Asia, and Africa, the infection is also seen in the southeastern United States Patients present with itchy papules at the entry site with a migratory, raised, erythematous, serpiginous pattern as the larvae migrate The feet and buttocks most commonly are affected The parasites enter the bloodstream and have a maturation phase in the lungs With a large inoculation, eosinophilic pneumonitis (Löeffler syndrome) can be seen Eosinophilia can also be seen with invasive enteritis, but is not a feature of isolated CLM The diagnosis is clinical; biopsy is not recommended, but pathology may demonstrate an eosinophilic infiltrate Serologies and EIAs are not commercially available While usually a self-limited disease, albendazole or ivermectin can be used for treatment Patients with substantial eosinophilia should be monitored for manifestations of mast cell degranulation after treatment, and some may require corticosteroids along with antiparasitic therapy Contact precautions are recommended for the incontinent child Filariasis Filariases are mosquito-borne infections caused by the nematodes (roundworms) Wuchereria bancrofti, Brugia malayi, or Brugia timori ( e-Table 94.25 ) The incubation period ranges from to 12 months depending on the species W bancrofti ’s clinical manifestations include acute adenolymphangitis (ADL), hydrocele, lymphedema, elephantiasis, chyluria, and tropical pulmonary eosinophilia (TPE) ADL is characterized by malaise, fever, chills, and enlarged painful lymph nodes, usually in the lower limb Hydrocele (unilaterally or bilateral) is the most common chronic manifestation of W bancrofti Chronic lymphedema may progress to elephantiasis and typically involves the lower extremities Edema usually becomes nonpitting with skin thickening and loss of skin elasticity Secondary bacterial and fungal infections are common Chyluria is seen when dilated lymphatics rupture and drain into the urinary excretory system It is typically recurrent and lasts for days to weeks TPE is the result of immune hyperresponsiveness to microfilaria in the lung Patients with TPE typically present with nocturnal coughing and wheezing and extreme peripheral eosinophilia (counts >3,000 cells/mm3) If left untreated, TPE may progress to chronic interstitial fibrosis and permanent lung damage Brugian filariasis (caused by both B malayi and B timori ) is very similar to Bancroftian filariasis, except that hydroceles, genital manifestations, and chyluria are less common, and that the elephantiasis is usually limited to the lower legs in Brugian filariasis