A Trial of Antiparasitic Treatment to Reduce the Rate of Seizures Due to Cerebral Cysticercosis

Department of International Health, Johns Hopkins University, Baltimore, Maryland, United States
New England Journal of Medicine (Impact Factor: 55.87). 02/2004; 350(3):249-58. DOI: 10.1056/NEJMoa031294
Source: PubMed


Neurocysticercosis is the main cause of adult-onset seizures in the developing world. Whether therapy with antiparasitic agents results in improved seizure control has been questioned because of the lack of adequate, controlled studies.
We conducted a double-blind, placebo-controlled trial in which 120 patients who had living cysticerci in the brain and seizures treated with antiepileptic drugs were randomly assigned to receive either 800 mg of albendazole per day and 6 mg of dexamethasone per day for 10 days (60 patients) or two placebos (60 patients). The patients were followed for 30 months or until they had been seizure-free for 6 months after the doses of the antiepileptic drugs had been tapered. The efficacy of treatment was measured as the decrease in the number of seizures after treatment.
In the albendazole group, there was a 46 percent reduction in the number of seizures (95 percent confidence interval, -74 to 83 percent) during months 2 to 30 after treatment. This reduction, which was not statistically significant, was composed of a nonsignificant reduction of 41 percent in the number of partial seizures (95 percent confidence interval, -124 to 84 percent) and a significant 67 percent reduction in the number of seizures with generalization (95 percent confidence interval, 20 to 86 percent). Most of the difference in the number of partial seizures was attributable to a few patients who had many seizures during follow-up. The proportions of patients who had partial seizures during follow-up were similar in the two groups (19 of 57 in the albendazole group and 16 of 59 in the placebo group), but the patients in the placebo group had a greater tendency to have seizures with generalization (22 of 59, vs. 13 of 57 in the albendazole group; risk ratio, 1.63; 95 percent confidence interval, 0.91 to 2.92). More of the intracranial cystic lesions resolved in the albendazole group than in the placebo group. With the sole exception of abdominal pain, side effects did not differ significantly between the two groups.
In patients with seizures due to viable parenchymal cysts, antiparasitic therapy decreases the burden of parasites and is safe and effective, at least in reducing the number of seizures with generalization.

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    • "Some studies have reported that NC patients with acute symptomatic seizures have a good prognosis in terms of remission of seizures (Carpio and Hauser 2009 ; Singhi et al. 2000 ; Manreza 2000 ; Ferreira et al. 2001 ; Goel et al. 2010 ). Other studies have reported that most patients have a high risk of seizure recurrence, and suggest that prognosis improves after antihelminthic treatment (Garcia et al. 2004 ). Prospective cohort studies have determined a risk between 17 and 56 % of seizure recurrence after a fi rst seizure due to NC, depending on the viability of the parasite. "
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    ABSTRACT: Neurocysticercosis, the most common parasitic brain disease worldwide, is due to the larvae infestation of Taenia solium. It is an endemic, neglected disease in poor countries with deprived sanitation, and is increasingly being reported in wealthy countries due to migration. Humans are the only defi nitive host of T. solium , while pigs are the intermediate hosts. Humans may become intermediate host by ingesting food or water contaminated by T. solium eggs. Infection is associated with local and systemic immune-infl ammatory responses modulated by the developmental stage of the parasite in the host (vesicular, colloi-dal. granular-nodular, and calcifi ed stages) and by the central nervous system compartment where the parasites are located. Genetic diversity of cysticerci has been studied and the genome of T. solium is currently being sequenced. The clinical manifestations are heterogeneous and depend mainly on the local-ization of cysts and immune response to the host. Seizures, headache, focal defi cits and cognitive abnormalities are the most frequent manifestations. The prognosis is good; nevertheless, it may lead to long-term neurological sequels such as epilepsy and hydrocephalus. Diagnosis is made mainly by neuroimaging, which is useful in the detection of evolutionary stage, number and localization of cysts. Immunological testing can be helpful; nonetheless, a negative test does not rule out the diagnosis. 128 Treatment is complex and should be individualized, based on location and viability of the parasites. In most cases treatment is only symptomatic. Antihelminthic drugs are effective in approximately one-third of patients with parenchymal viable cysts. The most effective approach to Taeniasis/cysticercosis is prevention. This should be a primary public health focus for poor countries.
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    • "Regarding NCC treatment, two cestocidal drugs (Praziquantel and Albendazole) have been used for at least 30 years. Although different studies evaluating their efficacy have shown that these drugs are not efficient in all patients, they also revealed that they eliminate the parasites and diminish the symptomatology significantly more than placebo [99] [100] [101]. As a consequence, investigation in this area must continue. "

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    • "The administration of a single first-line antiepileptic drug usually results in control of seizures in patients with neurocysticercosis-related epilepsy. There is some evidence that patients with viable intracranial cysts should first be treated with cysticidal drugs to achieve an adequate control of seizures with antiepileptic drugs [18, 56]. The optimal length of antiepileptic drug therapy in patients with neurocysticercosis has not been settled. "
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    ABSTRACT: Neuroysticercosis is the most common helminthic infection of the nervous system, and a leading cause of acquired epilepsy worldwide. The disease occurs when humans become intermediate hosts of Taenia solium by ingesting its eggs from contaminated food or, most often, directly from a taenia carrier by the fecal-to-oral route. Cysticerci may be located in brain parenchyma, subarachnoid space, ventricular system, or spinal cord, causing pathological changes that are responsible for the pleomorphism of neurocysticercosis. Seizures are the most common clinical manifestation, but many patients present with focal deficits, intracranial hypertension, or cognitive decline. Accurate diagnosis of neurocysticercosis is possible after interpretation of clinical data together with findings of neuroimaging studies and results of immunological tests. The introduction of cysticidal drugs have changed the prognosis of most patients with neurocysticercosis. These drugs have shown to reduce the burden of infection in the brain and to improve the clinical course of the disease in most patients. Further efforts should be directed to eradicate the disease through the implementation of control programs against all the interrelated steps in the life cycle of T. solium, including human carriers of the adult tapeworm, infected pigs, and eggs in the environment.
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