gov/newsroom/focuson/bugborne01/filar.htm
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Lymphatic Filariasis
http://www.who.int/health-topics/lymphfil.htm
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Lymphatic Filariasis
http://www.who.int/tdr/diseases/lymphfil/default.htm
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Lymphatic Filariasis
http://www.cdc.gov/ncidod/dpd/parasites/lymphaticfilariasis/default.htm
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Lymphatic Filariasis
Filariasis, Lymphatic
Description
Lymphatic filariasis is caused
primarily by adult worms (filariae)
that live in the lymphatic vessels. The female worms release
microfilariae that
circulate in the peripheral blood and are ingested by mosquitoes; thus,
infected
mosquitoes transmit the infection from person to person. The two major
species
of filariae that cause lymphatic disease in humans are Wuchereria
bancrofti
and Brugia malayi.
Occurrence
Lymphatic filariasis affects
an estimated 120 million
persons in tropical areas of the world, including sub-Saharan Africa,
Egypt,
southern Asia, the western Pacific islands, the northeastern coasts of
South and
Central America, and the Caribbean Islands.
Risk
for Travelers
Short-term travelers to
endemic areas are at low risk for
this infection. Travelers who visit endemic areas for extended periods
of time
and who are intensively exposed to infected mosquitoes can become
infected. Most
infections seen in the United States are in immigrants from endemic
countries.
Clinical
Presentation
Most infections are
asymptomatic, but the living adult
worm causes progressive lymphatic vessel dilation and dysfunction.
Lymphatic
dysfunction leads to lymphedema of the leg, scrotum, penis, arm, or
breast,
which can increase in severity as a result of recurrent secondary
bacterial
infections. Tropical pulmonary eosinophilia is a potentially serious
progressive
lung disease with nocturnal cough, wheezing, and fever, resulting from
immune
hyperresponsiveness to microfilaria in the pulmonary capillaries.
Prevention
No vaccine is available, nor
has the effectiveness of
chemoprophylaxis been well documented. Protective measures include
avoidance of
mosquito bites through the use of personal protection measures (see
Protection against Mosquitoes and Other Arthropods).
Treatment
The drug of choice for
treatment of travelers with W.
bancrofti or B. malayi infections is
diethylcarbamazine (DEC). DEC,
which is available to U.S.-licensed physicians for this purpose, can be
obtained
from the CDC Parasitic Diseases Drug Service at
404-639-3670. (See Immunobiologics
Distributed by The Centers for Disease Control and Prevention
from the CDC
Drug Service.) DEC kills circulating microfilaria and is partially
effective
against the adult worms and tropical pulmonary eosinophilia. Many
patients with
lymphedema are no longer infected with the filarial parasite and do not
benefit
from antifilarial drug treatment. For chronic manifestations of
lymphatic
filariasis, such as lymphedema and hydrocele, specific lymphedema
treatment
(including hygiene, skin care, physical therapy, and in some cases,
antibiotics)
and surgical repair, respectively, are recommended. Travelers should be
advised
to consult an infectious disease or tropical medicine specialist.
http://www.cdc.gov/travel/diseases/filariasis.htm
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Filariasis
http://filariasis.net/
Recently published in Filaria
Journal (Vol.
3, 2004)
Latest article, 30 January 2004
Willingness
to pay for prevention and treatment of Lymphatic Filariasis in Leogane,
Haiti see http://www.filariajournal.com/content/3/1/2
Rheingans RD, Haddix AC, Messonnier ML, Meltzer M, Mayard G, Addiss DG.
Filaria J. 2004, 3:2
Li BW, Rush A, Zhang SR, Curtis KC, Weil GJ. Filaria J. 2004,
3:1 (22 January 2004)
DNA vaccination is a convenient means
of immunizing animals with recombinant parasite antigens. DNA delivery
methods are believed to affect the qualitative nature of immune
responses to DNA vaccines in ways that may affect their protective
activity. However, relatively few studies have directly compared immune
responses to plasmids encoding the same antigens after injection by
different routes. Therefore, the purpose of this study was to explore
the influence of the route of administration on antibody responses to
plasmids encoding antigens from the filarial nematode parasite Brugia
malayi. Methods: Four B. malayi
genes and partial genes encoding paramyosin (BM5), heat shock protein
(BMHSP-70), intermediate filament (BMIF) and a serodiagnostic antigen
(BM14) were inserted in eukaryotic expression vectors (pJW4303 and
pCRTM3.1). BALB/c mice were immunized with individual recombinant
plasmids or with a cocktail of all four plasmids by intramuscular
injection (IM) or by gene gun-intradermal inoculation (GG). Antibody
responses to recombinant antigens were measured by ELISA. Mean IgG1 to
IgG2a antibody ratios were used as an indicator of Th1 or Th2 bias in
immune responses induced with particular antigens by IM or GG
immunization. The statistical significance of group differences in
antibody responses was assessed by the nonparametric Kruskal-Wallis
test. Results: Mice produced antibody responses to
all four filarial antigens after DNA vaccination by either the IM or GG
route. Antibody responses to BM5 paramyosin were strongly biased toward
IgG1 with lower levels of IgG2a after GG vaccination, while IM
vaccination produced dominant IgG2a antibody responses. Antibody
responses were biased toward IgG1 after both IM and GG immunization
with BMIF, but antibodies were biased toward IgG2a after IM and GG
vaccination with BMHSP-70 and BM14. Animals injected with a mixture of
four recombinant plasmid DNAs produced antibodies to all four antigens.
Conclusions: Our results show that monovalent and
polyvalent DNA vaccination successfully induced antibody responses to a
variety of filarial antigens. However, antibody responses to different
antigens varied in magnitude and with respect to isotype bias. The
isotype bias of antibody responses following DNA vaccination can be
affected by route of administration and by intrinsic characteristics of
individual antigens.
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Beyond Swollen Limbs, a Diseases's Hidden Agony
Ny Times
http://www.nytimes.com/2006/04/09/world/americas/09lymph.html?pagewanted=all
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Building a
future free from lymphatic filariasis
http://www.filariasis.org.uk/
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Lymphatic
Filariasis (Elephantiasis)
http://www.niaid.nih.gov/newsroom/focuson/bugborne01/filar.htm
---------------------
Elephantiasis
Gale Encyclopedia of Medicine
http://www.findarticles.com/cf_0/g2601/0004/2601000473/p1/article.jhtml
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Some
observations on the effect of Daflon (micronized
purified flavonoid fraction of Rutaceae aurantiae)
in bancroftian
filarial lymphoedema
LK
Das1 
,
G Subramanyam Reddy2
and SP Pani1 
1Vector
Control Research Centre,
(Indian Council of Medical Research), Pondicherry-605006, India
2Government General Hospital,
Pondicherry-605001, India
Filaria Journal 2003, 2:5 doi:10.1186/1475-2883-2-5
The electronic version
of this article is the complete one and can be found online at:
http://www.filariajournal.com/content/2/1/5
| Received |
|
25 June 2002 |
| Accepted |
|
12 March 2003 |
| Published |
|
12 March 2003 |
© 2003 Das et al;
licensee BioMed Central Ltd.
This is an Open Access article: verbatim copying and redistribution of
this
article are permitted in all media for any purpose, provided this
notice is
preserved along with the article's original URL.
Abstract
Background
Morbidity management is a core component
of the global
programme for the elimination of lymphatic filariasis. In a
double-blind
clinical trial, the tolerability and efficacy of Daflon (500 mg) + DEC
(25 mg)
or DEC (25 mg) alone, twice daily for 90 days, was studied in 26
patients with
bancroftian filarial lymphoedema.
Results
None of the patients in either drug group
reported any adverse
reaction throughout the treatment period (90 days). Haematological and
biochemical parameters were within normal limits and there was no
significant
difference between the pre-treatment (day 0) and post-treatment (day
90) values.
The group receiving Daflon showed significant reduction in oedema
volume from
day 90 (140.6 ± 18.8 ml) to day 360 (71.8 ± 20.7 ml) compared to the
pre-treatment (day 0, 198.4 ± 16.5 ml) value. This accounted for a
63.8%
reduction in oedema volume by day 360 (considering the pre-treatment
(day 0) as
100%). In the DEC group, the changes in oedema volume (between day 1
and day
360) were not significant when compared to the pre-treatment (day 0)
value. The
percentage reduction at day 360 was only 9%, which was not significant
(P >
0.05).
Conclusion
This study has shown that Daflon (500 mg,
twice a day for 90
days) is both safe and efficacious in reducing oedema volume in
bancroftian
filarial lymphoedema. Further clinical trials are essential for
strengthening
the evidence base on the role of this drug in the morbidity management
of
lymphatic filariasis.
Background
Lymphatic filariasis (LF) is endemic in
as many as 80 countries
[1,2].
An estimated 1.1 billion people are at risk of infection, and there are
approximately 120 million people with patent infection or disease round
the
globe [3-5].
In India alone, 553 million people are estimated to live in areas
endemic for
lymphatic filariasis and there are approximately 21 million people with
symptomatic filariasis [6]. Progressive
lymphoedema (from the early reversible stages to irreversible and
complicated
stages) associated with the increase in episodic attacks of acute
adenolymphangitis (ADL) [7] is the most
important cause of physical suffering, permanent disability and
economic loss [8-10].
It has been estimated that there are some 16.02 million cases of
lymphoedema
caused by LF globally, and of these, 7.44 million (46.4%) live in India
[3].
LF is recognized as one of six
potentially eradicable diseases [11]
and in 1997, the World Health Assembly (WHA) passed a resolution
calling for
it's global elimination as a public health problem [4,12].
The current strategy for the global
elimination of LF
recommended by the Global Alliance for the Elimination of Lymphatic
Filariasis (GAELF)
[1]
has two major components:
transmission control and morbidity management [13].
Transmission control
The most important transmission control
strategy being
implemented is the annual mass administration of single-dose
anti-parasitic
drugs (albendazole with diethylcarbamazine citrate (DEC) in countries
where
onchocerciasis or loiasis is not co-endemic with LF, or albendazole
with
ivermectin in countries where onchocerciasis or loaiasis is co-endemic
with LF)
to the entire at risk community, aimed at a significantly reducing
community
parasite load [14,15].
Morbidity management
For morbidity management, the current
emphasis is on use of an
appropriate hygiene and skin care regimen, (pioneered by Gerusa Dryer
in Brasil),
that lymphoedema patients can use everyday [16]
for the prevention of episodic attacks of adenolymphangitis (ADL) and
progression of disease [2,17].
Availability of other measures for
morbidity management (such
as drugs or physiotherapy or surgery) which can reduce oedema volume
(along with
appropriate hygiene and skin care) will be important in the alleviation
of
suffering and consequent improvement in psycho-social condition of
these
patients.
Daflon, (micronized purified flavonoid
fraction of Rutaceae
aurantiae) [18] has been used in
clinical practice to treat a variety of lymphoedemas, such as post
radical
mastectomy oedema [19], chronic venous
insufficiency [20], haemorrhoids [21,22],
varicose ulcers [23,24],
post-phlebitic syndrome, dysfunctional uterine bleeding [25]
and idiopathic cyclic oedema syndrome [26].
To date, no clinical trials have been
conducted to assess the
suitability of this drug in the treatment of filarial lymphoedema. In
this
paper, we are presenting our observations on the tolerability and
efficacy of
Daflon (500 mg, twice a day for 90 days) in reducing oedema volume in
patients
with bancroftian filarial lymphoedema.
Materials and
Methods
Selection of patients
Initially, patients with unilateral lower
limb lymphoedema were
detected by conducting a morbidity survey in a village known to be
endemic for
lymphatic filariasis near Pondicherry in south India (recording Wuchereria
bancrofti microfilaria rate of 17.2%, an overall disease
rate of 14.1%,
lymphoedema rate of 6.3% and antigenaemia rate of 28.6% using ICT card
test;
Vector Control Research Centre – unpublished data). These patients were
referred to the Government General Hospital at Pondicherry, where they
were
examined by a senior physician and recruited to the study as per
inclusion/exclusion criteria (Table 1).
In the natural history of LF, many
patients with lymphoedema do
not have demonstrable microfilaraemia [27-29]
nor antigenaemia [30]. Therefore, in
areas which are considered to be highly endemic for LF, (such as in the
current
study), cases of unilateral lymphoedema are considered to be of
filarial origin
by exclusion of all other conditions, (such as venous insufficiency and
varicose
ulcers, which could also present with lymphoedema), by careful history
taking
and clinical examination, using the clinical criteria for diagnosis and
grading
recommended by the World Health Organization (WHO) [31].
Study design and treatment
regimen
Twenty-six patients (18 female and 8 male
patients) between the
ages of 20 and 55 years, (mean 39 years), who met the inclusion /
exclusion
criteria [Table 1],
and who had given written informedconsent, were admitted to the
Government
General Hospital at Pondicherry for a period of four days and randomly
allocated
into one of two drug groups:
Group A: Daflon (500 mg) + DEC (25 mg)
twice a day for 90 days
Group B: DEC (25 mg) twice a day for 90
days.
The drugs were repackaged in look-alike
capsules containing
either Daflon (500 mg) + DEC (25 mg) or DEC (25 mg).
The appropriate drug regimen was
administered to the patients
twice daily (morning and evening) from day 1 to day 3 (three days
excluding day
0, i.e. day of admission) of hospitalization, under the direct
supervision of
the medical team. Patients were discharged on the morning of day 4 with
a pack
of the appropriate drug capsules (for the next 12 days: to complete the
treatment up to day 15). The patients were educated and instructed by
the
physician and a social worker to comply with the dosage schedule and
were asked
initially to report every fortnight for measurement of oedema volume
and to
receive a further supply of drug capsules for the proceeding 15 days,
up to day
90. Thereafter, patients were requested to attend 3 subsequent times,
day(s)
180, 270 and 360 to allow measurement of oedema volume.
Ethical considerations
The study conformed to the principles of
Helsinki Declaration
II [32],
the Guidelines for Good
Clinical Practice (GCP) for Trials on Pharmaceutical Products [33]
and the guidelines of the Indian Council of Medical Research for
bio-medical
research involving human subjects [34].
Furthermore, the study was approved by the Institutional Scientific
Advisory
Committee and the Institutional Ethical Committee. The study was
"blind" to the extent that patients, clinicians evaluating the adverse
effects, and laboratory staff carrying out the laboratory tests were
unaware of
the individual treatment schedules. Blinding and coding of the drugs
was done by
an independent monitor (a senior scientist who was not an investigator)
after
repacking in look-alike capsules by a pharmaceutical company in
Pondicherry. The
codes were broken only after completion of the study.
Assessment of results
Tolerability
All patients were clinically monitored
for any adverse
reactions (such as abdominal pain, nausea, vomiting, chest pain,
arthralgia,
diarrhoea, fever, headache, myalgia and chills) at 8 hourly intervals
for first
24 hours and thereafter every 24 hours for further two days (until the
end of
day 3). All systemic reactions, if any, were recorded in a pre-designed
form.
Laboratory investigations on haematology and biochemistry parameters
(haemoglobin
concentration, total white blood count, differential count, absolute
eosinophil
count, erythrocyte sedimentation rate, packed cell volume, blood urea,
sugar,
bilirubin, creatinine, cholesterol, serum sodium, potassium, chloride,
protein,
albumin, globulin, glutamic pyruvic transaminase, alkaline phosphatase)
were
assessed on day 0, (pre-treatment), and on completion of treatment (day
90).
Efficacy
Oedema volume was recorded using a water
displacement method [35]
on day 0 (pre-treatment) and every fortnight from day 15 to day 90, and
thereafter every 3 months on day(s) 180, 270 and 360.
On day 0, during the clinical history
taking, the senior
physician enquired about patient experiences of ADL attacks, and their
frequency
in the past 6 months prior to admission. At each follow-up point the
patients
were asked about the occurrence of ADL attacks in the period between
the visits,
and were also clinically examined for signs and symptoms of acute
disease, as
per WHO criteria [31].
Statistical analysis
The mean age of the patients and the mean
frequency of ADL
attacks (6 months prior to treatment) in the two drug groups were
compared using
independent t test. The statistical significance in the difference
between the
mean oedema volume was calculated using paired t-test.
Results
A total of 26 ambulatory patients with
unilateral lymphoedema,
(selected as per inclusion and exclusion criteria [Table 1]),
were recruited to the study; 13 in each drug group (Group A: Daflon
(500 mg) +
DEC (25 mg) twice a day, for 90 days; Group B: DEC (25 mg) twice a day,
for 90
days). The mean age (± SD) of the patients in the Daflon + DEC group
was 40 (±
11.5) years (range 20–55) and in the DEC group it was 38 (± 6.8) years
(range
24–50) (P > 0.05 between the two groups). There were 12 patients
with grade
II oedema and one patient with grade I oedema in each drug group. There
was no
significant difference in the pre-treatment (day 0) mean oedema volume
(± SEM)
between the Daflon + DEC (198.4 ± 16.5 ml) and the DEC alone (272.9 ±
48.0 ml)
groups (P > 0.05). All the 26 patients completed the full 90 day
treatment
schedule.
Tolerability
None of the patients in either study
group complained of any
adverse reaction during the 90 days of treatment. The haematological
and
biochemical parameters were within normal limits for all patients, and
did not
vary significantly between pre-treatment (day 0) and on completion of
treatment
(day 90) (data not shown).
Efficacy
The mean oedema volume (± SEM) in the
Daflon + DEC group was
140.6 (± 18.8) ml at the end of treatment period (day 90) and it was
71.8 (±
20.7) ml at the end of the follow-up period (day 360) (Figure 1).
There was a significant difference in the mean oedema volume on day 90
and on
day 360 in comparison to the pre-treatment value (198.4 ± 16.5 ml on
day 0, P
< 0.05) (Table 2).
The mean oedema (± SEM) volume in the DEC group was 272.9 ± 48.0 ml the
end of
the follow-up period (day 360) (Figure 1).
There was no significant difference in the mean oedema volumes on day
90 and on
day 360 in comparison to the pre-treatment value (272.9 ± 48.0 ml on
day 0, P
> 0.05).
The percentage change of oedema volume in
comparison to
pre-treatment (day 0) (considering day 0 volume as 100%) in the two
treatment
groups is shown in Figure 2.
It was observed that in the Daflon + DEC group the oedema volume
reduced by
29.1% at the end of treatment period (day 90) and by 63.8% at the end
of the
follow-up period (day 360). On the other hand, in the DEC group the
percentage
reduction was nil at the end of the treatment period (day 90) and it
was 9% at
the end of the follow-up period (day 360).
Comparison of the patterns of change in
the day-specific mean
oedema volume (Figure 1)
and its percentage change (considering day 0 as 100%) (Figure 2)
between the two treatment groups (Table 2)
showed that in the Daflon + DEC group, maximum reduction was observed
between
day 75 to day 180 (significant reduction in oedema volume; t = 3.31, P
<
0.01) and stabilized thereafter (no significant difference in oedema
volume
between day 180 versus day 270 or between day 180 versus day 360, P
> 0.05).
In the DEC group, the mean oedema volume was more or less stable
through out the
observation period (Table 2).
In the 6 month period prior to starting
the treatment, the mean
frequency of episodic ADL attacks (± SD) was 0.9 ± 1.1 in the Daflon +
DEC
group and it was 0.6 ± 0.9 in the DEC group (P > 0.05 between
the two
groups). None of the patients in either of the drug groups suffered
from an ADL
attack through out the treatment and follow-up period (i.e. between day
1 and
day 360).
Discussion
The World Health Organisation has
targeted lymphatic filariasis
for elimination as a public health problem by the year 2020 [1,2].
India, which has the highest burden of LF, has set a target for
national
elimination of LF by the year 2015 [36].
Although annual mass administration of single-dose anti-filarial drugs
to entire
endemic communities for the control of transmission of lymphatic
filariasis is
being implemented in many counties, including India, (under which
approximately
50 million citizens are currently being covered annually) [2,15],
morbidity management [13] aimed at the
alleviation of suffering of the individual patients has, in many
countires, only
recently begun to be addressed.
There is no doubt that the introduction
of an appropriate
hygiene and skin care regimen that patients can practice in their own
environment will be most important in providing long term gains in the
management of their morbidity. However, realisation of this strategy in
many
communities (living in rural and urban settings) in different endemic
countries
with wide socio-economic diversity remains a major challenge [17].
While the above strategy is being
implemented, it is important
to develop other measures, which could reduce oedema volume in patients
with
filarial lymphoedema, and, which can be integrated alongside a hygiene
and skin
care regimen.
Although, surgical procedures have been
developed for filarial
lymphoedema cases [37,38],
these can only be performed in a few specialized centers, where
expertise is
available. Furthermore, it is costly and it has been observed that
sustaining
the gains achieved by surgery depends on the ability to prevent
subsequent ADL
episodes (by following a hygiene and skin care regimen) [38].
Physiotherapeutic measures such as manual
massage, pneumatic
compression and interferential current therapy have been found to be
useful in
odemea volume reduction in other secondary lymphoedema cases [39,40,43],
however, these have yet to be properly evaluated in the management of
filarial
lymphoedema. Interferential current therapy showed significant oedema
reduction
in brugian filarial lymphoedema cases [41].
Although, pneumatic compression also results in oedema volume
reduction, the
results are not sustained [42]. Manual
massage could be most useful as a self-help measure [43],
but objective data are yet to be generated in LF cases. Of the
chemotherapeutic
agents investigated previously, 5,6 benzo-alpha-pyrone was most
promising. In a
double-blind placebo controlled study on bancroftian filarial
lymphoedma cases
in south India, it was observed that 5,6 benzo-alpha-pyrone (given at
the dosage
of 200 mg twice daily) resulted in significant reduction in oedema
volume (63%
in grade II cases) at the end of a two year treatment period [44].
The efficacy of this drug has also been demonstrated in a study in
China [45].
However, 5,6 benzo-aplha-pyrone cannot be currently recommended for use
as the
drug has been shown to be hepato-toxic [46].
Earlier studies have shown that DEC has
limited role in the
management of filarial lymphoedema. In areas endemic for burgian
filariasis in
Indonesia considerable improvement in lymphoedema, including reversal
of
elephantiasis, has been reported [47].
However, these observations were based on community studies and
objective
measurement of oedema volume was not carried out. A significant
reduction in
oedema volume was reported with repeated courses of DEC along with
supportive
measures (such as pneumatic compression, use of crepe bandage etc.) in
a study,
again on brugian filarial lymphoedema cases, from south India [48].
However, this was an open trial and it is not possible to differentiate
the
effect of DEC alone from that of the supportive measures. In
bancroftian
filarial lymphoedema cases, long term DEC therapy (6 mg /kg /day in two
divided
doses for 2 years) resulted in reduction in oedema volume ranging only
between 3
to 7 % in different grades of oedema [44].
A double blind clinical trial with single dose DEC (6 mg / kg body
weight) or
ivermectin (400 mg / kg body weight) did not show any significant
change in
oedema volume in bancroftian filarial lymphoedema cases over a one-year
follow-up period (Vector Control Research Centre – unpublished data).
In the
current study, DEC treatment alone at the dosage of 25 mg twice a day
for 90
days did not result in significant change oedema volume in filarial
lymphoedema
cases. Freedman et al., using lymphoscintigraphy
did not observe any
improvement in lymphatic pathology after two courses of DEC (for 12
days each)
in bancroftian filarial lymphoedema cases [49].
Furthermore, DEC did not reduce the incidence of episodic ADL attacks
in
individual lymphoedema cases [50,51]
as well as in the community after mass drug administration [52].
These results suggest the limitations of DEC in the morbidity
management in LF.
This is the first report of a clinical
trial on the
tolerability and efficacy of Daflon in filarial lymphoedema cases.
Daflon is
known to be phlebotonic, it reduces capillary permeability and has an
anti-lipidaemic
effect [19,26].
This drug is known to be safe and without any adverse reaction in the
dosage of
2 tablets of 500 mg each per day, and it has been given up to one-year
period [53,54].
The results of the current study showed that there was neither any
adverse
reaction during the 90 days treatment period nor any significant change
between
the pre-treatment (day 0) and post-treatment (day 90) haematological or
biochemical parameters in any of the patients (which were within normal
limits).
This demonstrates that Daflon (500 mg, twice a day for 90 days) is
safe, well
tolerated, and can be used up to 90 days in patients with filarial
lymphoedema.
Furthermore, the drug is also efficacious, reflected by a significant
reduction
in oedema volume of 63.8% (recorded between day 0 and day 360,
inclusive of 90
days of treatment period) (Figure 2).
A significant reduction in oedema volume was detected by the end of day
90
(Table 2).
In other clinical conditions, appreciable change has been detected
between 6
weeks to 6 months [55]. The pattern of
change in oedema volume showed a marked reduction from day 75 until day
180
(Figure 1),
after which the change was marginal (Table 2).
This could suggest that repeat course(s) may be required for further
decrease in
oedema volume. Although Daflon was given along with DEC in the current
study,
since DEC alone did not show any significant reduction in oedema volume
(Table 2,
Figure 1),
the results seen in the former group is likely to be due to Daflon.
None of the patients in either drugs
group suffered from an ADL
attack during the treatment and follow-up period. The reason for this,
however,
is not clear. Although DEC, (25 mg twice a day for 90 days), was given
to all
patients, it is difficult to assign this effect to DEC, as previous
experience,
in both hospital and community studies, did not favour this [50-52].
All the patients were also from a limited geographical area with
similar
environmental and socio-economic conditions having similar risk for
ADL. None of
the patients were advocated a specific hygiene and skin care regimen as
a part
of the protocol (since this is not yet a routine measure advocated by
the
National Filariasis Control Programme [56]
and also as this could confound the results of effects of the drug
(however, for
ethical reasons all patients were educated in an appropriate hygiene
and skin
care regimen after completion of the study)).
We conclude that Daflon (500 mg, twice a
day for 90 days) is
both safe and efficacious in reducing oedema volume in filarial
lymphoedema.
DEC, at the dosage given, did not result in any significant change in
oedema
volume. However, as the current study was limited to a few patients in
south
India (and did not have an arm of Daflon alone) further clinical trials
(preferably multi-centre) with larger numbers of patients need to be
carried out
(and should address the effect of Daflon on lymphatic pathology). This
is
essential for strengthening the evidence base on the use of Daflon in
the
management of filarial lymphoedema, before recommending its use in
morbidity
management to the Global Programme for the Elimination of Lymphatic
Filariasis.
Competing
interests
None declared
Authors'
contributions
LKD; Study design, case detection,
recruitment and follow-up,
data analysis and manuscript preparation. GSR; Study of tolerability
and
efficacy in the hospital. SPP; Study concept, design, implementation
and
manuscript preparation.
Acknowledgements
The authors would like to thank Dr.
Vijayan for his assistance
in organizing the laboratory investigations and Dr. P. Vanamail, Senior
Research
Scientist, Vector Control Research Centre (VCRC) for his help in the
statistical
analysis and Dr P.K.Das, Director, VCRC for his initiative and
administrative
support. The authors acknowledge the gift of the Daflon by M/S Serdia
Phramaceutical Ltd., Mumbai, India (coordinated by Dr. Prashant Desai).
The authors would also like to thank Mr.
Palaniswamy of Caplin
Laboratories Ltd., Pondicherry, India, for repacking the drugs used in
the
study.
The study was funded by the Indian
Council of Medical Research,
New Delhi, India http://icmr.nic.in/.
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http://www.filariajournal.com/content/2/1/5
Submitted
by
member: Tania
=======================================================
External Links:
Enlarging the "Audacious Goal": Elimination of the World's high prevalence neglected tropical diseases. 2011
Keywords: Neglected
tropical diseases; Ascariasis; Hookworm infection; Trichuriasis;
Schistosomiasis; Lymphatic filariasis (LF); Blinding trachoma;
Onchocerciasis; Kinetoplastid infections; Leprosy; Disease;
Elimination; Disease eradicationhttp://www.sciencedirect.com/science/article/pii/S0264410X11008887
Lymphatic Filariasis and its Control in Japan —The Background of Success 2011
http://www.sciencedirect.com/science/article/pii/S0035920311002100
Neglected
Tropical Diseases and the Millenium Development Goals - why the "other"
diseases" matter: reality versus rhetetoric 2011
http://www.parasitesandvectors.com/content/4/1/234/abstract
Lymphatic filariasis in western Ethiopia with special emphasis on
prevalance of Wuchereria bancrofti antigenaemia in and around
onchoceriasis endemic areas 2011
http://www.sciencedirect.com/science/article/pii/S0035920311002100
Managing
morbidity and preventing disability in the Global Programme to
Eliminate Lymphatic Filariasis: WHO position statement. Dec 2011
http://www.who.int/wer/2011/wer8651_52.pdf
Epidemiological
and entomological evaluations after six years or more of mass drug
administration for lymphatic filariasis elimination in Nigeria. Oct 2011
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3191131/?tool=pubmed
Bayesian
geostatistical modelling of malaria and lymphatic filariasis infections
in Uganda: predictors of risk and geographical patterns of
co-endemicity. Oct 2011
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3216645/?tool=pubmed
=======================================================
Join
us as we work for lymphedema patients everywehere:
Advocates
for Lymphedema
Dedicated to be an advocacy group for lymphedema patients.
Working towards
education, legal reform, changing insurance practices, promoting
research,
reaching for a cure.
http://health.groups.yahoo.com/group/AdvocatesforLymphedema/
| Subscribe: |
AdvocatesforLymphedema-subscribe@yahoogroups.com |
Pat O'Connor
Lymphedema People
/ Advocates for Lymphedema
=======================================================
For information about
Lymphedema
http://www.lymphedemapeople.com/thesite/all_about_lymphedema.htm
For
Information about
Lymphedema Complications
http://www.lymphedemapeople.com/thesite/lymphedema_complications.htm
For
Lymphedema Personal
Stories
http://www.lymphedemapeople.com/forum/forum.asp?FORUM_ID=7
For
information about
Lymphedema Wounds
http://www.lymphedemapeople.com/thesite/lymphedema_wound_care_revised.htm
For information about
Lymphedema Treatment Options
http://www.lymphedemapeople.com/thesite/lymphedema_treatment_options_revised.htm
For
information about
Children's Lymphedema
http://www.lymphedemapeople.com/thesite/lymphedema_childrens_pediatric.htm
=======================================================
Lymphedema People
Support Groups
-----------------------------------------------
Children
with Lymphedema
The time has come for families, parents, caregivers to have a support
group of
their own. Support group for parents, families and caregivers of
chilren with
lymphedema. Sharing information on coping, diagnosis, treatment and
prognosis.
Sponsored by Lymphedema People.
http://health.groups.yahoo.com/group/childrenwithlymphedema/
Subscribe: childrenwithlymphedema-subscribe@yahoogroups.com
......................
Lipedema
Lipodema Lipoedema
No matter how you spell it, this is another very little understood and
totally
frustrating conditions out there. This will be a support group for
those
suffering with lipedema/lipodema. A place for information, sharing
experiences,
exploring treatment options and coping.
Come join, be a part of the family!
http://health.groups.yahoo.com/group/lipedema_lipodema_lipoedema/?yguid=209645515
Subscribe: lipedema_lipodema_lipoedema-subscribe@yahoogroups.com
......................
MEN
WITH LYMPHEDEMA
If you are a man with
lymphedema; a man with a loved
one with lymphedema who you are trying to help and understand come join
us and
discover what it is to be the master instead of the sufferer of
lymphedema.
http://health.groups.yahoo.com/group/menwithlymphedema/
Subscribe: menwithlymphedema-subscribe@yahoogroups.com
......................
All
About Lymphangiectasia
Support group for parents, patients, children who suffer from all forms
of
lymphangiectasia. This condition is caused by dilation of the
lymphatics. It can
affect the intestinal tract, lungs and other critical body areas.
http://health.groups.yahoo.com/group/allaboutlymphangiectasia/
Subscribe: allaboutlymphangiectasia-subscribe@yahoogroups.com
......................
Lymphatic
Disorders Support Group @ Yahoo Groups
While we have a number of support groups for lymphedema... there is
nothing out
there for other lymphatic disorders. Because we have one of the most
comprehensive information sites on all lymphatic disorders, I thought
perhaps,
it is time that one be offered.
DISCRIPTION
Information and support for rare and unusual disorders affecting the
lymph
system. Includes lymphangiomas, lymphatic malformations,
telangiectasia,
hennekam's syndrome, distichiasis, Figueroa
syndrome, ptosis syndrome, plus many more. Extensive database of
information
available through sister site Lymphedema People.
http://health.groups.yahoo.com/group/lymphaticdisorders/
Subscribe: lymphaticdisorders-subscribe@yahoogroups.com
===========================
Our Home Page:
Lymphedema People
http://www.lymphedemapeople.com/
Updated Jan. 5, 2012
