Quantitative assessment of lesion load and efficacy of 3 cycles of albendazole in disseminated cysticercosis: a prospective evaluation

Treatment Outcome in Patients with Disseminated Cysticercosis: A Systematic Review of Case Reports and Case Series

Disseminated cysticercosis is defined by multiple brain lesions and involvement of other body sites. Cysticidal treatment in disseminated cysticercosis is considered life-threatening. We conducted a systematic review of all published cases and case series to assess the safety and efficacy of cysticidal treatment. We conducted a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (PROSPERO CRD42022331895) to assess the safety and efficacy of cysticidal treatment. Using the search term "disseminated neurocysticercosis OR disseminated cysticercosis," databases like PubMed, Scopus, Embase, and Google Scholar were searched. Outcomes included death and secondary measures like clinical improvement and lesion reduction. We calculated the predictors of primary outcome (death) using the binary logistic regression analysis. We reviewed 222 published cases from 101 publications. Approximately 87% cases were reported from India. Of 222 cases, 134 (60%) received cysticidal treatment. Follow-up information was available from 180 patients, 11 of them died, and 169 showed clinical improvement. The death rate was 4% (5 out of 114) in patients treated with cysticidal drugs plus corticosteroids, in comparison with 13% (5 out of 38) in patients who were treated with corticosteroids alone. All patients using only praziquantel faced fatality. Death predictors identified were altered sensorium and lack of treatment with albendazole. We noted that the risk of death after cysticidal treatment is not as we expected, and a multicentric randomized controlled trial is needed to resolve this issue.

Triggered: Discovery of Neurocysticercosis Following Self-Administered Albendazole

A 25-year-old man with no medical history presented with a seizure one month after taking a self-administered dose of albendazole. Magnetic resonance imaging (MRI) of the brain revealed multiple ring-enhancing lesions, and the workup confirmed neurocysticercosis (NCC). Treatment with antiparasitics was delayed due to concern for worsening symptoms from the presence of cysts in the midbrain and hippocampus. The balance between treating NCC and limiting cerebral inflammation is delicate and relies on judgment from a multispecialty clinical team. In this case, corticosteroids and antiepileptics alone prevented additional seizures but failed to reduce the overall inflammation of cysts and the progression of the disease. Evidence of new cysts on MRI at week 13 from the onset of symptoms was evidence of an acute, evolving infectious process. Treatment with albendazole and praziquantel was initiated at 13 weeks from the onset of symptoms, and by 31 weeks, nearly all cysts had resolved with minimal residual inflammation.

Value of whole-body MRI for the assessment of response to albendazole in disseminated neurocysticercosis: a prospective follow-up study

BACKGROUND

Disseminated neurocysticercosis is defined as simultaneous involvement of the brain (≥3 cysts) and at least one additional body site/organ. We aimed to identify disseminated cystic lesions in other body parts and investigate the effect of albendazole.

METHODS

We enrolled patients with multiple (≥3) neurocysticercosis brain lesions. Whole-body MRI (short tau inversion recovery coronal sequences) was performed to assess the number of lesions in the brain and other body parts at baseline and 3 months after albendazole therapy.

RESULTS

We screened 35 patients with multiple brain neurocysticercosis. In 13 patients, whole-body MRI demonstrated disseminated neurocysticercosis lesions. Ten patients were treated with albendazole. We excluded three patients. Brain MRI showed a mean lesion count of 163.6±193.8. Whole-body MRI (excluding the brain) showed a mean lesion count of 629.9±486.1. After albendazole therapy, the lesion load of the brain reduced significantly (163.6±193.8 to 99±178.3; p=0.008). Similarly, whole-body MRI showed a significant reduction in extracerebral neurocysticercosis lesion load (629.9±486.1 to 183.4±301.9; p=0.005). Three patients had complete resolution, five patients showed ≥50% reduction and two patients had <50% reduction in extracerebral lesion load.

CONCLUSION

Whole-body MRI should routinely be performed in multiple neurocysticercosis lesions of the brain. Albendazole treatment leads to a remarkable reduction in neurocysticercosis lesions throughout the body.

THE EFFICACY AND SAFETY OF THREE 30-DAY COURSES OF ALBENDAZOLE IN PATIENTS WITH NEUROCYSTICERCOSIS

Albendazole is one of the drugs indicated for the treatment of neurocysticercosis. However, data on the treatment outcome of a long course of this drug is scarce. This study aims to investigate the efficacy and safety of three 30-day courses of albendazole in patients with neurocysticercosis. Methods: The diagnosis of neurocysticercosis was based on epidemiological, clinical and laboratory criteria as guided by the Vietnamese Ministry of Health. Sixty patients with a mean age of 50.17 10.03 years old, with 86.7% (95% CI: 77.8 95.5%) men, were involved in this study. Patients received three 30-day courses of albendazole with an intermittence of 20 days. Additional treatment included steroids, anticonvulsants or analgesics. Based on brain magnetic resonance imaging 6 months after the therapy, the efficacy was classified as cure (viable cysts not discernible), improvement (50% or more cysts disappeared or calcified) or inefficacy (changes in less than 50% of the cysts). The safety was determined based on the changes of biochemical parameters after each treatment course. Results: The most common clinical presentations were headache (90.0%, 95% CI: 82.2 97.8) and/or seizure (68.3%, 95% CI: 56.2 70.4), followed by other symptoms such as fainting, memory loss, and limb numbness. Active cysts were discovered in all cases and located mainly in the parenchymal region. After therapy, the rates of cure, improvement or inefficacy were 43.3% (95% CI: 30.4 56.2%), 51.7% (95% CI: 38.7 64.7%) and 5.0% (95% CI: 0 10.7%), respectively. Liver enzymes were slightly higher compared to those before therapy and mostly returned to normal ranges after drug interruption. Alanine aminotransferase levels before the 3rd course were higher than values before the first and second courses. No abnormalities in blood urea or creatinine after therapy were reported. Conclusions: Three 30-day cycles of albendazole appear to have good efficacy and tolerability in patients with neurocysticercosis.

Neurocysticercosis: an update on diagnosis, treatment, and prevention

Neurocysticercosis (NCC) is an important cause of neurological disease worldwide, including imported cases in nonendemic countries.

PURPOSE OF REVIEW

The purpose of this review is to update information on diagnosis, management, and prevention of neurocysticercosis.

RECENT FINDINGS

WHO and Infectious Diseases Society of America/American Society of Tropical Medicine and Hygiene guidelines emphasize the importance of corticosteroids and antiparasitic drugs for viable parenchymal disease and single enhancing lesions. Subarachnoid NCC is associated with a high fatality rate unless optimally treated. Advances in subarachnoid NCC include use of prolonged antiparasitic and anti-inflammatory courses and the increasing use of antigen-detection and quantitative PCR assays in diagnosis and follow-up. Emerging data support the safety and efficacy of minimally invasive surgery in ventricular cases. Calcified neurocysticercosis continues to be associated with a high burden of disease. Field studies are demonstrating the feasibility of eradication using a combination of mass chemotherapy for human tapeworms and vaccination/treatment of porcine cysticercosis.

SUMMARY

NCC remains an important and challenging cause of neurological disease with significant morbidity despite advances in treatment and prevention.

Comparative Efficacy and Safety of Lacosamide and Oxcarbazepine for Seizure Control in Children with Newly Diagnosed Solitary Neurocysticercosis

BACKGROUND

In newly diagnosed neurocysticercosis (NCC) with seizures, the choice of anti-seizure medication (ASM) seems to be arbitrary due to a lack of comparative studies. Although oxcarbazepine (OXC) is often considered efficacious for focal seizures in NCC, due to adverse effects, newer ASMs like levetiracetam (LCM) and lacosamide are also being explored.

METHODS

This study was performed by case record review of children with newly diagnosed solitary viable parenchymal NCC aged 4-18years who received lacosamide and OXC at least for 12 weeks between August 2019 and April 2021, from a prospective registry of a tertiary care teaching hospital in north India. Seizure control, electroencephalographic abnormalities, resolution of inflammatory granulomas and adverse effects were compared between two arms at 12 and 24 weeks.

RESULTS

Total 31 (8.3 ± 4.7 years, 19 boys) and 72 (8.6 ± 4.2 years, 43 boys) completed at least 12 weeks follow-up in LCM and OXC groups, out of which 2 and 51 completed at least 24 weeks follow-up in LCM and OXC groups, respectively. The occurrence of breakthrough seizure was comparable in both arms at 12 and 24 weeks (1/31 and 2/22 in lacosamide group vs. 2/72 and 4/51 in OXC group, p = 0.66 and 0.59, respectively). Patients receiving OXC had more frequent treatment-emergent adverse events (p = 0.0001) and four patients required discontinuation due to severe adverse events (SAEs), while none in the lacosamide group had SAEs.

CONCLUSIONS

Lacosamide appears to be efficacious and safe for achieving seizure freedom in patients with solitary viable parenchymal neurocysticercosis.

Disseminated cysticercosis: a case report and review of treatment protocols

Cysticercosis is caused by the larvae of Taenia solium and is a significant health problem. Disseminated cysticercosis is an infrequent manifestation of the same. A woman in her 30s presented to us with a history of seizures, outward protrusion of both eyes and multiple soft-tissue swellings over the face and tongue for 3 years. Imaging studies revealed multiple cystic lesions in the brain parenchyma, extraocular muscles, subcutaneous tissue, muscles of mastication and tongue. A high index of suspicion and a planned therapeutic approach is required in such cases.

Cysticercosis in ophthalmology

Cysticercosis is caused by Taenia solium, a cestode or tapeworm that preferentially affects the subcutaneous tissue, brain, muscle, and the eye. It is traditionally a disease of low socioeconomic regions, but large-scale population migration has made it a matter of global concern. Its ocular invasion is a potentially blinding disease. In the last two decades, there has been considerable discussion of cysticercosis; however, most comes from a limited number of case observations. Thus, to overcome this limitation, we summarize and analyse twenty years of medical literature (from 2000 to 2020) on cysticercosis in ophthalmology.

Nightmares with a starry sky - Treating neurocysticercal encephalitis, how far to go

Cysticercosis, an infection caused by the larval stage of tapeworm Taenia solium, is the most common parasitic disease of the human nervous system and the single most common cause of acquired epileptic seizures in the developing world. Here, we describe the stormy course of a 67-year-old female with neurocysticercosis (NCC) having a recurrent encephalitic presentation. She went through the most severe spectrum of this disease, namely NCC encephalitis and disseminated cysticercosis and had a classical starry sky brain in neuroimaging. In contrary to the popular practice of avoiding antihelminthic drugs in such extreme presentation, as a desperate measure, we had to use albendazole in this case, which showed clinical and radiological improvement.