Therapy of parenchymal brain cysticercosis with praziquantel

Neurocysticercosis: regression of a fourth ventricular cyst with praziquantel

Symptomatic intraventricular cysticerci are said to respond poorly to the anticestodial agent praziquantel. A case is reported of rapid regression of a large cyst of the fourth ventricle after oral praziquantel, avoiding the need for surgery.

Albendazole versus praziquantel in the treatment of cerebral cysticercosis: clinical evaluation

One hundred consecutive patients presenting with symptoms and signs of neurocysticercosis, confirmed by neuroimaging techniques, were randomly assigned to treatment with either praziquantel 50 mg/kg/d for 15 d or albendazole 15 mg/kg/d for 30 d. All patients were treated in addition with steroids for 45 d. Follow-up was for 90 d for response to treatment and at least 1 year for recurrence. Although similar numbers of patients showed no improvement in neuroimaging criteria at 3 months, the response to albendazole was more pronounced with larger numbers showing marked improvement or disappearance of lesions. Resolution of the presenting neurological signs and symptoms was also more frequent in the albendazole group. Electroencephalographic changes also became normal. The use of steroid cover eliminated the headache frequently present during the first few days of treatment and permitted severe cases to be treated. Both albendazole and praziquantel appeared to be effective at the doses used, with albendazole showing a slightly better overall response.

[Neurocysticercosis: neuropathologic study of a fatal case treated with praziquantel]

The neuropathological findings in a fatal case of neurocysticercosis treated with praziquantel are reported in this paper. The extensive necrosis of the parasites besides the exuberant inflammatory response evidence the efficacy of the drug. The severe and necrotizing type of the inflammatory response to the dead parasites may have played an important role in the cause of death of this patient, by developing severe intracranial hypertension.

[Neurocysticercosis in childhood. II. Computed tomography of 24 patients according to symptomatic and praziquantel treatment]

We studied 24 children (15 months to 13 years old) which clinical, CSF and CT findings were compatible to the diagnosis of active neurocysticercosis. The patients were divided into three groups based on the type of treatment: Group I (10 patients) treated with analgesics and/or anticonvulsants; Group II (4 patients) treated with analgesics and or anticonvulsants and corticosteroids; Group III (10 patients) treated with analgesics and/or anticonvulsants, corticosteroids and praziquantel. The first patients CT scan were compared with the sequential CT scan findings (1 month to 5 years). The initial CT scan of 12 patients showed multiple active cysts, in 5 patients an isolated active cyst, in 3 patients partial calcified cysts, in 2 patients cerebral edema and in 2 patients were normal. The final results of the three groups of patients, as far as concern the normalization of CSF abnormalities or calcification of the cysts were the same, no matter the type of treatment applied to them. These results, although the small number of patients, showed that most of the children have good final results, with improvement of clinical symptoms and CT findings. We suggest that neurocysticercosis in children need multicenter study. So, a great number of patients can be followed and better definition can be established on the treatment of neurocysticercosis.

Neurocysticercosis: an epidemiological survey in two small rural communities

The authors describe the epidemiological findings related to human taeniasis and cysticercosis, and swine cysticercosis in two small rural communities, Postinho (P) and Tigre (T), of South Brazil. The prevalence of epilepsy was 2.04% (P) and 2.25% (T). The prevalence of neurocysticercosis was 0.47% (P) and 0.93% (T), and prevalence of swine cysticercosis was 12.8% (P) and 27.8% (T). Taenia sp. infestation was detected in 4.3% (P) and 4.6% (T) of stool examinations. The hyperendemic human taeniasis and cysticercosis and swine cysticercosis seems to be related to poor hygienic habits of the population, and the free access to human excreta by the pigs.

Computed tomography in neurocysticercosis: a 10-year long evolution analysis of 100 patients with an appraisal of a new classification

Three hundred and fifty seven computed tomography (CT) from 100 different patients with neurocysticercosis (NC) were studied between 1979 and 1988. All patients were treated with praziquantel (PZQ). A new classification attempting to recognize the CT evolution profile in NC as well as assigning a possible link between CT findings and biological conditions of cysts is evaluated. It was possible to conclude that: intact cysts remain unchanged in consecutive CTs by 11 months and exhibit signs of degeneration in about 18 months after PZQ drug therapy; degenerating cysts can be detected by 10.5 months, disappear in 11 months and become nodular calcifications in about 25 months. Therefore, a time period of at least 36 months can be estimated for the complete evolution profile of cysts in the brain parenchyma.

[Treatment of neurocysticercosis with praziquantel]

Twenty seven patients with neurocysticercosis were treated with praziquantel in progressive doses reaching 50 mg/kg/day associated with dexamethasone for 21 days. The patients were followed during and after treatment and those followed up for one year repeated their immunological tests (indirect immunofluorescence and ELISA) at this time. Headache was the most frequent symptom during the treatment, occurring on 37% of patients. During the treatment 18.5% of patients had intracranial hypertension and one died. One year after treatment 72.2% of patients who finished treatment improved. The immunological tests became negative in 45.4% of patients sera and 42.8% of cerebrospinal fluids. There was no correlation between the clinical evolution and immunological tests. In this study it is not possible to affirm that both negative immunological tests and good clinical evolution were consequent to the efficacy of praziquantel treatment. Due to the great frequency and seriousness of this treatment complications, the patients with neurocysticercosis must be individually evaluated to know the risks and the benefits of the treatment with praziquantel.

Cerebral cysticercosis

We studied 143 cases of cerebral cysticercosis over a 30-year period. In 46 there was hydrocephalus due to cysts obstructing the cerebrospinal fluid pathways, with signs of hydrocephalus and cerebellar dysfunction. In 97 there were cysts in the cerebral parenchyma, causing symptoms of intracranial hypertension alone in 22 cases, with additional neurological deficits in the remainder. Before 1980 diagnosis was made by pneumoencephalography and ventriculography, but since then it has mostly been done by computed tomography. In 28 cases scanned, typical abnormalities were present in 25. Complement fixation tests were positive in serum in 74% of cases and in cerebrospinal fluid in 73%, and the enzyme-linked immunosorbent assay test was positive in serum in 90% and in cerebrospinal fluid in 92%. Treatment of cases with hydrocephalus was by removal of the cysts at craniotomy, with placement of a shunt where necessary. Intracranial hypertension caused by parenchymal cysts was treated with steroids and osmotic agents, if possible. In resistant cases subtemporal decompression was needed, unilateral in 55 cases and bilateral in eight. Mortality in the acute stage was 11%, with a further 20% at follow up.

Clinical, radiological and cerebrospinal fluid presentation of neurocysticercosis: a prospective study

The wide clinical spectrum of neurocysticercosis has led to many attempts at clinical, radiological, CSF and other classifications. Based on an objective review of the relevant literature and on a prospective study of 42 patients with active neurocysticercosis, a new classification is proposed, based on clinical, tomographic, magnetic resonance and CSF evidence of viability of cysts. The first step is to define whether the disease is active or not. Inactive disease may be parenchymal calcifications or hydrocephalus. Active disease may be intraparenchymal, extraparenchymal or mixed. Statistical analysis of 42 cases with active disease shows intraparenchymal disease to occur in younger patients, perhaps more frequently in females, and to have a better prognosis than extraparenchymal of mixed disease. The latter appears to have the worst prognosis. Therapeutic implications are that only active disease warrants etiological therapy. There remain doubts about the best therapy for some infrequent subtypes of extraparenchymal and mixed disease.

Dexamethasone increases plasma levels of albendazole

Therapy of neurocysticercosis with cysticidal drugs is frequently complicated by the exacerbation of symptoms that follows the inflammation triggered by the acute destruction of cysticerci. Treatment of such adverse reactions with dexamethasone is highly effective. However, it has been shown that dexamethasone lowers the plasma levels of praziquantel, thus reducing its cysticidal efficacy. We measured plasma levels of albendazole, another strong cysticidal drug, when dexamethasone was given simultaneously. We found that dexamethasone increased the plasma levels of albendazole by about 50% (P less than 0.002); hence, it seems that cysticercosis and the ensuing inflammation can be treated simultaneously with albendazole and dexamethasone without diminishing the efficacy of the cysticidal drug.

High-dose praziquantel for neurocysticercosis: serum and CSF concentrations

Serum and CSF concentrations of praziquantel were analyzed in 8 patients with active neurocysticercosis aged 35 +/- 16 (mean +/- sd) years, in order to determine factors that may improve the therapeutic ratio. Praziquantel was given orally at 6-h intervals for 10 days at a daily dose of 100 mg/kg. Serum concentrations were determined at 1, 2 and 4 h, and CSF concentrations at 2 h after the morning dose. Peak serum concentrations occurred between 1 and 2 h after administration. There was a trend towards a drop in serum concentration from Days 1 through 5 to 10 of therapy. A fourfold increase in oral dose led to an eightfold rise in serum and CSF concentration, indicating saturation of hepatic metabolism. There were linear correlations (p less than 0.01) between serum and CSF concentrations of praziquantel, indicating free flow across the blood-brain barrier, above an apparent threshold, which may be related to occupation of plasma protein-binding sites. The results indicate that monitoring of serum concentrations may be clinically useful.

Neurocysticercosis: an under-recognized cause of neurological problems

Neurocysticercosis is an uncommon, and under-recognized condition in Australia. Changes in immigration patterns may lead to a rising prevalence in this country. Epilepsy is the most common presentation, but it has many other variable forms of neurological manifestations. Eight cases are described, all in immigrants from Eastern Europe, Asia or Central America; the disease was presumably acquired before arrival in Australia. Six patients had symptoms for two to 30 years before the diagnosis was made and, in some cases, the first neurological manifestations appeared decades after initial infection. In patients with active disease a successful outcome followed therapy with praziquantel and corticosteroids. We advise that all patients requiring treatment be admitted to hospital for corticosteroid and anticonvulsant therapy to minimize the clinical deterioration which may result from therapeutic destruction of larvae.

Comparison of therapeutic regimen of anticysticercal drugs for parenchymal brain cysticercosis

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.

[Neurocysticercosis. II. Evaluation of treatment with praziquantel]

The results of the use of praziquantel (PZQ) for the etiologic treatment of neurocysticercosis (NC) are presented. The drug was administered to 45 patients (24 women and 21 men) at increasing doses of 10 to 50 mg/kg/day during the first week and with maintenance on the last dose for two additional weeks, preferentially for patients that presented intraparenchymatous cystic lesions in the computed axial tomography. Follow-up ranged from 8 months to 4 years and a half (median, 2.7 years). During PZQ administration 27 patients (60%) presented side effects which required interruption of treatment in three cases. Decompensation of the increased ICP occurred in two cases (one of them fatal). Exacerbation of CSF pleocytosis occurred in 26 patients (57.7%). Evaluation of the results of PZQ treatment showed a lower clinical-laboratory rate of success than reported in the literature. The most appropriate indications for the use of PZQ are discussed on the basis of the present data and of reports by other investigators. In view of the risks and fallibility of treatment with PZQ, the solution of NC resides in the prevention of infestation.

Effect of praziquantel on the eggs of Schistosoma mansoni, with a note on the implications for managing central nervous system schistosomiasis

The morphology of Schistosoma mansoni eggs in intestinal tissues (oograms), and egg hatching in faeces, were studied after parenteral administration of praziquantel (PZQ) to infected mice. PZQ was given parentally in doses of 60 mg kg-1 for one day, five days or 10 days. Eleven days after initiation of therapy, oograms from all groups receiving PZQ showed more dead eggs than controls; a dose response was also observed. Depression of faecal egg hatching occurred within 24 hours of PZQ administration. Our observations suggest that PZQ kills most S. mansoni eggs in host tissues when administered in higher doses than are routinely recommended for treatment of intestinal schistosomiasis mansoni. In order to reduce the lifespan of metabolically active eggs in sensitive tissues, prolonged courses of PZQ could be used when treating central nervous system schistosomiasis.

Humoral immune response in patients with cerebral parenchymal cysticercosis treated with praziquantel

The humoral immune response to treatment with praziquantel (PZQ) was studied in eight patients with parenchymal cerebral cysticercosis (CC). In the serum and in the cerebrospinal fluid (CSF) before, during and after the administration of the drug, the following were quantitated (a) levels of specific anticysticercous antibodies measured in optical densities by the ELISA method; (b) levels of IgG, IgM, IgA and IgE; (c) levels of complement fraction C3, C4; (d) presence of immune complexes; (e) total number of white blood cells in the CSF. It was found that after treatment with PZQ, the level of specific anticysticercous antibodies and the level of IgG rose significantly in the CSF but not in the blood. The levels of the fractions of the complement and the immunoglobulins IgM, IgA and IgE did not change significantly either in the serum or in the CSF. The blood-brain barrier was found ruptured in three patients before therapy and in five patients after the therapy as measured by the albumin index. Nevertheless, the IgG index showed that there was local production of IgG in five patients before treatment and in seven after the end of it. The relative specific antibody index was greater than 1.0 in five patients before therapy and in seven after therapy. This data strongly supports the idea that the specific antibodies are produced intrathecally and are not derived from the serum pool through a ruptured blood-brain barrier. It was concluded that patients with parenchymal CC have an elevation of specific anticysticercous probably due to a combination of a ruptured blood-brain barrier and intrathecal synthesis. The relatively small rupture of the blood-brain barrier and the high IgG and relative specific antibody index suggest that intrathecal synthesis is the most important mechanism. The humoral immune response may be of importance not only in the elimination of the parasite but also in the genesis of the illness.

Seizures and praziquantel. A case report

A 27 year Old male developed seizures after receiving a single 20 mg/kg dose of praziquantel for the treatment of an intestinal Hymenolepis nana infection. On further clinical and laboratorial evaluations, he was found to suffer from an until then asymptomatic parenchymal brain cysticercosis. Praziquantel must be used with caution in those areas where cysticercosis represents a mayor public health problem. The occurrence of unexpected seizures in an individual being treated with the compound, must prompt clinicians to rule out cysticercosis of the CNS.

Cerebral cysticercosis. A disease to suspect in recent travelers or immigrants

The initial assessment of the young adult patient with multiple intracerebral lesions is challenging. The etiologic factors must be categorized as neoplastic, infectious, inflammatory, vascular, and hematologic, among others. Unfortunately, these lesions are not easily accessible for sampling, and all other diagnostic methods must first be exhausted. This case report describes a patient who was brought to an emergency department in New Jersey after her first seizure. The diagnosis was cerebral cysticercosis, an intracerebral parasitic infection that is extremely rare in this area but very common in other areas of the world. As more and more people immigrate to the United States, researchers believe that cerebral cysticercosis will become more common. It is imperative, therefore, for primary care physicians to understand this disease and to consider it in the appropriate setting.

Brain cysticercosis treated with praziquantel. Report of six cases

Cysticercosis is the most common parasitosis affecting the central nervous system and it is endemic in many countries. Although cysticercosis is nowadays a rare disease in Spain, three of such cases have been treated with Praziquantel at the Hospital "Princesa Sofía" of León and another three at the Hospital General de Galicia of Santiago, and the six of them are reported together. The six patients presented at CT scans cysts located at different levels in the brain parenchyma, subarachnoid space and ventricular system. Praziquantel was administrated at daily dosage of 50 mg per kilogram of body weight, by oral route, distributed in three doses during 15 days. Moderate hepatotoxic effect were detected in two cases. No significant neurological disfunction was observed in any case during the treatment. The therapeutic effect on the brain cysts was evaluated in the CT scans obtained after treatment. In four cases a positive effect on the cysts was observed, but no apparent effect was noticed in the other two.

Comparative analysis of human and porcine neurocysticercosis by computed tomography

Human and porcine cases of neurocysticerosis were compared by computed tomography in regard to the morphological characteristics of the parasites and the impact of the infection on the brain. In pigs and young people many parasites were usually found, but this was seldom the case in adult humans. These parasites were small and located mainly in the parenchyma and the subarachnoid space; no calcified cysticerci were found. In contrast, in adult humans cysticerci were heterogeneous in appearance and distribution. The brain of the pigs showed no evidence of inflammatory reaction while young people had oedema, enhancement and hydrocephalus; in contrast, adults showed diverse tomographic characteristics of brain response. Thus, the disease has at least 2 different forms. It may be mild with short development and parasites of similar appearance, as occurs in young hosts. In contrast, a long lasting disease occurs in adults, with diverse tomographic, neurological and parasitological features.

Empty sella syndrome associated with central nervous system cysticercosis

A 55-year-old woman presented with severe recurrent headache accompanied by dizziness. The brain CT scan showed multiple low-density cystic lesions in the suprasellar and left sylvian cisternae with total empty sell syndrome. The communication between the cisternae and the suprasellar cyst was not verified on the metrizamide CT scan. Treatment with praziquantel resulted in headache inilially and a rise in specific IgG.

Intrasellar cysticercosis

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.

Parasitic infections: therapeutic considerations

Parasitic infections are a problem even in developed countries. Since the agents used to treat these infections are infrequently used, most physicians are unfamiliar with antiparasitic compounds. The activity, mode of action, and use of antiparasitic agents is reviewed.

Serological diagnosis of neurocysticercosis: evaluation of ELISA tests using cyst fluid and other components of Taenia solium cysticerci as antigens

An ELISA system was developed to assist with the diagnosis of neurocysticercosis. Antigens were prepared from the fluid, the protoscolex and the cyst wall of cysticerci dissected from infected pigs. The fluid antigen was tested both fresh and after freeze-drying and one year's storage. Sera from patients with proven neurocysticercosis were most reactive using the fluid and least reactive using the cyst wall antigens. Freeze-drying and prolonged storage of fluid antigen did not reduce its reactivity and repeated testing of sera with this antigen gave optical density values within 15% of the original value. Using this ELISA system positive results were obtained from all patients with active neurocysticercosis. Sera from patients with calcified cysts were usually non-reactive or marginally reactive to the fluid antigen.

Cerebral cysticercosis successfully treated with praziquantel

A 28-year-old woman presented with signs of relapsing meningeal inflammation 5 months after immigration from Chile. Cerebral cysticercosis was diagnosed with computed tomography (CT) scan, showing signs of intracranial hypertension and cystic lesions, and was confirmed by serological investigation. After treatment with praziquantel all clinical symptoms disappeared. A CT scan obtained 6 months after treatment showed almost complete resolution of the cystic changes in the brain.

Líquido cefalorraqueano e neurocisticercose: aspectos evolutivos da resposta inflamatória celular

Foram estudadas 357 amostras de LCR de 40 pacientes com neurocisticercose, submetidos a tratamento medicamentoso com praziquantel associado a dexametasona. No sentido de avaliar aspectos evolutivos do componente celular da resposta inflamatória, foram programadas, para cada paciente, avaliações do exame de LCR em 13 oportunidades: por ocasião do dagnóstico; durante o tratamento; e posteriormente, a intervalos prefixados até completar dois anos de evolução. Foi utilizada metodologia adequada ao estudo citológico e citomorfológico, bem como à quantificação de linfócitos B e T. Para determinação de subpopulações T-ativa, T-sensibilizada e T-ávidas foram utilizados, como marcadores de superfície, receptores para hemácias de carneiro. O grupo controle é constituído de 50 pacientes com cefaléia crônica e que não apresentavam alterações ao exame físico e ao exame neurológico. Em todos, o exame de LCR estava dentro dos limites normais. Linfócitos B e T não apresentavam alterações no exame inicial de LCR; não houve modificações no seu comportamento durante toda a evolução. Os elementos da resposta inflamatória celular capazes de fornecer informações significativas acerca do perfil evolutivo em estudo foram: o número de células, a presença e o número de polimorfonucleares neutrófilos e de células eosinófilas e a quantificação de subpopulações T-ativa e T-sensibilizada. A presença de polimorfonucleares neutrófilos embora influenciada pela ação dos corticosteróides e pela presença de sistema de derivação do trânsito do LCR, pode constituir-se em elemento qualitativo sugestivo de atividade inflamatória. Os valores percentuais para linfócitos T-ativos, diminuídos na primeira amostra, e T-sensibilizados, aumentados na primeira amostra, podem ser indicadores quantitativos e qualitativos adequados a reconhecer a vigência de atividade inflamatória local no sistema LCR; estas subpopulações linfocitárias, com alterações significativas em 63,2% dos pacientes no exame inicial, não são influenciadas significativamente pelo uso de corticosteróides. Os valores de eosinófilos e de linfócitos T-sensibilizados estão significativamente aumentados em pacientes que apresentaram complicações clínicas durante o período de acompanhamento após o tratamento; subpopulação de linfócitos T-ativos estava significativamente diminuída nestes casos. O número de células e a presença de eosinófilos são os elementos da resposta inflamatória celular relacionáveis a tipos de alterações detectadas pela tomografia computadorizada do crânio. Os elementos da resposta inflamatória celular estudados não apresentam correlação significativa entre si, podendo traduzir cada um deles aspectos particulares da reação inflamatória celular no SNC em pacientes com neurocisticercose.

Cerebral cysticercosis in pigs studied by computed tomography and necropsy

An original technique for computed tomography (CT) of the pig's brain is described. Brains of 11 cysticercotic pigs were studied by CT and by macroscopic and microscopic examination after necropsy, in order to compare the tomographic images with the anatomic findings. By CT, cysticerci could be seen in all the brains except one which had only one parasite. Good correlation was found when the CT sections were compared with the anatomic slices, nevertheless not all cysticerci seen during necropsy examination could be identified in the CT images. Only two parasites were found in the ventricles. There were difficulties in differentiating submeningeal and parenchymal localization of the cysticerci. Most cysticerci had similar morphologic appearance; inflammatory reactions of different degrees and characteristics were observed around some of them.

[A cerebrospinal fluid syndrome in neurocysticercosis]

The study is based on 371 cerebrospinal fluid (CSF) samples and 324 serum samples from 40 patients with neurocysticercosis (NC) submitted to treatment with praziquantel. The aim of the study is a critical evaluation on humoral immunity in CSF NC syndrome. The analysis of NC patients at diagnosis and in the follow-up period was performed considering three connected criteria: the clinical one, the CSF examination and the computed tomography. For the study of CSF and serum samples a systematization of collection was scheduled in relation to: diagnosis; period of treatment; follow-up. A total of 13 samples for each case for a follow-up period of two years was scheduled. For the study of humoral immunity a semiquantitative methodology was employed to verify the intra blood-brain barrier (BBB) gamma globulins synthesis. It was based upon electrophoretic profile data on CSF and serum proteins, and relations and indexes. Normal values were previously characterized in a normal control group. This group was formed by 50 patients with chronic headache who presented normal neurological examination, as well as, CSF-examination and serum proteinogram under the safety limits of normality. To verify intra BBB gamma globulins synthesis it was considered the gamma globulin content of the CSF and serum, the gamma globulins/prealbumin + albumin relationship, the Link and Tibbling index, the intra BBB gamma globulins synthesis of Tourtellotte and col., and the appearance of oligoclonal bands in the CSF. Confirmation of the disease was performed by immunological reactions for cysticercosis: complement fixation test in CSF and serum; immunofluorescent test and enzyme-linked immunosorbent assay (ELISA) in CSF. Interference factors in the CSF NC syndrome were analysed at first such as those related to: clinical aspects, time of disease, previous dependence on corticotherapy, ventricular derivation shunts, tomographic findings. It was shown that all of them produce several degrees of interference in the intensity of the CSF NC syndrome. Data on intra BBB gamma globulins synthesis were verified in 37 patients (92.5%). It occurred in a persistent pattern in 18 cases (45%) during all the study phases, and not showed changes that might be related to treatment. On the other hand, it was shown that analysis of the results must always be performed case by case due to large dispersion of events observed and the differences of behavior of data related to humoral immunity, when critically analysed during diagnosis, treatment period and in the follow-up.(ABSTRACT TRUNCATED AT 400 WORDS)

Cerebral cysticercosis in a European patient: problems of disease activity and therapeutic implications

The case of a German patient who was treated with two courses of praziquantel for parenchymal cerebral cysticerosis (CC) is reported. Efficacy of the treatment could not reliably be distinguished from the natural course of the disease. After a brief review of the literature concerning problems with assessment of the activity of CC, the criteria recommending praziquantel therapy are discussed.

Penetration of praziquantel into cerebrospinal fluid and cysticerci in human cysticercosis

Two patients with cysticercosis received praziquantel (PZQ) 75 mg/kg/day orally together with 30 mg prednisone daily for 3 weeks. The first patient presented with grand-mal seizures, a pyramidal tract syndrome and subcutaneous cysticerci, and the other had internal hydrocephalus necessitating drainage. Serial plasma samples were taken after the first dose of PZQ. Lumbar CSF was obtained from the first patient and ventricular CSF from the second. Subcutaneous cysticerci were removed from the first patient. PZQ in the specimens was assayed by GLC. For distribution between plasma and CSF a rate constant of 4.9 h-1 for free PZQ, corresponding to a t1/2 of 8 min or less for the non-protein bound fraction was calculated for Patient 1. In the second patient the distribution was so rapid that the rate constant could not be calculated. The difference in distribution rate might have been due to use of different sampling times or to a time lag in the entry of PZQ between the ventricles and the lumbar sac. The rate constant for distribution of the drug between plasma and parasites was 1.4 h-1, corresponding to a t1/2 of 30 min or less. Thus PZQ penetrates rapidly into the CSF. It enters the parasite more slowly, although still more rapidly than the plasma half-life of PZQ (1-1 1/2 h).

Long-term results of praziquantel therapy in neurocysticercosis

The long-term results of praziquantel therapy in 141 patients with neurocysticercosis are presented. Seventy-five patients (53%) were considered to be cured because the cysts or nodules disappeared or became calcified following praziquantel treatment and the patients were asymptomatic at the end of a 5-year follow-up period. An additional 35 patients (24.8%) improved clinically and radiographically. The intraventricular Cysticercus cysts of five patients in this group were not affected by praziquantel and had to be surgically removed. The remaining 31 patients (21.9%) were unchanged or became worse probably because, prior to therapy, Cysticercus larvae had caused tissue damage. The fact that praziquantel did not affect intraventricular cysts suggests a low concentration of the drug in the cerebrospinal fluid. Surgery continues to be an important tool in the treatment of cysticercosis to remove parasites that do not respond to praziquantel therapy as well as for the relief of intracranial hypertension.

Cerebral cysticercosis: a case report with particular reference to recent advances in diagnosis and treatment

Cerebral cysticercosis is becoming more common in Australia as the immigrant population from areas of endemic disease increases. The case reported exemplifies the common presentation of this interesting infestation. Treatment consists primarily of Praziquantel with or without steroids and anti-seizure medication if indicated. Follow-up is by both clinical and radiological assessment.

Neurocysticercosis in childhood

Manifestations of cysticercosis in 11 children (mean age 9.5 years) are presented. Features of raised intracranial pressure dominated the clinical picture (10 cases), followed by seizures (7 cases). Subretinal cysts occurred in three children. Focal signs were infrequent and often not attributable to anatomical lesions. Electro-encephalograms were invariably abnormal, but did not help to localize lesions. Plain roentgenograms of the skull showed sutural diastasis in the majority. Computerized tomography revealed white matter oedema with throttled ventricles in 6 patients and single localized lesions in 3 others. None had hydrocephalus. Histopathology and indirect haemagglutination test aided diagnosis in 6 cases. Two children recovered completely, one after surgical excision of a parietal lobe cyst and the other following praziquantel therapy. Half of the remaining patients improved spontaneously.

Intramedullary spinal cysticercosis. Case report and review of literature

Intramedullary spinal cysticercosis is extremely uncommon; only 29 cases have been reported previously. A case of solitary intramedullary spinal cysticercosis is described. Factors accounting for the rarity of intramedullary cysticerci are reviewed and the probability of reaching a preoperative diagnosis is discussed. This is the fifth such case reported from India.

Therapy of neurocysticercosis

The different manifestations of neurocysticercosis are classified and the appropriate therapy in each group is described.

Serologic follow-up study in neurocysticercosis patients by ELISA after praziquantel treatment

/A total of 69 patients of confirmed neurocysticercosis was followed serologically by ELISA up to 22 months after praziquantel treatment. The intervals and numbers of follow-up were variable by patients. Serially collected samples of serum and CSF were examined simultaneously for their specific IgG antibody levels by ELISA, using cystic fluid, saline extracts of bladder wall and scolex as antigen. Within 4 months after praziquantel treatment, the antibody levels were elevated temporarily in both serum and CSF in most patients. In some cases antibody levels exhibited steady declining tendency after the treatment. Concomitant administration of dexamethasone appeared to suppress the elevation of antibody levels. The rate of mean absorbance of antibody changed more in serum than in CSF. The rate of elevation was greater in antibodies to parenchymal antigens than that to cystic fluid, but absolute difference of antibody levels was greater in anitbody to cystic fluid. Previously negative samples for IgG antibody may become positive after praziquantel treatment, which could be used as a complementary tool(provocation test) in serodiagnosis. One month was considered to be sufficient interval for the follow-up test for that purpose. In the follow-up of up to 22 months, only few cases of chronic neurocysticercosis showed declining tendency of IgG antibody levels below negative range. During acute encephalitic attacks in chronic patients, IgG antibody to parenchymal antigen were elevated in CSF temporarily. These results indicated that serologic follow-up of every year was recommendable to differentiate the cured patients from chronic patients with slowly calcifying lesions.

Truncal seizures: an unusual presentation of cerebral cysticercosis

We present the case of a 24-year-old woman who developed repetitive partial simple seizures confined to her right rib cage. Computed tomography scan of the head was consistent with the diagnosis of cerebral cysticercosis. The patient was started on a regimen of anticonvulsants, steroids, and praziquantel with full resolution of symptoms.

A prognostic classification of cerebral cysticercosis: therapeutic implications

Cerebral cysticercosis is a parasitic infestation with a highly variable prognosis and diverse clinical manifestations. Over the period of two years 51 patients were studied prospectively with this infestation, paying particular attention to the duration and severity of the illness, clinical course, CT findings and therapeutic modalities. Patients with parenchymal cysts or calcification without hydrocephalus had a benign disorder presenting commonly with seizures. This type of infestation usually is long-standing, almost never requires surgical treatment, responds to praziquantel therapy and has a good prognosis. In contrast, patients who present with hydrocephalus, large supratentorial cysts, multiple granulomata with cerebral oedema or with vasculitis and cerebral infarction, have an aggressive, acute or subacute illness, presenting with raised intracranial pressure, gait disturbances, mental changes, seizures, cranial nerve palsies, hemisphere syndromes, chronic meningitis and stroke. This malignant form usually requires surgical therapy, does not respond to praziquantel and may produce a fatal outcome or serious sequelae.

Neurocysticercosis: clinical and therapeutic considerations. Review of Italian literature

We describe two cases of neurocysticercosis, the first with a spinal extramedullary form, the second with hydrocephalus secondary to basal cistern and convexity arachnoiditis. Praziquantel was given without evident benefit; this therapeutic response is discussed in relation to the clinical and radiological findings. The Italian literature is reviewed.