Neurocysticercosis: an update

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Abstract

Taeniosis and cysticercosis, diseases caused by the parasitic tapeworm Taenia solium, are distributed worldwide where pigs are eaten and sanitation is poor, and also in the more developed countries as a result of increasing migration. Neurocysticercosis is the commonest parasitic disease of the human nervous system. Immunological assays detect positivity for human cysticercosis in 8-12% of people in some endemic regions, which indicates the presence of antibodies against the parasite but not necessarily active or central-nervous-system infection. The only reliable tool for diagnosis of neurocysticercosis is imaging by CT or MRI. The presence of viable cysts with a mural nodule, associated with degenerative cysts and calcifications, is typical. Classification of neurocysticercosis into active, transitional, and inactive forms gives a good clinical-imaging correlation and facilitates medical and surgical treatment. The main clinical manifestations of neurocysticercosis are seizures, headache, and focal neurological deficits, and it can have such sequelae as epilepsy, hydrocephalus, and dementia. Treatment should be individually fitted for each patient, with antiepileptic drugs, analgesics, corticosteroids, or a combination of these. Anthelmintic drugs (praziquantel and albendazole) are used routinely, but so far no controlled clinical trial has established specific indications or definitive doses of treatment. Parenchymal forms of neurocysticercosis have a good prognosis in terms of clinical remission. The most effective approach to taeniosis and cysticercosis is prevention, which should be a primary public-health focus for less developed countries.

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Proposed diagnostic criteria for neurocysticercosis.

V Rajshekhar, Stimson P Schantz, O Del Maschio … (2001)

Neurocysticercosis is the most common helminthic infection of the CNS but its diagnosis remains difficult. Clinical manifestations are nonspecific, most neuroimaging findings are not pathognomonic, and some serologic tests have low sensitivity and specificity. The authors provide diagnostic criteria for neurocysticercosis based on objective clinical, imaging, immunologic, and epidemiologic data. These include four categories of criteria stratified on the basis of their diagnostic strength, including the following: 1) absolute--histologic demonstration of the parasite from biopsy of a brain or spinal cord lesion, cystic lesions showing the scolex on CT or MRI, and direct visualization of subretinal parasites by funduscopic examination; 2) major--lesions highly suggestive of neurocysticercosis on neuroimaging studies, positive serum enzyme-linked immunoelectrotransfer blot for the detection of anticysticercal antibodies, resolution of intracranial cystic lesions after therapy with albendazole or praziquantel, and spontaneous resolution of small single enhancing lesions; 3) minor--lesions compatible with neurocysticercosis on neuroimaging studies, clinical manifestations suggestive of neurocysticercosis, positive CSF enzyme-linked immunosorbent assay for detection of anticysticercal antibodies or cysticercal antigens, and cysticercosis outside the CNS; and 4) epidemiologic--evidence of a household contact with Taenia solium infection, individuals coming from or living in an area where cysticercosis is endemic, and history of frequent travel to disease-endemic areas. Interpretation of these criteria permits two degrees of diagnostic certainty: 1) definitive diagnosis, in patients who have one absolute criterion or in those who have two major plus one minor and one epidemiologic criterion; and 2) probable diagnosis, in patients who have one major plus two minor criteria, in those who have one major plus one minor and one epidemiologic criterion, and in those who have three minor plus one epidemiologic criterion.

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Current consensus guidelines for treatment of neurocysticercosis.

E Gonzalez, Caroline Martinez, Osvaldo M Takayanagui … (2002)

Taenia solium neurocysticercosis is a common cause of epileptic seizures and other neurological morbidity in most developing countries. It is also an increasingly common diagnosis in industrialized countries because of immigration from areas where it is endemic. Its clinical manifestations are highly variable and depend on the number, stage, and size of the lesions and the host's immune response. In part due to this variability, major discrepancies exist in the treatment of neurocysticercosis. A panel of experts in taeniasis/cysticercosis discussed the evidence on treatment of neurocysticercosis for each clinical presentation, and we present the panel's consensus and areas of disagreement. Overall, four general recommendations were made: (i) individualize therapeutic decisions, including whether to use antiparasitic drugs, based on the number, location, and viability of the parasites within the nervous system; (ii) actively manage growing cysticerci either with antiparasitic drugs or surgical excision; (iii) prioritize the management of intracranial hypertension secondary to neurocysticercosis before considering any other form of therapy; and (iv) manage seizures as done for seizures due to other causes of secondary seizures (remote symptomatic seizures) because they are due to an organic focus that has been present for a long time.

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Neurocysticercosis in an Orthodox Jewish community in New York City.

Peter M. Schantz, Anne Moore, José Muñoz … (1992)

From June 1990 through July 1991, intracerebral infection with the larval stage of the pork tapeworm Taenia solium was diagnosed in four unrelated persons in an Orthodox Jewish community in New York City. None of the patients had eaten pork, and only one had traveled to a country in which T. solium infection was endemic. We investigated this outbreak, screened serum samples from family members and household contacts for antibodies to cysticercosis, and examined stool specimens from household employees for eggs of taenia species. The four patients had recurrent seizures and brain lesions that were radiologically consistent with the presence of cysticerci. The diagnosis was confirmed in two patients by a brain biopsy, and in two by immunoblot assays for cysticercus antibodies. Of 17 immediate family members screened serologically, 7 from two families had cysticercus antibodies. Magnetic resonance imaging of the brain showed cystic lesions in two of the seropositive family members, one of whom had had a seizure. Examinations of six domestic employees from all four households revealed an active infection with taenia species in one and a positive serologic test in another. Since these women had recently emigrated from Latin American countries where T. solium infection is endemic, they were the most likely sources of infection in the members of these households. A diagnosis of neurocysticercosis should be considered in patients with seizures and radiologic evidence of cystic brain lesions, even in those who do not eat pork and who have not traveled to a country in which T. solium infection is endemic. Recent emigrants from countries in which T. solium infection is endemic should be screened for tapeworm infection in their stools before they are employed as housekeepers or food handlers.