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Episodic attacks of lymphangitis, lymphadenitis, and fever Chronic progressive swelling of extremities and genitals; hydrocele; chyluria; lymphedema Microfilariae in blood, chyluria, or hydrocele fluid; positive serologic tests Lymphatic filariasis is caused by three filarial nematodes: Wuchereria bancrofti, Brugia malayi, and Brugia timori, and is among the most important parasitic diseases of man Approximately 120 million people are infected with these organisms in tropical and subtropical countries, about a third of these suffer clinical consequences of the infections, and many are seriously disfigured W bancrofti causes about 90% of episodes of lymphatic filariasis It is transmitted by Culex, Aedes, and Anopheles mosquitoes and is widely distributed in the tropics and subtropics, including subsaharan Africa, southeast Asia, the western Pacific, India, South America, and the Caribbean B malayi is transmitted by Mansonia and Anopheles mosquitoes and is endemic in parts of China, India, southeast Asia, and the Pacific B timori is found only in islands of southeastern Indonesia Humans are infected by the bites of infected mosquitoes Larvae then move to the lymphatics and lymph nodes, where they mature over months to thread-like adult worms, and then can persist for many years The adult worms produce large numbers of microfilariae, which are infective to mosquitoes, and released into the circulation, particularly at night (except for the South Pacific, which microfilaremia peaks during daylight hours)

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Anisakiasis is caused by infection with larvae of saltwater fish and squid Multiple species of the family Anisakidae may occasionally infect humans Definitive hosts for these parasites are marine mammals Eggs are passed in the feces and ingested by crustaceans, which are then eaten by fish and squid When ingested by humans in undercooked seafood, larvae penetrate the stomach or intestinal wall but cannot complete their life cycle The disease is most common in Japan Clinical manifestations of anisakiasis follow burrowing of worms into the stomach or intestinal wall, leading to localized ulceration, edema, and eosinophilic granuloma formation Symptoms usually occur within 2 days of parasite ingestion and include severe epigastric or abdominal pain, nausea, and vomiting Intestinal involvement can mimic appendicitis Allergic symptoms, including urticaria, angioedema, and anaphylaxis, have also been attributed to acute infection Acute symptoms generally resolve within 2 weeks, but chronic symptoms may also be seen, suggesting chronic intestinal diseases such as inflammatory bowel disease, diverticulitis, or carcinoma Rarely, worms may migrate to other sites or be coughed up Eosinophilia is usually not seen The diagnosis of anisakiasis is suggested in those with acute abdominal symptoms after ingestion of raw fish Radiographic studies may identify stomach or intestinal lesions, and endoscopy may allow visualization and removal of the worm When surgery is performed due to consideration of other diagnoses, eosinophilic inflammatory lesions and the invading worms are found Specific therapy is not indicated, but endoscopic worm removal hastens recovery The parasites are killed by cooking or deep freezing fish

Many infections remain asymptomatic despite circulating microfilariae Clinical consequences of filarial infection are principally due to inflammatory responses to developing, mature, and dying worms The initial manifestation of infection is often acute lymphangitis, with fever, painful lymph nodes, edema, and inflammation spreading peripherally from involved lymph nodes (in contrast to bacterial lymphangitis,

which spreads centrally) Lymphangitis and lymphadenitis of the upper and lower extremities is common; genital involvement, including epididymitis and orchitis, with scrotal pain and tenderness, occurs principally only with W bancrofti infection Acute attacks of lymphangitis last for a few days to a week and may recur a few times per year Filarial fevers may also occur without lymphatic inflammation The most common chronic manifestation of lymphatic filariasis is swelling of the extremities or genitals due to chronic lymphatic inflammation and obstruction Extremities become increasingly swollen, with a progression over time from pitting edema, to nonpitting edema, to sclerotic changes of the skin that are referred to as elephantiasis Genital involvement, particularly with W bancrofti, occurs more commonly in men, progressing from painful epididymitis to hydroceles that are usually painless but can become very large, with inguinal lymphadenopathy, thickening of the spermatic cord, scrotal lymphedema, thickening and fissuring of the scrotal skin, and occasionally chyluria Lymphedema of the female genitalia and breasts may also occur Tropical pulmonary eosinophilia is a distinct syndrome principally infecting young adult males with either W bancrofti or B malayi infection but typically without microfilaremia This syndrome is characterized by asthma-like symptoms, with cough, wheezing, dyspnea, and low-grade fevers, usually at night Without treatment, tropical pulmonary eosinophilia can progress to interstitial fibrosis and chronic restrictive lung disease

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