Cerebrovascular Complications of Neurocysticercosis

Report of three patients with extensive neurocysticercosis in rural southern Tanzania: neurological, serological and neuroradiological findings

BACKGROUND

Neurocysticercosis (NCC) is common in eastern Africa, but disease presentation varies considerably. Most patients have single or few NCC-typical lesions in their brain but some present with a large number of lesions. We present three patients with positive antibody-based serology for Taenia solium cysticercosis screened at the Vwawa district hospital, Mbozi district, southern Tanzania, in whom extensive NCC was confirmed by neuroimaging.

CASE PRESENTATIONS

Patient 1 was a 55-year-old female from the tribe Malila smallholder farmer who has had four generalized tonic-clonic epileptic seizures over a period of 11 years and one episode of transient left hemiparesis one year before seizure onset. The patient also reported monthly to weekly episodes of severe, progressive, unilateral headache. The computed tomography (CT) scan of the brain showed 25 NCC lesions of which 15 were in the vesicular stage. Patient 2 was a 30-year-old male from tribe Nyha mechanic who reported monthly episodes of moderate to severe, progressive, bilateral headache, but no epileptic seizures. The CT scan showed 63 NCC lesions of which 50 were in the vesicular stage. Patient 3 was a 54-year-old female from the tribe Malila smallholder farmer who suffered from frequent generalized tonic-clonic epileptic seizures with potential signs of focal seizure onset. She also reported weekly to daily episodes of severe, progressive, unilateral headache. The CT scan showed 29 NCC lesions of which 28 were in the vesicular stage.

CONCLUSIONS

Clinical presentation of NCC with multiple brain lesions varies considerably ranging from few epileptic seizures and severe headache to severe epilepsy with frequent epileptic seizures. Individuals with neurological signs/symptoms that may be due to NCC, based for example on epidemiological criteria or serological evidence of cysticercosis, are recommended to undergo neuroimaging before anthelminthic treatment is considered.

Spectrum of Large- and Medium-Vessel Vasculitis in Adults: Neoplastic, Infectious, Drug-Induced, Autoinflammatory, and Primary Immunodeficiency Diseases

Purpose of Review

To provide a comprehensive review of drugs and neoplastic, infectious, autoinflammatory, and immunodeficiency diseases causing medium- to large-vessel vasculitis in adults with emphasis on information essential for the initial diagnostic process.

Recent Findings

Entities with medium- to large-vessel vasculitis as clinical manifestations have been described recently (e.g., adenosine deaminase-2 deficiency, VEXAS-Syndrome), and vasculitis in established autoinflammatory or immunodeficiency diseases is increasingly being identified.

Summary

In the diagnostic process of medium- to large-vessel vasculitis in adults, a large variety of rare diseases should be included in the differential diagnosis, especially if diagnosis is made without histologic confirmation and in younger patients. Although these disorders should be considered, they will undoubtedly remain rare in daily practice.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11926-022-01083-5.

My experience on taeniasis and neurocysticercosis

Taeniasis and neurocysticercosis (NCC) are major public health problems in developing countries. NCC is the leading cause of community-acquired active epilepsy. NCC may present as a medical emergency, especially when there is cysticercotic encephalitis or raised intracranial hypertension. Systematic community-based studies on taeniasis and NCC are lacking. We studied taeniasis and NCC-related active epilepsy disease burden in the pig farming community of Lucknow district, Uttar Pradesh, India. Based on the 30 cluster sampling approach as recommended by the World Health Organization, we estimated the prevalence of taeniasis, NCC-related active epilepsy, and silent NCC in the community. We also estimated the prevalence of swine cysticercosis. Taeniasis was detected in 18.6% of populations. Expulsions of tapeworm segments in stool, consumption of undercooked pork, age above 15 years, and handwash with clay or plain water after defecation were associated with taeniasis. On molecular analyses of positive stool samples, T. solium was identified in 40% and Taenia asiatica in 60% of cases. Active epilepsy was identified in 5.8% of subjects; 48% of them had NCC. On neuroimaging, NCC was detected in 15% of asymptomatic individuals. We observed that host genetic factors such as toll-like receptor-4, matrix metalloproteinase-9, intercellular adhesion molecule-1, and glutathione-S transferase gene polymorphisms were associated with seizure in NCC. When peripheral blood mononuclear cells (PBMCs) from NCC subjects were exposed to cysticerci fluid antigens in-vitro, PBMCs from symptomatic and asymptomatic subjects showed significantly higher Th 1 and Th 2 cytokines response respectively, symptomatic patients had significant Th-1 cytokines response, while asymptomatic individuals showed Th-2 response. Porcine cysticercosis was detected in 26% of swine; 38% of them had cysticerci in the brain. Swine with brain involvement showed clinical signs such as excessive salivation, excessive blinking and tearing, and subconjunctival nodule. On molecular analysis, 15% of cysticerci in swine were identified as T. asiatica. Infected swine when treated with albendazole plus/minus steroid, the response rate of cysticerci (either dead or resolved lesion) was 100% in albendazole-treated group and 71% in albendazole plus steroid-treated group. The above studies suggest that taeniasis and NCC are alarmingly high in the pig farming community of North India. Taeniasis in human and cysticercosis in swine due to T. asiatica call for further studies on this parasite.

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.

Ischaemic stroke in young adults: a global perspective

Ischaemic stroke at young age is an increasing problem in both developing and developed countries due to rising incidence, high morbidity and mortality and long-term psychological, physical and social consequences. Compared with stroke in older adults, stroke in young adults is more heterogeneous due to the wide variety of possible underlying risk factors and aetiologies. In this review, we will provide an overview of the global variation in the epidemiology of stroke in young adults, with special attention to differences in geography, ethnicity/race and sex, as well as traditional and novel risk factors for early-onset ischaemic stroke, such as air pollution. Understanding global differences is an important prerequisite for better region-specific prevention and treatment of this devastating condition.

Brain Magnetic Resonance Imaging Findings Associated With Cognitive Impairment in Children and Adolescents With Human Immunodeficiency Virus in Zambia

BACKGROUND

Cognitive impairment is common in children and adolescents with human immunodeficiency virus (HIV). Brain magnetic resonance imaging (MRI) is a potentially useful tool to investigate the pathophysiology of HIV-associated cognitive impairment and may serve as a biomarker in future clinical trials. There are few published data on brain imaging in children with HIV in sub-Saharan Africa.

METHODS

Thirty-four perinatally infected subjects with HIV and age-matched HIV-exposed uninfected controls between the ages nine and 17 years were recruited from the Pediatric Center of Excellence in Lusaka, Zambia, as part of the HIV-associated Neurocognitive Disorders in Zambia study. Brain MRI sequences were acquired, and clinical and volumetric assessments were performed. Subjects underwent a comprehensive neuropsychologic battery, and cognitive impairment status was classified using a global deficit score approach. Regression models were used to evaluate relationships between MRI findings and cognitive function.

RESULTS

We identified cerebrovascular disease in seven of 34 subjects with HIV compared with zero of 17 controls (21% vs 0%, P = 0.04). We also identified decreased total brain volumes (1036 vs 1162 cm³, P = 0.03) and decreased cortical thickness in the right temporal lobes (3.12 vs 3.29 mm; P = 0.01) and right fusiform gyri (3.10 vs 3.25 mm; P = 0.02) of HIV-infected subjects with cognitive impairment.

CONCLUSIONS

These findings support the hypothesis that brain volumes may be useful biomarkers for cognitive outcomes in children with HIV. Further studies are necessary to investigate mechanisms of cerebrovascular disease and volume loss in children with HIV.

Ischemic stroke and infectious diseases in low-income and middle-income countries

PURPOSE OF REVIEW

To address the important relationships between stroke and infection, focusing on the most frequent infections found in low-income and middle-income countries.

RECENT FINDINGS

Stroke is one of the leading causes of mortality and disability worldwide, with a great proportion of the stroke burden occurring in low-income and middle-income countries. Infectious diseases are still a great health problem in developing countries and it is possible that the proportion of infection-related strokes is greater in these nations. Infectious diseases and stroke have a bidirectional relationship. Common infections may act as risk factors and can trigger stroke through different mechanisms in their acute phase. Several intracranial and systemic infections can cause stroke as a direct complication, such as Chagas disease, neurosyphilis, tuberculous meningitis, and neurocysticercosis. These conditions are of particular interest to low-income and middle-income countries, but also relevant to high-income nations because of increasing migration. Finally, infection is a frequent poststroke complication, with great impact in the patient outcome.

SUMMARY

Infectious diseases and stroke are common problems in low-income and middle-income countries. More studies are necessary to fully elucidate the real impact of infectious diseases on stroke burden, especially in countries where epidemiological data are still scarce.

Neurocysticercosis: mimics and chameleons

Neurocysticercosis is the most common parasitic neurological disease worldwide, yet in Europe, it remains relatively uncommon, with many practitioners rarely seeing a case. However, immigration and international travel mean that it is becoming increasingly recognised and diagnosed in developed countries. Being a treatable condition, it is essential to be familiar with the diagnosis and to appreciate its mimics and breadth of its possible clinical presentations.

Next generation sequencing based pathogen analysis in a patient with neurocysticercosis: a case report

BACKGROUND

Accurate and early diagnosis of neurocysticercosis (NCC) remains a challenge due to the heterogeneity of its clinical, immunological and imaging characteristics. The presence of cysticercus DNA in cerebrospinal fluid (CSF) of NCC patients has been previously detected via conventional PCR assays. To the best of our knowledge, the use of CSF Next-Generation Sequencing (NGS) based pathogen analysis in patients with NCC infection has never been reported.

CASE PRESENTATION

This study reports the clinical, imaging, and immunological features of a patient initially presenting with several months of headache who further developed a pure sensory stroke. NGS was used to detect the pathogen, and her CSF demonstrated the presence of Taenia solium-DNA. This finding was confirmed by a positive reaction to CSF cysticercosis antibodies. After antiparasitic treatment, secondary CSF NGS revealed the DNA index have dropped considerably compared to the initial NGS readings.

CONCLUSIONS

NGS is a promising tool for the early and accurate diagnosis of central nervous system (CNS) infection, especially in the setting of atypical clinical manifestations. Further studies are required to evaluate the persistence of DNA in the CSF of patients.

Neuroimaging in Central Nervous System Infections

Radiologic imaging is often employed to supplement clinical evaluation in cases of suspected central nervous system (CNS) infection. While computed tomography (CT) is superior for evaluating osseous integrity, demineralization, and erosive changes and may be more readily available at many institutions, magnetic resonance imaging (MRI) has significantly greater sensitivity for evaluating the cerebral parenchyma, cord, and marrow for early changes that have not yet reached the threshold for CT detection. For these reasons, MRI is generally superior to CT for characterizing bacterial, viral, fungal, and parasitic infections of the CNS. The typical imaging features of common and uncommon CNS infectious processes are reviewed.

Report of three imported cases of neurocysticercosis in Guadeloupe

BACKGROUND

Neurocysticercosis is endemic in most countries of Central and South America but has rarely been described in the French West Indies. We aimed to better understand the clinical and radiological presentation of our cases.

CASE PRESENTATION

We report three cases of neurocysticercosis in patients living in Guadeloupe, with different clinical and radiological presentations.

CONCLUSION

Given the eventuality of autochtonous transmission, the diagnosis should be considered in all patients living in Guadeloupe presenting with seizures.

Molecular analyses reveal two geographic and genetic lineages for tapeworms, Taenia solium and Taenia saginata, from Ecuador using mitochondrial DNA

Tapeworms Taenia solium and Taenia saginata are the causative agents of taeniasis/cysticercosis. These are diseases with high medical and veterinary importance due to their impact on public health and rural economy in tropical countries. The re-emergence of T. solium as a result of human migration, the economic burden affecting livestock industry, and the large variability of symptoms in several human cysticercosis, encourage studies on genetic diversity, and the identification of these parasites with molecular phylogenetic tools. Samples collected from the Ecuadorian provinces: Loja, Guayas, Manabí, Tungurahua (South), and Imbabura, Pichincha (North) from 2000 to 2012 were performed under Maximum Parsimony analyses and haplotype networks using partial sequences of mitochondrial DNA, cytochrome oxidase subunit I (COI) and NADH subunit I (NDI), from Genbank and own sequences of Taenia solium and Taenia saginata from Ecuador. Both species have shown reciprocal monophyly, which confirms its molecular taxonomic identity. The COI and NDI genes results suggest phylogenetic structure for both parasite species from south and north of Ecuador. In T. solium, both genes gene revealed greater geographic structure, whereas in T. saginata, the variability for both genes was low. In conclusion, COI haplotype networks of T. solium suggest two geographical events in the introduction of this species in Ecuador (African and Asian lineages) and occurring sympatric, probably through the most common routes of maritime trade between the XV-XIX centuries. Moreover, the evidence of two NDI geographical lineages in T. solium from the north (province of Imbabura) and the south (province of Loja) of Ecuador derivate from a common Indian ancestor open new approaches for studies on genetic populations and eco-epidemiology.

Clinical management of infectious cerebral vasculitides

A wide range of infections (virus, bacteria, parasite and fungi) may cause cerebral vasculitides. Headache, seizures, encephalopathy and stroke are common forms of presentation. Infection and inflammation of intracranial vessels may cause pathological vascular remodelling, vascular occlusion and ischemia. Vasculitis in chronic meningitis may cause ischemic infarctions, and is associated with poor outcome. Appropriate neuroimaging (CT-angiography, MR-angiography, conventional 4-vessel angiography) and laboratory testing (specific antibodies in blood and CSF, CSF culture and microscopy) and even brain biopsy are needed to quickly establish the aetiology. Enhancement of contrast, wall thickening and lumen narrowing are radiological signs pointing to an infectious vasculitis origin. Although corticosteroids and prophylactic antiplatelet therapy have been used in infectious cerebral vasculitis, there are no randomized clinical trials that have evaluated their efficacy and safety. Stable mycotic aneurysms can be treated with specific antimicrobial therapy. Endovascular therapy and intracranial surgery are reserved for ruptured aneurysms or enlarging unruptured aneurysms.

Under seize: neurocysticercosis in an immigrant woman and review of a growing neglected disease

Neurocysticercosis (NCC) is a significantly neglected tropical disease and, with increasing globalisation, a notable emerging infection in the developed world. We describe a case of ventricular NCC in a 22-year-old Mexican-American woman with a history of seizures, who presented with 2 weeks of headaches and intermittent fevers progressing to altered mental status and vomiting. Initial imaging revealed a cystic mass at the posteroinferior aspect of the third ventricle superior to the aqueduct of Sylvius, calcifications scattered throughout the parenchyma, and enlargement of the lateral and third ventricles. Initial laboratories were unrevealing and serum investigations for Taenia solium antibody were negative, but T. solium antibody was subsequently returned positive from cerebrospinal fluid. This case highlights important issues regarding the clinical presentation, diagnostic evaluation and treatment of NCC relevant to providers not only in areas with endemic disease but, importantly, in locales with diverse immigrant populations.

Conservative management of neurocysticercosis in a patient with hematopoietic stem cell transplantation: a case report and review

Neurocysticercosis, an infection of the central nervous system with the larval stage of the cestode Taenia solium, is common in developing countries but its occurrence and management in allogeneic hematopoietic stem cell transplantation (HSCT) has not been reported previously, to our knowledge. We report the case of an immigrant female patient who underwent a matched-related allogeneic HSCT for acute lymphoblastic leukemia and was incidentally found to have a solitary viable neurocysticercosis lesion. However, despite severe immunosuppression, the size of the cyst did not increase. More importantly, restoration of the immune system did not induce significant inflammation or seizures. Subsequent follow-up demonstrated complete resolution of the neurocysticercosis lesion. Thus, in the setting of HSCT, an asymptomatic patient with a single neurocysticercosis lesion was successfully managed without the use of anthelmintics, steroids, or anti-epileptics.

Neurocysticercosis

Neurocysticercosis, the most common helminthic infection of the nervous system, is a major cause of acquired epilepsy worldwide. The disease occurs when humans become intermediate hosts of the tapeworm Taenia solium after ingesting its eggs by contagion from an asymptomatic Taenia carrier. Within the nervous system, parasites may locate in brain parenchyma, subarachnoid space, ventricular system, or spinal cord, causing several pathological changes that are responsible for the clinical pleomorphism of the disease. Seizures are the most common clinical manifestation, but a sizable proportion of patients develop focal deficits, intracranial hypertension, or cognitive decline. Preoperative diagnosis of neurocysticercosis is possible after proper integration of data from neuroimaging studies and immunological tests. Cysticidal drugs (albendazole and praziquantel) have changed the prognosis of most patients with neurocysticercosis. The use of these drugs has shown to reduce the parasite load within the central nervous system and to improve the clinical prognosis of the disease in many cases. Future studies should focus on disease eradication through the implementation of control programs against all the interrelated steps in the life cycle of T solium, including human carriers of the adult tapeworm, infected pigs, and eggs in the environment.

Magnetic resonance imaging in neurocysticercosis

Cysticercosis in one of the most common parasitic infections in the central nervous system. The complex and unpredictable nature of the host immune reaction against cysticercosis as well as the pleomorphism of your injuries make the disease neurocysticercosis interesting and fascinating to study. Imaging studies play an important role in the diagnosis of this disease. Advanced imaging techniques have improved detection and visualization of scolex cysts extraparenchymal spaces.

The importance of neurocysticercosis in stroke in rural areas of a developing Latin American country

There is limited information on the prevalence of neurocysticercosis (NCC) among stroke patients, and no community-based survey has addressed this issue. We performed a 3-Phase, population-based study, to assess the prevalence and pathogenesis of stroke in a rural village of coastal Ecuador, where cysticercosis is highly endemic. Twenty stroke patients were found among 642 individuals ≥ 40 years of age. Eighteen of these patients underwent neuroimaging studies and no patient had evidence of NCC or angiitis of intracranial vessels. The serum immunoblot test for the detection of anticysticercal antibodies, performed in 15 of these 20 patients during a previous survey, were negative in 13 cases and the remaining two had a normal computed tomography of the head. This study suggests that NCC is not responsible for the increasing burden of stroke in rural areas of developing countries.

Angiographic findings in 2 children with cerebral paragonimiasis with hemorrhage

Hemorrhagic events associated with cerebral paragonimiasis are not rare, especially in children and adolescents; however, angiographic evidence of cerebrovascular involvement has not been reported. The authors describe angiographic abnormalities of the cerebral arteries seen in 2 children in whom cerebral paragonimiasis was associated with hemorrhagic stroke. The patients presented with acute intracerebral and subarachnoid hemorrhage. Angiography revealed a beaded appearance and long segmental narrowing of arteries, consistent with arteritis. In both patients, involved vessels were seen in the area of the hemorrhage. The vascular changes and the hemorrhage, together with new lesions that developed close to the hemorrhage and improved after praziquantel treatment, were attributed to paragonimiasis. Further study of the frequency and mechanism of hemorrhagic cerebrovascular complications associated with cerebral paragonimiasis is needed.

Parasitoses of the human central nervous system

Cerebral involvement in parasitoses is an important clinical manifestation of most of the human parasitoses. Parasites that have been described to affect the central nervous system (CNS), either as the dominant or as a collateral feature, include cestodes (Taenia solium (neurocysticerciasis), Echinococcus granulosus (cerebral cystic echinococcosis), E. multilocularis (cerebral alveolar echinococcosis), Spirometra mansoni (neurosparganosis)), nematodes (Toxocara canis and T. cati (neurotoxocariasis), Trichinella spiralis (neurotrichinelliasis), Angiostrongylus cantonensis and A. costaricensis (neuroangiostrongyliasis), Gnathostoma spinigerum (gnathostomiasis)), trematodes (Schistosoma mansoni (cerebral bilharziosis), Paragonimus westermani (neuroparagonimiasis)), or protozoa (Toxoplasma gondii (neurotoxoplasmosis), Acanthamoeba spp. or Balamuthia mandrillaris (granulomatous amoebic encephalitis), Naegleria (primary amoebic meningo-encephalitis), Entamoeba histolytica (brain abscess), Plasmodium falciparum (cerebral malaria), Trypanosoma brucei gambiense/rhodesiense (sleeping sickness) or Trypanosoma cruzi (cerebral Chagas disease)). Adults or larvae of helminths or protozoa enter the CNS and cause meningitis, encephalitis, ventriculitis, myelitis, ischaemic stroke, bleeding, venous thrombosis or cerebral abscess, clinically manifesting as headache, epilepsy, weakness, cognitive decline, impaired consciousness, confusion, coma or focal neurological deficits. Diagnosis of cerebral parasitoses is dependent on the causative agent. Available diagnostic tools include clinical presentation, blood tests (eosinophilia, plasmodia in blood smear, antibodies against the parasite), cerebrospinal fluid (CSF) investigations, imaging findings and occasionally cerebral biopsy. Treatment relies on drugs and sometimes surgery. Outcome of cerebral parasitoses is highly variable, depending on the effect of drugs, whether they are self-limiting (e.g. Angiostrongylus costaricensis) or whether they remain undetected or asymptomatic, like 25% of neurocysticerciasis cases.