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Nateros F, Saenz E, Saavedra H, Gonzales I, Pretell EJ, Perez E, Castillo Y, Bustos JA, Garcia HH. Older Age in Subarachnoid Neurocysticercosis Reflects a Long Prepatent Period. Am J Trop Med Hyg 2023; 108:1188-1191. [PMID: 37127275 PMCID: PMC10540123 DOI: 10.4269/ajtmh.22-0791] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 03/07/2023] [Indexed: 05/03/2023] Open
Abstract
Patients with subarachnoid neurocysticercosis (NCC) are usually older than those with parenchymal disease. Whether this difference reflects a prolonged presymptomatic period or a delay in diagnosis is not clear. From 408 eligible patients, we retrospectively compared the age at symptom onset in 140 patients diagnosed with parenchymal (pure viable or pure calcified) and subarachnoid NCC who had a confirmatory image available not more than 2 years after the beginning of symptoms. Patients with mixed (parenchymal and subarachnoid) NCC or those with parenchymal cysts at different stages (viable and/or degenerating and/or calcified) were not included. After controlling by sex and residence in rural endemic regions, the mean age at symptom onset in patients with subarachnoid disease was 13.69 years older than those with viable parenchymal disease. A long incubation period is a major contributing factor to older age at presentation in subarachnoid NCC, independent of delayed diagnosis or access to care.
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Affiliation(s)
- Fernando Nateros
- Facultad de Medicina Alberto Hurtado, Universidad Peruana Cayetano Heredia, Lima, Peru
- Centro Básico de Investigación en Exámenes Auxiliares en Parasitosis del Sistema Nervioso Central, Instituto Nacional de Ciencias Neurológicas, Lima, Peru
| | - Edith Saenz
- Centro Básico de Investigación en Exámenes Auxiliares en Parasitosis del Sistema Nervioso Central, Instituto Nacional de Ciencias Neurológicas, Lima, Peru
| | - Herbert Saavedra
- Centro Básico de Investigación en Exámenes Auxiliares en Parasitosis del Sistema Nervioso Central, Instituto Nacional de Ciencias Neurológicas, Lima, Peru
| | - Isidro Gonzales
- Centro Básico de Investigación en Exámenes Auxiliares en Parasitosis del Sistema Nervioso Central, Instituto Nacional de Ciencias Neurológicas, Lima, Peru
- Unidad de Investigación, Instituto Nacional de Ciencias Neurológicas, Lima, Peru
| | | | - Erika Perez
- Centro Básico de Investigación en Exámenes Auxiliares en Parasitosis del Sistema Nervioso Central, Instituto Nacional de Ciencias Neurológicas, Lima, Peru
| | - Yesenia Castillo
- Centro de Salud Global, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Javier A. Bustos
- Centro Básico de Investigación en Exámenes Auxiliares en Parasitosis del Sistema Nervioso Central, Instituto Nacional de Ciencias Neurológicas, Lima, Peru
- Centro de Salud Global, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Hector H. Garcia
- Centro Básico de Investigación en Exámenes Auxiliares en Parasitosis del Sistema Nervioso Central, Instituto Nacional de Ciencias Neurológicas, Lima, Peru
- Centro de Salud Global, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - for the Cysticercosis Working Group in Peru
- Facultad de Medicina Alberto Hurtado, Universidad Peruana Cayetano Heredia, Lima, Peru
- Centro Básico de Investigación en Exámenes Auxiliares en Parasitosis del Sistema Nervioso Central, Instituto Nacional de Ciencias Neurológicas, Lima, Peru
- Unidad de Investigación, Instituto Nacional de Ciencias Neurológicas, Lima, Peru
- Hospital Nacional Alberto Sabogal, Callao, Peru
- Centro de Salud Global, Universidad Peruana Cayetano Heredia, Lima, Peru
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Zapata WR, Yang SY, Bustos JA, Gonzales I, Saavedra H, Guzman C, Pretell EJ, Garcia HH. Quality of life in patients with symptomatic epilepsy due to neurocysticercosis. Epilepsy Behav 2022; 131:108668. [PMID: 35483205 PMCID: PMC9879681 DOI: 10.1016/j.yebeh.2022.108668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 02/23/2022] [Accepted: 03/08/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND Neurocysticercosis (NCC) is a common cause of late-onset epilepsy worldwide, but there is still minimal information regarding its impact on a patient's quality of life. This study evaluated quality of life in a series of patients with epilepsy secondary to NCC using the QOLIE (Quality of Life in Epilepsy)-31 questionnaire. METHODOLOGY This cross-sectional study included 155 Peruvian patients between 16 and 70 years of age with epilepsy due to viable intraparenchymal NCC, who enrolled in two trials of anti-parasitic treatment during the period 2006-2011. The QOLIE-31 questionnaire was applied before the onset of anti-parasitic treatment. The associations between QOLIE-31 scores, sociodemographic characteristics, clinical, and neuroimaging data were analyzed with Kruskal-Wallis test and generalized linear models (GLM). RESULTS The average QOLIE-31 score was 55.8 (SD ± 7.6), with 119 individuals (76.8%) scoring in the poor quality-of-life category. Generalized tonic-clonic seizures and secondarily generalized epileptic seizures were associated with a lower QOLIE-31, as well as a low level of education with a value of p = 0.05. There were no associations between QOLIE-31 scores and other variables such as sex, age, antiepileptic medication, number of parasitic cysts, and number of compromised brain regions. On multivariate analysis, a greater number of generalized epileptic seizures maintained a statistically significant association with detrimental QOLIE-31 scores. CONCLUSION Quality of life is affected in NCC, mainly in relation to the number of prior generalized epileptic seizures.
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Affiliation(s)
- Willy R Zapata
- Departamento de Epilepsia, Instituto Nacional de Ciencias Neurológicas, Lima, Peru.
| | - Susan Y Yang
- School of Medicine, Trinity College Dublin, Dublin, Ireland; Cysticercosis Unit, Instituto Nacional de Ciencias Neurológicas, Lima, Peru; Center for Global Health, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Javier A Bustos
- Cysticercosis Unit, Instituto Nacional de Ciencias Neurológicas, Lima, Peru; Center for Global Health, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Isidro Gonzales
- Cysticercosis Unit, Instituto Nacional de Ciencias Neurológicas, Lima, Peru
| | - Herbert Saavedra
- Cysticercosis Unit, Instituto Nacional de Ciencias Neurológicas, Lima, Peru
| | - Carolina Guzman
- Cysticercosis Unit, Instituto Nacional de Ciencias Neurológicas, Lima, Peru
| | | | - Hector H Garcia
- Cysticercosis Unit, Instituto Nacional de Ciencias Neurológicas, Lima, Peru; Center for Global Health, Universidad Peruana Cayetano Heredia, Lima, Peru
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Sánchez SS, Bustos JA, Del Brutto OH, Herrera G, dos Santos AC, Javier Pretell E, Gonzales I, Saavedra H, Garcia HH. Hippocampal Atrophy/Sclerosis Is Associated with Old, Calcified Parenchymal Brain Neurocysticercosis, But Not with More Recent, Viable Infections. Am J Trop Med Hyg 2022; 106:215-218. [PMID: 34695784 PMCID: PMC8733520 DOI: 10.4269/ajtmh.21-0392] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 09/02/2021] [Indexed: 01/03/2023] Open
Abstract
Magnetic resonance images from 197 patients with calcified neurocysticercosis (NCC), 38 with viable NCC and 197 NCC-free healthy rural villagers were evaluated to compare the frequency of hippocampal atrophy/sclerosis (HAS) across these populations. Scheltens' medial temporal atrophy scale was used for hippocampal rating. The median age of the 432 study participants was 46 years (interquartile range, 29-62 years), and 58% were women. Hippocampal atrophy/sclerosis was disclosed in 26.9% patients with calcified NCC, compared with 7.9% in patients with viable NCC and 8.1% in healthy rural villagers. After adjusting for age, gender, and history of epilepsy, hippocampal atrophy/sclerosis was more frequent in patients with calcified NCC than in those with viable cysts (RR, 3.60; 95% CI, 1.18- 0.99; P = 0.025) and healthy rural villagers (RR, 3.43; 95% CI, 1.94-6.06; P < 0.001), suggesting that hippocampal damage develops late in the course of this parasitic disease.
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Affiliation(s)
- Sofía S. Sánchez
- Center for Global Health, Department of Microbiology, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Javier A. Bustos
- Center for Global Health, Department of Microbiology, Universidad Peruana Cayetano Heredia, Lima, Peru;,Cysticercosis Unit, Instituto Nacional de Ciencias Neurológicas, Lima, Peru
| | - Oscar H. Del Brutto
- School of Medicine, Universidad Espíritu Santo–Ecuador, Samborondón, Ecuador;,Address correspondence to Oscar H. Del Brutto, Urbanización Toscana, Apt 3H, Km 4.5 vía Puntilla-Samborondón, 092301, Samborondón, Ecuador. E-mail:
| | - Genaro Herrera
- Cysticercosis Unit, Instituto Nacional de Ciencias Neurológicas, Lima, Peru
| | - Antonio Carlos dos Santos
- Centro de Cirurgia de Epilepsia, Faculdade de Medicina, Universidade de São Paulo, Ribeirão Preto, Brazil
| | - E. Javier Pretell
- Cysticercosis Unit, Instituto Nacional de Ciencias Neurológicas, Lima, Peru;,Department of Neurology, Hospital Alberto Sabogal, Callao, Peru
| | - Isidro Gonzales
- Cysticercosis Unit, Instituto Nacional de Ciencias Neurológicas, Lima, Peru
| | - Herbert Saavedra
- Cysticercosis Unit, Instituto Nacional de Ciencias Neurológicas, Lima, Peru
| | - Héctor H. Garcia
- Center for Global Health, Department of Microbiology, Universidad Peruana Cayetano Heredia, Lima, Peru;,Cysticercosis Unit, Instituto Nacional de Ciencias Neurológicas, Lima, Peru
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Bustos JA, Arroyo G, Gilman RH, Soto-Becerra P, Gonzales I, Saavedra H, Pretell EJ, Nash TE, O’Neal SE, Del Brutto OH, Gonzalez AE, Garcia HH. Frequency and Determinant Factors for Calcification in Neurocysticercosis. Clin Infect Dis 2021; 73:e2592-e2600. [PMID: 32556276 PMCID: PMC8563199 DOI: 10.1093/cid/ciaa784] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 06/11/2020] [Indexed: 11/14/2022] Open
Abstract
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.
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Affiliation(s)
- Javier A Bustos
- Cysticercosis Unit, Instituto Nacional de Ciencias Neurológicas, Lima, Perú
- Center for Global Health, School of Public Health and Management, and School of Sciences and Philosophy, Universidad Peruana Cayetano Heredia, Lima, Perú
| | - Gianfranco Arroyo
- Cysticercosis Unit, Instituto Nacional de Ciencias Neurológicas, Lima, Perú
- Center for Global Health, School of Public Health and Management, and School of Sciences and Philosophy, Universidad Peruana Cayetano Heredia, Lima, Perú
| | - Robert H Gilman
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Percy Soto-Becerra
- Center for Global Health, School of Public Health and Management, and School of Sciences and Philosophy, Universidad Peruana Cayetano Heredia, Lima, Perú
| | - Isidro Gonzales
- Cysticercosis Unit, Instituto Nacional de Ciencias Neurológicas, Lima, Perú
| | - Herbert Saavedra
- Cysticercosis Unit, Instituto Nacional de Ciencias Neurológicas, Lima, Perú
| | - E Javier Pretell
- Cysticercosis Unit, Instituto Nacional de Ciencias Neurológicas, Lima, Perú
- Department of Neurology, Hospital Alberto Sabogal, Callao, Perú
| | - Theodore E Nash
- Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Seth E O’Neal
- Center for Global Health, School of Public Health and Management, and School of Sciences and Philosophy, Universidad Peruana Cayetano Heredia, Lima, Perú
- School of Public Health, Oregon Health and Science University and Portland State University, Portland, Oregon, USA
| | - Oscar H Del Brutto
- School of Medicine, Universidad Espíritu Santo–Ecuador, Samborondón, Ecuador
| | - Armando E Gonzalez
- Center for Global Health, School of Public Health and Management, and School of Sciences and Philosophy, Universidad Peruana Cayetano Heredia, Lima, Perú
| | - Hector H Garcia
- Cysticercosis Unit, Instituto Nacional de Ciencias Neurológicas, Lima, Perú
- Center for Global Health, School of Public Health and Management, and School of Sciences and Philosophy, Universidad Peruana Cayetano Heredia, Lima, Perú
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Abanto J, Blanco D, Saavedra H, Gonzales I, Siu D, Pretell EJ, Bustos JA, Garcia HH. Mortality in Parenchymal and Subarachnoid Neurocysticercosis. Am J Trop Med Hyg 2021; 105:176-180. [PMID: 34232912 DOI: 10.4269/ajtmh.20-1330] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 01/07/2021] [Indexed: 11/07/2022] Open
Abstract
Neurocysticercosis (NCC) is endemic in many parts of the world, carrying significant neurological morbidity that varies according to whether lesions are located inside the cerebral parenchyma or in extraparenchymal spaces. The latter, in particular subarachnoid NCC, is assumed to be more severe, but no controlled studies comparing mortality between types of NCC exist. The aim of this study was to compare all-cause mortality between patients with intraparenchymal NCC and those with subarachnoid NCC. Vital status and sociodemographic characteristics were evaluated in patients with intraparenchymal viable, intraparenchymal calcified, and subarachnoid NCC attending a neurological referral hospital in Lima, Perú. Survival analyses using Kaplan-Meier curves and Cox proportional regression models were carried out to compare mortality rates between groups. From 840 NCC patients followed by a median time of 82.3 months, 42 (5.0%) died, six (1.8%) in the intraparenchymal viable group, four (1.3%) in the calcified group, and 32 (16.6%) in the subarachnoid group (P < 0.001). Older age and lower education were significantly associated with mortality. The age-adjusted hazard ratio for death in the subarachnoid group was 13.6 (95% CI: 5.6-33.0, P < 0.001) compared with the intraparenchymal viable group and 10.7 (95% CI: 3.7-30.8, P < 0.001) when compared with the calcified group. We concluded that subarachnoid disease is associated with a much higher mortality in NCC.
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Affiliation(s)
- Jesus Abanto
- 1Centro de Salud Global, Universidad Peruana Cayetano Heredia, Lima, Peru.,2Centro Básico de Investigación en Exámenes Auxiliares en Parasitosis Del Sistema Nervioso Central, Instituto Nacional de Ciencias Neurológicas, Lima, Peru
| | - Daniel Blanco
- 3Unidad de Investigación, Instituto Nacional de Ciencias Neurológicas, Lima, Peru
| | - Herbert Saavedra
- 2Centro Básico de Investigación en Exámenes Auxiliares en Parasitosis Del Sistema Nervioso Central, Instituto Nacional de Ciencias Neurológicas, Lima, Peru
| | - Isidro Gonzales
- 2Centro Básico de Investigación en Exámenes Auxiliares en Parasitosis Del Sistema Nervioso Central, Instituto Nacional de Ciencias Neurológicas, Lima, Peru.,3Unidad de Investigación, Instituto Nacional de Ciencias Neurológicas, Lima, Peru
| | - Diego Siu
- 1Centro de Salud Global, Universidad Peruana Cayetano Heredia, Lima, Peru
| | | | - Javier A Bustos
- 1Centro de Salud Global, Universidad Peruana Cayetano Heredia, Lima, Peru.,2Centro Básico de Investigación en Exámenes Auxiliares en Parasitosis Del Sistema Nervioso Central, Instituto Nacional de Ciencias Neurológicas, Lima, Peru
| | - Hector H Garcia
- 1Centro de Salud Global, Universidad Peruana Cayetano Heredia, Lima, Peru.,2Centro Básico de Investigación en Exámenes Auxiliares en Parasitosis Del Sistema Nervioso Central, Instituto Nacional de Ciencias Neurológicas, Lima, Peru
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Arroyo G, Bustos JA, Lescano AG, Gonzales I, Saavedra H, Rodriguez S, Pretell EJ, Bonato PS, Lanchote VL, Takayanagui OM, Horton J, Gonzalez AE, Gilman RH, Garcia HH. Albendazole Sulfoxide Plasma Levels and Efficacy of Antiparasitic Treatment in Patients With Parenchymal Neurocysticercosis. Clin Infect Dis 2020; 69:1996-2002. [PMID: 30715265 DOI: 10.1093/cid/ciz085] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 01/25/2019] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND The efficacy of albendazole therapy in patients with parenchymal neurocysticercosis (NCC) is suboptimal. Plasma levels of albendazole sulfoxide (ASOX), the active metabolite of albendazole, are highly variable among patients. We hypothesized that high ASOX plasma levels during albendazole therapy may be associated with an increased antiparasitic efficacy. METHODS ASOX plasma levels were measured at treatment day 7 in 118 patients with parenchymal NCC enrolled in a treatment trial. The relationships between increasing ASOX plasma levels with the proportion of cysts resolved and the proportion of patients with complete cyst resolution (evaluated by 6-month brain magnetic resonance) were assessed. RESULTS There was a trend toward a higher proportion of cysts resolved and a higher proportion of patients cured with increasing quartiles of ASOX plasma levels. In patients with 3 or more brain cysts, the regression analysis adjusted by the concomitant administration of praziquantel (PZQ) showed a 2-fold increase in the proportion of cysts resolved (risk ratio [RR], 1.98; 95% confidence interval [CI], 1.01-3.89; P = .048) and 2.5-fold increase in the proportion of patients cured (RR, 2.45; 95% CI, .94-6.36; P = .067) when ASOX levels in the highest vs the lowest quartile were compared. No association was found in patients with 1-2 brain cysts. CONCLUSIONS We suggest an association between high ASOX plasma levels and increased antiparasitic efficacy in patients with parenchymal NCC. Nonetheless, this association is also influenced by other factors including parasite burden and concomitant administration of PZQ. These findings may serve to individualize and/or adjust therapy schemes to avoid treatment failure.
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Affiliation(s)
| | - Javier A Bustos
- Department of Microbiology, School of Sciences, Lima.,Center for Global Health, Universidad Peruana Cayetano Heredia, Lima.,Cysticercosis Unit, Instituto Nacional de Ciencias Neurológicas, Lima
| | | | - Isidro Gonzales
- Cysticercosis Unit, Instituto Nacional de Ciencias Neurológicas, Lima
| | - Herbert Saavedra
- Cysticercosis Unit, Instituto Nacional de Ciencias Neurológicas, Lima
| | - Silvia Rodriguez
- Cysticercosis Unit, Instituto Nacional de Ciencias Neurológicas, Lima
| | | | - Pierina S Bonato
- Faculdade de Ciências Farmacêuticas de Ribeirão Preto, United Kingdom
| | - Vera L Lanchote
- Faculdade de Ciências Farmacêuticas de Ribeirão Preto, United Kingdom
| | - Osvaldo M Takayanagui
- Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo Brasil, United Kingdom
| | | | - Armando E Gonzalez
- School of Veterinary Medicine, Universidad Nacional Mayor de San Marcos, Lima, Peru
| | - Robert H Gilman
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Hector H Garcia
- Department of Microbiology, School of Sciences, Lima.,Center for Global Health, Universidad Peruana Cayetano Heredia, Lima.,Cysticercosis Unit, Instituto Nacional de Ciencias Neurológicas, Lima
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Arroyo G, Rodriguez S, Lescano AG, Alroy KA, Bustos JA, Santivañez S, Gonzales I, Saavedra H, Pretell EJ, Gonzalez AE, Gilman RH, Tsang VCW, Garcia HH. Antibody Banding Patterns of the Enzyme-Linked Immunoelectrotransfer Blot and Brain Imaging Findings in Patients With Neurocysticercosis. Clin Infect Dis 2019; 66:282-288. [PMID: 29020381 DOI: 10.1093/cid/cix774] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 08/29/2017] [Indexed: 11/12/2022] Open
Abstract
Background The enzyme-linked immunoelectrotransfer blot (EITB) assay is the reference serological test for neurocysticercosis (NCC). A positive result on EITB does not always correlate with the presence of active infections in the central nervous system (CNS), and patients with a single viable brain cyst may be EITB negative. Nonetheless, EITB antibody banding patterns appears to be related with the expression of 3 protein families of Taenia solium, and in turn with the characteristics of NCC in the CNS (type, stage, and burden of viable cysts). Methods We evaluated EITB antibody banding patterns and brain imaging findings of 548 NCC cases. Similar banding patterns were grouped into homogeneous classes using latent class analysis. The association between classes and brain imaging findings was assessed. Results Four classes were identified. Class 1 (patients negative or only positive to the GP50 band, related to the protein family of the same name) was associated with nonviable or single viable parenchymal cysticerci; class 2 (patients positive to bands GP42-39 and GP24, related to the T24-42 protein family, with or without anti-GP50 antibodies) was associated with intraparenchymal viable and nonviable infections; classes 3 and 4 (positive to GP50, GP42-39, and GP24 but also responding to low molecular weight bands GP21, GP18, GP14, and GP13, related to the 8 kDa protein family) were associated with extraparenchymal and intraparenchymal multiple viable cysticerci. Conclusions EITB antibody banding patterns correlate with brain imaging findings and complement imaging information for the diagnosis of NCC and for staging NCC patients.
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Affiliation(s)
- Gianfranco Arroyo
- School of Public Health and Management, Universidad Peruana Cayetano Heredia, Lima, Peru.,Department of Microbiology, School of Sciences, Universidad Peruana Cayetano Heredia, Lima, Peru.,Center for Global Health-Tumbes, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Silvia Rodriguez
- Cysticercosis Unit, Instituto Nacional de Ciencias Neurológicas, Lima, Peru
| | - Andres G Lescano
- School of Public Health and Management, Universidad Peruana Cayetano Heredia, Lima, Peru.,Department of Microbiology, School of Sciences, Universidad Peruana Cayetano Heredia, Lima, Peru.,Center for Global Health-Tumbes, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Karen A Alroy
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Javier A Bustos
- School of Public Health and Management, Universidad Peruana Cayetano Heredia, Lima, Peru.,Department of Microbiology, School of Sciences, Universidad Peruana Cayetano Heredia, Lima, Peru.,Center for Global Health-Tumbes, Universidad Peruana Cayetano Heredia, Lima, Peru.,Cysticercosis Unit, Instituto Nacional de Ciencias Neurológicas, Lima, Peru
| | - Saul Santivañez
- Instituto Peruano de Parasitología Clínica y Experimental, Lima
| | - Isidro Gonzales
- Cysticercosis Unit, Instituto Nacional de Ciencias Neurológicas, Lima, Peru
| | - Herbert Saavedra
- Cysticercosis Unit, Instituto Nacional de Ciencias Neurológicas, Lima, Peru
| | | | - Armando E Gonzalez
- School of Veterinary Medicine, Universidad Nacional Mayor de San Marcos, Lima, Peru
| | - Robert H Gilman
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | | | - Hector H Garcia
- School of Public Health and Management, Universidad Peruana Cayetano Heredia, Lima, Peru.,Department of Microbiology, School of Sciences, Universidad Peruana Cayetano Heredia, Lima, Peru.,Center for Global Health-Tumbes, Universidad Peruana Cayetano Heredia, Lima, Peru.,Cysticercosis Unit, Instituto Nacional de Ciencias Neurológicas, Lima, Peru
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8
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Garcia HH, Lescano AG, Gonzales I, Bustos JA, Pretell EJ, Horton J, Saavedra H, Gonzalez AE, Gilman RH. Cysticidal Efficacy of Combined Treatment With Praziquantel and Albendazole for Parenchymal Brain Cysticercosis. Clin Infect Dis 2016; 62:1375-9. [PMID: 26984901 DOI: 10.1093/cid/ciw134] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 02/26/2016] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND The efficacy of current antiparasitic treatment for cerebral Taenia solium cysticercosis with either albendazole (ABZ) or praziquantel (PZQ) is suboptimal. A recent study demonstrated that combining these 2 antiparasitic drugs improves antiparasitic efficacy. We present here the parasiticidal efficacy data obtained during a previous phase II pharmacokinetic study that compared combined ABZ plus PZQ with ABZ alone. METHODS The study was a randomized, double-blinded, placebo-controlled phase II evaluation of the pharmacokinetics of ABZ (15 mg/k/d, for 10 days) and PZQ (50 mg/k/d, for 10 days) in intraparenchymal brain cysticercosis. Patients received the usual concomitant medications, including an antiepileptic drug (phenytoin or carbamazepine), dexamethasone, and ranitidine. Randomization was stratified by antiepileptic drug. Patients underwent safety laboratory evaluations at days 4, 7, and 11, as well as magnetic resonance (MR) imaging at 6 months to assess parasiticidal efficacy. RESULTS Thirty-two patients were included, 16 in each arm. All of them completed antiparasitic treatment and underwent follow-up brain MR imaging. Cysticidal efficacy was strikingly higher in the combined ABZ-plus-PZQ group than in the ABZ-alone group (proportion of cysts resolved, 78 of 82 [95%] vs 23 of 77 [30%] [relative risk {RR}, 3.18; 95% confidence interval {CI}, 2.08-4.88; P < .001]; patients with complete cyst clearance, 12 of 16 [75%] vs 4 of 16 [25%] [RR, 3.00; 95% CI, 1.23-7.34; P = .005]). CONCLUSIONS The combination of ABZ plus PZQ is more effective in destroying viable brain cysticercosis cysts than ABZ alone. CLINICAL TRIALS REGISTRATION NCT00441285.
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Affiliation(s)
- Hector H Garcia
- Cysticercosis Unit, Department of Transmissible Diseases, Instituto Nacional de Ciencias Neurologicas Department of Microbiology, School of Sciences Center for Global Health
| | - Andres G Lescano
- School of Public Health, Universidad Peruana Cayetano Heredia, San Martín de Porres Department of Parasitology, US Naval Medical Research Unit No. 6
| | - Isidro Gonzales
- Cysticercosis Unit, Department of Transmissible Diseases, Instituto Nacional de Ciencias Neurologicas
| | | | | | | | - Herbert Saavedra
- Cysticercosis Unit, Department of Transmissible Diseases, Instituto Nacional de Ciencias Neurologicas
| | - Armando E Gonzalez
- School of Veterinary Medicine, Universidad Nacional Mayor de San Marcos, Salamanca de Monterrico, Ate, Lima
| | - Robert H Gilman
- Department of Microbiology, School of Sciences Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Nash TE, Mahanty S, Loeb JA, Theodore WH, Friedman A, Sander JW, Singh G, Cavalheiro E, Del Brutto OH, Takayanagui OM, Fleury A, Verastegui M, Preux PM, Montano S, Pretell EJ, White AC, Gonzales AE, Gilman RH, Garcia HH. In response: Multifactorial basis of epilepsy in patients with neurocysticercosis. Epilepsia 2015; 56:975-6. [PMID: 26040533 DOI: 10.1111/epi.12986] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Theodore E Nash
- Laboratory of Parasitic Disease, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, U.S.A.
| | - Siddhartha Mahanty
- Laboratory of Parasitic Disease, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, U.S.A
| | - Jeffrey A Loeb
- Department of Neurology and Rehabilitation, University of Illinois at Chicago, Chicago, Illinois, U.S.A
| | - William H Theodore
- Epilepsy Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, U.S.A
| | - Alon Friedman
- The Zlotowski Center for Neuroscience, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Department of Medical Neuroscience, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Josemir W Sander
- Department of Clinical & Experimental Epilepsy, UCL Institute of Neurology, Hospitals Biomedical Research Centre, London, United Kingdom.,London & Epilepsy Society, Buckinghamshire, United Kingdom.,Epilepsy Institute of the Netherlands Foundation, Heemstede, The Netherlands
| | - Gagandeep Singh
- Department of Neurology, Dayan and Medical College, Ludhiana, India
| | - Esper Cavalheiro
- Department of Neurology and Neurosurgery, Federal University of São Paulo, São Paulo, Brazil
| | | | - Osvaldo M Takayanagui
- Department of Neurosciences and Behavior, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Agnes Fleury
- Institute of Biomedical Research, National Institute of Neurology and Neurosurgery (INNN), National Autonomous University of Mexico, Mexico City, Mexico
| | - Manuela Verastegui
- Department of Cellular and Molecular Sciences, Faculty of Science and Philosophy, University Peruana Cayetano Heredia, Lima, Peru
| | - Pierre-Marie Preux
- UMR1094 INSERM, CHU Limoges, Institute of Neuroepidemiology and Tropical Neurology, University of Limoges, Limoges, France
| | | | | | - A Clinton White
- Infectious Disease Division, Department of Internal Medicine, University of Texas, Galveston, Texas, U.S.A
| | - Armando E Gonzales
- Department of Veterinary Public Health, School of Veterinary Medicine, National University of San Marcos, Lima, Peru
| | - Robert H Gilman
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, U.S.A
| | - Hector H Garcia
- Cysticercosis Unit, Institute of Neurological Diseases, Lima, Peru.,Center for Global Health-Tumbes, University Peruana Cayetano Heredia, Lima, Peru.,Department of Microbiology, University Peruana Cayetano Heredia, Lima, Peru
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Garcia HH, Gonzales I, Bustos JA, Saavedra H, Gavidia M, Rodriguez L, Najar E, Umeres H, Pretell EJ. Combined antiparasitic treatment for neurocysticercosis - Authors' reply. Lancet Infect Dis 2015; 15:266-7. [PMID: 25749227 DOI: 10.1016/s1473-3099(15)70047-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Hector H Garcia
- Cysticercosis Unit, Instituto Nacional de Ciencias Neurológicas, Barrios Altos, Lima 1, Peru; Department of Microbiology, Universidad Peruana Cayetano Heredia, Lima, Perú; Center for Global Health - Tumbes, Universidad Peruana Cayetano Heredia, Lima, Perú.
| | - Isidro Gonzales
- Cysticercosis Unit, Instituto Nacional de Ciencias Neurológicas, Barrios Altos, Lima 1, Peru
| | - Javier A Bustos
- Department of Microbiology, Universidad Peruana Cayetano Heredia, Lima, Perú
| | - Herbert Saavedra
- Cysticercosis Unit, Instituto Nacional de Ciencias Neurológicas, Barrios Altos, Lima 1, Peru
| | - Martin Gavidia
- Hospital Nacional Edgardo Rebagliatti, ESSALUD, Lima, Perú
| | | | - Enrique Najar
- Hospital Nacional Cayetano Heredia, Ministerio de Salud, Lima, Perú
| | - Hugo Umeres
- Hospital Nacional Cayetano Heredia, Ministerio de Salud, Lima, Perú
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Nash TE, Mahanty S, Loeb JA, Theodore WH, Friedman A, Sander JW, Singh G, Cavalheiro E, Del Brutto OH, Takayanagui OM, Fleury A, Verastegui M, Preux PM, Montano S, Pretell EJ, White AC, Gonzales AE, Gilman RH, Garcia HH. Neurocysticercosis: A natural human model of epileptogenesis. Epilepsia 2014; 56:177-83. [PMID: 25534640 DOI: 10.1111/epi.12849] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2014] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To develop a better understanding of mechanisms of seizures and long-term epileptogenesis using neurocysticercosis. METHODS A workshop was held bringing together experts in epilepsy and epileptogenesis and neurocysticercosis. RESULTS Human neurocysticercosis and parallel animal models offer a unique opportunity to understand basic mechanisms of seizures. Inflammatory responses to degenerating forms and later-stage calcified parasite granulomas are associated with seizures and epilepsy. Other mechanisms may also be involved in epileptogenesis. SIGNIFICANCE Naturally occurring brain infections with neurocysticercosis offer a unique opportunity to develop treatments for one of the world's most common causes of epilepsy and for the development of more general antiepileptogenic treatments. Key advantages stem from the time course in which an acute seizure heralds a start of the epileptogenic process, and radiographic changes of calcification and perilesional edema provide biomarkers of a chronic epileptic state.
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Affiliation(s)
- Theodore E Nash
- Laboratory of Parasitic Disease, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, U.S.A
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Garcia HH, Gonzales I, Lescano AG, Bustos JA, Pretell EJ, Saavedra H, Nash TE. Enhanced steroid dosing reduces seizures during antiparasitic treatment for cysticercosis and early after. Epilepsia 2014; 55:1452-9. [PMID: 25092547 DOI: 10.1111/epi.12739] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Neurocysticercosis (NCC) is a major cause of seizures and epilepsy in endemic countries. Antiparasitic treatment of brain cysts leads to seizures due to the host's inflammatory reaction, requiring concomitant steroids. We hypothesized that increased steroid dosing will reduce treatment-associated seizures. METHODS Open-label randomized trial comparing 6 mg/day dexamethasone for 10 days (conventional) with 8 mg/day for 28 days followed by a 2-week taper (enhanced) in patients with NCC receiving albendazole. Follow-up included active seizure surveillance and brain imaging. Study outcomes were seizure days and patients with seizures, both measured in days 11-42. Additional analyses compared days 1-10, 11-21, 22-32, 33-42, 43-60, and 61-180. RESULTS Thirty-two individuals were randomized into each study arm; two did not complete follow-up. From days 11 to 42, 59 partial and 6 generalized seizure days occurred in 20 individuals, nonsignificantly fewer in the enhanced arm (12 vs. 49, p = 0.114). The numbers of patients with seizures in this period showed similar nonsignificant differences. In the enhanced steroid arm there were significantly fewer days and individuals with seizures during antiparasitic treatment (days 1-10: 4 vs. 17, p = 0.004, and 1 vs. 10, p = 0.003, number needed to treat [NNT] 4.6, relative risk [RR] 0.1013, 95% confidence interval [CI] 0.01-0.74) and early after dexamethasone cessation (days 11-21: 6 vs. 27, p = 0.014, and 4 vs. 12, p = 0.021, NNT 4.0, RR 0.33, 95% CI 0.12-0.92) but not after day 21. There were no significant differences in antiparasitic efficacy or relevant adverse events. SIGNIFICANCE Increased dexamethasone dosing results in fewer seizures for the first 21 days during and early after antiparasitic treatment for viable parenchymal NCC but not during the first 11-42 days, which was the primary predetermined time of analysis.
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Affiliation(s)
- Hector H Garcia
- Cysticercosis Unit, National Institute of Neurological Sciences, Lima, Peru; Department of Microbiology, School of Sciences, Cayetano Heredia Peruvian University, Lima, Peru; Center for Global Health - Tumbes, Cayetano Heredia Peruvian University, Lima, Peru; School of Public Health, Cayetano Heredia Peruvian University, Lima, Peru
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13
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Garcia HH, Gonzales I, Lescano AG, Bustos JA, Zimic M, Escalante D, Saavedra H, Gavidia M, Rodriguez L, Najar E, Umeres H, Pretell EJ. Efficacy of combined antiparasitic therapy with praziquantel and albendazole for neurocysticercosis: a double-blind, randomised controlled trial. Lancet Infect Dis 2014; 14:687-695. [PMID: 24999157 DOI: 10.1016/s1473-3099(14)70779-0] [Citation(s) in RCA: 112] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Neurocysticercosis causes a substantial burden of seizure disorders worldwide. Treatment with either praziquantel or albendazole has suboptimum efficacy. We aimed to establish whether combination of these drugs would increase cysticidal efficacy and whether complete cyst resolution results in fewer seizures. We added an increased dose albendazole group to establish a potential effect of increased albendazole concentrations. METHODS In this double-blind, placebo-controlled, phase 3 trial, patients with viable intraparenchymal neurocysticercosis were randomly assigned to receive 10 days of combined albendazole (15 mg/kg per day) plus praziquantel (50 mg/kg per day), standard albendazole (15 mg/kg per day), or increased dose albendazole (22·5 mg/kg per day). Randomisation was done with a computer generated schedule balanced within four strata based on number of cysts and concomitant antiepileptic drug. Patients and investigators were masked to group assignment. The primary outcome was complete cyst resolution on 6-month MRI. Enrolment was stopped after interim analysis because of parasiticidal superiority of one treatment group. Analysis excluded patients lost to follow-up before the 6-month MRI. This trial is registered with ClinicalTrials.gov, number NCT00441285. FINDINGS Between March 3, 2010 and Nov 14, 2011, 124 patients were randomly assigned to study groups (41 to receive combined albendazole plus praziquantel [39 analysed], 43 standard albendazole [41 analysed], and 40 increased albendazole [38 analysed]). 25 (64%) of 39 patients in the combined treatment group had complete resolution of brain cysts compared with 15 (37%) of 41 patients in the standard albendazole group (rate ratio [RR] 1·75, 95% CI 1·10-2·79, p=0·014). 20 (53%) of 38 patients in the increased albendazole group had complete cyst resolution at 6-month MRI compared with 15 (37%) of 41 patients in the standard albendazole group (RR 1·44, 95% CI 0·87-2·38, p=0·151). No significant differences in adverse events were reported between treatment groups (18 in combined treatment group, 11 in standard albendazole group, and 19 in increased albendazole group). INTERPRETATION Combination of albendazole plus praziquantel increases the parasiticidal effect in patients with multiple brain cysticercosis cysts without increased side-effects. A more efficacious parasiticidal regime without increased treatment-associated side-effects should improve the treatment and long term prognosis of patients with neurocysticercosis. FUNDING National Institute of Neurological Disorders and Stroke (NINDS), National Institutes of Health.
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Affiliation(s)
- Hector H Garcia
- Instituto Nacional de Ciencias Neurológicas, Lima, Peru; Department of Microbiology, Universidad Peruana Cayetano Heredia, Lima, Peru; Center for Global Health Tumbes, Universidad Peruana Cayetano Heredia, Lima, Peru.
| | | | - Andres G Lescano
- School of Public Health, Universidad Peruana Cayetano Heredia, Lima, Peru; Department of Parasitology and Public Health Training Program, US Naval Medical Research Unit No 6 (NAMRU6), Callao, Peru
| | - Javier A Bustos
- Department of Microbiology, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Mirko Zimic
- Bioinformatics Unit, Laboratory of Research and Development, School of Sciences and Philosophy, Universidad Peruana Cayetano Heredia, Lima, Peru
| | | | | | - Martin Gavidia
- Hospital Nacional Edgardo Rebagliati, Essalud, Lima, Peru
| | | | - Enrique Najar
- Hospital Nacional Cayetano Heredia, Ministerio de Salud, Lima, Peru
| | - Hugo Umeres
- Hospital Nacional Cayetano Heredia, Ministerio de Salud, Lima, Peru
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Zea-Vera A, Cordova EG, Rodriguez S, Gonzales I, Pretell EJ, Castillo Y, Castro-Suarez S, Gabriël S, Tsang VCW, Dorny P, Garcia HH. Parasite antigen in serum predicts the presence of viable brain parasites in patients with apparently calcified cysticercosis only. Clin Infect Dis 2013; 57:e154-9. [PMID: 23788241 DOI: 10.1093/cid/cit422] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Computed tomography (CT) remains the standard neuroimaging screening exam for neurocysticercosis, and residual brain calcifications are the commonest finding. Magnetic resonance imaging (MRI) is more sensitive than CT but is rarely available in endemic regions. Enzyme-linked immunoelectrotransfer blot (EITB) assay uses antibody detection for diagnosis confirmation; by contrast, enzyme-linked immunosorbent assay (ELISA) antigen detection (Ag-ELISA) detects circulating parasite antigen. This study evaluated whether these assays predict undetected viable cysts in patients with only calcified lesions on brain CT. METHODS Serum samples from 39 patients with calcified neurocysticercosis and no viable parasites on CT were processed by Ag-ELISA and EITB. MRI was performed for each patient within 2 months of serologic testing. Conservatively high ELISA and EITB cutoffs were used to predict the finding of viable brain cysts on MRI. RESULTS Using receiver operating characteristic-optimized cutoffs, 7 patients were Ag-ELISA positive, and 8 had strong antibody reactions on EITB. MRI showed viable brain cysts in 7 (18.0%) patients. Patients with positive Ag-ELISA were more likely to have viable cysts than Ag-ELISA negatives (6/7 vs 1/32; odds ratio, 186 [95% confidence interval, 1-34 470.0], P < .001; sensitivity 85.7%, specificity 96.9%, positive likelihood ratio of 27 to detect viable cysts). Similar but weaker associations were also found between a strong antibody reaction on EITB and undetected viable brain cysts. CONCLUSIONS Antigen detection, and in a lesser degree strong antibody reactions, can predict viable neurocysticercosis. Serological diagnostic methods could identify viable lesions missed by CT in patients with apparently only calcified cysticercosis and could be considered for diagnosis workup and further therapy.
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Garcia HH, Lescano AG, Lanchote VL, Pretell EJ, Gonzales I, Bustos JA, Takayanagui OM, Bonato PS, Horton J, Saavedra H, Gonzalez AE, Gilman RH. Pharmacokinetics of combined treatment with praziquantel and albendazole in neurocysticercosis. Br J Clin Pharmacol 2011; 72:77-84. [PMID: 21332573 DOI: 10.1111/j.1365-2125.2011.03945.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
AIMS Neurocysticercosis is the most common cause of acquired epilepsy in the world. Antiparasitic treatment of viable brain cysts is of clinical benefit, but current antiparasitic regimes provide incomplete parasiticidal efficacy. Combined use of two antiparasitic drugs may improve clearance of brain parasites. Albendazole (ABZ) has been used together with praziquantel (PZQ) before for geohelminths, echinococcosis and cysticercosis, but their combined use is not yet formally recommended and only scarce, discrepant data exist on their pharmacokinetics when given together. We assessed the pharmacokinetics of their combined use for the treatment of neurocysticercosis. METHODS A randomized, double-blind, placebo-controlled phase II evaluation of the pharmacokinetics of ABZ and PZQ in 32 patients with neurocysticercosis was carried out. Patients received their usual concomitant medications including an antiepileptic drug, dexamethasone, and ranitidine. Randomization was stratified by antiepileptic drug (phenytoin or carbamazepine). Subjects had sequential blood samples taken after the first dose of antiparasitic drugs and again after 9 days of treatment, and were followed for 3 months after dosing. RESULTS Twenty-one men and 11 women, aged 16 to 55 (mean age 28) years were included. Albendazole sulfoxide concentrations were increased in the combination group compared with the ABZ alone group, both in patients taking phenytoin and patients taking carbamazepine. PZQ concentrations were also increased by the end of therapy. There were no significant side effects in this study group. CONCLUSIONS Combined ABZ + PZQ is associated with increased albendazole sulfoxide plasma concentrations. These increased concentrations could independently contribute to increased cysticidal efficacy by themselves or in addition to a possible synergistic effect.
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Affiliation(s)
- Hector H Garcia
- Cysticercosis Unit, Department of Transmissible Diseases, Instituto Nacional de Ciencias Neurologicas, Jr. Ancash 1271, Barrios Altos, Lima.
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García HH, Gonzalez AE, Rodriguez S, Tsang VCW, Pretell EJ, Gonzales I, Gilman RH. Neurocysticercosis: unraveling the nature of the single cysticercal granuloma. Neurology 2010; 75:654-8. [PMID: 20713953 DOI: 10.1212/wnl.0b013e3181ed9eae] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
A single enhancing lesion in the brain parenchyma, also called an inflammatory granuloma, is a frequent neurologic diagnosis. One of the commonest causes of this lesion is human neurocysticercosis, the infection by the larvae of the pork tapeworm, Taenia solium. Following the demonstration that viable cysticercosis cysts survive in good conditions for several years in the human brain, single cysticercal granulomas have been consistently interpreted as representing late degeneration of a long-established parasite. On the basis of epidemiologic, clinical, and laboratory evidence detailed in this article, we hypothesize that in most cases these inflammatory lesions correspond to parasites that die in the early steps of infection, likely as the natural result of the host immunity overcoming mild infections.
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Affiliation(s)
- H H García
- Cysticercosis Unit, Instituto Nacional de Ciencias Neurologicas, Jr. Ancash 1271, Barrios Altos, Lima 1, Peru.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Nash TE, Pretell EJ, Lescano AG, Bustos JA, Gilman RH, Gonzalez AE, Garcia HH. Perilesional brain oedema and seizure activity in patients with calcified neurocysticercosis: a prospective cohort and nested case-control study. Lancet Neurol 2008; 7:1099-105. [PMID: 18986841 DOI: 10.1016/s1474-4422(08)70243-6] [Citation(s) in RCA: 134] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Cysticercosis due to Taenia solium is a cause of adult-acquired seizures and epilepsy even in patients with only calcified larval cysts. Transient perilesional brain oedema is seen around the calcified foci but its importance, association with seizures, incidence, and pathophysiology are unknown. METHODS 110 patients with only calcified lesions and a history of seizures or severe headaches were followed prospectively in a cohort design to assess the incidence of seizure relapse. In a nested case-control substudy, perilesional oedema was assessed by MRI at the time of seizure in symptomatic patients and in matched asymptomatic controls taken from the study population. FINDINGS Between November, 1999, and December, 2006, 29 patients had an incident seizure during a median follow up of 32.33 (SD 19.99) months, with an estimated 5-year seizure incidence of 36% (95% CI 25% to 49%). 24 of 29 (83%) patients with seizure relapse had an MRI evaluation within 5 days of the event; perilesional oedema was seen in 12 patients (50%) compared with two (9%) of 23 asymptomatic matched controls. INTERPRETATION Perilesional oedema is common and associated with episodic seizure activity in patients with calcified neurocysticercosis. Our findings are probably representative of symptomatic patients in regions where T solium neurocysticercosis is endemic and suggest a unique and possibly preventable cause of seizures in this population.
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Affiliation(s)
- Theodore E Nash
- Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA.
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Nash TE, Singh G, White AC, Rajshekhar V, Loeb JA, Proaño JV, Takayanagui OM, Gonzalez AE, Butman JA, DeGiorgio C, Del Brutto OH, Delgado-Escueta A, Evans CAW, Gilman RH, Martinez SM, Medina MT, Pretell EJ, Teale J, Garcia HH. Treatment of neurocysticercosis: current status and future research needs. Neurology 2006; 67:1120-7. [PMID: 17030744 PMCID: PMC2923067 DOI: 10.1212/01.wnl.0000238514.51747.3a] [Citation(s) in RCA: 135] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Here we put forward a roadmap that summarizes important questions that need to be answered to determine more effective and safer treatments. A key concept in management of neurocysticercosis is the understanding that infection and disease due to neurocysticercosis are variable and thus different clinical approaches and treatments are required. Despite recent advances, treatments remain either suboptimal or based on poorly controlled or anecdotal experience. A better understanding of basic pathophysiologic mechanisms including parasite survival and evolution, nature of the inflammatory response, and the genesis of seizures, epilepsy, and mechanisms of anthelmintic action should lead to improved therapies.
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Affiliation(s)
- T E Nash
- Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD, USA.
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Bustos JA, Pretell EJ, Llanos-Zavalaga F, Gilman RH, Del Brutto OH, Garcia HH. Efficacy of a 3-day course of albendazole treatment in patients with a single neurocysticercosis cyst. Clin Neurol Neurosurg 2006; 108:193-4. [PMID: 16412842 DOI: 10.1016/j.clineuro.2004.12.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2004] [Accepted: 12/06/2004] [Indexed: 10/25/2022]
Affiliation(s)
- Javier A Bustos
- Cysticercosis Unit, Instituto de Ciencias Neurologicas, Lima, Peru
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21
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Bustos JA, Garcia HH, Dorregaray R, Naranjo M, Pretell EJ, Gonzalez AE, Gilman RH. Detection of muscle calcifications by thigh CT scan in neurocysticercosis patients. Trans R Soc Trop Med Hyg 2005; 99:775-9. [PMID: 16099008 DOI: 10.1016/j.trstmh.2005.04.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2004] [Revised: 04/23/2005] [Accepted: 04/25/2005] [Indexed: 11/23/2022] Open
Abstract
Twenty-five patients with calcified neurocysticercosis (two to four intraparenchymal brain calcifications) were asked to have a non-contrasted computed tomography (CT) scan of the thighs to determine the frequency of muscle calcifications detected by this technique. Thirteen (52%) showed one or more muscle calcifications. The numbers of calcifications in the thighs and the brain were not correlated. Patients with a positive CT scan for muscle calcifications were also examined by X-rays to compare both methods. Only 6 of 13 had visible calcifications on X-ray. Thigh CT scans can demonstrate muscle calcifications in a significant proportion of patients with calcified neurocysticercosis.
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Affiliation(s)
- Javier A Bustos
- Cysticercosis Unit, Instituto de Ciencias Neurologicas, Lima, Peru
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Pretell EJ, Martinot C, Garcia HH, Alvarado M, Bustos JA, Martinot C. Differential Diagnosis Between Cerebral Tuberculosis and Neurocysticercosis by Magnetic Resonance Spectroscopy. J Comput Assist Tomogr 2005; 29:112-4. [PMID: 15665695 DOI: 10.1097/01.rct.0000149959.63294.8f] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Single enhancing brain lesions (SELs), mostly as a result of neurocysticercosis or tuberculosis, are a common cause of seizures. Ten patients with SELs caused by neurocysticercosis (n=6) or tuberculosis (n=4) were examined by proton magnetic resonance spectroscopy. Tuberculomas had a high peak of lipids, more choline, and less N-acetylaspartate and creatine. The choline/creatine ratio was greater than 1 in all tuberculomas but in none of the cysticerci. Magnetic resonance spectroscopy differentiates SELs caused by cysticercosis or tuberculosis and may avoid brain biopsies or unnecessary antituberculosis treatments.
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Affiliation(s)
- E Javier Pretell
- Cysticercosis Unit, Instituto Especializado en Ciencias Neurologicas, Lima, Peru
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23
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Nash TE, Del Brutto OH, Butman JA, Corona T, Delgado-Escueta A, Duron RM, Evans CAW, Gilman RH, Gonzalez AE, Loeb JA, Medina MT, Pietsch-Escueta S, Pretell EJ, Takayanagui OM, Theodore W, Tsang VCW, Garcia HH. Calcific neurocysticercosis and epileptogenesis. Neurology 2004; 62:1934-8. [PMID: 15184592 PMCID: PMC2912520 DOI: 10.1212/01.wnl.0000129481.12067.06] [Citation(s) in RCA: 179] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Neurocysticercosis is responsible for increased rates of seizures and epilepsy in endemic regions. The most common form of the disease, chronic calcific neurocysticercosis, is the end result of the host's inflammatory response to the larval cysticercus of Taenia solium. There is increasing evidence indicating that calcific cysticercosis is not clinically inactive but a cause of seizures or focal symptoms in this population. Perilesional edema is at times also present around implicated calcified foci. A better understanding of the natural history, frequency, epidemiology, and pathophysiology of calcific cysticercosis and associated disease manifestations is needed to define its importance, treatment, and prevention.
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Affiliation(s)
- T E Nash
- Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA.
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Garcia HH, Pretell EJ, Gilman RH, Martinez SM, Moulton LH, Del Brutto OH, Herrera G, Evans CAW, Gonzalez AE. A trial of antiparasitic treatment to reduce the rate of seizures due to cerebral cysticercosis. N Engl J Med 2004; 350:249-58. [PMID: 14724304 DOI: 10.1056/nejmoa031294] [Citation(s) in RCA: 232] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Neurocysticercosis is the main cause of adult-onset seizures in the developing world. Whether therapy with antiparasitic agents results in improved seizure control has been questioned because of the lack of adequate, controlled studies. METHODS We conducted a double-blind, placebo-controlled trial in which 120 patients who had living cysticerci in the brain and seizures treated with antiepileptic drugs were randomly assigned to receive either 800 mg of albendazole per day and 6 mg of dexamethasone per day for 10 days (60 patients) or two placebos (60 patients). The patients were followed for 30 months or until they had been seizure-free for 6 months after the doses of the antiepileptic drugs had been tapered. The efficacy of treatment was measured as the decrease in the number of seizures after treatment. RESULTS In the albendazole group, there was a 46 percent reduction in the number of seizures (95 percent confidence interval, -74 to 83 percent) during months 2 to 30 after treatment. This reduction, which was not statistically significant, was composed of a nonsignificant reduction of 41 percent in the number of partial seizures (95 percent confidence interval, -124 to 84 percent) and a significant 67 percent reduction in the number of seizures with generalization (95 percent confidence interval, 20 to 86 percent). Most of the difference in the number of partial seizures was attributable to a few patients who had many seizures during follow-up. The proportions of patients who had partial seizures during follow-up were similar in the two groups (19 of 57 in the albendazole group and 16 of 59 in the placebo group), but the patients in the placebo group had a greater tendency to have seizures with generalization (22 of 59, vs. 13 of 57 in the albendazole group; risk ratio, 1.63; 95 percent confidence interval, 0.91 to 2.92). More of the intracranial cystic lesions resolved in the albendazole group than in the placebo group. With the sole exception of abdominal pain, side effects did not differ significantly between the two groups. CONCLUSIONS In patients with seizures due to viable parenchymal cysts, antiparasitic therapy decreases the burden of parasites and is safe and effective, at least in reducing the number of seizures with generalization.
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Affiliation(s)
- Héctor H Garcia
- Department of Transmissible Diseases, Instituto Nacional de Ciencias Neurologicas, Barrios Altos, Lima, Peru.
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Garcia HH, Gonzalez AE, Gilman RH, Bernal T, Rodriguez S, Pretell EJ, Azcurra O, Parkhouse RME, Tsang VCW, Harrison LJS. Circulating parasite antigen in patients with hydrocephalus secondary to neurocysticercosis. Am J Trop Med Hyg 2002; 66:427-30. [PMID: 12164300 DOI: 10.4269/ajtmh.2002.66.427] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
End stages of neurocysticercosis include residual intraparenchymal brain calcifications and hydrocephalus. Although brain calcifications alone have a benign prognosis, hydrocephalus is frequently associated with chronic inflammation and intracranial hypertension, together with a protracted clinical evolution, and may lead to patient deaths. By using a monoclonal-based antigen detection enzyme-linked immunosorbent assay, we measured the levels of circulating parasite antigen in the sera of 56 patients with neurocysticercosis: 27 with calcifications only and 29 with hydrocephalus. The assay gave positive results in 14 of 29 patients with hydrocephalus but was consistently negative in patients with calcifications. Circulating parasite antigen in hydrocephalus secondary to neurocysticercosis indicates the presence of live parasites in these patients and thus a potential benefit from antiparasitic therapy.
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Affiliation(s)
- H H Garcia
- Department of Microbiology, Universidad Peruana Cayetano Heredia, Lima.
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Pretell EJ, García HH, Gilman RH, Saavedra H, Martinez M. Failure of one-day praziquantel treatment in patients with multiple neurocysticercosis lesions. Clin Neurol Neurosurg 2001; 103:175-7. [PMID: 11532559 DOI: 10.1016/s0303-8467(01)00137-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
A recently described one-day regimen of praziquantel (PZQ) therapy for neurocysticercosis (NCC), three doses of 25 mg/k given at 2 h intervals, was applied in eight patients with viable NCC cysts without any evidence of inflammation. Resolution of lesions in computed tomography (CT) was observed in all five patients with a single cyst, whereas all cysts survived in three patients with multiple brain parasites. One-day praziquantel is a good regimen for patients with a single viable brain cysticercus but is poorly effective for multiple cysts.
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Affiliation(s)
- E J Pretell
- Department of Transmissible Diseases, Instituto Nacional de Ciencias Neurológicas, Jr. Ancash 1271, Barrios Altos, 1, Lima, Peru
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Pretell EJ, Garcia HH, Custodio N, Padilla C, Alvarado M, Gilman RH, Martinez M. Short regimen of praziquantel in the treatment of single brain enhancing lesions. Clin Neurol Neurosurg 2000; 102:215-218. [PMID: 11154807 DOI: 10.1016/s0303-8467(00)00110-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Twenty-six patients with single enhancing brain lesion (SEL) were openly assigned to receive single-day praziquantel therapy (n=14), or not (n=12). From 14 treated patients, complete resolution was found in 11, partial resolution in two, and the remaining case was later diagnosed as an arteriovenous malformation. Side effects presented in only one patient and remitted in the same day with symptomatic treatment. Conversely, the lesions persisted unchanged in six of 12 patients in the non-treatment group. Untreated patients with persisting lesions were prescribed praziquantel treatment. After this, SELs disappeared in three cases, other diagnoses (brain tuberculoma and arteriovenous malformation) were made in two, and one was not evaluated. When analyzed in regard to the baseline serology, resolution of lesions on computed tomography was found in 13 (complete=12, partial=1) of 14 seropositive patients, whereas it only happened in six (complete=5, partial=1) of 12 seronegative patients. Serological screening defines a subset of SEL patients with good prognosis. If antiparasitic therapy is to be used in patients with SEL, and we cannot find a strong argument against it, single-day praziquantel is the regimen of choice based on duration, costs, and minimal side effects.
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Affiliation(s)
- E J Pretell
- Department of Transmissible Diseases, Instituto Nacional de Ciencias Neurologicas, Jr. Ancash 1271, Barrios Altos, Lima, Peru
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