Neurocysticercosis: treatment with albendazole and dextrochloropheniramine

Natural History of Treated Subarachnoid Neurocysticercosis

Subarachnoid neurocysticercosis (SUBNCC) is usually caused by an aberrant proliferative form of Taenia solium causing mass effect and arachnoiditis. Thirty of 34 SUBNCC patients were treated with extended cysticidal and anti-inflammatory regimens and followed up a median of 4.2 years posttreatment (range: 15 for ≥ 4 years, 20 ≥ 2 years, 26 > 1 year, and 3 < 1 year). The median ages at the time of first symptom, diagnosis, and enrollment were 29.7, 35.6, and 37.9 years, respectively; 58.8% were male and 82.4% were Hispanic. The median time from immigration to symptoms (minimum incubation) was 10 years and the estimated true incubation period considerably greater. Fifty percent also had other forms of NCC. Common complications were hydrocephalus (56%), shunt placement (41%), infarcts (18%), and symptomatic spinal disease (15%). Thirty patients (88.2%) required prolonged treatment with albendazole (88.2%, median 0.55 year) and/or praziquantel (61.8%; median 0.96 year), corticosteroids (88.2%, median 1.09 years), methotrexate (50%, median 1.37 years), and etanercept (34.2%, median 0.81 year), which led to sustained inactive disease in 29/30 (96.7%) patients. Three were treated successfully for recurrences and one has continuing infection. Normalization of cerebral spinal fluid parameters and cestode antigen levels guided treatment decisions. All 15 patients with undetectable cestode antigen values have sustained inactive disease. There were no deaths and moderate morbidity posttreatment. Corticosteroid-related side effects were common, avascular necrosis of joints being the most serious (8/33, 24.2%). Prolonged cysticidal treatment and effective control of inflammation led to good clinical outcomes and sustained inactive disease which is likely curative.

Reversible dementia due to neurocysticercosis: Improvement of the racemose type with antihistamines

Infection of the human central nervous system (CNS) by the larvae of Taenia solium, termed neurocysticercosis (NCC), is endemic in most developing countries, where it is a major cause of acquired seizures and other neurological morbidity, including neuropsychiatric symptoms. However, despite its frequent manifestation, some findings, such as cognitive impairment and dementia, remain poorly understood. Less commonly, NCC may affect the ventricular system and subarachnoid spaces and this form is known as extraparenchymal neurocysticercosis. A particular presentation of the subarachnoid form is called racemose cysticercosis, which has a progressive pattern, frequently leads to hydrocephalus and can be life-threatening. Here we review a case of the racemose variety of cysticercosis, complicated by hydrocephalus and reversible dementia, with remission of symptoms after derivation and that remained stable with use of dexchlorpheniramine. We discuss the challenges in diagnosis, imaging findings, treatment and follow-up of this disease.

Steroids in neuroinfection

The consequences of inflammatory response are primarily responsible for morbimortality in bacterial meningitis. Early use of steroids in these cases can reduce mortality and hearing loss and improve functional outcome without causing significant side effects. The formal recommendation towards pneumoccocal meningitis is being extended to other forms of Bacterial Meningitis. The same thought can be applied to tuberculous meningitis. In neurocysticercosis and neuroschistosomiasis steroids are more useful than parasiticides in most cases. Despite the evidence favoring the use of steroids in herpes simplex encephalitis, it is not sufficient to definitely support such indication. Among the opportunistic infections that affect AIDS patients, neurotoxoplasmosis and progressive multifocal leukoencephalopaty are those most often considered for the use of steroids; steroids are safe to use, but no definite benefit could be demonstrated in both conditions.

Cysticercosis of the central nervous system: how should it be managed?

PURPOSE OF REVIEW

Taenia solium neurocysticercosis (NCC) has been long recognized as an important cause of neurological morbidity in most of the world. Unwarranted generalization of diagnostic and treatment recommendations made it difficult to assess individual prognosis and responses for each type of NCC. Understanding of the main clinical presentations (dependent on number, location, size, and stage of parasites, as well as on the immune response of the host) allows a better view of treatment options and expected outcomes.

RECENT FINDINGS

Current treatment options are still limited and involve symptomatic agents, antiparasitic agents, or surgery. The importance of adequate symptomatic management, the potential for improved antiparasitic treatment regimes, in particular combination therapy, and the increasingly important role of minimally invasive neurosurgery are also reviewed in this article.

SUMMARY

Treatment decisions in NCC should be individualized in relation to the type of NCC. Initial measures should focus on the symptomatic management before considering antiparasitic therapy when appropriate. Appropriate patient categorization, new antiparasitic regimes, and minimally invasive surgery are improving the prognosis of patients with NCC.

Clinical aspects of neurocysticercosis in children

The purpose of this report was to evaluate the clinical aspects of neurocysticercosis in children from a Brazilian region. A retrospective study of 25 children with this neuroparasitosis was performed. The diagnosis was based on clinical, cerebrospinal fluid, and neuroimaging findings. The patients were predominantly male (72%), were 1 to 11 years of age (average = 8 years, 6 months), and most resided in urban areas (68%). The more frequent manifestations were epileptic seizures (72%), headache (60%), learning disability (24%), behavioral changes (12%), psychomotor involution (8%), and intracranial hypertension (4%). The neurologic examination was normal in 80% of the patients. Twenty-two children received only symptomatic drugs. Three patients underwent treatment with cysticidal drugs, one with praziquantel and two with albendazole, with complete remission of the signs in one patient (33%) and improvement in two others (67%). Of the 25 patients, 43.4% had remission and 47.8% had improvement. We emphasize the need to consider neurocysticercosis as a differential diagnosis in children coming from endemic areas and presenting with learning disabilities, behavioral changes, and psychomotor involution. The clinical aspects in most of the children from the Botucatu region suggest a spontaneous resolution of neurocysticercosis without the need for cysticidal treatment.

Neurocysticercosos in South-Central America and the Indian subcontinent. A comparative evaluation

Neurocysticercosis is an important public health problem in South-Central American and South Asia. A review of the differences in epidemiological and clinical attributes of cysticercosis and taeniasis in South Central America and India, respectively, is undertaken in the present communication. Intestinal taeniasis is hyperendemic in several American countries. In comparison, the prevalence of Taenia solium infestation is lower in India. The clinical manifestations in several American neurocysticercosis series comprise epilepsy, intracranial hypertension and meningeal-racemose cysticercosis, in roughly equal proportions. An overwhelming majority of the Indian subjects present with seizures. The commonest pathological substrate of the disorder in Indian patients is the solitary parenchymal degenerating cyst. The reasons for the predominance of solitary forms in India, and of multilesional forms in South Central America are discussed. The magnitude of Taenia solium infestation and the frequency of pork consumption in a given population appear to influence the quantum of cyst load in affected individuals.

Epidemiology of neurocysticercosis in Brazil

A revision of literature was done with the objective of tracing an epidemiologic profile of neurocysticercosis (NCC) in Brazil. The prevalence was 0.12-9% in autopsies. The frequency was 0.03-7.5% in clinical series and 0.68-5.2% in seroepidemiological studies. The disease corresponds to 0.08-2.5% of admissions to general hospitals. Patient origin was rural in 30-63% of cases. The most involved age range (64-100%) was 11 to 60 years, with a predominance (22-67%) between 21 and 40 years. The male sex was the most affected (51-80%). In the severe forms there was a predominance of urban origin (53-62%) and of the female sex (53-75%). The period of hospitalization ranges from 1 to 254 days and 33 to 50% of patients suffer 1.7 +/- 1.4 admissions. The clinical picture was variable, with a predominance of epileptic syndrome (22-92%) and intracranial hypertension (19-89%). Psychiatric manifestations were associated in 9-23% of patients. Lethality was 0.29% in terms of all diseases in general and 4.8-25.9% in terms of neurologic diseases. The asymptomatic form was detected in 6% of patients in clinical series and in 48.5% of case from autopsies. The racemose form and ventricular localization also was observed as asymptomatic form. Among the patients with cutaneous cysticercosis 65% of them showed neurologic manifestations.

Severe forms of neurocysticercosis: treatment with albendazole

Study of 22 patients with the severe form of neurocysticercosis treated with albendazole (ABZ) administered in 6 different schedules ranging from 15 to 30 mg/kg/day for 21 to 60 days. Dextrochloropheniramine and ketoprofen were the adjuvant drugs. Multiple symptoms were observed in 90.9% of patients. Intracranial hypertension was manifested in 90.9%. Hydrocephaly occurred in 86.4%. Evolution was satisfactory in 10 patients, 8 died and 4 had sequelae. Tomographic studies showed the appearance of an isolated IVth ventricle in 9 patients, after ventriculoperitoneal shunt, before ABZ treatment in 3 of them, during in 5 and after treatment in one. Median clinical follow-up duration was 10 months for the patients who died and 3-4 years for survivors. In 3 patients there was an increase in cyst size during the administration of the 15 mg/kg/day ABZ dose, which was not observed in any patient when the 30 mg/kg/day dose was used.

Oral albendazole in the management of extraocular cysticercosis

Surgical removal of extraocular cysticerci is fraught with complications. The effect of oral albendazole in such cases has been evaluated in a randomised, controlled, clinical trial. Of 24 ultrasonographically diagnosed, and ELISA positive cases of extraocular cysticerci, 12 received oral albendazole 15 mg/kg once daily for 1 month, while the 12 controls received a placebo. Marked clinical improvement was seen in all the cases in the treatment group at 4 weeks, with collapse of the cyst at 6 weeks (75%), and complete disappearance at 3 months (100%). No clinical or ultrasonographical change was noted in the control group. A trial of medical management with oral albendazole merits consideration in cases of extraocular cysticerci.

Cysticercosis of the central nervous system. II. Spinal cysticercosis

The compromising of the spinal canal by cysticercus is considered infrequent, varying from 16 to 20% in relation to the brain involvement. In the spinal canal the cysticercus predominantly places in the subarachnoid space. Clinical signs in spinal cysticercosis can be caused by direct compression of the spinal cord/roots by cysticerci and by local or at distance inflammatory reactions (arachnoiditis). Another mechanism of lesion is degeneration of the spinal cord due to pachymeningitis or circulatory insufficiency. The most frequent clinical features are signs of spinal cord and/or cauda equina compression. The diagnosis of spinal cysticercosis is based on evidence of cerebral cysticercosis and on neuroradiological examinations (myelography and myelo-CT) that show signs of arachnoiditis and images of cysts in the subarachnoid space and sometimes, signs of intramedullary lesions, but the confirmation can only be made through immunological reactions in the CSF or during surgery. The clinical course of 10 patients with diagnosis of spinal cysticercosis observed among 182 patients submitted to surgical treatment due to this disease are analyzed. The clinical pictures in all cases were signs of spinal cord or roots compression. All but two presented previously signs of brain cysticercosis. Neuroradiological examinations showed signs of arachnoiditis in 4 patients, images of cysts in the subarachnoid space in 5, and signs of arachnoiditis and images of cysts in one. The 6 patients that presented intraspinal cysts were submitted to exeresis of the cysts and 2 patients with total blockage of the spinal canal underwent surgery for diagnosis. The 2 remaining patients with arachnoiditis and blockage of the spinal canal were clinically treated. All of the six patients submitted to cyst exeresis had initial improvement but 4 of them later developed arachnoiditis and recurrence of the clinical signs and only 2 remained well for long-term. The 2 non operated patients had no improvement of their clinical signs. Two patients died later due to complications of cerebral cysticercosis. Based on the experience acquired in the management of these patients we indicate surgical treatment for patients that present free cyst in subarachnoid space. For those who present arachnoiditis, surgery is indicated only when there is doubt in the diagnosis. Intramedullary cysts should also be surgically treated.

[Cystic oligodendroglioma and positivity of reactions for cysticercosis: report of a case]

A case of a 32-year old male patient with complaints of frontal headache progressive decrease in visual acuity, altered behaviour, and positive results of immunological tests for cysticercosis performed on the cystic and cerebrospinal fluids is presented. After several clinical and surgical proceedings, the frontal craniotomy was indicated and a multi-lobulated cystic tumor was excised. Biopsy material revealed an oligodendroglioma invading the degenerated membrane of cystic wall. Some aspects related to the possible mechanisms involved in the association of oligodendroglioma with neurocysticercosis in the presented case are discussed. Three different types of conclusions may be reached: (1) neurocysticercosis may have acted as an oncogenetic factor for the oligodendroglioma; (2) the glycoprotein nature of the antigens of gliomas and cysticercosis and the similarity in the molecular weight range of their polypeptides may be responsible for the positivity of the reactions for cysticercosis in the cystic fluid; or (3) the association of oligodendroglioma with cysticercosis may be a simple coincidence. The present study strengthens the opinion that other pathologies should be looked for when clinical treatment of cysticercosis does not follow the expected course.

Neurocysticercosis: a short review and presentation of a Scandinavian case

Cysticercosis is a disease entity caused by the larval form (Cysticercus cellulosae) of the pork tapeworm (Taenia solium). When man becomes the intermediate host, cysticercal cysts can develop in various organs. Neurocysticercosis, i.e. cysticercosis of the central nervous system, can lead to a broad range of neurological disturbances. The disease is usually confined to geographical regions where sanitation is poor but can occur among immigrants or travellers from such regions. Due to increased travel and immigration the disease may appear in non-endemic areas. We describe a recent case of neurocysticercosis in a 28-year-old Danish woman, who had been travelling in the Far East. She was successfully treated with praziquantel. A short review of the literature is given as the knowledge of the diagnosis and treatment of the disease has increased greatly in the last decade.