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Rodriguez S, Wilkins P, Dorny P. Immunological and molecular diagnosis of cysticercosis. Pathog Glob Health 2013; 106:286-98. [PMID: 23265553 DOI: 10.1179/2047773212y.0000000048] [Citation(s) in RCA: 93] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Cysticercosis, the infection with the larval stage of Taenia solium, is a cause of neurological symptoms including seizures, affecting the quality of life of patients and their families. Diagnosis focuses on brain imaging and serological tests are mostly used as confirmatory tools. Most cases, however, occur in poor endemic areas, where both kinds of diagnostic tools are poorly available. Development of point of care diagnostic tests is one of the most important priorities for cysticercosis researches today. The ideal point of care test would require detection of viable cysticercosis and hopefully identify cases with severe or progressive forms of neurocysticercosis, leading to referral of the patient for specialized medical attention. This manuscript describes the evolution of the serological diagnosis of cysticercosis over time, and the characteristics of the most common currently available tools, their advantages and disadvantages, and their potential use in future diagnostic tests.
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Affiliation(s)
- Silvia Rodriguez
- Infectious Diseases, Instituto Nacional de Ciencias Neurológicas, Jr. Anchash 1271, Lima 1, Peru.
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Loyo-Varela M, Estañol B, Manrique-Guzman S. Development of neurological symptoms in patients with asymptomatic cerebral cysticercosis undergoing albendazol therapy for intestinal parasites. World Neurosurg 2012; 79:69-70. [PMID: 22548885 DOI: 10.1016/j.wneu.2012.04.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2012] [Accepted: 04/24/2012] [Indexed: 10/28/2022]
Affiliation(s)
- Mauro Loyo-Varela
- Department of Neurosurgery, Hospital Regional Veracruz, Veracruz, Mexico.
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Rodriguez S, Dorny P, Tsang VCW, Pretell EJ, Brandt J, Lescano AG, Gonzalez AE, Gilman RH, Garcia HH. Detection of Taenia solium antigens and anti-T. solium antibodies in paired serum and cerebrospinal fluid samples from patients with intraparenchymal or extraparenchymal neurocysticercosis. J Infect Dis 2009; 199:1345-52. [PMID: 19358669 DOI: 10.1086/597757] [Citation(s) in RCA: 95] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Neurocysticercosis (NCC) is a frequent cause of epilepsy worldwide. Compared with the more common parenchymal brain cysts, extraparenchymal infections are difficult to manage and have a poor prognosis. Serological assays are used to detect circulating Taenia solium antigens or anti-T. solium antibodies in serum or cerebrospinal fluid (CSF) samples. There are no guidelines on whether to use serum or CSF specimens for a particular assay. METHODS We obtained paired serum and CSF samples from 91 patients with NCC (48 had intraparenchymal NCC, and 43 had extraparenchymal NCC) for detection of antibodies, using an enzyme-linked immunotransfer blot (EITB) assay, and antigens, using a monoclonal antibody-based enzyme-linked immunosorbent assay (ELISA). RESULTS For the intraparenchymal NCC group, the EITB assay yielded more true-positive results for serum samples, and the ELISA yielded slightly more true-positive results for CSF samples than for serum samples, but none of these differences were statistically significant. Most patients with calcified NCC were antibody positive but antigen negative. For extraparenchymal disease, all samples were antibody positive, and all but 2 were antigen positive, with most samples containing high antigen levels. CONCLUSIONS The sensitivity of antibody-detecting EITB assays is not increased through the use of CSF samples rather than serum samples. The antigen-detecting ELISA performed better for CSF samples than for serum samples, but for both specimen types it was less sensitive than the EITB assay. Active and inactive NCC are better differentiated from each other by the antigen-detecting ELISA, for both serum and CSF samples. High antigen levels suggest the presence of subarachnoid NCC.
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Affiliation(s)
- Silvia Rodriguez
- Cysticercosis Unit, Instituto Nacional de Ciencias Neurológicas, Universidad Peruana Cayetano Heredia, Lima, Peru
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Padilla-Docal B, Dorta-Contreras AJ, Bu-Coifiu-Fanego R, Rey AR. CSF/serum quotient graphs for the evaluation of intrathecal C4 synthesis. Cerebrospinal Fluid Res 2009; 6:8. [PMID: 19573230 PMCID: PMC2709889 DOI: 10.1186/1743-8454-6-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2009] [Accepted: 07/02/2009] [Indexed: 11/13/2022] Open
Abstract
Background Cerebrospinal fluid (CSF)/serum quotient graphs have been used previously to determine local synthesis in brain of immunoglobulins and C3 complement component. The aim of this study was to use the same technique to construct quotient graphs, or Reibergrams, for the beta globulin C4 and to evaluate the method for assessing intrathecal synthesis in neurological disease. Methods The constants in the previously-defined Reibergram for immunoglobulin IgA were used to calculate the CSF/serum quotient for C4. CSF and serum were analyzed for C4, IgA and albumin from a total of 12 patients with meningoencephalitis caused by encapsulated microorganisms and 10 subjects without infections or inflammatory neurological disease, some of which had dysfunction of the blood-CSF barrier, Results The formula and C4 Reibergram with the constants previously found for IgA, determined the intrathecal C4 synthesis in CSF. The intrathecal C4 fraction in CSF (C4 loc in mg/l) was compared to the C4-Index (fraction of CSF: serum for C 4/fraction of CSF: serum for albumin). There was a significant correlation between the two formulae. The CSF/Serum quotient graph was superior for detecting intrathecal synthesis of C4 under variable conditions of blood-CSF barrier permeability. Conclusion The C4 Reibergram can be used to quantify the intrathecal synthesis of this component of the complement system in different infectious diseases of the central nervous system and is especially useful for patients with blood-brain barrier dysfunction.
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Affiliation(s)
- Barbara Padilla-Docal
- Central Laboratory of Cerebrospinal Fluid (LABCEL) Faculty of Medical Sciences "Dr Miguel Enriquez" Superior Institute of Medical Sciences of Havana AP 10049, 11000 CP Havana City, Cuba.
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Lipid peroxidation in the cerebrospinal fluid of patients with neurocysticercosis. Trans R Soc Trop Med Hyg 2008; 102:1025-31. [DOI: 10.1016/j.trstmh.2008.06.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2008] [Revised: 06/06/2008] [Accepted: 06/06/2008] [Indexed: 12/26/2022] Open
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Husain N, Shukla N, Kumar R, Husain M, Chaturvedi A, Agarwal GG, Gupta RK. ELISA in the evaluation of therapeutic response to albendazole in neurocysticercosis. J Infect 2008; 56:65-73. [DOI: 10.1016/j.jinf.2007.09.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2007] [Revised: 09/26/2007] [Accepted: 09/27/2007] [Indexed: 10/22/2022]
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Arruda GC, Quagliato EMAB, Rossi CL. Intrathecal synthesis of specific immunoglobulin G antibodies in neurocysticercosis: evaluation of antibody concentrations by enzyme-linked immunosorbent assay using a whole cysticercal extract and cyst vesicular fluid as antigens. Diagn Microbiol Infect Dis 2006; 54:45-9. [PMID: 16290026 DOI: 10.1016/j.diagmicrobio.2005.08.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2005] [Accepted: 08/16/2005] [Indexed: 11/23/2022]
Abstract
The demonstration of intrathecal antibody production has proven useful for showing the involvement of the central nervous system (CNS) in several diseases. In the present study, the intrathecal synthesis of cysticercus-specific immunoglobulin G (IgG) antibodies was investigated in 30 patients with neurocysticercosis based on calculation of the specific IgG antibody index (AI(IgG)). An AI(IgG) > or =1.5 was considered to be indicative of intrathecal antibody production. Antibody concentrations in serum and cerebrospinal fluid samples were evaluated using an enzyme-linked immunosorbent assay with 2 antigen preparations from Taenia solium cysticerci, namely, a whole cysticercal extract (TsoW) and the vesicular fluid of the parasite (TsoVF). Intrathecal, cysticercus-specific IgG antibody synthesis was observed in 21 (70%) and 23 (76.6%) patients using the TsoW and TsoVF antigens, respectively. The detection of the intrathecal synthesis of specific antibodies may be a potentially useful tool in establishing the involvement of CNS in cysticercosis.
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Affiliation(s)
- Gisele C Arruda
- Department of Clinical Pathology, Faculty of Medical Sciences, State University of Campinas (UNICAMP), P.O. Box 6111, Campinas 13083-970, São Paulo, Brazil
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Bueno EC, Snege M, Vaz AJ, Leser PG. Serodiagnosis of human cysticercosis by using antigens from vesicular fluid of Taenia crassiceps cysticerci. CLINICAL AND DIAGNOSTIC LABORATORY IMMUNOLOGY 2001; 8:1140-4. [PMID: 11687454 PMCID: PMC96240 DOI: 10.1128/cdli.8.6.1140-1144.2001] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Neurocysticercosis (NC), caused by the presence of Taenia solium metacestodes in tissues, is a severe parasitic infection of the central nervous system with universal distribution. To determine the efficiency of enzyme-linked immunosorbent assay (ELISA) and immunoblot with antigens of T. crassiceps vesicular fluid (Tcra) compared to standard techniques (indirect immunofluorescence test [IFT] and complement fixation test [CFT]) using T. solium cysticerci (Tso) for the serodiagnosis of NC, we studied serum samples from 24 patients with NC, 30 supposedly healthy individuals, 76 blood bank donors, 45 individuals with other non-NC parasitoses, and 97 samples from individuals screened for cysticercosis serology (SC). The sensitivity observed was 100% for ELISA-Tso and ELISA-Tcra, 91.7% for the IFT, and 87.5% for the CFT. The specificity was 90% for ELISA-Tso, 96.7% for ELISA-Tcra, 50% for IFT, and 63.3% for CFT. The efficiency was highest for ELISA-Tcra, followed by ELISA-Tso, IFT, and CFT. Of the 23 samples from SC group, which were reactive to ELISA-Tso and/or ELISA-Tcra, only 3 were positive to immunblot-Tcra (specific peptides of 14- and 18-kDa) and to glycoprotein peptides purified from Tcra antigen (gp-Tcra), showing the low predictive value of ELISA for screening. None of the samples from the remaining groups showed specific reactivity in immunoblot-Tcra. These results demonstrate that ELISA-Tcra can be used as a screening method for the serodiagnosis of NC and support the need for specific tests for confirmation of the results. The immunoblot can be used as a confirmatory test both with Tcra and gp-Tcra, with the latter having an advantage in terms of visualization of the results.
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Affiliation(s)
- E C Bueno
- Laboratory of Clinical Immunology, Faculty of Pharmacy, University of the Vale do Itajaí, Itajaí SC
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Bueno EC, Vaz AJ, Machado LD, Livramento JA. Total IgE detection in paired cerebrospinal fluid and serum samples from patients with neurocysticercosis. Rev Inst Med Trop Sao Paulo 2000; 42:67-70. [PMID: 10810320 DOI: 10.1590/s0036-46652000000200002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Neurocysticercosis (NC), the presence of Taenia solium metacestodes in tissues, is the most frequent and severe parasitic infection of the central nervous system. We investigated the presence of total IgE by an automated chemiluminescence assay in 53 paired cerebrospinal fluid (CSF) and serum samples from patients with NC (P) and in 40 CSF samples from individuals with other neurological disorders as the control group (C). Total IgE concentration ranged from 1.2 to 6.6 IU/ml (mean = 1.4 IU/ml, standard deviation-sd = 1.1 IU/ml) in 28.3% of CSF samples from the P group, a value significantly higher than for the C group ( pound1.0 IU/ml). The serum samples from the P group showed concentrations ranging from 1. 0 to 2330.0 IU/ml (mean = 224.1 IU/ml, sd = 452.1 IU/ml), which were higher than the normal value cited by the manufacturer (<100.0 IU/ml) in 32.1% of the samples. A significant difference was observed in CSF samples from the P and C groups (p = 0.005) and in serum samples from the P group compared to the normal value (p = 0. 005), with sera showing more frequent abnormal results.
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Affiliation(s)
- E C Bueno
- Laboratory of Clinical Immunology, Faculty of Pharmaceutical Sciences, University of São Paulo, São Paulo, SP, Brazil.
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Bueno EC, Vaz AJ, Machado LD, Livramento JA. Neurocysticercosis: detection of IgG, IgA and IgE antibodies in cerebrospinal fluid, serum and saliva samples by ELISA with Taenia solium and Taenia crassiceps antigens. ARQUIVOS DE NEURO-PSIQUIATRIA 2000; 58:18-24. [PMID: 10770861 DOI: 10.1590/s0004-282x2000000100003] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
We assayed samples of cerebrospinal fluid (CSF), serum and saliva from patients with neurocysticercoses, control group and individuals with other parasitoses, by ELISA with Taenia crassiceps vesicular fluid antigen (Tcra) and Taenia solium total antigen (Tso) for the detection of antibodies. The sensitivity for IgG-Tcra was 100% for CSF and serum, and 32.0% for saliva; and for IgG-Tso 100% for CSF, 80.0% for serum and 24.% for saliva. Specificity was 100% for CSF and 80.0% for serum with both antigens, and 100% for saliva with Tcra and 87.5% with Tso. The sensitivity and specificity for IgA-Tcra was, respectively, 40.0% and 100% for CSF, 36.0% and 97.1% for serum, and 4.0% and 90.0% for saliva. IgE detection showed 24.0% sensitivity and 97.1% specificity for serum, with no detection in CSF samples. The search for antibodies revealed the presence of IgG > IgA > IgE in CSF, serum and saliva samples, with IgG being present in all phases of the disease, while IgA/IgE were more frequent in the inactive form.
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Affiliation(s)
- E C Bueno
- Faculty of Pharmaceutical Sciences (FPS), University of São Paulo (USP), São Paulo, Brazil.
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Bueno EC, Vaz AJ, Machado LD, Livramento JA, Mielle SR. Specific Taenia crassiceps and Taenia solium antigenic peptides for neurocysticercosis immunodiagnosis using serum samples. J Clin Microbiol 2000; 38:146-51. [PMID: 10618078 PMCID: PMC86041 DOI: 10.1128/jcm.38.1.146-151.2000] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Neurocysticercosis (NC), i.e., the presence of the larval form of Taenia solium in tissues, is the most frequent and severe infection involving the central nervous system. Paired serum and cerebrospinal fluid (CSF) samples from patients with NC, CSF and serum samples from a control group, and serum samples from patients with other parasitoses were studied by enzyme-linked immunosorbent assay (ELISA) and by immunoblotting with Taenia crassiceps vesicular fluid antigen (Tcra) and Taenia solium total saline antigen (Tso) for the detection of immunoglobulin G antibodies. ELISAs carried out with the Tso and Tcra antigens showed 94.1 and 95.6% sensitivities, respectively, for the detection of antibodies in CSF and 70.6% and 91.2% sensitivities, respectively, for the detection of antibodies in serum, with 100% specificity for the detection of antibodies in CSF and 80% specificity for the detection of antibodies in serum for both antigens. On the basis of the reactivities of the peptides in the samples analyzed, the peptides of </=23, 39, 85 to 77, and 97 kDa were found to be Tso specific by immunoblotting and the peptides of </=62, 74, 109, 121, and 131 kDa were found to be Tcra specific. Tests with Tcra extract had higher sensitivities and more homogeneous results and permitted us to obtain the parasites easily. We suggest the use of Tcra ELISA for the study of serum and confirmation of the results for sera positive by an immunoblotting analysis in which specific peptides (e.g., peptides of 19 to 13 kDa) are detected.
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Affiliation(s)
- E C Bueno
- Laboratory of Clinical Immunology, Faculty of Pharmaceutical Sciences, University of São Paulo, São Paulo, SP, Brazil.
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Jung H, Medina R, Castro N, Corona T, Sotelo J. Pharmacokinetic study of praziquantel administered alone and in combination with cimetidine in a single-day therapeutic regimen. Antimicrob Agents Chemother 1997; 41:1256-9. [PMID: 9174180 PMCID: PMC163896 DOI: 10.1128/aac.41.6.1256] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
A brief therapeutic regimen of praziquantel, reduced to a single day, has been effective for treatment of neurocysticercosis. To study its pharmacokinetic characteristics, levels of praziquantel in plasma were determined for eight healthy volunteers after the administration of three oral doses of 25 mg/kg of body weight given at 2-h intervals, alone and with the simultaneous administration of cimetidine. Each volunteer received both regimens in a randomized crossover design. Blood samples were taken during a period of 12 h, and praziquantel concentration was measured by high-performance liquid chromatography. Levels of praziquantel in plasma remained above 300 ng/ml during a period of 12 h; they increased 100% when cimetidine was jointly administered. Compared with other regimens, the high levels obtained and the longer duration of action seem to be advantageous in prolonging the exposure of the parasites to the drug and support previous clinical experience showing that the treatment of neurocysticercosis with praziquantel can be reduced from 2 weeks to 1 day with the drug still retaining its cysticidal properties. Moreover, simultaneous administration of praziquantel and cimetidine could improve further the efficacy of the single-day therapy for cysticercosis and other parasitic diseases, such as schistosomiasis.
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Affiliation(s)
- H Jung
- Instituto Nacional de Neurologia y Neurocirugia and Universidad Nacional Autonoma de Mexico, Mexico City
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Abstract
Cysticercosis is an infection caused by Taenia solium larvae (cysticerci). When the cysticercus is lodged in the central nervous system (CNS), the disease is known as neurocysticercosis (NCC). NCC is the most frequent and most widely disseminated human neuroparasitosis. It is endemic in many parts of the world, particularly Latin America, Africa, and Asia, and still relatively frequent in Portugal, Spain and Eastern European countries It is also endemic in developed countries with high rates of immigration from endemic areas. Man may act as an intermediate host after ingestion of mature, viable T. solium eggs via the fecal-oral route. The development of lesions in the brain and leptomeninges, and the consequent of onset of symptoms associated with NCC are mainly due to the host immune-inflammatory response. As long as the cysticercus remains viable, there is relative host immune tolerance. It is only when the parasite dies that massive antigen exposure occurs, with intensification of the immune response/inflammatory reaction and the appearance or worsening of symptoms. NCC can be asymptomatic or cause widely varied clinical manifestations, such as seizures, increased intracranial pressure, ischemic cerebrovascular disease, dementia, and signs of compression of the spinal roots/cord. The combination of two or more symptoms is common. Such clinical polymorphism is determined by 1) the number of lesions (single or multiple cysticerci); 2) the location of CNS lesions (subarachnoid, intracerebral, intraventricular, intramedullary); 3) the type of cysticercus (Cysticercus cellulosae, Cysticercus racemosus); 4) the stage of development and involution of the parasite (vesicular or viable, necrotic, fibrocalcified nodule); and 5) the intensity of the host immune-inflammatory response (no inflammatory reaction, leptomeningitis, encephalitis, granular ependymitis, arteritis).
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Affiliation(s)
- J E Pittella
- Department of Pathology and Legal Medicine, School of Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil.
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Simac C, Michel P, Andriantsimahavandy A, Esterre P, Michault A. Use of enzyme-linked immunosorbent assay and enzyme-linked immunoelectrotransfer blot for the diagnosis and monitoring of neurocysticercosis. Parasitol Res 1995; 81:132-6. [PMID: 7731920 DOI: 10.1007/bf00931618] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
A total of 70 proven cases of neurocysticercosis from la Réunion (Indian Ocean) were studied with enzyme-linked immunoassay (ELISA) and immunoelectrotransfer blot (EITB) to detect specific antibodies in serum and cerebrospinal fluid (CSF). Absorbance levels of antibody to crude Taenia solium cyst extract as an antigen were compared with EITB banding-pattern and computed tomography-scan results. The EITB analysis of sera and CSF from patients with active neurocysticercosis, confirmed with characteristic brain-scan imaging and highest ELISA absorbance, regularly revealed two bands with molecular weights of 13 and 14 kDa, respectively. These low-molecular-weight fractions are potential markers of active cerebral cysticercosis, a result obtained in the simple epidemiological situation of La Réunion (Indian Ocean). A parallel study is underway in Madagascar, where cross-reactivities with other parasitic diseases, including Schistosoma infections, may interfere.
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Affiliation(s)
- C Simac
- Department of Parasitology, Regional Hospital of Saint-Pierre, La Réunion
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Hens MJ, Lolli F, Martín-Moro M, Giménez-Roldán S, Link H. High-dose intravenous-penicillin in neurosyphilis: effect on intrathecal synthesis of IgG, IgM, IgA and IgD. Acta Neurol Scand 1990; 82:381-5. [PMID: 2291399 DOI: 10.1111/j.1600-0404.1990.tb03321.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
We evaluated occurrence and levels of intrathecal synthesis of IgG, IgM, IgA and IgD by calculating corresponding index values in 8 patients with definite and 4 with suspected or possible neurosyphilis, prior to, during and after high-dose intravenous penicillin therapy. Four patients with active neurosyphilis displayed intrathecal synthesis of IgG, IgM and IgA. Only 2 of them showed elevated IgD index, and both had taboparesis, pleocytosis and positive VDRL in CSF, and simultaneous elevation of the IgG, IgA and especially of the IgM indices. This suggests that intrathecal synthesis of IgD may occur in patients with severe CNS inflammation in response to diffuse CNS treponemal damage. Penicillin therapy incited transitory elevation of one or more of the immunoglobulin index values in most patients, possibly in response to massive treponemal lysis inside the CNS. Thereafter, the values became mostly normalized but exceptions occurred, including one patient who had elevated IgG and IgM index which persisted 31 months after therapy. Our data indicate that determinations of immunoglobulin indices performed on consecutive specimens from individual patients with neurosyphilis may be helpful in the evaluation of treatment.
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Affiliation(s)
- M J Hens
- Department of Neurology, Karolinska Institutet, Huddinge University Hospital, Stockholm, Sweden
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