Disease Centered Around Calcified Taenia solium Granuloma

Calcified cerebral toxoplasmosis associated with recurrent perilesional edema causing neurological manifestations in an HIV-infected individual: case report with a decade-long follow-up

Four cases of people living with HIV/AIDS (PLWHA) with calcified cerebral toxoplasmosis associated with perilesional edema causing a single episode of neurological manifestations have recently been reported. Here, we describe the first detailed description of perilesional edema associated with calcified cerebral toxoplasmosis causing three episodes of neurological manifestations in a PLWHA, including seizures in two of them. These recurrences occurred over approximately a decade. Throughout this period, the patient showed immunological and virological control of the HIV infection, while using antiretroviral therapy regularly. This case broadens the spectrum of an emerging presentation of calcified cerebral toxoplasmosis, mimicking a well-described finding of neurocysticercosis in immunocompetent hosts.

Calcified Neurocysticercosis: Demographic, Clinical, and Radiological Characteristics of a Large Hospital-Based Patient Cohort

Neurocysticercosis (NCC), the infection of the central nervous system caused by Taenia solium larvae (cysticerci), is a major cause of acquired epilepsy worldwide. Calcification in NCC is the most common neuroimaging finding among individuals with epilepsy in T. solium-endemic areas. We describe the demographic, clinical, and radiological profiles of a large hospital cohort of patients with calcified NCC in Peru (during the period 2012-2022) and compared profiles between patients with and without a previous known diagnosis of viable infection. A total of 524 patients were enrolled (mean age at enrollment: 40.2 ± 15.2 years, mean age at symptom onset: 29.1 ± 16.1 years, 56.3% women). Of those, 415 patients (79.2%) had previous seizures (median time with seizures: 5 years, interquartile range (IQR): 2-13 years; median number of seizures: 7 (IQR: 3-32)), of which 333 (80.2%) had predominantly focal to bilateral tonic-clonic seizures; and 358 (68.3%) used antiseizure medication). Patients had a median number of three calcifications (IQR: 1-7), mostly located in the frontal lobes (79%). In 282 patients (53.8%) there was a previous diagnosis of viable infection, while 242 only had evidence of calcified NCC since their initial neuroimaging. Most patients previously diagnosed with viable infection were male, had previous seizures, had seizures for a longer time, had more calcifications, and had a history of taeniasis more frequently than patients without previously diagnosed viable infection (all p < 0.05). Patients with calcified NCC were heterogeneous regarding burden of infection and clinical manifestations, and individuals who were diagnosed after parasites calcified presented with milder disease manifestations.

Correlation between Monocyte Gene Expression and Inflammation on Brain Imaging in Patients with Solitary Cerebral Cysticercus Granuloma

Prior work has shown that 14 monocyte genes are upregulated in patients with different forms of parenchymal neurocysticercosis, including solitary cysticercus granuloma (SCG). The aim of this study was to investigate whether changes in inflammation associated with SCG seen on follow-up brain imaging are also reflected in changes in expression of these 14 genes. Peripheral blood CD14+ monocytes were isolated from 20 patients with SCG at initial diagnosis and at clinical and imaging follow-up of 6 months or more. Expressions of 14 target monocyte genes were determined by quantitative polymerase chain reaction at each visit. At a median follow-up of 14 months, the SCG had resolved in 11 patients, was persistent in four patients, and had calcified in five patients. Edema seen in the initial imaging in 17 patients had resolved in 15 patients and was markedly reduced in two patients. The expression levels of the monocyte genes LRRFIP2, TAXIBP1, and MZB1 were significantly lower at follow-up, regardless of the status of SCG on follow-up imaging. Our findings show that expression levels of monocyte genes involved with inflammatory processes decrease in patients with SCG concomitant with follow-up imaging that reveals a reduction in inflammation as revealed by complete or near-complete resolution of edema, as well as resolution or reduction in the enhancement of the granuloma.

Characteristics of people with epilepsy and Neurocysticercosis in three eastern African countries-A pooled analysis

BACKGROUND

Neurocysticercosis (NCC), a zoonotic disease caused by the pork tapeworm T. solium, represents one of the most common causes of secondary epilepsy but remains often undiagnosed due to lack of awareness and diagnostic facilities.

METHODOLOGY

We pooled data from four cross-sectional studies on epilepsy and NCC in eastern Africa. Study sites were in Uganda, Malawi and in Tanzania (Dar es Salaam and Haydom). The study in Uganda and Malawi were community-based, the two studies in Tanzania were hospital-based. The same questionnaire was used for assessment of clinical characteristics of patients with epilepsy. Computed tomography (CT) scans and serological testing were performed in order to diagnose NCC.

RESULTS

Overall, 1,179 people with epilepsy were included in our analysis. Of those, 941 PWE underwent CT scanning and were pooled for NCC analysis. Seventy patients were diagnosed with NCC, but NCC prevalence differed considerably between sites ranging from 2.0% (95%CI 0.4% to 3.6%) in Dar es Salaam to 17.5% (95%CI 12.4% to 22.6%) in Haydom. NCC prevalence did not show any association with sex but increased with age and was higher in rural than urban settings. In addition, being a farmer, non-Muslim, eating pork and living with pigs close by was associated with a higher NCC prevalence. PWE with NCC experienced their first epileptic seizure around 3 years later in life compared to PWE without NCC and their epileptic seizures seemed to be better controlled (p&lt;0.001). There was no difference between focal onset seizures and focal signs on neurological examination in both groups (p = 0.49 and p = 0.92, respectively). The rT24H-EITB had a sensitivity for the detection of NCC of 70% (95% confidence interval [CI] 51 to 84%), the LLGP of 76% (95%CI 58 to 89%) and the antigen ELISA of 36% (95% CI 20 to 55%).

CONCLUSIONS

NCC is prevalent among PWE in eastern Africa, although it may not be as common as previously stated. Demographic characteristics of PWE with NCC differed from those without NCC, but semiological characteristics and results on neurological examination did not differ compared to PWE without NCC. Interestingly, seizures seemed to be less frequent in PWE with NCC. Being aware of those differences and similarities may help triaging PWE for neuroimaging in order to establish a diagnosis of NCC.

Porcine model of neurocysticercosis by intracarotid injection of Taenia solium oncospheres: Dose assessment, infection outcomes and serological responses

BACKGROUND

Neurocysticercosis (NCC) is the infection of the human central nervous system (CNS) by Taenia solium larvae that cause significant neurological morbidity. Studies on NCC pathophysiology, host-parasite interactions or therapeutic agents are limited by the lack of suitable animal models. We have previously reported that carotid injection of activated T. solium oncospheres directs parasites into the CNS and consistently reproduces NCC. This study assessed the minimal dose required to consistently obtain NCC by intracarotid oncosphere injection and compared antigen and antibody response profiles by dose-group.

METHODS/PRINCIPAL FINDINGS

Three groups of pigs were infected with either 2500 (n = 10), 5000 (n = 11), or 10000 (n = 10) oncospheres. Two pigs died during the study. Necropsy exam at day 150 post-infection (PI) demonstrated viable NCC in 21/29 pigs (72.4%), with higher NCC rates with increasing oncosphere doses (4/9 [44.4%], 9/11 [81.8%] and 8/9 [88.9%] for 2500, 5000, and 10000 oncospheres respectively, P for trend = 0.035). CNS cyst burden was also higher in pigs with increasing doses (P for trend = 0.008). Viable and degenerated muscle cysticerci were also found in all pigs, with degenerated cysticerci more frequent in the 2500 oncosphere dose-group. All pigs were positive for circulating parasite antigens on ELISA (Ag-ELISA) from day 14 PI; circulating antigens markedly increased at day 30 PI and remained high with plateau levels in pigs infected with either 5000 or 10000 oncospheres, but not in pigs infected with 2500 oncospheres. Specific antibodies appeared at day 30 PI and were not different between dose-groups.

CONCLUSION/SIGNIFICANCE

Intracarotid injection of 5000 or more oncospheres produces high NCC rates in pigs with CNS cyst burdens like those usually found in human NCC, making this model appropriate for studies on the pathogenesis of NCC and the effects of antiparasitic treatment.

Epileptogenesis in Common Parasitic Infections

Purpose of the review

Neurocysticercosis (NCC) has been well recognized as a leading cause of epilepsy. More recently, studies of other parasitic diseases such as cerebral malaria (CM) and onchocerciasis are yielding novel insights into the pathogenesis of parasite-associated epilepsy. We compare the clinical and electrophysiological findings in epilepsy associated with these highly prevalent parasites and discuss the mechanisms involved in epileptogenesis.

Recent Findings

Electrophysiological and imaging biomarkers continue to emerge, and individuals who are at-risk of developing parasite-associated epilepsies are being identified with greater reliability. While both Taenia solium and Plasmodium falciparum directly affect the brain parenchyma, Onchocerca volvulus is not known to invade the central nervous system. Thus, the causal association between O. volvulus and epilepsy remains controversial.

Summary

Both NCC and CM have a well-defined acute phase when the parasites directly or indirectly invade the brain parenchyma and lead to local inflammatory changes. This is followed by a chronic phase marked by recurrent seizures. However, these stages of epileptogenic process have not been identified in the case of O. volvulus.

Case Report: Calcified Cerebral Toxoplasmosis Associated with Perilesional Edema in People Living with HIV/AIDS: Case Series of a Presentation Mimicking Neurocysticercosis

Perilesional edema, associated or not with neurological manifestations, is a well-characterized finding in cases of calcified neurocysticercosis. There are no previous reports of HIV-related calcified toxoplasmosis that mimics this presentation of neurocysticercosis. We report on five patients, four of them with new-onset neurological manifestations, who showed brain calcifications associated with perilesional edema. All cases had a history of HIV-related toxoplasmosis and current virological and immunological control of HIV infection. Similar to neurocysticercosis, brain calcified toxoplasmosis may cause perilesional edema and symptoms in people living with HIV/AIDS.

Predictors of Seizure Recurrence in Solitary Calcified Neurocysticercosis in Relation to Computed Tomography Scan: Prospective Observational Study

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.

Frequency and Determinant Factors for Calcification in Neurocysticercosis

BACKGROUND

Neurocysticercosis is a major cause of acquired epilepsy. Larval cysts in the human brain eventually resolve and either disappear or leave a calcification that is associated with seizures. In this study, we assessed the proportion of calcification in parenchymal neurocysticercosis and risk factors associated with calcification.

METHODS

Data for 220 patients with parenchymal NCC from 3 trials of antiparasitic treatment were assessed to determine what proportion of the cysts that resolved 6 months after treatment ended up in a residual calcification at 1 year. Also, we evaluated the risk factors associated with calcification.

RESULTS

The overall proportion of calcification was 38% (188/497 cysts, from 147 patients). Predictors for calcification at the cyst level were cysts larger than 14 mm (risk ratio [RR], 1.34; 95% confidence interval [CI], 1.02-1.75) and cysts with edema at baseline (RR, 1.39; 95% CI, 1.05-1.85). At the patient level, having had more than 24 months with seizures (RR, 1.25; 95% CI, 1.08-1.46), mild antibody response (RR, 1.14; 95% CI, 1.002-1.27), increased dose albendazole regime (RR, 1.26; 95% CI, 1.14-1.39), lower doses of dexamethasone (RR, 1.36; 95% CI, 1.02-1.81), not receiving early antiparasitic retreatment (RR, 1.45; 95% CI, 1.08-1.93), or complete cure (RR, 1.48; 95% CI, 1.29-1.71) were associated with a increased risk of calcification.

CONCLUSIONS

Approximately 38% of parenchymal cysts calcify after antiparasitic treatment. Some factors associated with calcification are modifiable and may be considered to decrease or avoid calcification, potentially decreasing the risk for seizure relapses.

Neurocysticercosis. A frequent cause of seizures, epilepsy, and other neurological morbidity in most of the world

Neurocysticercosis is endemic in most of the world and in endemic areas it accounts for approximately 30% of cases of epilepsy. Appropriate diagnosis and management of neurocysticercosis requires understanding the diverse presentations of the disease since these will vary in regards to clinical manifestation, sensitivity of diagnostic tests, and most importantly, therapeutic approach. This review attempts to familiarize tropical neurology practitioners with the diverse types of neurocysticercosis and the more appropriate management approaches for each.

Neurocysticercosis in Epileptic Children: An Overlooked Condition in Mozambique, Challenges in Diagnosis, Management and Research Priorities

Previous studies suggest that neurocysticercosis (NCC), the most common cause of acute symptomatic seizures (ASS), epilepsy and other neuropsychiatric disorders, typically presents with a solitary lesion and focal seizures in children from places where cysticercosis is endemic. We report a series of 3 patients, aged 7 to 11 years, with a history of epilepsy and or recurrent headache referred from Mocuba to the Quaternary Central Hospital in Quelimane, Zambeze Province, Mozambique, an area endemic for cysticercosis. Clinical history and examination, blood chemistry and hemogram screening, serological testing for Cysticercus antigens and antibodies detection, and a computerized tomography (CT) scan, were performed. NCC was confirmed in all 3 patients, based on criteria defined by Del Bruto. Two confirmed cases tested positive for antigen (Ag) by enzyme-linked immunosorbent assay (ELISA) with CT lesions in different stages of parasite evolution. Headache/encephalopathy was present in all patients. This case series of children with epilepsy confirms for the first time the presence of NCC in children from Zambezia province, an east-central region of Mozambique. Further, NCC should be included in the differential diagnosis of children with ASS, epilepsy and other neuropsychiatric disorders. Future studies should be targeted to the identification of biomarkers to support the diagnosis of NCC, given the limited availability of imaging tools and limited value of serological assays for the diagnosis and management of NCC.

Imaging correlates of serum enzyme-linked immunoelectrotransfer blot (EITB) positivity in patients with parenchymal neurocysticercosis: results from 521 patients

BACKGROUND

The presence of perilesional edema among patients with parenchymal neurocysticercosis (pNCC) of various lesion subtypes has not been correlated with results of serum enzyme-linked immunotransfer blot (EITB) for cysticercal antibodies.

METHODS

In total, 521 patients with pNCC were classified into solitary cysticercus granuloma (SCG), multiple lesions, at least one of which was an enhancing granuloma (GMNCC), solitary calcified cysticercal lesion (SCC) and multiple calcified cysticercal lesions (CMNCC). The proportion of EITB positivity among each lesion subtype and its association with perilesional edema were determined.

RESULTS

There were significantly higher positive EITB results in patients with GMNCC (90/111, 81.1%) compared with other lesion types. Perilesional edema was associated with positive EITB in patients with CMNCC. On univariate analysis, perilesional edema and GMNCC were associated with EITB positivity. On multivariate analysis, only GMNCC (OR 7.5; 95% CI 3.5 to 16.2) was significantly associated with EITB positivity.

CONCLUSIONS

In patients with pNCC, the presence of perilesional edema is associated with a higher probability of a positive EITB result in patients with CMNCC, suggesting a synchronicity in the mechanisms associated with formation of perilesional edema and the antibody response in this subtype. In patients with enhancing granulomas, edema is not an independent predictor of a positive EITB, suggesting that the enhancement itself is associated with a strong antibody response.

Brain calcification because of neurocysticercosis: a vast field to be explored

PURPOSE OF REVIEW

Neurocysticercosis is the most common helminthic infection of the central nervous system caused by the larval stage of the pork tapeworm, Taenia solium. Endemic regions include Latin American countries, sub-Saharan Africa, and large regions of Asia, including the Indian subcontinent and is a global health problem. Seizures are the most common manifestation and approximately 30% of adult-onset seizures in endemic regions are attributable to NCC. Calcifications because of neurocysticercosis is the most common finding on imaging in endemic regions and are important seizure foci contributing to the burden of epilepsy.

RECENT FINDINGS

After treatment with antiparasitics for multiple viable parenchymal disease, approximately 38% of cysts that resolved after 6 months of therapy will result in residual calcifications, which represents a significant burden of residual disease. Calcified disease has been referred to as 'inactive disease', but there is accumulating evidence to suggest that calcified granulomas are actually dynamic and substantially contribute to the development and maintenance of seizures.

SUMMARY

Calcified parenchymal neurocysticercosis contributes significantly to the development and maintenance of seizures in endemic regions. Understanding the pathogenesis of the role of calcified NCC in seizure development and risk factors for development of calcifications after treatment is critical to decreasing the burden of symptomatic disease in endemic regions.

Epilepsy outcomes and hippocampal volumes in children with multiple parenchymal neurocysticercoses

Background:

We aimed to study the radiological and epilepsy outcomes of children with multiple neurocysticercosis (NCC) and the relationship with hippocampus volume.

Study Design:

Observational study.

Materials and Methods:

Children between 5 and 18 years of age with NCC lesions and completed more than 2-year follow-up were enrolled. Magnetic resonance imaging (MRI) brain with a predefined protocol was done as per clinical indication, and bilateral hippocampi volume was measured with a region of interest-based manual method. Proportion of children who had radiological resolution of lesions, proportion of children who were seizure-free for at least 3 months after antiepileptic drugs withdrawal, and mean hippocampi volume were calculated.

Results:

During the study period, 229 children followed up in pediatric NCC clinic were enrolled, the mean age was 10.5 ± 3 years, and 129 (56%) were boys. A total of 159 (65%) children had single-lesion NCC, and 79 (35%) had multiple lesion (> 2) NCC. Resolution of lesions was seen in 8% children with multiple NCC, significantly less as compared to the single NCC group (8% vs. 27%, P = 0.006). Multiple-lesion NCC group had a higher rate of calcification as compared to children with a single lesion (66% vs. 47%, P = 0.008). Twenty-nine (37%) children with multiple-lesion NCC were seizure free for at least 3 months after antiepileptic drug withdrawal. Mean combined hippocampal volume in children with single-lesion NCC was 2.96 (0.62) mL and multiple-lesion NCC was 2.88(0.43) mL.

Conclusion:

Children with multiple-lesion NCC have lower resolution, and higher calcification during follow-up in comparison to single-lesion NCC. Frequency of children who remained seizure-free 3-month post AED withdrawal was similar in single- and multiple-lesion groups.

Taenia solium Cysticercosis and Its Impact in Neurological Disease

Taenia solium neurocysticercosis (NCC) is endemic in most of the world and contributes significantly to the burden of epilepsy and other neurological morbidity. Also present in developed countries because of immigration and travel, NCC is one of few diseases targeted for eradication. This paper reviews all aspects of its life cycle (taeniasis, porcine cysticercosis, human cysticercosis), with a focus on recent advances in its diagnosis, management, and control. Diagnosis of taeniasis is limited by poor availability of immunological or molecular assays. Diagnosis of NCC rests on neuroimaging findings, supported by serological assays. The treatment of NCC should be approached in the context of the particular type of infection (intra- or extraparenchymal; number, location, and stage of lesions) and has evolved toward combined symptomatic and antiparasitic management, with particular attention to modulating inflammation. Research on NCC and particularly the use of recently available genome data and animal models of infection should help to elucidate mechanisms of brain inflammation, damage, and epileptogenesis.

An Ambispective Cohort Study to Assess Seizure Recurrences in Children with Calcified Parenchymal Neurocysticercosis

Calcified neurocysticercosis (NCC), previously thought to be a dead end, is an important risk factor for seizure recurrences. We studied the pattern of seizure recurrences and associated radiological findings in children with calcified NCC. In this ambispective cohort study, we enrolled children (age 1-15 years) with calcified NCC attending the pediatric NCC clinic between January 2017 and December 2017. Retrospective data were collected from the hospital records, and all enrolled children were prospectively followed up till June 2018. The study group divided into two groups: 1) children first presenting with calcified granuloma and 2) children presented with ring-enhancing lesion (REL) and transformed into the calcified lesion during follow-up imaging. During the study period (January 2017-December 2017), 520 children with NCC were screened and 128 with calcified NCC were enrolled. The mean age was 10.8 ± 3.2 years, and 63% were boys. Among 128 children, 40 (31%) had calcified granuloma and 88 (69%) had REL transformed to calcified granuloma. Sixty-one (49%) children had seizure recurrence: 22 (58%) within calcified granuloma group and 39 (45%) within REL transformed to calcified granuloma group (P = 0.18). Seizure recurrence was associated with the presence of perilesional edema (PE) in 35 (57.4%) children on computed tomography scan. The median interval between two seizure recurrences was 30 (17-56) months, and the median antiepileptic drug-free interval was 17 (12-22) months. The total duration of continued seizures was 42 (26-58) months, slightly longer in children with REL transformed to calcified granuloma group (42, 95% CI: 18-66 months) in comparison to calcified granuloma group (35, 95% CI: 10-60 months, P = 0.32). To conclude, children with calcified NCC have seizure recurrences over a prolonged period. Seizure recurrences are intermittent and may be interspersed with a prolonged period of quiescence in between. The presence of PE and contrast enhancement around the lesion during seizure recurrence suggests lesion reactivation.

Prevalence, clinical characteristics, and seizure outcomes of epilepsy due to calcific clinical stage of neurocysticercosis: Study in a rural community in south India

OBJECTIVE

The objective of this research was to study the prevalence, clinical characteristics, and seizure remission rates of epilepsy due to calcific stage of neurocysticercosis (cNCC) in a rural community in south India.

MATERIAL AND METHODS

Comprehensive Rural Epilepsy Study South India (CRESSI) is a prospective longitudinal study of epilepsy care in a rural community in south India. As part of this study, prevalence of epilepsy was studied in a population of 74,086 in 22 villages. The prevalence study identified 451 people with epilepsy including 62 (13.7%) with epilepsy due to cNCC. Diagnosis of cNCC was based on computed tomography (CT) findings. The clinical characteristics and seizure outcomes were studied in this cohort of 62 patients. The data collected included demographics, seizure type, antiepileptic drugs (AEDs), seizure remission rates, and predictors of long-term seizure remissions.

RESULTS

The crude prevalence of epilepsy due to cNCC in this rural community was 0.84 per 1000 (95% confidence interval [CI]: 0.65-1.07). This lesion accounted for 41% of the established etiology among 451 prevalence cases of epilepsy. Mean age at presentation was 28.87 ± 14.45 (range: 8-65 years) with equal gender distribution. The common location of the lesion was in the perirolandic region. Focal onset motor seizures were the common seizure type. Seizure remission (≥2 years) rate was 80.3%. The independent predictor of drug resistance was failure to respond to monotherapy (odds ratio: 63.9; 95% CI: 8.4-485.4; p < 0.0001). Focal impaired awareness behavioral arrest/automatisms with lesion located in the temporal lobe in all the three patients were drug-resistant.

CONCLUSIONS

In this rural community in south India, epilepsy due to cNCC was the commonest acquired epilepsy in people aged ≥20 years. Long-term seizure remission rates were high, and failure to respond to monotherapy was the predictor of drug resistance. Drug-resistant epilepsy was extremely rare with this lesion.

Long-term Cognitive Outcome of Children With Parenchymal Neurocysticercosis: A Prospective Observation Study

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.

TNF-α blockade suppresses pericystic inflammation following anthelmintic treatment in porcine neurocysticercosis

Background

Neurocysticercosis (NCC) is an infection of the brain with the larval cyst of the tapeworm, Taenia solium. Cysticidal treatment induces parasite killing resulting in a post inflammatory response and seizures, which generally requires corticosteroid treatment to control inflammation. The nature of this response and how to best control it is unclear. We investigated the anti-inflammatory effects of pretreatment with etanercept (ETN), an anti-tumor necrosis factor agent, or dexamethasone (DEX), a high potency corticosteroid, on the post treatment inflammatory response in naturally infected pigs with neurocysticercosis after a single dose of the cysticidal drug praziquantel (PZQ).

Methodology/Principal findings

We followed the methods from a previously developed treatment model of NCC in naturally infected swine. The four study groups of infected pigs included 3 groups treated with PZQ on day 0: PZQ-treated alone (100 mg/kg PO; n = 9), pretreated with dexamethasone (DEX, 0.2 mg/kg IM administered on days -1, +1 and +3; n = 6), and pretreated with etanercept (ETN, 25 mg IM per animal on days -7 and 0; n = 6). The fourth group remained untreated (n = 3). As measured by quantitative RT-PCR, ETN pretreatment depressed transcription of a wide range of proinflammatory, regulatory and matrix protease encoding genes at 120 hr post PZQ treatment in capsules of cysts that demonstrated extravasated Evans Blue (EB) (a measure of blood brain barrier dysfunction) compared to animals not receiving ETN. Transcription was significantly depressed for the proinflammatory genes tumor necrosis factor (TNF)-α, and interferon (IFN)-γ; the inflammation regulating genes cytotoxic T-lymphocyte-associated protein (CTLA)4, interleukin (IL)-13 and transforming growth factor (TGF)-β; the tissue remodeling genes matrix metalloprotease (MMP)1 and 9, tissue inhibitors of metalloproteases (TIMP)1 and 2, and the genes regulating endothelial function vascular endothelial growth factor (VEGF)1, angiopoietin (Ang)1, Ang 2, and platelet endothelial cell adhesion molecule (PECAM)-1. In contrast, transcription was only modestly decreased in the DEX pretreated pigs compared to PZQ alone, and only for TNF-α, IL-6, IFN-γ, TGF-β and Ang1. IL-10 was not affected by either ETN or DEX pretreatments. The degree of inflammation, assessed by semi-quantitative inflammatory scores, was modestly decreased in both ETN and DEX pretreated animals compared to PZQ treated pigs whereas cyst damage scores were moderately decreased only in cysts from DEX pretreated pigs. However, the proportion of cysts with EB extravasation was not significantly changed in ETN and DEX pretreated groups.

Conclusions/Significance

Overall, TNF-α blockade using ETN treatment modulated expression of a large variety of genes that play a role in induction and control of inflammation and structural changes. In contrast the number of inflammatory cells was only moderately decreased suggesting weaker effects on cell migration into the inflammatory capsules surrounding cysts than on release of modulatory molecules. Taken together, these data suggest that TNF-α blockade may provide a viable strategy to manage post-treatment pericystic inflammation that follows antiparasitic therapy for neurocysticercosis.

Infection of the brain with larvae of the tapeworm Taenia solium is called neurocysticercosis (NCC), a disease with varied and serious neurological symptoms. Therapy requires antiparasitic drugs and corticosteroids to prevent seizures caused by treatment due to inflammation around dying parasites. The gene expression of the proinflammatory molecule tumor necrosis factor alpha (TNF-α) is increased in NCC. We treated three groups of naturally infected pigs with an antiparasitic drug: one group was also pretreated with an anti-TNF-α inhibitor, the second one with a corticosteroid, and the third was not pretreated. All pigs were infused with Evans blue dye (EB), which leaks where the blood brain barrier is damaged by inflammation around cysts. We compared the expression of several genes involved in inflammation, healing and fibrosis and regulation of vascular function in tissues surrounding cysts. In inflamed samples showing leaked EB, the inhibition of TNF-α suppressed nearly all the genes assessed, and this suppression was significantly stronger than the moderate decrease caused by corticosteroid pretreatment on most of the genes. On microscopic examination, the inflammation observed was slightly decreased with both pretreatments in relation to the group that was not pretreated. We believe that the inflammatory route that includes TNF-α should be further explored in the search for better management of inflammation directed to degenerating cysts.

Antiparasitic treatment of neurocysticercosis - The effect of cyst destruction in seizure evolution

Antiparasitic agents against Taenia solium cysticercosis have been in use since 1979, although its use has been questioned on the basis that cysts would die naturally and thus treatment-induced inflammation is unnecessary. In addition, isolated reports have also questioned whether neurocysticercosis (NCC) is a cause of epilepsy. After more than three and a half decades, a large body of evidence is available. Little if any doubt exists about NCC as a cause of seizures - NCC is consistently associated with seizures when appropriate groups are compared, and in a large subset of cases, seizure semiology correlates with the anatomical location of lesions. Cyst degeneration and the subsequent inflammatory reaction increase seizure expression, although patients with non-inflamed cysts may have seizures, as do patients with long-standing, not inflamed calcified scars. Assessment of the evidence on cysticidal efficacy, safety, and the impact of cyst destruction in decreasing seizures leads to the conclusion that the benefits of antiparasitic treatment in parenchymal brain cysticercosis clearly outweigh the risks, and have provided substantive evidence of the role of NCC as a cause of seizures and epilepsy. Antiparasitic therapy should be considered a primary option in the management of patients with live or degenerating brain NCC cysts. This article is part of a Special Issue entitled "Neurocysticercosis and Epilepsy".

Target product profiles for the diagnosis of Taenia solium taeniasis, neurocysticercosis and porcine cysticercosis

Target Product Profiles (TPPs) are process tools providing product requirements to guide researchers, developers and manufacturers in their efforts to develop effective and useful products such as biologicals, drugs or diagnostics. During a WHO Stakeholders Meeting on Taenia solium diagnostics, several TPPs were initiated to address diagnostic needs for different stages in the parasite's transmission (taeniasis, human and porcine cysticercosis). Following the meeting, draft TPPs were completed and distributed for consultation to 100 people/organizations, including experts in parasitology, human and pig cysticercosis, diagnostic researchers and manufacturers, international organizations working with neglected or zoonotic diseases, Ministries of Health and Ministries of Livestock in some of the endemic countries, WHO regional offices and other interested parties. There were 53 respondents. All comments and feedback received were considered and discussions were held with different experts according to their area of expertise. The comments were consolidated and final TPPs are presented here. They are considered to be live documents which are likely to undergo review and updating in the future when new knowledge and technologies become available.

Neurocysticercosis: A case study of a Mongolian traveler who visited China and India with an updated review in Asia

BACKGROUND

Neurocysticercosis (NCC) of Taenia solium has never been reported in Mongolia. A Mongolian traveler who visited China and India presented with epileptic seizures after his return to Mongolia. Magnetic resonance imaging showed multiple ring enhancing lesions with edema surrounding several lesions in his brain that were initially diagnosed to be viral encephalitis or NCC.

METHODS

Serology for cysticercosis using diagnostic antigens partially purified by cation-exchange chromatography and chimeric recombinant antigens and DNA analysis of a proglottid found in the patient's stool were applied for differential diagnosis.

RESULTS

Serology showed strong positivity for NCC, and mitochondrial cox1 gene analysis revealed Indian but not Chinese haplotype of T. solium.

CONCLUSION

This NCC case was considered to be caused by eggs released from adult tapeworm(s) established after eating uncooked or undercooked pork contaminated with cysticerci during his stay in India. This is a case report of taeniasis and secondary NCC associated with travel to India with an updated review of NCC in Asia. Molecular tracking of the specimen is highly informative as a way to identify where the infection was acquired.

CSF in acute and chronic infectious diseases

Infections of the nervous system are an important and challenging aspect of clinical neurology. Immediate correct diagnosis enables to introduce effective therapy, in conditions that without diagnosis may leave the patient with severe neurological incapacitation and sometimes even death. The cerebrospinal fluid (CSF) is a mirror that reflects nervous system pathology and can promote early diagnosis and therapy. The present chapter focuses on the CSF findings in neuro-infections, mainly viral and bacterial. Opening pressure, protein and glucose levels, presence of cells and type of the cellular reaction should be monitored. Other tests can also shed light on the causative agent: serology, culture, staining, molecular techniques such as polymerase chain reaction. Specific examination such as panbacterial and panfungal examinations should be examined when relevant. Our chapter is a guide-text that combines clinical presentation and course with CSF findings as a usuaful tool in diagnosis of neuroinfections.