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Cysticercosis working group in Peru. Neurocysticercosis: updated concepts about an old disease. Lancet Neurol 4:653-661
Abstract
Neurocysticercosis, the infection of the human brain by the larvae of Taenia solium, is a major cause of acquired epilepsy in most low-income countries. Cases of neurocysticercosis are becoming more common in high-income countries because of increased migration and travel. Diagnosis by neuroimaging and serological assessment has greatly improved over the past decade, and the natural progression of the disease and response to antiparasitic drugs is now much better understood. Neurocysticercosis is potentially eradicable, and control interventions are underway to eliminate this infection. Meanwhile, updated information on diagnosis and management of neurocysticercosis is required, especially for clinicians who are unfamiliar with its wide array of clinical presentations.
... They are mostly deposited in the brain, muscle, and the subcutaneous tissue, where they eventually develop into cysts; serious manifestation of the disease usually follows lodgment of the cysts in the brain, spinal cord, or the eye. [2][3][4] In the tissues, the oncospheres develop into metacestodes, and following the multiple stages of development, they become cysticerci. A membrane develops around each oncospheres with a vesicle-containing clear fluid and the parasite head/ scolex. ...
... It further allows the identification of any of the four morphological phases of disease, namely vesicular, colloidal, granular nodular, and the calcified nodule. [4] MR imaging is more sensitive than computed tomography in identifying the scolex and diagnosing parenchymal NCC. [11] Imaging studies are useful tools for making the diagnosis in experienced hands, particularly in the endemic regions. ...
... [3] Cysticercosis is known to be endemic in many developing countries including Nigeria, where Ahidjo et al. reported a case of nuerocysticercosis with additional temporal bone changes in a-32 year-old Nigerian. [17] Similar cases had been reported in Central and South America, East, West and Central Africa, and Asia, [2,4,7,9,18,19] with recognized pig-to-pig transmission and a human-to-human transmission through the fecal-oral route to human. It is noteworthy that the authors were not able to find any literature report of cerebral cysticercosis from Nigeria. ...
... Cysticercosis caused by the pig tapeworm Taenia solium (T. solium) remains an important parasitic zoonotic disease affecting men and women equally across all age groups worldwide [Dixon et al.,2020., Sorvillo andDeGiorgio C., 2020., Sorvillo et al., 2011., Phiri et al., 2003., Schantz PM et al.,1988., Garcia and Del Brutto, 2005]. Human cysticercosis occurs when food or water contaminated with T. solium ova are ingested [WHO, 2021]. ...
... There are several notable findings from our study. Although cysticercosis is widespread globally [WHO 2021., CDC 2021., Dixon et al.,2020., Sorvillo and DeGiorgio C., 2020., Sorvillo et al., 2011., Phiri et al., 2003., Schantz PM et al.,1988., Garcia and Del Brutto, 2005], autopsy data regarding sudden and unexpected community deaths due to cardiac cysticercosis are scarce. First, to our knowledge, this is the first and largest case series reporting 9 cases of cysticercosis as an incidental finding at autopsy in sudden unexpected deaths in the community subjected to forensic investigations. ...
... Whilst cysticercosis is known to have a predilection for the brain [WHO, 2021., Schantz PM et al.,1988., Nash and Garcia 2011., Wallin and Kurtzke., 2004., Garcia and Del Brutto, 2005, and is a leading cause of adult-onset seizures in developing countries [Dixon et al.,2020., Sorvillo andDeGiorgio C., 2020], there have been only a few individual autopsy case reports of neuro cysticercosis as a cause of sudden death [Esberg and Reske-Nielsen 1988., Hortobágyi et al., 2009., Ndhlovu CE., 1997. One case involved a road traffic accident which resulted in previously undiagnosed neuro cysticercosis causing cerebral complications [Holmes et al.,2010]. ...
Background: Cysticercosis is a WHO designated neglected human zoonoses worldwide. Data on cardiac cysticercosis and its contribution to sudden and unexpected community deaths are scarce and require study.
Methods: We performed a study of cysticercosis-related deaths and other incidental cases of cysticercosis seen at forensic post-mortem examination over a period of 12 months in individuals who died suddenly and unexpectedly in the community, Lusaka, Zambia.
Whole-body post-mortem examinations were performed according to Standard Operating Procedures for post mortem examinations. Representative samples were obtained from all body organs and subjected to histopathological examination. Information on circumstances surrounding the death was obtained. Data were collated on patient demographics, history, co-morbidities, pathological gross and microscopic findings, and forensic autopsy cause(s) of death. We also reviewed available literature on cardiac cysticercosis.
Results: Nine cases of cysticercosis were identified. Eight out of nine cases had cardiac cysticercosis. There was no prior history of cysticercosis before death. All were male, aged between 28 to 56 years, from high- population density and low-socioeconomic communities. There was no community case clustering identified.
Conclusions: Cardiac cysticercosis and Neuro cysticercosis are important incidental finding in sudden and unexpected deaths in the community and can easily be missed antemortem. More investments into forensic autopsy services are required to define the undiagnosed burden of deaths due to treatable communicable diseases.
... They are mostly deposited in the brain, muscle, and the subcutaneous tissue, where they eventually develop into cysts; serious manifestation of the disease usually follows lodgment of the cysts in the brain, spinal cord, or the eye. [2][3][4] In the tissues, the oncospheres develop into metacestodes, and following the multiple stages of development, they become cysticerci. A membrane develops around each oncospheres with a vesicle-containing clear fluid and the parasite head/ scolex. ...
... It further allows the identification of any of the four morphological phases of disease, namely vesicular, colloidal, granular nodular, and the calcified nodule. [4] MR imaging is more sensitive than computed tomography in identifying the scolex and diagnosing parenchymal NCC. [11] Imaging studies are useful tools for making the diagnosis in experienced hands, particularly in the endemic regions. ...
... [3] Cysticercosis is known to be endemic in many developing countries including Nigeria, where Ahidjo et al. reported a case of nuerocysticercosis with additional temporal bone changes in a-32 year-old Nigerian. [17] Similar cases had been reported in Central and South America, East, West and Central Africa, and Asia, [2,4,7,9,18,19] with recognized pig-to-pig transmission and a human-to-human transmission through the fecal-oral route to human. It is noteworthy that the authors were not able to find any literature report of cerebral cysticercosis from Nigeria. ...
... This review focuses on parasitic diseases of the spinal cord and nerve roots, which are widespread and have the potential to be extremely lethal and infectious. Such diseases include schistosomiasis, which is common in endemic regions, and neurocysticercosis, which is the most common parasitic disease of the spinal cord [16][17][18]. Radiologists are very important in this field, as they are responsible for detecting the disease and working alongside the clinicians to facilitate the appropriate testing needed for correct treatment and to diagnose it early. ...
... After the embryos are released and dislodged into the small intestines, they then enter neural and subcutaneous tissues and then enter skeletal and ocular globes and continue their development [1]. When in the CNS, cysticerci can develop anytime between 3 weeks and 2 months following the initial oncosphere formation [1,17]. ...
... Due to the fact that neurological issues are a clinical manifestation of NCC, anti-epileptic therapies have also been recommended [67,80]. In these cases, phenobarbitone and carbamazepine should be used to control seizures, but this is also not without controversy, as relapse is quite common following improvement while no improvement has also been shown in some cases [17,67,68,84]. ...
Parasitic diseases of the spinal cord and nerve roots are a potentially deadly matter. They are mainly found in areas where there are poor sanitary conditions such as Africa, the Middle East, and the West Indies. The most common diseases include schistosomiasis and neurocysticercosis. Furthermore, it is clear that through an understanding of all the various diseases there are, it is imminent that patients are treated as soon as possible to avoid the deadly outcomes that the diseases can have to the body. This disease can have several impacts on individuals that include epilepsy, health problems, and implications on various organs.
... Aristotle was the first to report the presence of cysticerci in animals, between 389 and 375 b.C (7). In ancient Greece, the disease was known as a pig disease (8). From the nineteenth century, it was clear that the disease was transmitted by man and not by animals as it was thought (7). ...
... From the nineteenth century, it was clear that the disease was transmitted by man and not by animals as it was thought (7). NC was considered a public health problem after the second half of the twentieth century (8,9). Taenia solium is an enteroparasite belonging to the Platyhelminthes phylum, the Cestoda class, the Taeniidae family, the genus Taenia, and the solium species (7). ...
... In its adult form, Taenia solium measures typically 2-4 meters in length and consists of scolex (head), neck (neck) and strobile (body) (8). Adults live on average 3 years and can live up to 25 years, housed in the digestive tract of humans (1). ...
Neurocysticercosis (NC) is the most common parasitic infection of the central nervous system (CNS). Several studies have reported an association between NC and mesial temporal lobe epilepsy (MTLE). We intended to evaluate the frequency of hippocampal atrophy (HA), clinical evolution and imaging findings in patients with calcified neurocysticercotic lesions (CNLs).
Methods: One hundred and eighty-one subjects (70 cases and 111 controls) were evaluated for the presence or absence of HA. We assessed the imaging findings, and the evolution of patients with NC treated or not with anthelmintics for NC.
Results: Hippocampal volumes were different between cases and controls (p < 0.001). Seventy percent of the cases presented HA. 52.2% of the patients without a history of anthelmintic treatment for NC had reports of epileptic seizures. There was an association between non-treatment and the later occurrence of epileptic seizures (p = 0.006). There was an association between perilesional edema on MRI and the presence of uncontrolled epileptic seizures (p = 0.004).
Conclusions: Hippocampal atrophy is frequent in patients with NCC. There was an association between no anthelmintic treatment in the acute phase of NC, perilesional edema, more pronounced hippocampal atrophy, and the occurrence of refractory seizures.
... Recent reviews describe a total of 275 case reports for western Europe and 58 for eastern Europe for the period 1990 to 2015 [10,11]. Cysticercosis cases diagnosed in these areas often arise from returning travellers and immigrants from endemic areas [15], as well as from untreated T. solium tapeworm carriers who would pose a risk to themselves, family members and other contacts in non-endemic areas [16][17][18]. It is important to obtain accurate epidemiological data on cysticercosis cases in humans and pigs, as well on taeniasis cases caused by T. solium in humans. ...
... Furthermore, for 23.1% of taeniasis cases in our study, the causative species was not known and this group could thus potentially include some T. solium carriers. They would pose a risk to themselves, family members and other contacts with respect to cysticercosis development [16][17][18]. Unfortunately, classical methods to examine stool cannot always distinguish species and molecular differentiation, although recommended, is not routinely done in Europe [10,11]. ...
Background
Few case reports on human infections with the beef tapeworm Taenia saginata and the pork tapeworm, Taenia solium, diagnosed in Belgium have been published, yet the grey literature suggests a higher number of cases.AimTo identify and describe cases of taeniasis and cysticercosis diagnosed at two Belgian referral medical institutions from 1990 to 2015.Methods
In this observational study we retrospectively gathered data on taeniasis and cysticercosis cases by screening laboratory, medical record databases as well a uniform hospital discharge dataset.ResultsA total of 221 confirmed taeniasis cases were identified. All cases for whom the causative species could be determined (170/221, 76.9%) were found to be T. saginata infections. Of those with available information, 40.0% were asymptomatic (26/65), 15.4% reported diarrhoea (10/65), 9.2% reported anal discomfort (6/65) and 15.7% acquired the infection in Belgium (11/70). Five definitive and six probable cases of neurocysticercosis (NCC), and two cases of non-central nervous system cysticercosis (non-CNS CC) were identified. Common symptoms and signs in five of the definitive and probable NCC cases were epilepsy, headaches and/or other neurological disorders. Travel information was available for 10 of the 13 NCC and non-CNS CC cases; two were Belgians travelling to and eight were immigrants or visitors travelling from endemic areas.Conclusions
The current study indicates that a non-negligible number of taeniasis cases visit Belgian medical facilities, and that cysticercosis is occasionally diagnosed in international travellers.
... The cycle is ended by the development of an adult worm in the small intestine of the host. [6][7][8] Most severe manifestation of cysticercosis is neurocysticercosis that involves the central nervous system characterized by symptoms, such as headache, fever and myalgia or more severe signs and symptoms, such as convulsions, increase in intracranial pressure, meningitis, and mental disorders. 1,9 The World Health Organization estimates that more than 50,000 deaths per year are caused by neurocysticercosis worldwide. ...
... 1,9 The World Health Organization estimates that more than 50,000 deaths per year are caused by neurocysticercosis worldwide. 8,10 In the present case, the patient denied any symptoms, and a lack of systemic involvement was confirmed by laboratory tests and diagnostic imaging carried out by the medical team. The patient had a single asymptomatic nodule in the submandibular region. ...
Introduction
Cysticercosis is a condition that occurs when humans are infested by the larvae of Taenia solium , acting as an intermediate host instead of definitive occurrence in neural and extra-neural forms. The latter commonly involves subcutaneous tissue, skeletal muscles, and eyes.
Aims and objectives
Oral cysticercosis is a rare event, and it represents great difficulty for clinical diagnosis. In present report we report a case of cysticercosis in the right submandibular region where it presented as a large, soft cystic swelling and tried to explain the clinical sign & symptom of oral cysticercosis. We emphasize on the importance of ultrasonographic and routine microscopic examinations for the diagnosis of even apparently innocuous lesions in submandibular regions.
Results
This is a very rare case of oral cysticercosis showing neck swelling extended from the lower border of the mandible to the thyroid cartilage. The diagnosis was made by sonography and confirmed by gross and microscopic examination of cysticercosis cellulosae. In ultrasonography, there was well-defined cystic lesion with hyperechoic eccentric tiny nodules.
How to cite this article
Chandak RM, Chandak MG, Rawlani SM. Cysticercosis presenting as Neck Swelling: A Rare Case diagnosed on Ultrasound Report. J Contemp Dent 2017;7(2):122-124.
... Even though the occurrence of these infections is very rare in the oral cavity it has gained its significance as they are the most common diseases occurring worldwide, with an estimated prevalence of more than 50 million individuals getting infected annually. 5 It has varied site predilection of occurrence involving the oral mucosa, lips, gums, tongue, masseter muscle, etc. as solitary or multiple lesions. 6 The disease is said to be commonly encountered in the 4th to 5th decade of life while showing significant female predilection. ...
... 7 The humans gets effected or transmitted by eggs or larval form of these parasites when they consume food and water contaminated by them or by a bite of mosquito carrying them as vector or by consuming a pork or beef which acts as intermediate host for these parasites. 8,9 Finally these individuals' acts as intermediate hosts where further development of these larval forms occurs and now enters into lymphatic or vascular circulation lodging in These parasitic infections does not exhibits any pathognomonic clinical features and commonly presents as an asymptomatic swellings with no bleeding, pulsations, etc. 5,11 Hence includes mucoceles, benign tumor of the minor salivary glands, lipoma, fibroma, hemangioma, myoma, glandular cell tumor, 11 sebaceous cyst, 5 etc as differential diagnosis. A preoperative diagnostic investigation can be performed using fine-needle aspiration cytology 12,13 followed by conventional radiography to rule out calcifications in muscle tissue. ...
... It is regarded as one of the most representative neglected tropical diseases (NTD), worldwide. Moreover, cysticercosis has been designated as a "biological marker" of the social and economic development of a community (Prasad et al. 2008a;Carpio et al. 1998;Garcia and Del Brutto 2005). ...
... Cysticerci may invade almost any organ or tissue of the human economy, including subcutaneous tissue, striated muscle, heart, liver, or other organs; however, apart from some cases of massive muscle involvement by hundreds of cysts, which may cause muscular pseudo-hypertrophy and myositis, or some sporadic cases of intraocular cysticercosis and arrhythmias related to cardiac cysts, most instances of systemic nonneurological cysticercosis are clinically irrelevant and account for less than 5 % of all cases of symptomatic disease (Garcia and Del Brutto 2005;Del Brutto 1997). ...
... Humans may be either definitive hosts (adult tapeworm residing in the gastrointestinal area) or intermediate hosts (larval stage in the tissues) for Taenia solium. Humans are commonly the definitive hosts for Taenia solium and pigs are the usual intermediate hosts [5]. Tapeworm contaminations are universal in underdeveloped countries where there is weak access to cleanliness, hygiene, and close interplay between persons and mammals and where pigs are a major source of food. ...
Isolated muscular cysticercosis is an emerging problem worldwide with varied presentations. Although it commonly affects the brain in the form of neurocysticercosis, it may also present as a pseudotumor-like mass intramuscularly. Although classically associated with measly pork ingestion, it might present in vegetarians too based on several factors. It has a similar presentation to various other diseases often benign, such as lipoma or dermoid, and is thus difficult to diagnose clinically. While ultrasound might give a clue to diagnosis, magnetic resonance imaging (MRI) forms a non-invasive and accurate investigation. Here, we present a case of isolated intramuscular cysticercosis in a 6-year-old female with swelling in the right forearm for the past 1 year. After confirmation of the diagnosis through ultrasound and MRI, medical management was started and surgical excision was planned in view of the abscess. The mass along with the abscess was excised and sent for biopsy. Surgery has to be considered in cases with abscesses although otherwise it might be managed medically.
... It has been designated a "biological marker" of a community's social and eco-nomic development (Carpio et al., 1998). A severe parasitic infection of the central nervous system is neurocysticercosis (NCC), which occurs due to the development of metacestodes of T. solium in the brain and spinal cord, often manifested by epilepsy and epileptogenic seizures between 69 -96 % of patients in the developing world (Del Brutto et al., 1992Bern et al., 1999;Román et al., 2000;Carpio & Hauser, 2002;Garcia & Del Brutto, 2005). Some other clinical manifestations include severe chronic headaches, blindness, hydrocephalus, meningitis, dementia and even death (Townes et al., 2004;Sorvillo et al., 2007). ...
Neurocysticercosis (NCC), one of the most important neuroparasitic diseases in humans, is caused by Cysticercus cellulosae , the metacestode stage of digenetic zoonotic cestode Taenia solium . The present study aims at the detection of anti-cysticercus antibodies in the sera of epileptic patients (n=26) visiting a tertiary care hospital in Nagpur, Maharashtra state, India, by an in-house developed indirect IgG-ELISA and enzyme-linked immunoelectro transfer blot (EITB) assay using different antigens (namely, Whole Cyst Antigen (WCA), Cystic Fluid Antigen (CFA), Scolex Antigen (SA), Excretory-Secretory Antigen (ESA) and Membrane-Body Antigen (MBA)) prepared from T. solium metacestodes to find out the status of NCC. An attempt has also been made for molecular detection of NCC from blood samples of those patients by Polymerase Chain Reaction (PCR) assay targeted at large subunit rRNA gene of T. solium . The IgG ELISA level of anti-cysticercus antibodies against WCA, CFA, SA, ESA and MBA antigens were as follows: 19.23 %, 23.07 %, 38.46 %, 30.76 % and 15.38 %. The seroreactivity to CFA, SA and ESA was found in equal proportions in patients with ring-enhancing lesions. In the EITB assay, the lower and medium molecular weight protein bands of SA and ESA were immunodominant compared to the higher WCA and CFA peptides. PCR positivity could be observed in 34.6 % (9/26) of the patients under study. It is the first report of detecting NCC among epileptic patients of the Nagpur region of Maharashtra state in India using serological and molecular tools.
... Third stage is granular stage showing cyst with thicker wall and degenerated scolex. Final stage is calcification stage in which cyst develops into calcified nodule [8]. ...
Background
Neurocysticercosis (NCC) is thought to be the most common helminthic infection of central nervous system in India. In children, it has pleomorphic clinical and radiological presentations depending on location and stage of lesion. Solitary cystic granuloma appearing as a single ring enhancing lesion is the most frequently encountered neuroimaging finding in patients with neurocysticercosis or tuberculoma in India. This series reports unusual clinico-radiological aspects of pediatric neurocysticercosis patients of Asian ethnicity.
Case presentation
In the present case series, we have described socio-demographic and clinico-radiological profile of eight cases of neurocysticercosis with parenchymal lesions in varying stages of development. Among these two had single discrete ring enhancing lesion (SDREL), two had single conglomerated ring enhancing lesion (SCREL), and five cases reported to have multiple ring enhancing lesions (MREL). Two cases with recurrent neurocysticercosis have been reported which is quite rare. Magnetic resonance spectroscopy helps to differentiate between neurocysticercosis and tuberculoma and may avoid brain biopsies or unnecessary anti-tubercular treatment. Magnetic resonance spectroscopy (MRS) was done in three cases with findings of absence of lipid peak and choline/creatinine ratio less than 1.2.
Conclusion
Despite the advances in neuroimaging, accurate diagnosis of NCC is still sometimes difficult, which is related to the pleomorphic nature of disease and significant overlapping features with tuberculoma. A combination of proper diagnostic criteria and neuroimaging findings are helpful in making the diagnosis without invasive and potentially harmful investigations in paediatric patients.
... Neurocysticercosis (NCC), the infection of the human brain by the larvae of Taenia solium, is the leading cause of seizure(s) or epilepsy in low and middle income countries [1]. Pathological and observational cohort studies suggest that the calcified lesions seen on computed tomography (CT) scan, measuring less than 20 mm, represent the end result of the host's inflammatory response to the larval form of Taenia solium [ Figure 1A] [2][3][4]. ...
The calcified stage of the neurocysticercosis (NCC) is the common cause of acquired epilepsy in low and middle income countries in people aged > 20 years. Approximately 30% of adult onset seizures and epilepsy are attributable to NCC. In India and some of the Latin American countries, epilepsy due to solitary calcified NCC is the common adult onset epilepsy. The current evidence suggests that the calcified cysticercus granuloma is probably the epileptogenic focus. The mechanisms involved in the epileptogenic process are not well understood; Focal-onset seizures with or without impaired awareness are the common seizure type. Focal-onset seizure can evolve to bilateral tonic-clonic seizure. Seizure outcome with anti-seizure medication, most often with monotherapy, is very good. The seizure disorders associated with various stages of NCC can be preventable.
... En los seres humanos los síntomas se deben principalmente a la afectación del sistema nervioso central. Los quistes situados dentro del parénquima cerebral (NCC intraparenquimatosa), por lo general se degeneran en la siguiente secuencia: de quistes viables a quistes inflamados, a tejido granulomatoso focal, y aproximadamente el 40% termina con la formación de una cicatriz calcificada (5) . ...
Objetivo. Explorar la viabilidad de desarrollar un modelo de neurocisticercosis (NCC) de oveja mediante infección intracraneal de oncosferas de T. solium. Materiales y métodos. Se realizó un modelo de infección experimental de NCC en ovejas. Se inocularon aproximadamente 10 posoncósferas de T. solium cultivadas previamente por 30 días por vía intracraneal en diez ovejas. Las oncósferas, en 0,1 mL de solución salina fisiológica, se inyectaron en el lóbulo parietal a través de una aguja de calibre 18. Resultados. Después de tres meses, en dos ovejas se encontraron granulomas y en una tercera identificó un quiste de 5 mm de diámetro en el ventrículo lateral derecho y la evaluación histológica confirmó que el quiste corresponde a una larva de T. solium. También se utilizó inmunohistoquímica con anticuerpos monoclonales dirigidos contra componentes de membrana y antígenos excretorios/secretorios del quiste de T. solium para confirmar la etiología de los granulomas encontrados. Uno de ellos mostro reactividad ante los anticuerpos monoclonales utilizados, confirmando así que se trató de un cisticerco Conclusión. Este experimento es la prueba de concepto de que es posible infectar ovejas con cisticercosis por inoculación intracraneal.
... NCC, a parasitic infection of the CNS, is a major health problem (neurologic diseases) in developing countries [5]. Initially, it was restricted to the endemic zones (sub-Saharan Africa, Latin America, India, Southeast Asia) [15]. Now many cases have been reported from the developed countries (USA, Canada, Australia, European countries) [16][17][18][19][20] as well, because of an increased number of immigrants from the disease-endemic areas to developed nations. ...
Introduction:
Cysticercosis, caused by Cysticercus cellulosae, is one of the common parasitic diseases that can affect the central nervous system (neurocysticercosis, NCC). Isolated involvement of cysticercosis of the spine, without the involvement of the brain, has been very rarely reported.
Case presentation:
This report presented a case, who was presenting with low back pain with radiation and cauda equina syndrome (CES). On MRI, the patient was found to have a subarachnoid cystic lesion at the level of lumbosacral vertebrae. Under neurosurgery, the patient underwent L5/S1 laminectomy, decompression, and excision of the cyst. On histopathological examination, the patient was diagnosed of having Cysticercosis. Immediately after surgery, the patient had neurological deterioration. However, at the end of 1 year, the patient had significant improvement both neurologically and functionally.
Discussion:
Spinal NCC should be considered in the differential diagnosis for a patient, who presents with a cystic lesion in the spinal subarachnoid space. Surgical exploration and excision of the cysts should be conducted not only to establish the diagnosis but also to decompress the cord and peripheral nerves.
... 62 According to recent data, among HIV/AIDS-patients the global incidence of CrM was 223,100 cases in 2014 and the mortality was estimated at 181,100 annual global deaths, with 135,900 (75%) deaths in sub-Saharan Africa. Globally, CrM was responsible for 15% of AIDS-related deaths (95% CI [10][11][12][13][14][15][16][17][18][19] ...
This chapter is dedicated to the epidemiology of common non-bacterial central nervous system infections: parasitic, fungal, and viral infections. Non-bacterial central nervous system infections are public health challenges in developing and developed countries. Clinical manifestations and severity depend on pathogenic characteristics of the agents and of the patients (areas affected, age, immune status, etc.). These infections are an emerging problem with a poor prognosis if treatment is not adequate. Furthermore, these agents have been commonly implicated as risk factors to other neurological disorders and sequelae that impose a high burden on the healthcare resources.
... 62 According to recent data, among HIV/AIDS-patients the global incidence of CrM was 223,100 cases in 2014 and the mortality was estimated at 181,100 annual global deaths, with 135,900 (75%) deaths in sub-Saharan Africa. Globally, CrM was responsible for 15% of AIDS-related deaths (95% CI [10][11][12][13][14][15][16][17][18][19] ...
... c Associated with possible neurocysticercosis (a parasitic infection of T. solium and T. saginata prevalent to the area and having seizure as a clinical symptom) infection. All subjects were without edema, EITB negative, and AgELISA negative [21,22]. ...
Diagnosis of non-symptomatic epilepsy includes a history of two or more seizures and brain imaging to rule out structural changes like trauma, tumor, infection. Such analysis can be problematic. It is important to develop capabilities to help identify non-symptomatic epilepsy in order to better monitor and understand the condition. This understanding could lead to improved diagnostics and therapeutics. Serum mass peak profiling was performed using electrospray ionization mass spectrometry (ESI-MS). A comparison of sera mass peaks between epilepsy and control groups was performed via leave one [serum sample] out cross-validation (LOOCV). MS/MS peptide analysis was performed on serum mass peaks to compare epilepsy patient and control groups. LOOCV identified significant differences between the epilepsy patient group and control group (p = 10−22). This value became non-significant (p = 0.10) when the samples were randomly allocated between the groups and reanalyzed by LOOCV. LOOCV was thus able to distinguish a non-symptomatic epilepsy patient group from a control group based on physiological differences and underlying phenotype. MS/MS was able to identify potential peptide/protein changes involved in this epilepsy versus control comparison, with 70% of the top 100 proteins indicating overall neurologic function. Specifically, peptide/protein sera changes suggested neuro-inflammatory, seizure, ion-channel, synapse, and autoimmune pathways changing between epilepsy patients and controls.
... The etiopathogenie is due to viable cysts that can cause mass effect on the cerebral parenchyma. [5][6] In the case of colloidal and granular cysticercus the cause is the inflammatory reaction; and in calcified lesions, gliosis around dead parasites and sclerosis may explain the epileptogenic activity. (See Table 1). ...
... Neurocysticercosis (NCC) is a neurological disease of humans caused by the infection of the central nervous system (CNS) with the larval form (cysticercus) of the pork tapeworm Taenia solium [1]. NCC continues to be the leading cause of human acquired epilepsy in most developing countries [2,3], and is also increasingly diagnosed in nonendemic countries because of travel and immigration of tapeworm carriers from endemic areas [4,5]. NCC is one of the major contributors to the global burden of parasitic zoonosis in the world [6]. ...
Background: Albendazole is the drug of choice for the treatment of parenchymal neurocysticercosis, although its efficacy is suboptimal. Plasma levels of albendazole sulfoxide (ASOX), the active metabolite of albendazole, are highly variable among patients. We hypothesized that high ASOX plasma levels during albendazole therapy may be associated with an increased antiparasitic efficacy.
Methods: ASOX plasma levels were measured at treatment day 7 in 118 patients with parenchymal neurocysticercosis enrolled in a trial of antiparasitic efficacy. The relationships between increasing ASOX plasma levels with (1) the proportion of cysts resolved, and (2) the proportion of patients with complete cyst clearance (evaluated by brain MRI 6 months after treatment) were assessed.
Results: There was a trend towards a higher proportion of cysts resolved and a higher proportion of patients cured with increasing quartiles of ASOX plasma levels. In patients with ≥3 brain cysts, the regression analysis adjusted by the concomitant administration of PZQ showed a 2-fold increase in the proportion of cysts resolved (RR 1.98, 95% CI 1.01-3.89, p = 0.048) and 2.5-fold increase in the proportion of patients cured (RR 2.45, 95% CI 0.94-6.36, p = 0.067) when comparing ASOX levels in the highest versus the lowest quartile. In patients with 1-2 brain cysts no association was found.
Conclusions/significance: We suggest an association between high ASOX plasma levels and increased antiparasitic efficacy in patients with parenchymal neurocysticercosis. Nonetheless, this association is also influenced by other factors including parasite burden and concomitant administration of PZQ. These findings may serve to individualize and/or adjust therapy schemes to avoid treatment failure.
The ILAE Neuroimaging Task Force aims to publish educational case reports highlighting basic aspects related to neuroimaging in epilepsy consistent with the educational mission of the ILAE. Neurocysticercosis (NCC) is highly endemic in resource-limited countries and increasingly more often seen in non-endemic regions due to migration. Cysts with larva of the tapeworm Taenia solium lodge in the brain and cause several neurological conditions, of which seizures are the most common. There is great heterogeneity in the clinical presentation of neurocysticercosis because cysts vary in number, larval stage, and location amongst patients. We here present two illustrative cases with different clinical features to highlight the varying severity of symptoms secondary to this parasitic infestation. We also present several examples of imaging characteristics of the disease at various stages, which emphasize the central role of neuroimaging in the diagnosis of neurocysticercosis.
Neurocysticercosis is the most common parasitic infection of the nervous system. However, the improvement in public health made the prevalence of neurocysticercosis low. Neurocysticercosis may have symptoms such as seizures, headache, and hydrocephalus, and calcified neurocysticercosis is generally known to be asymptomatic and inert. Also, status epilepticus associated with neurocysticercosis has been rarely reported. Therefore, we report a case of focal status epilepticus caused by calcified neurocysticercosis that invaded the subarachnoid space, which is uncommon pathophysiology of neurocysticercosis.
Human cysticercosis is caused by ingestion of T. solium eggs from taenia carriers. Neurocysticercosis (NCC), defined as the infection of the CNS and the meninges by the larval stage of Taenia solium, is the most common helminthic infection of the CNS worldwide. Parasites may lodge in brain parenchyma, subarachnoid space, ventricular system, or spinal cord, causing pathological changes that account for the pleomorphism of this disease. Seizures/epilepsy are the most common clinical manifestation, but other patients present with headache, focal deficits, intracranial hypertension, or cognitive decline. Accurate diagnosis of NCC is possible after interpretation of clinical data together with findings of neuroimaging studies and results of immunological tests. However, neuroimaging studies are fundamental for diagnosis because immunological test and clinical manifestations only provide circumstantial evidence of NCC. The introduction of cysticidal drugs changed the prognosis of most NCC patients. These drugs have been shown to reduce the burden of infection and to improve the clinical course of the disease in many patients. Efforts should be directed to eradicate the disease through the implementation of control programs against all the steps in the life cycle of T. solium, including carriers of the adult tapeworm, infected pigs, and eggs in the environment.
Focal neurological deficit like monoparesis due to cortical lesions is a rare entity. In spite of the common presentations like seizures and headaches in neurocysticercosis, occurrence of reversible monoparesis is an atypical phenomenon. Even in the absence of infarct or hemorrhages, manifestation of neural deficit due to compressive effect only is an interesting finding. And on top of that, reversible nature of the deficit in space occupying lesion is a rare occurrence in the existing literature. Here, we describe a known case of neurocysticercosis with reversible acute monoparesis secondary to multiple neurocysticercosis. The variations with which neurocysticercosis can present broaden our understanding in its pathophysiology and management protocol.
Patients with neurocysticercosis, a common infection of the central nervous system caused by Taenia solium, have been reported to develop neuropsychiatric complications. We report a unique case of recurrent psychosis caused by neurocysticercosis in a 37-year-old El Salvador immigrant woman and discuss the underlying pathophysiological mechanisms of the complications. We reviewed published case reports of neurocysticercosis that presented with psychotic features and compared their diagnostic evaluation, the underlying pathophysiology of complications and treatment regimen with our case. This review concludes that neurocysticercosis should be considered in the differential diagnosis of patients presenting with psychosis with a history of residence in an endemic area.
Objectives
Neurocysticercosis, the commonest neuro-parasite, sometimes presents as complex ring enhancing lesion causing diagnostic dilemma. We aim to establish radio-histo-morphological equivalents of early events in degeneration of the parasite to explain such imaging phenotypes.
Methods
We compared patterns of degeneration in 23 randomly selected complex NCC on MRI with histo-morphology in 30 cysts obtained from an unrelated post mortem brain.
Results
The anatomy of the parasite and the degenerative patterns of the scolex (hydropic changes, calcification, evagination, and fragmentation) and the cyst wall (undulation, accessory loculi, and frank disruption) were well demonstrated on both. The intact scolex remarkably resembled head of intestinal Taenia. The complex lesions were conglomeration of multiple communicating cysts with a single parent cyst and multiple daughter cysts. The parent cysts contained a solitary variably degenerated scolex, had thicker walls and associated chronic inflammation. The remaining cysts of the lesion complex contained no scolex, had poorly organized walls, turbid contents, and florid perilesional enhancement with leakage of contrast. Three lesions assumed a multi-cystic pseudo-tumorous pattern, of which two resolved into solitary calcific remnants on follow up.
Conclusion
Complex lesion in NCC result from degeneration of solitary parasite with perilesional gliosis, surrounded by multiple non-larval daughter cysts inciting acute intra and perilesional inflammation due to enhanced antigenic challenge. Possibly, attempted abortive asexual reproduction by the cellulose cyst as a preterminal event results in a “limited Racemose like transition.” Correct interpretation has diagnostic and therapeutic implications as active lesions and their fibrocalcific residue may have greater epileptogenic potential.
Neurocysticercosis (NCC) remains the most common helminth infection of the human central nervous system worldwide. Patients with NCC are especially predisposed to cerebrovascular events such as acute ischemic stroke (AIS), intracerebral hemorrhage (ICH), and subarachnoid hemorrhage due to an immune-mediated process in which infiltration of inflammatory cells into blood vessel walls leads to endothelial hyperplasia and endarteritis, known as cysticercotic angiitis. Additionally, the oncosphere of the parasite causing NCC produces T. solium enolase, an enzyme which binds and activates human plasminogen receptor proteins to plasmin, leading to a hypercoagulable state. Currently, NCC is not a contraindication to administration of tissue plasminogen activator (tPA) for a suspected AIS. However, to our knowledge, it has not been assessed whether the presence of NCC increases the likelihood of hemorrhagic conversion of an AIS after tPA administration. We present the case of an 83-year-old lady with NCC who developed multifocal right-sided ICH involving the temporal, parietal, and frontal lobes six and a half hours after tPA administration for a suspected AIS. Given this event and the cellular mechanisms provided, we recommend a safety surveillance study to further determine the potential risks of hemorrhagic conversion in this population.
Intracranial inflammatory disorders are common in children, including infection and immune-associated encephalitis. Common intracranial infectious encephalitis pathogens include bacteria, viruses, fungi, tuberculosis, parasites, and other pathogens. Immune-associated encephalitis is becoming more common due to its underlying abnormal immune response in the central nervous system. Some immune-associated encephalitis are associated with antibodies against cell surface antigens, which include NMDAR, MOG, AQP4, etc. CT and MRI examinations can assist clinicians to determine the location and extent of the lesions, follow up the evolution of the lesions, find out the complications, observe the treatment effect, and give a qualitative diagnosis in certain cases. MRI is much more effective than CT and has become the preferred method for the examination of inflammatory disorders in children.
Background:
The burden of premature mortality associated with human cysticercosis is largely ignored mainly due to poor record-keeping in Taenia solium endemic regions.
Objective:
To document mortality and survival characteristics of an historical cohort with cysticercosis.
Methods:
The years of onset of symptoms and death untill 1957 were extracted from published reports of a British military cohort (n=450) examined in London in the early twentieth century. Data were entered into a Kaplan Meier survival analysis with the presence (or absence) of clinical manifestations as independent variables, which were then fitted into a Cox proportional hazards model to determine their significance.
Results:
Cysticercosis was responsible for 24 (52.2%) of 46 deaths in the first 15 years of follow-up in comparison to 7 (19.4%) of 36 deaths in the 20-40 years of follow-up period. In the univariate and Cox analyses, intracranial hypertension (hazard ratio [HR]: 8.26; CI: 4.71, 14.49), ocular cysticercosis (HR: 6.60; CI: 3.04, 14.33), and mental disorder (HR: 3.98; CI: 2.22, 7.13) but not epilepsy (HR: 0.66; CI: 0.20, 2.18) were associated with mortality. Over half of all deaths in the first 15 years of follow-up were attributed to cysticercosis.
Conclusions:
Several deaths occurred early after acquiring cysticercotic infection. Intracranial hypertension, ocular cysticercosis, and mental disorder but not epilepsy were predictors of mortality in this cohort.
Background and purpose:
Solitary calcified neurocysticercosis (NCC) on the computed tomography (CT) scan of brain in patients of epilepsy is common finding in endemic regions. Factors causing seizures in such cases are debatable. Immature calcification may be the causative factor for seizure recurrence. Thus, we aimed to study predictors of seizure recurrence specific to morphological characteristics on CT scan.
Methods:
Patients with solitary calcified NCC on CT scan brain and active seizures were prospectively included. The protocol included clinical evaluation, contrast-enhanced CT scan of the brain, and electroencephalogram (EEG) at baseline and 9th month of 1-year follow-up in all patients. Seizure recurrence after 1 week of enrolment was recorded.
Results:
One hundred twenty patients with a mean age of 23.33±12.81 years were included with a final follow-up of 109 patients and 35 patients had seizure recurrence. On univariate analysis, seizure frequency of more than 1 episode/month (45.7% vs. 25.7%, p=0.037; odds ratio [OR], 2.06; 95% confidence interval [CI], 1.05-5.68), perilesional edema on CT head (45% vs. 10.8%, p<0.001; OR, 6.95; 95% CI, 2.58-18.7), lower density (HU) of lesion on CT head (139.85±76.54 vs. 204.67±135.9 HU p=0.009) and abnormal EEG at presentation (p<0.001; OR, 18.25; 95% CI, 2.15-155.13) were significantly associated with seizure recurrence. On multivariate analysis, presence of perilesional edema on CT head (p=0.001; OR, 6.854; 95% CI, 2.26-20.77), density of lesion on CT (HU) (p=0.036; OR, 0.995; 95% CI, 0.99-1) and abnormal EEG (p=0.029; OR, 12.125; 95% CI, 1.29-113.74) were independently associated with seizure recurrence.
Conclusions:
The presence of perilesional edema, HU of calcification on CT brain, and abnormal EEG suggest an increased risk of seizure recurrence in patients of epilepsy with solitary calcified NCC.
Cysticercosis is one of the main causes of secondary epilepsy in sub-Saharan Africa. To estimate the seroprevalence of cysticercosis among epileptic patients, we conducted a cross-sectional study of patients attending neurology consultation in Abidjan, Côte d’Ivoire. Methods: Patients’ socio-demographic and lifestyle data were collected as well as blood samples for serological testing using ELISA and Western blot based on IgG antibodies detection. For qualitative variables comparison, Chi2 or Fisher tests were used; a Student’s t-test was used to compare quantitative variables. A multivariate logistic regression model was fit to identify risks factors. Results: Among 403 epileptic patients included in the study, 55.3% were male; the median age was 16.9 years; 77% lived in Abidjan; 26.5% were workers. Most patients included in the study had tonic-clonic seizures (80%), and 11.2% had focal deficit signs. The seroprevalence of cysticercosis was 6.0%. The risk was higher in patients over 30 years old (aOR = 5.1 (1.3–20.0)) than in patients under 16. The risk was also considerably high in patients who reported epileptics in the family (aOR = 5 (1.7–14.6)). The risk was three-fold less in females than in males. Conclusions: This study highlighted the exposure of epileptic patients to Taenia solium larvae in an urban area. The risk of positive serology was increased with age, male gender, and family history of epilepsy.
Asmaa M El-Kady,1 Khaled S Allemailem,2 Ahmad Almatroudi,2 Birgit Abler,3 Mohamed Elsayed3 1Department of Medical Parasitology, Faculty of Medicine, South Valley University, Qena, Egypt; 2Department of Medical Laboratories, College of Applied Medical Sciences, Qassim University, Buraydah, Saudi Arabia; 3Department of Psychiatry and Psychotherapy III, University of Ulm, Ulm, 89075, GermanyCorrespondence: Asmaa M El-KadyDepartment of Medical Parasitology, Faculty of Medicine, South Valley University, Qena, EgyptTel +201114229741Email Asmaa.elkady@med.svu.edu.egAbstract: Neurocysticercosis, the most common type of neuroparasitosis, is a condition in which the central nervous system (CNS) is infested with the pork tapeworm Taenia solium cysticercosis’ larvae. Neurocysticercosis is the most widespread parasitic CNS disease worldwide, affecting more than 50 million individuals. As neurocysticercosis is prevalent in developing countries, the growing number of migrants and travelers increases prevalence in developed countries. Possible neuropsychiatric manifestations are depression, cognitive dysfunction, dementia, and visual hallucinations. Depending on the cysts’ location in the CNS, focal neurology or psychiatric symptoms manifest. The diagnosis of neurocysticercosis is based on neuroimaging and serology. The correlation between specific symptoms and the cyst’s location might help better understand psychiatric disorders’ pathophysiology. Nonetheless, the exact prevalence of neurocysticercosis is seldom reported in patients with psychiatric disorders, which may be due to the lack of imaging availability in developing countries with a high prevalence.Keywords: psychiatric, neurocysticercosis, cognitive functions, depression, dementia
Objectives In patients with neurocysticercosis (NCC), an accurate risk prediction would allow a better therapeutic approach; however, there are currently no tools that can enhance the accuracy of risk prediction. We designed a prognostic scoring system to be used by neurologists and other physicians managing patients with NCC.
Materials and Methods Using data from clinical records of patients from a third-level national reference center for neurological diseases, we assessed demographic, clinical, and tomographic variables among 293 patients diagnosed with NCC. Multivariable logistic regression analyses were used to develop a clinical prognostic scoring instrument. Patients with NCC were assessed for neurological impairment at 3 months after diagnosis.
Statistical Analysis Score accuracy was assessed by receiver operating characteristic (ROC) curve analysis. The primary outcome was the presence of neurological impairment, resulting in disability according to self-report or caregiver reports; this outcome was assessed during follow-up visits at 3 ± 1 months after discharge.
Results The most common symptoms at presentation were headache (67%) and seizure (63%). A six-item (total score from –4 to + 2) prognostic instrument was constructed on the basis of the presence of seizures/headache at presentation, a leukocyte count above 12x 109/dL, the presence of six to ten parasites, subarachnoid localization, and the use of anthelmintic drugs. Among 113 patients with negative scores, 79.6% developed neurological deficits. Among patients with scores of 1 to 2, 64.6% recovered completely, with an overall accuracy of prediction of 74.7% and area under the ROC curve = 0.722 (95% CI, 0.664–0.780, p < 0.0001).
Conclusions The clinical prognostic scoring system for NCC described in this study is a new instrument for use in daily clinical practice. It is simple to administer, and it has a prognostic accuracy of 75%. Its use has the potential to improve the quality of care by guiding appropriate decision-making and early management of patients with NCC.
Taenia solium is endemic in Madagascar and presents a significant burden on the population and the health system. The parasite cycles through humans who host the adult tapeworm, and pigs that host the larval stages. Accidental infection of humans may occur with the larval stages which encyst in the nervous central system causing neurocysticercosis, a major cause of seizure disorders and a public health problem. One of the interventions to facilitate the control of the disease is mass drug administration (MDA) of the human population with taeniacide. Here we describe a pilot project conducted in Antanifotsy district of Madagascar from 2015 to 2017 where three annual rounds of MDA (praziquantel, 10mg/Kg) were undertaken in 52 villages. Changes in the prevalence of taeniasis were assessed before, during and after the treatments. A total of 221,308 treatments were given to all eligible people above 5 years of age representing a 95% coverage of the targeted population. No major adverse effects were notified related to the implementation of the MDA. The prevalence of taeniasis was measured using Kato-Katz and copro-antigen techniques. Analyses undertaken combining the results of the Kato-Katz with copro-antigen, or using the Kato-Katz results alone, showed that there was a significant reduction in taeniasis 4 months after the last MDA, but 12 months later (16 months after the last MDA) the taeniasis prevalence had returned to its original levels. Results of the pilot project emphasize the need of a multi-sectorial One-Health approach for the sustained control of T. solium.
A major source of epilepsy is Neurocysticercosis (NCC), caused by Taenia solium infection. Solitary cysticercus granuloma (SCG), a sub-group of NCC induced epilepsy, is the most common form of NCC in India. Current diagnostic criteria for SCG epilepsy require brain imaging which may not be available in communities where the disease is endemic. Identification of serum changes and potential biomolecules that could distinguish SCG epilepsy from idiopathic generalized epilepsy (IE), without the initial need for imaging, could assist in disease identification, understanding, and treatment. The objective here was to investigate, using mass spectrometry (MS), sera biomolecule differences between patients with SCG epilepsy or IE to help distinguish these disorders based on physiological differences, to understand underlying phenotypes and mechanisms, and to lay ground work for future therapeutic and biomarker analyses. Sera were obtained from patients with SCG or IE (N = 29 each group). Serum mass peak profiling was performed with electrospray ionization (ESI) MS, and mass peak area means in the two groups were compared using leave one [serum sample] out cross validation (LOOCV). Serum LOOCV analysis identified significant differences between SCG and IE patient groups (p = 10⁻²⁰), which became non-significant (p = 0.074) when the samples were randomly allocated to the groups and reanalyzed. Tandem MS/MS peptide analysis of serum mass peaks from SCG or IE patients was performed to help identify potential peptide/protein biochemical and phenotypic changes involving these two forms of epilepsy. Bioinformatic analysis of these peptide/protein changes suggested neurological, inflammatory, seizure, blood brain barrier, cognition, ion channel, cell death, and behavior related biochemical systems were being altered in these disease states. This study provides groundwork for aiding in distinguishing SCG and IE patients in minimally invasive, lower-cost manners, for improving understanding of underlying epilepsy mechanisms, and for further identifying discriminatory biomarkers and potential therapeutic targets.
Neurocysticercosis (NCC), a disease caused by the larval pork tapeworm Taenia solium, has emerged as an important infection in the United States. In this study, we describe the spectrum of NCC infection in eastern Long Island, where there is a growing population of immigrants from endemic countries. A retrospective study was designed to identify patients diagnosed with NCC using ICD-9 and ICD-10 codes in the electronic medical records at Stony Brook University Hospital between 2005 and 2016. We identified 52 patients (56% male, median age: 35 years) diagnosed with NCC in the only tertiary medical center in Suffolk County. Twenty-five cases were reported in the last three years of the study. Forty-eight (94%) patients self-identified as Hispanic or Latino in the electronic medical record. Twenty-two (44%) and 28 (56%) patients had parenchymal and extraparenchymal lesions, respectively. Nineteen (41.3%) patients presented with seizures to the emergency department. Six patients (11.7%) had hydrocephalus, and five of them required frequent hospitalizations and neurosurgical interventions, including permanent ventriculoperitoneal shunts or temporary external ventricular drains. No deaths were reported. The minimum accumulated estimated cost of NCC hospitalizations during the study period for all patients was approximately 1.4 million United States dollars (USD). In conclusion, NCC predominantly affects young, Hispanic immigrants in Eastern Long Island, particularly in zip codes correlating to predominantly Hispanic communities. The number of cases diagnosed increased at an alarming rate during the study period. Our study suggests a growing need for screening high-risk patients and connecting patients to care in hopes of providing early intervention and treatment to avoid potentially detrimental neurological sequelae.
The diagnosis of neurocysticercosis in pregnancy is challenging, even in endemic areas, as other neurological conditions with similar manifestations are common. Obstetricians and physicians may be reluctant to do neuroimaging in pregnancy and often the availability is limited in endemic areas. Management of neurocysticercosis depends on the symptomatology. In those presenting with features of increased intracranial pressure early treatment is necessary, taking into consideration the gestational age and the maternal condition at presentation. Presence of intraventricular cysts causing obstructive hydrocephalus necessitates their removal due to the risk of intracranial hypertension which could be life-threatening, particularly peripartum. We report a case of a woman with intraventricular neurocysticercosis, who presented in the third trimester, and described the management dilemmas that were encountered. The differential diagnoses and other aspects of the medical and surgical management of neurocysticercosis in pregnancy are also discussed.
Neurocysticercosis, or brain infestation with the larval stage of Taenia solium, is the most common risk factor for epilepsy in many endemic regions of the world. Hardly any cases are seen in Western developed countries, including Britain. However, a sizeable number (n = 450) was seen among British soldiers returning from deputation to India, then a British colony, first reported by Col. MacArthur at the Queen Alexandria Military Hospital in 1931. Here, we review the influence of the perceptive observations of British Army medics on the understanding of the parasitic disorder. The majority of these people presented with epilepsy. Among the contributions of the army medics were establishing the diagnosis, initially by histological examination of subcutaneous and muscular infestation, and later by radiography, clarifying the prognosis and the role of medical and surgical treatments and uncovering the close relationship between the larval (cysticercosis) and adult (intestinal tapeworm) stages of T. solium.
Neurocysticercosis (NCC) is a helminth infection affecting the central nervous system caused by the larval stage (cysticercus) of Taenia solium. Since vascular alteration and blood–brain barrier (BBB) disruption contribute to NCC pathology, it is postulated that angiogenesis could contribute to the pathology of this disease. This study used a rat model for NCC and evaluated the expression of two angiogenic factors called vascular endothelial growth factor (VEGF‐A) and fibroblast growth factor (FGF2). Also, two markers for BBB disruption, the endothelial barrier antigen and immunoglobulin G, were evaluated using immunohistochemical and immunofluorescence techniques. Brain vasculature changes, BBB disruption, and overexpression of angiogenesis markers surrounding viable cysts were observed. Both VEGF‐A and FGF2 were overexpressed in the tissue surrounding the cysticerci, and VEGF‐A was overexpressed in astrocytes. Vessels showed decreased immunoreactivity to endothelial barrier antigen marker and an extensive staining for IgG was found in the tissues surrounding the cysts. Additionally, an endothelial cell tube formation assay using human umbilical vein endothelial cells showed that excretory and secretory antigens of T. solium cysticerci induce the formation of these tubes. This in vitro model supports the hypothesis that angiogenesis in NCC might be caused by the parasite itself, as opposed to the host inflammatory responses alone. In conclusion, brain vasculature changes, BBB disruption, and overexpression of angiogenesis markers surrounding viable cysts were observed. This study also demonstrates that cysticerci excretory‐secretory processes alone can stimulate angiogenesis.
Purpose of review
Neurocysticercosis (NCC) results from the localization in the central nervous system (CNS) of larval stages of the cestode parasite Taenia solium. NCC is the most common helminthic parasitic disease of the nervous system and the main cause of acquired epilepsy. This literature review presents an update in NCC diagnostic techniques, including neuroimaging, immunological assays, molecular assays, and clinical manifestations.
Recent findings
NCC can cause a wide array of neurological manifestations, most of them being non-pathognomonic. Diagnosis of this infection represents a challenge due to its nonspecific symptoms and limited resources in endemic regions. Diagnoses by neuroimaging and immunological assessment are the current criteria used to diagnose NCC.
Summary
Current diagnostic techniques continue to be non-affordable and non-available in most endemic regions. The development of novel and affordable standardized diagnostic techniques is of urgent need in order to determine the actual global burden caused by NCC.
To study the cognitive profile and scholastic performance of children with parenchymal neurocysticercosis. A total of 500 children with a diagnosis of neurocysticercosis and epilepsy registered in our pediatric neurocysticercosis clinic between January 1996 and December 2002 were enrolled. Patients were evaluated for their scholastic performance using their school grades. Cognitive assessment was done using Parental interview and the “Draw-a-Man” test. Poor scholastic performance was seen in 22.2% (111) children. Draw-a-Man test was done in 148 children; 18.2% (27/148) had scores equivalent to IQ <70. Intermittent headache, behavior problems, and poor memory were reported in 40% (201) children. Multiple lesions, lower socioeconomic status, and calcified lesions on follow-up were associated with academic underachievement (P < .05). About a fourth of children with neurocysticercosis had cognitive impairment during follow-up. This was mostly seen in children from lower socioeconomic status and in those with multiple-lesion neurocysticercosis.
The immune system plays an essential role in distinguishing between self and non-self and hence protecting the host from infections. Upon the pathogen encounter, the host seeks to ensure an adequate inflammatory reaction to combat infection but at the same time tries to prevent collateral damage due to excessive immune activation. As such, limiting inflammation during an infection is an essential goal, for which several counterregulatory mechanisms are put into play, like the production of adrenal steroid hormones. This will assure a successful defense and adaptation of the organism to injury, highlighting the relevance of the relationship between adrenal hormones and the immune response. Chronic infections with bacteria, or parasites were found to display several endocrine abnormalities, ranging from subtle disturbances to substantial alterations in the regulation of the HPA axis. Facts accounting for such disturbances encompass several non-mutually exclusive possibilities, inflammation in neuroendocrine tissues, partly due to the presence of pathogens and the ensuing structural and functional alterations; along with the exploitation of the host's hormonal microenvironment by the infectious agent. Alterations in the steroid hormone axis may be also viewed as one of the consequences resulting from the re-directioning of energy to the immune system during chronic infections. Collectively, these alterations further contribute to a deficient control of infection and immunopathology, together with metabolic changes, which promote an unsuitable scenario for disease prognosis.
Infectious myelopathies can be caused by viral, bacterial, fungal, and parasitic agents. In this chapter, the most common causes of infectious and tropical myelopathies will be reviewed. HIV and HTLV-1 retroviruses have been associated with subacute and chronic myelopathy; herpesviruses may cause radiculomyelitis and transverse myelitis; enterovirus and flavivirus seem to have a tropism for the anterior horns of the spinal cord. Paralytic poliomyelitis can occur as a complication of poliovirus infection in around 1–2% of cases. Enterovirus D68 and 71 have been identified as the etiologic agent of a poliomyelitis-like syndrome. The Flaviviridae family includes some mosquito-borne virus such as dengue, chikungunya, Zika, Japanese encephalitis, West Nile and Murray Valley viruses, and tick-borne virus and has also been associated with a flaccid poliomyelitis-like syndrome. Tuberculous myelopathy may develop as a secondary extension of vertebral body tuberculosis (Pott’s disease), as a downward extension of tuberculous meningitis, and even as a primary tuberculous lesion. Spinal schistosomiasis is a common cause of acute myelopathy in tropical regions, and acute transverse myelitis, conus medullaris syndrome, and lower limb myeloradiculopathy are the most common schistosomal spinal syndromes. Other parasitary diseases that may affect the spinal cord are gnathostomiasis, cysticercosis, hydatid disease, and paragonimiasis. Invasive fungus may provoke a spinal cord compression syndrome from osteomyelitis, epidural abscess, or paravertebral lesions.
Taenia solium has been ranked as the most important foodborne parasite and Taenia saginata as the most commonly found human Taenia tapeworm worldwide. The last official reports of taeniosis from Estonia were in 2003 for T. solium and 2012 for T. saginata. By law, all animal cases of cysticercosis must be registered and reported when found. Our aim was to estimate the prevalence of cysticercosis in Estonia caused by T. solium in pigs and T. saginata in cattle. The four slaughterhouses participating in the study slaughter between them approximately 80% of pigs and cattle in Estonia annually. Sampling spanned from February to April 2014, visiting the slaughterhouses five times per week. Visual inspection, palpation, and incisions at predilection sites were used to find cysts in both species. The sites inspected in both species were the external masseter, tongue, heart, and diaphragm. In addition, the internal masseter in pigs was examined, and the internal pterygoid muscle and esophagus in cattle. DNA was extracted from the cysts and used for PCR amplification of the cox1-gene for Taenia genus and species identification. A total of 564 cattle and 1217 pigs were examined. Cysts were found in 0.36% (n = 2; CI 0.06–1.17) of cattle and in 0.08% (n = 1; CI 0.004–0.40) of pigs. Cestode PCR was negative from all cysts. Results should be considered taking into account the low sensitivity and specificity of finding cysts. Results reflect the situation in larger slaughterhouses, and the possibility that the situation in smaller slaughterhouses is different should not be excluded.
O b s e r v a t i o n Une femme, âgée de 27 ans, d'origine portugaise, est adressée aux urgences médicales pour une confusion fébrile évoluant depuis cinq jours dans un contexte de syndrome pseudo-grippal. Elle vit en France depuis un an sans être retournée au Portugal. Elle n'a pas d'antécédent médical. Rapidement après son admission, elle présente des troubles de la conscience, une raideur méningée et des myoclonies du pied droit. La patiente est transférée dans le service de réanimation. Les examens biologiques sont normaux (absence d'hyperleucocytose et protéine C réactive normale). Une tomodensitométrie (TDM) cérébrale sans et avec injection ne retrouve qu'une hydrocéphalie quadriventriculaire modérée (figure 1). La ponction lombaire (PL) montre un liquide clair, avec 350 leucocytes/mm 3 (lymphocytes : 43 %, neutrophiles : 15 %, monocytes : 30 %, éosinophiles : 5 %), une hyperprotéi-norachie à 0,96 g/l et une hypoglycorachie (1,5 mmol/l pour 5,1 mmol/l dans le sang). L'examen direct du liquide céphalora-chidien (LCR) après coloration de Gram est négatif, ainsi que la recherche des antigènes de cryptocoque et de pneumocoque. Après la réalisation de deux hémocultures à 15 minutes d'inter-valle, un traitement par voie intraveineuse (i.v.) associant amoxicilline (200 mg/kg/j en 6 injections) et aciclovir (30 mg/ kg/j en 3 injections) a été instauré. En parallèle, un traitement anticonvulsivant par valproate de sodium i.v. est mis en place (dose de charge puis entretien i.v. en continu). En quelques heures, l'état neurologique de la patiente s'améliore très nettement, suggérant que le tableau neurologique initial était en rapport avec une crise convulsive. Un électroencé-phalogramme (EEG) réalisé sous traitement anticonvulsivant s'avère normal. Le bilan est complété par une imagerie par résonance magnétique (IRM) du cerveau qui retrouve une lésion isolée intraventriculaire (mesurant 18 × 14 × 15 mm), localisée dans la corne occipitale du ventricule latéral gauche, générant un hypersignal en séquence T1. Une ventriculite en regard des parois de cette lésion ainsi que l'hydrocéphalie, déjà mentionnée sur la TDM (figures 2 et 3, p. 224), sont également observées.
Helminths are multicellular eukaryotic organisms that are common parasites of the human gastrointestinal tract. There are three major groups of helminth that can cause human disease: nematodes, trematodes and cestodes. Nematodes are round worms with a tubular gut, including the genus Enterobius, Trichuris, Trichinella, Capillaria, Trichostrongylus, Strongyloides, Ascaris, Necator and Ancylostoma, Angiostrongylus, Anisakis and Eustrongylides. There are two groups of flatworms: trematodes and cestodes. Trematodes, or flukes, have a blind gut and include the genus Schistosoma, Clonorchis, Opisthorchis, Fasciola, Fasciolopsis, Dicrocoelium, Echinostoma, Heterophyae and Metagonimus. The cestodes, or tapeworms, include Diphyllobothrium, Taenia, Hymenolepis and Echinococcus. Historically, infestation with intestinal helminths has been a normal part of the human condition. Epidemiological studies of inflammatory bowel disease and other diseases caused by immune dysregulation suggest a possible protective role for helminth infections in these conditions. According to the hygiene hypothesis, the loss of helminth exposure which has accompanied socioeconomic improvements has impaired the function of immune regulatory circuits that previously protected humans from immunologic diseases.
Lesion-deficit mapping remains the most powerful method for localising function in the human brain. As the highest court of appeal where competing theories of cerebral function conflict, it ought to be held to the most stringent inferential standards. Though at first sight elegantly transferable, the mass-univariate statistical framework popularized by functional imaging is demonstrably ill-suited to the task, both theoretically and empirically. The critical difficulty lies with the handling of the data's intrinsically high dimensionality. Conceptual opacity and computational complexity lead lesion-deficit mappers to neglect two distinct sets of anatomical interactions: those between areas unified by function, and those between areas unified by the natural pattern of pathological damage. Though both are soluble through high-dimensional multivariate analysis, the consequences of ignoring them are radically different. The former will bleach and coarsen a picture of the functional anatomy that is nonetheless broadly faithful to reality; the latter may alter it beyond all recognition. That the field continues to cling to mass-univariate methods suggests the latter problem is misidentified with the former, and that their distinction is in need of elaboration. We further argue that the vicious effects of lesion-driven interactions are not limited to anatomical localisation but will inevitably degrade purely predictive models of function such as those conceived for clinical prognostic use. Finally, we suggest there is a great deal to be learnt about lesion-mapping by simulation-based modelling of lesion data, for the fundamental problems lie upstream of the experimental data themselves.
Neurocysticercosis (NC) remains a major public health problem in developing and some developed countries. Currently, the best procedures for diagnosing NC are neuroimaging studies. Immunoserologic assays, such as enzyme‐linked immunoelectrotransfer blot assay (EITB) or enzyme‐linked immunosorbent assay (ELISA), detect antibodies against Taenia solium , or cysticercus. Consequently, they are useful in identifying a population at risk of contact with the parasite but do not necessarily indicate a systemic active infection. Most seropositive individuals are asymptomatic. No data from prospective studies concern the proportion of these individuals that will develop seizures or other neurologic symptoms. There is a discrepancy between the results of serologic assays and neuroimaging studies: >50% of those individuals with NC diagnosed by computed tomography (CT) scan test EITB negative.
Pathophysiologic classification of NC into active, transitional, and inactive forms permits a good correlation between clinical manifestations and neuroimaging procedures and facilitates medical and surgical management and research. The most frequent clinical manifestations of NC are seizures. We assume that NC is the main cause of symptomatic epilepsy in developing countries; however, no case‐control or cohort studies demonstrate this association. Most patients with NC with seizures have a good prognosis; nevertheless, further studies analyzing factors related to recurrence of seizures and possibilities of discontinuation of antiepileptic medications (AEDs) are needed.
Regarding treatment of NC with antihelminthic drugs, no controlled clinical trials exist that establish specific indications, definitive doses, and duration of treatment. The most effective approach to taeniasis/cysticercosis infection is prevention. This should be a primary public health focus for developing countries.
We critically review the available information regarding the epidemiology and diagnosis of human cysticercosis, the physiopathology and imaging correlation of the parasite in the central nervous system (CNS) of the host, the relation between seizures or epilepsy and NC, and the issues surrounding the treatment and prognosis of NC, including the use of antihelminthic therapy.
Ischaemic cerebrovascular disease is a relatively common but under-recognised complication of neurocysticercosis. It is usually caused by inflammatory occlusion of the arteries at the base of the brain secondary to cysticercotic arachnoiditis. In most cases, the involved vessels are of small diameter and the neurological picture is limited to a lacunar syndrome secondary to a small cerebral infarct. However, large infarcts related to the occlusion of the middle cerebral artery or even the internal carotid artery have also been reported in this setting. CT and CSF examination usually support the cause-and-effect relationship between neurocysticercosis and the cerebral infarct by showing abnormalities compatible with cysticercotic arachnoiditis. An accurate diagnosis of this condition is important since early treatment with steroids is advised to ameliorate the subarachnoid inflammatory reaction which may cause recurrent cerebral infarcts.
Taenia solium cysticercosis is a frequent cause of neurological disease in developing countries. Specific diagnosis of cysticercosis is difficult. We obtained serum and/or CSF samples from 204 consecutive patients admitted to a neurological ward in Lima, Peru, and looked for antibodies specific for T solium with the enzyme-linked immunoelectrotransfer blot (EITB) assay. 21 (12%) of 173 serum samples from these patients were EITB-positive. In contrast, only 2 (1.5%) of 135 patients attending a public endoscopy clinic and 1 (1%) of 88 patients attending a private endoscopy clinic were seropositive. 1 (1%) of 98 pregnant women living in a Lima shanty town was EITB-positive. 15 (58%) of 26 neurology patients diagnosed clinically as having cysticercosis were seronegative. Routine screening by EITB of all patients with neurological symptoms from areas of endemic cysticercosis would avoid misdiagnosis of this common and treatable disease.
A study was carried out in a rural community of the state of Guerrero in order to find ways to control human taeniasis/cysticercosis (Taenia solium). At the beginning of the study the frequency of porcine cysticercosis was established to be around 6.6%. Fecal examination in the human population showed that of 760 persons, 24 were carriers of Taenia sp (3%). Of 440 human sera tested for antibodies against cysticercus cellulosae, 9 showed absorbance values of 0.2 or higher (2.3%). 900 persons received treatment against taeniasis. 400 soil samples and 600 flies were examined for the presence of eggs of Taenioae, all with negative results. Meetings with the adult population were organized to explain the disease and the life cycle of the parasite. Lectures and demonstrations for adults were given at the school for primary and secondary grade children. Special emphasis was given to the need to construct latrines in every home, as it was found that defaecation was practiced mainly in the open, usually at places where pigs had immediate access and ingested the faeces. One year after the initiation of the programme, pigs under the age of 1 year were inspected, to determine whether the cestocide treatment of humans has had an effect on the degree of parasitized pigs and if hygiene had improved. 11% of these animals were found to have cysticerci in their tongue. Two years after the initiation of the programme 78% of the children and 2% of adults answered questions about the lifecycle of the parasite correctly. The results of the trial are discussed and suggestions for future programmes are made.
A large-scale study in Loja and El Oro Provinces, Ecuador, demonstrated that population-based treatment of human taeniasis with a low dose of praziquantel is feasible and effective for the short-term control of transmission of Taenia solium in hyperendemic areas. Chemotherapeutic intervention also effectively promoted local preventive measures and contributed greatly to the elaboration of a long-term control programme.
Cysticercosis is the commonest parasitic disease of the central nervous system and is endemic not only in developing countries
but in industrialized nations with high rates of immigration from endemic areas. Clinical manifestations of neurocysticercosis
are nonspecific and depend mainly on the number and the topography of the lesions, the host immune response to the parasite,
and the sequelae of previous infections. Diagnosis is difficult on clinical grounds, but integration of data from computed
tomography and cerebrospinal fluid analysis permits accurate diagnosis of most cases. Therapy for neurocysticercosis is also
varied and must be individualized according to the activity of the disease and location of cysticerci. In this paper, the
experience of the authors with neurocysticercosis is summarized and current information on several controversial aspects of
this disease is reviewed.
Neurocysticercosis, occasionally associated with long-term neurologic sequelae such as epilepsy or hydrocephalus, is more often a condition characterized by a benign course and spontaneous remission without permanent neurologic symptoms. This variability in outcome has led to difficulties in the interpretation of studies of the effectiveness of drugs used to treat this condition.
To evaluate the relative efficacy of two antihelminthic agents against each other and against symptomatic treatment alone.
Randomized clinical trial of treatment of patients with newly identified active neurocysticercosis with oral prednisolone alone (27 patients), praziquantel with prednisolone (54 patients), or albendazole with prednisolone (57 patients).
At 6 months and at 1 year after treatment, there were no differences in the three treatment groups in terms of the proportion of patients who were free of cysts or the relative reduction of number of cysts. At 2 years, there was no difference in the proportion of patients free of seizures during the entire follow-up period. Early and late sequelae occurred in a higher proportion of patients treated with praziquantel and albendazole, compared with those receiving only prednisolone.
Previous reports of favorable response to treatment of neurocysticercosis with either praziquantel or albendazole are by no means definitive and may be a reflection of the natural history of the condition. The present study, with randomized treatment assignment and including a control group, raises questions as to what extent and in whom treatment with these drugs is effective, and suggests that treatment with antihelminthic agents may be associated with an increased frequency of long-term sequelae.
This book contains 44 chapters on Taenia solium cysticercosis. Six sections cover the following topics: basic science, epidemiology, clinical aspects, pathology, investigational aspects of neurocysticercosis, and therapy and prevention. The likely readership consists of researchers and students in parasitology, neurology, tropical medicine, tropical and infectious diseases and public health. The book is indexed and contains a list of abbreviations.
The authors report that neurocysticercosis is the most common parasitic infection of the central nervous system worldwide. Its incidence in the United States and the involvement of neurosurgical services in the treatment of this entity is increasing. Management options for ventricular cysticercosis include antihelminthic therapy, cerebrospinal fluid shunting, and/or surgical removal of cysts.
Purpose: To study the demographic factors, clinical diagnosis, results of investigation, modalities of treatment and their outcome in ocular and extraocular cysticercosis.
Method: A total of 20 patients were recruited for the study. Ultrasonography and computed tomography were done for all the patients. Serial ultrasound was obtained in patients receiving medical treatment. Therapy was individualized according to the location of the cyst.
Results: The commonest clinical presentation was proptosis (9 of 20) with restriction of ocular movements, followed by subconjunctival cyst, subretinal cyst, papilloedema, atypical optic neuritis, lid nodule and intraretinal cyst. Ultrasonography was comparable with computed tomographic scan for detection of scolex. Two of the twenty patients had associated cysts in the brain parenchyma. Medical or surgical therapy as indicated, had a satisfactory outcome.
Conclusion: Cysticerci can lodge themselves in any part of the ocular and extra ocular tissue. Associated brain parenchyma involvement is quite rare. The clinical presentation, treatment and outcome mainly depends on the location of the cyst.
In this report the authors review their 3-year experience with the endoscopic management of patients with hydrocephalus who harbored cysticercal cysts within the third and lateral ventricles. The management plan was to utilize an endoscopic approach to remove the cysts and to incorporate techniques useful in treating obstructive hydrocephalus. The ultimate goals were to avoid having to place a complication-prone cerebrospinal fluid shunt and to eliminate the risk of complications related to cyst degeneration.
A retrospective analysis of 10 patients with hydrocephalus and cysticercal cysts within the third or lateral ventricles who were endoscopically managed was performed. A general description of the instrumentation and technique used for removal of the intraventricular cysts is given. At presentation, neuroimaging revealed findings suggestive of obstructive hydrocephalus in eight patients. Seven of the 10 patients treated endoscopically were spared the necessity of shunt placement. Three successful third ventriculostomies and one therapeutic septum pellucidotomy were performed. Despite frequent rupture of the cyst walls during removal of the cysts, there were no cases of ventriculitis. The endoscopic approach allowed successful removal of a cyst situated in the roof of the anterior third ventricle. One patient suffered from recurrent shunt obstructions secondary to a shunt-induced migration of cysts from the posterior fossa to the lateral ventricles.
The endoscopic removal of third and lateral ventricle cysticercal cysts, combined with a third ventriculostomy or septum pellucidotomy in selected cases, is an effective treatment in patients with hydrocephalus and should be considered the primary treatment for this condition.
The micro-ELISA described in this report is simple and can give objective results for the serodiagnosis of human cysticercosis. The visual assessment of results was satisfactory. The ELISA results showed a remarkably good correlation with IHA. It gave good reproudcibility. Cross-reactions were eliminated by using whole worm antigen instead of the cysticercus.
A patient with diffuse involvement of the central nervous system and pseudohypertrophic muscular changes induced by cysticerci is described. Electromyographic and pathologic changes are reported for the first time. Electromyographic examination demonstrated numerous short-duration, low-amplitude motor unit potentials in proximal muscles. Biopsy showed swelling of muscle fibers, fiber atrophy with fibrosis, and cellular infiltration separate from inflammatory exudate surrounding numerous cysts.
From June 1990 through July 1991, intracerebral infection with the larval stage of the pork tapeworm Taenia solium was diagnosed in four unrelated persons in an Orthodox Jewish community in New York City. None of the patients had eaten pork, and only one had traveled to a country in which T. solium infection was endemic. We investigated this outbreak, screened serum samples from family members and household contacts for antibodies to cysticercosis, and examined stool specimens from household employees for eggs of taenia species.
The four patients had recurrent seizures and brain lesions that were radiologically consistent with the presence of cysticerci. The diagnosis was confirmed in two patients by a brain biopsy, and in two by immunoblot assays for cysticercus antibodies. Of 17 immediate family members screened serologically, 7 from two families had cysticercus antibodies. Magnetic resonance imaging of the brain showed cystic lesions in two of the seropositive family members, one of whom had had a seizure. Examinations of six domestic employees from all four households revealed an active infection with taenia species in one and a positive serologic test in another. Since these women had recently emigrated from Latin American countries where T. solium infection is endemic, they were the most likely sources of infection in the members of these households.
A diagnosis of neurocysticercosis should be considered in patients with seizures and radiologic evidence of cystic brain lesions, even in those who do not eat pork and who have not traveled to a country in which T. solium infection is endemic. Recent emigrants from countries in which T. solium infection is endemic should be screened for tapeworm infection in their stools before they are employed as housekeepers or food handlers.
To ascertain the reliability of serological diagnosis of neurocysticercosis in the everyday a priori situation of neurological consultation, the enzyme-linked immunosorbent assay test was used to predict the eventual diagnosis of neurocysticercosis in an unselected sample of 1064 consecutive neurological cases. Results showed 69% sensitivity and 71% specificity of the enzyme-linked immunosorbent assay test for the diagnosis of neurocysticercosis. In sharp contrast with publications that have proclaimed the excellent diagnostic performance of immunodiagnostic tests, our results suggest that identification of serum antibodies with standard enzyme-linked immunosorbent assay techniques is of little value when applied to a large and heterogeneous group of neurological patients in an endemic area of cysticercosis, and our results urge a reevaluation of currently used immunodiagnostic tests that are practiced in the serum of suspected cases.
We reviewed clinical, EEG, and CT findings of 203 patients with epilepsy due to neurocysticercosis. Seizures were generalized in 121 patients and partial in 82. Thirty-two patients had focal signs and eight had papilledema. Eighty-one had generalized and 16 had focal EEG abnormalities. CT showed parenchymal brain calcifications in 53 patients and cysts in 150. There was an increased rate of focal signs in patients with single cysts as compared with patients with multiple cysts, and focal EEG abnormalities were present only in patients with single cysts. Fifty patients were lost to follow-up. The remaining 153 patients were followed for 28 +/- 6 months; of these, 31 had calcifications and 122 had cysts. Anticonvulsants were started after the first visit in every patient. The 31 patients with calcifications remained free of seizures. Ninety-five of the 122 patients with cysts were also treated with anticysticercal drugs; of these, 79 (83%) had control of seizures. In contrast, only seven (26%) of 27 patients who did not receive anticysticercal drugs had control of seizures, indicating a strong correlation between the use of anticysticercal drugs and seizure control. Finally, of the 21 patients in whom anticonvulsants were withdrawn, 16 had relapses.
Thirty consecutive Indian patients with focal or generalised seizures and single, small (less than 10 mm), enhancing lesions on CT scans (SSECTL) were studied. Five patients (Group A) were treated with anticonvulsants alone and did not have a biopsy. In ten patients (Group B) a CT guided stereotaxic biopsy of the lesion was carried out and in the remainder (15-Group C) and excision biopsy of the lesion was carried out following CT guided stereotaxic localisation. In all patients in Group B the lesion were reported as "chronic nonspecific inflammation". In seven of 15 patients in Group C the lesions showed a cysticercus with a granuloma and in a further five the pathology was that of a "parasitic granuloma" but the parasite could not be identified. Biopsy did not reveal a tuberculoma or neoplasm in any of the patients. The lesions studied are the same as "disappearing" CT lesions reported in Indian patients, as in 12 of 15 patients in Groups A and B, who could be followed up for more than three months, the lesions had spontaneously disappeared or left calcific residues. It is concluded that in Indian epileptic patients with SSECTL cysticercosis is the commonest aetiology. A treatment protocol for these patients is suggested on the basis of the findings.
This study reports the results of an epidemiologic survey for the detection of Taenia solium in a rural village of 559 inhabitants in Sinaloa, Mexico, as well as a large scale treatment of the population with praziquantel. The study was carried out in two stages. In stage 1, serial stool analysis of 392 persons detected a cluster of three T. solium tapeworms. A fourth T. solium tapeworm was detected through a household census, giving a 1.32% prevalence rate for this helminth. Over 70% of the population over five years of age was treated with a 10 mg/kg dose of praziquantel, and no additional tapeworms were found. Environmental studies for the detection of Taenia sp. eggs in soil, water, and and objects from the houses of tapeworm-infected individuals showed only one soil sample containing eggs compatible with Taenia sp. A total of 72 domestic pigs were examined for the presence of cysticerci under the tongue. One animal had cysts, and belonged to a household that had two T. solium tapeworm infections. Stage 2 of the study was carried out one year after large scale antihelminthic treatment (LSAT), and no infections with Taenia sp. eggs were found. No cysticercus-infected pigs were detected. Intestinal parasitosis decreased from 69.2% to 37.5%. It is concluded that LSAT with praziquantel is efficient in decreasing endemic foci of T. solium. Seropositivity to T. solium bladder fluid antigens was tested by enzyme-linked immunosorbent assay and found to be 11% before LSAT and 7% one year later. In family members living with T. solium tapeworm carriers, the number of seropositive individuals was 28%. The relative risk ratio of seropositivity for persons living in the same household with a T. solium tapeworm carrier was 2.95. Positive response was significantly higher in the 30-39-year-old age group, in which 30% were seropositive in stage 1, compared with 7% one year after LSAT. High seropositivity rates were significantly associated with tapeworm clusters as well as with individuals with a clinical history of seizures.
The efficacy of different regimens of therapy for parenchymal brain cysticercosis either with praziquantel (PZQ) or with albendazole (ALB) was compared in 114 patients. Four schemes of treatment were used: PZQ 50 mg/kg per day for 15 days, PZQ 50 mg/kg per day for 8 days, ALB 15 mg/kg per day for 30 days, and ALB 15 mg/kg per day for 8 days. Three months after therapy, it was apparent that both PZQ and ALB were effective, as shown by the disappearance of cystic lesions in computed tomographic scans. Thirty-three control patients followed for a mean of 11 months had no spontaneous remission of lesions. When comparing PZQ with ALB, the latter was found to be more effective than the former for both the full and the short course of treatment: 85% vs 60% and 85% vs 48% disappearance of lesions, respectively (P less than 0.001). Comparison of the full vs the short course of PZQ showed that the short course had a further 12% reduction in drug effectiveness. In contrast, the length of ALB therapy could be shortened without lessening its efficacy. Based on these results, an 8-day course of ALB is recommended as treatment for parenchymal brain cysticercosis; a 15-day course of PZQ could be subsequently used in those patients who show only partial response to ALB.
Standard therapeutic regimens of praziquantel for neurocysticercosis use daily doses of 50 mg/kg for 15-21 days, with prolonged remission being achieved in 60-80% patients. In this prospective study, 100 mg/kg daily was used for 10 days in 13 patients aged 32 +/- 15 years (mean +/- SD) with severe intra-, extra-parenchymal or mixed forms of neurocysticercosis. Patients were monitored with computerized tomography and cerebrospinal fluid (CSF) examination on days 1, 5 and 10. Full blood count, sedimentation rate, blood sugar, urea, creatinine, bilirubin, liver transaminases, alkaline phosphatase, urine analysis and electrocardiogram were carried out before and after treatment. Doses of dexamethasone and of other drugs used concomitantly were controlled. There was no toxicity, clinical or detected by the methods employed in the study. After 22 +/- 5 (mean +/- SD) months follow-up, 6 patients needed ventriculoperitoneal shunting, 2 had died, 7 were improved and led useful lives and 4 were in prolonged remission. There was no correlation between serum or CSF praziquantel correlation and outcome of treatment. The proposed regimen is well tolerated, may be as efficient as previously advocated regimens, requires less hospitalization time and may be adopted routinely for therapy of neurocysticercosis.
An enzyme-linked immunoelectrotransfer blot (EITB) assay was developed for immunodiagnosing human cysticercosis. The assay
uses lentil-lectin, affinity-purified glycoprotein antigens. A battery of 532 serum and 46 cerebrospinal fluid (CSF) samples
(148 cases of parasitologically confirmed cysticercosis, 54 healthy controls, and 18 types of heterologous infections [376
cases]) were used to ascertain the assay's efficacy. All but three of the samples from cases of confirmed cysticercosis were
positive; none of the samples from healthy controls or heterologous infections reacted to any of the diagnostic bands. Thus,
the assay is 98% sensitive and 100% specific. We identified seven major glycoprotein bands that are commonly recognized by
virtually all serum and/or CSF samples from patients with confirmed cysticercosis. There was no significant difference in
test performance when CSF was compared with serum. The EITB assay is highly reproducible and simple to perform, and the reagents
(including the antigens blotted onto strips) are very stable.
Albendazole is now used for therapy of neurocysticercosis; however, duration of treatment has usually been empirically determined. In this study we shortened the length of therapy from one month in previous reports, to one week. Twelve patients with parenchymal brain cysticercosis were treated with albendazole for eight days at daily doses of 15 mg/kg of body weight. After three months of treatment the number of cysts on computed tomography had decreased from 185 to six; a 97% reduction in the number of lesions. Total remission of all cysts was seen in nine patients. Two cases had been unsuccessfully treated before with praziquantel, in both instances albendazole therapy was effective with 100% improvement. Our results indicated that a short course of albendazole is highly effective for treatment of neurocysticercosis.
Eight patients with cysticerci located inside the sella turcica are presented, and the clinical and radiological features of this rare form of neurocysticercosis are discussed. Clinical features included nonspecific ophthalmological and endocrinological disturbances similar to those produced by other sellar lesions. Computerized tomography (CT) usually showed a hypodense mass that simulated either a cystic tumor or an arachnoid cyst. Cerebrospinal fluid (CSF) findings were also nonspecific, as immunological reactions to cysticercosis were most often negative when inflammation was limited to suprasellar and intrasellar regions. An incorrect diagnosis of tumor was frequent in these cases. In contrast, when intrasellar cysticercosis was associated with other forms of neurocysticercosis, proper integration of CT and CSF data permitted an accurate diagnosis. Cysticercosis should be suspected in patients with hypodense juxtasellar lesions living in geographical areas where this disease is endemic. Prompt surgical resection of cysticerci will avoid irreversible damage to visual function.
A patient who developed a cerebral infarct during the course of praziquantel therapy for neurocysticercosis is described. Destruction of a large number of cysts by praziquantel followed by a massive inflammatory response was likely to have precipitated the event. Caution on the use of this drug in patients with heavy parasite loads is emphasized.
Ninety-two patients with hydrocephalus secondary to cysticercotic meningitis were followed for a mean period of 8 years 11 months. The mortality rate was 50%, with most patients dying within the first 2 years after cerebrospinal fluid (CSF) shunting. The prognosis was worse in females than in males. Multiple surgical procedures for shunt obstruction were necessary in half of the patients. Complications such as bacterial meningitis and shunt obstruction were more frequent in the patients who died than in those who survived. The follow-up data revealed that the clinical status was satisfactory in 78% of survivors and unsatisfactory in 22%. Spontaneous remission of the cysticercotic arachnoiditis, as shown by the CSF findings, occurred in only 18% of the cases. In most patients, arachnoiditis and positive immune reactions persisted unchanged even after several years. The results demonstrate the poor outcome of these patients and indicate the need for better medical and surgical therapy.
Treatment with praziquantel for neurocysticercosis frequently induces adverse reactions due to acute destruction of parasites; these reactions are suppressed by dexamethasone therapy. However, there is controversy about the most appropriate regimen with praziquantel and dexamethasone. We studied plasma levels of praziquantel in eight patients given the drug alone or with dexamethasone. Plasma levels of praziquantel were 50% lower in the same patient when dexamethasone was given simultaneously. Dexamethasone should not be added to praziquantel therapy as preventive treatment, but should be reserved for transient therapy of adverse reactions.
Clinical and computerized tomography findings in patients with miliary infestation of cysticerci in brain parenchyma are presented. Cysticercotic encephalitis produces a severe and frequently fatal neurological disorder. Although parenchymal cysticercosis is common in endemic areas, in the cases reported here, the pathology is induced by a severe inflammatory response in brain parenchyma rather than by the physical presence of multiple cysts. As a result of diffuse brain edema, all cases develop subacute severe intracranial hypertension and compromise of visual function. One important feature of this form of neurocysticercosis is that it particularly affects young women.
A case with cysticercosis cysts in the spinal subarachnoid space with unique myelographic features is discussed. One of the cysts moved within the spinal subarachnoid space during the myelographic examination. Recognition of the possibility that mobility of the cyst may occur between the time of the myelographic study and laminectomy is important for the surgeon.
Patients with hydrocephalus secondary to cerebral cysticercosis are a highly heterogeneous group. The mechanisms of hydrocephalus in these patients are multiple. Intraventricular cysts may be found in the 3rd and 4th ventricles, the sylvian aqueduct, and the foramen of Monro. Intraventricular cysts can be suspected when the 3rd and 4th ventricles or aqueduct remain enlarged despite shunting. Intraventricular contrast medium demonstrates the presence of the parasites. The intraventricular cysts should be removed surgically. Hydrocephalus due to cisternal cysticercosis can be diagnosed by isotope cisternography. These patients should receive shunts, but the long term prognosis is probably poor. Guidelines for the management of hydrocephalus due to cysticercosis are suggested.
The cases of 11 patients with hydrocephalus secondary to cerebral cysticercosis are analyzed. Most of the patients had suffered from epilepsy before they developed hydrocephalic symptoms, and computerized tomography showed that infestation of the parenchyma coexisted with ventricular or cisternal colonization. In four cases, the parasitic vesicles compromised cerebrospinal fluid (CSF) flow in the ventricular system, resulting in internal hydrocephalus. Communicating hydrocephalus, caused by the presence of Cysticercus larvae in the basal cisterns (Cysticercus racemosus) , or by the occurrence of a chronic basal meningitis, or both, developed in seven more patients. Changes in CSF pressure were related to the number and location of the cysts and to the leptomeningeal inflammatory reactions evoked by them. The majority of patients presented with a chronic and relatively normotensive hydrocephalus.
All patients except one had identifiable ventricular or cisternal Cysticercus larvae; these patients were treated with open removal of the cysts, and did well. However, most of them had impairment of CSF flow through the basal cisterns and required permanent CSF shunting. Communicating hydrocephalus due to leptomeningeal scarring was also successfully managed with extracranial shunting. Epilepsy was controlled with anticonvulsant therapy. Although good lasting results may be obtained with aggressive treatment of neurocysticercosis, patients are liable to relapse because surgery is only palliative in most instances.
We report a patient with seizures and a single ringlike enhancing lesion on MRI that resembled a low-grade glioma. The patient received a diagnostic trial with albendazole on the assumption that this lesion could be a cysticercus. Follow-up showed resolution of the brain lesion in 4 weeks. Albendazole administration to patients with single ringlike enhancing lesions may obviate unnecessary surgical procedures in selected cases.
The first studies on specific drug therapy for neurocysticercosis (NCC) appeared more than one decade ago.1-5 As usually occurs with pioneer work with many other drugs, such studies only included anecdotal case reports or small series of patients with different forms of the disease. Therefore, the efficacy of anticysticercal drugs was difficult to evaluate. A new age of knowledge on medical treatment for NCC began when Sotelo and coworkers6,7 published the first controlled trials of praziquantel therapy in patients with parenchymal brain cysts. The authors used historical controls to demonstrate that viable cysticerci may live unchanged for several years within the brain parenchyma and that a course with praziquantel at daily doses of 50 mg per kilogram of body weight for 15 days destroys more than 60% of these cysts in less than 3 months. Using a similar design, several articles from different areas of the world further
The therapy of cysticercosis can be divided into two general categories: disease-directed therapy or symptomatic therapy. The disease-directed therapies include the cysticidal antihelminthic drugs (albendazole and praziquantel), surgical cyst extirpation, and observation without intervention. Symptomatic therapies include corticosteroids for intracranial edema and inflammation, antiepileptic drugs for secondarily acquired epilepsy, surgical procedures such as shunts, and various medications for headaches. Unfortunately, there have been no well-controlled trials to evaluate or compare any of these therapies; therefore, controversy persists.
The life cycle of the parasite, Taenia solium, may include man as either the intermediate host—although swine commonly occupy this niche—or the definite host.1 Antihelminthic drugs have proven effective in eliminating the intestinal adult tapeworm, when man serves the role of definitive host; no further remarks will be made concerning this indication for therapy. When man serves as intermediate host, the hexacanth embryo undergoes hematogenous transport until it comes to rest
We tapered antiepileptic drugs in 40 patients with epilepsy due to neurocysticercosis who had been free of seizures for 2 years. All patients previously received a course of albendazole that resulted in complete destruction of brain cysts. We followed the patients prospectively from the time of diagnosis until 12 months after antiepileptic drug withdrawal. We evaluated the following prognostic factors for seizure recurrence: sex, number of seizures before control, type of seizures, number of parenchymal brain cysts before albendazole therapy, EEG findings, and CT findings after albendazole therapy. In the univariate analysis of prognostic factors for seizure recurrence, the development of brain calcifications caused by albendazole was the only factor associated with a significantly higher rate of relapse (p = 0.004). The multivariate analysis showed that patients who had both recurrent seizures and multiple brain cysts also had a higher risk of relapse than those with single seizures or single cysts (p = 0.05). This study suggests that the prognosis of epilepsy due to neurocysticercosis is not as benign as previously thought. Patients with residual calcifications and those with both recurrent seizures and multiple cysts before albendazole therapy have the highest rate of relapse after withdrawal of antiepileptic drugs.
Single, small, enhancing lesions that often resolve spontaneously are frequent findings on CTs of Indian patients with seizures. Based on ELISA and biopsy data, the majority of these lesions are probably cysticercosis. To determine if these patients should be treated with albendazole, we performed a double-blind, randomized, placebo-controlled study involving 75 patients with seizures and the appropriate CT abnormality without neurologic abnormality on examination. Patients were randomized to albendazole (15 mg/kg/d) and placebo for 1 week, and we obtained serial CTs at the end of 1 week, 1 month, and 3 months. All patients completed a 3-month follow-up and none had systemic evidence of tuberculosis or cysticercosis. The lesions varied in size from 3 mm to 2.1 cm, with an average size of 1.18 cm. Serum ELISA for cysticercosis was positive in 30 and CSF ELISA was positive in 20 of 45 patients. Forty patients received albendazole and 35 received placebo. At the end of 3 months, a total of 68 patients showed resolution. Thirty-five of 40 patients who received albendazole showed resolution, as opposed to 33 of 35 patients on placebo. We conclude that albendazole therapy was not beneficial.