[Diagnosis of neurocysticercosis in patients with epilepsy living in the south-western Dominican Republic]

INTRODUCTION

Neurocysticercosis (NCC), a possible cause of epilepsy with limited epidemiological data in the Dominican Republic, is endemic in four provinces in the country's south-western region. This study aimed to determine the association between NCC and epilepsy among people living in these endemic regions, and to obtain preliminary data on the prevalence of NCC in these provinces.

PATIENTS AND METHODS

A case-control design was used, consisting of 111 patients with epilepsy with unknown causes, and 60 controls without epilepsy or NCC. The diagnosis of NCC was based on computed tomography and magnetic resonance imaging of the skull, as well as Western immunoblotting for serum antibodies using Taenia solium, following the criteria of Del Brutto et al. RESULTS. NCC was found in 27% of the epileptic patients (n = 30/111) and in 5% of the controls (n = 3/60); the probability of the epileptic patients having NCC was seven times higher than the controls (odds ratio = 7.04, 95% confidence interval: 2.04-24.18; p < 0.001). The participants' sociodemographic characteristics, including their age, sex, level of education, occupation, and province of residence presented no statistical significance in terms of their association with NCC.

CONCLUSIONS

This study suggests that NCC is strongly associated with epilepsy in the south-western region of the Dominican Republic, and highlights the need for public health measures to improve the prevention, diagnosis and treatment of both diseases.

Evidence for Transmission of Taenia solium Taeniasis/Cysticercosis in a Rural Area of Northern Rwanda

Cysticercosis is a parasitic infection caused by the metacestode larval stage (cysticercus) of Taenia solium. In humans, cysticercosis may infect the central nervous system and cause neurocysticercosis, which is responsible for over 50,000 deaths per year worldwide and is the major cause of preventable epilepsy cases, especially in low-income countries. Cysticercosis infection is endemic in many less developed countries where poor hygiene conditions and free-range pig management favor their transmission. A cross-sectional study was conducted in 680 children from a rural primary school in Gakenke district (Northern province of Rwanda). Stool samples were collected from participants and analyzed using the Kato-Katz method (KK), formol-ether concentration (FEC), and/or copro-antigen enzyme-linked immunosorbent assay (CoAg-ELISA) to detect taeniasis. Blood samples were collected and analyzed using enzyme-linked immunoelectrotransfer blot (EITB) and antigen enzyme-linked immunosorbent assay (Ag-ELISA) to detect human cysticercosis. The overall proportion of taeniasis positivity was 0.3% (2/680), and both cases were also confirmed by CoAg-ELISA. A total of 13.3% (76/572) of the children studied were positive to cysticercosis (T. solium-specific serum antibodies detected by EITB), of whom 38.0% (27/71) had viable cysticercus (T. solium antigens by Ag-ELISA). This study provides evidence of the highest cysticercosis prevalence reported in Rwanda in children to date. Systematic investigations into porcine and human cysticercosis as well as health education and hygiene measures for T. solium control are needed in Gakenke district.

Incidence of human Taenia solium larval Infections in an Ecuadorian endemic area: implications for disease burden assessment and control

BACKGROUND

Human cysticercosis is a zoonotic disease causing severe health disorders and even death. While prevalence data become available worldwide, incidence rate and cumulative incidence figures are lacking, which limits the understanding of the Taenia solium epidemiology.

METHODOLOGY/PRINCIPAL FINDINGS

A seroepidemiological cohort study was conducted in a south-Ecuadorian community to estimate the incidence rate of infection with and the incidence rate of exposure to T. solium based on antigen and antibody detections, respectively. The incidence rate of infection was 333.6 per 100,000 person-years (95% CI: [8.4-1,858] per 100,000 person-years) contrasting with a higher incidence rate of exposure 13,370 per 100,000 person-years (95% CI: [8,730-19,591] per 100,000 person-years). The proportion of infected individuals remained low and stable during the whole study year while more than 25% of the population showed at least one antibody seroconversion/seroreversion during the same time period.

CONCLUSIONS/SIGNIFICANCE

Understanding the transmission of T. solium is essential to develop ad hoc cost-effective prevention and control programs. The estimates generated here may now be incorporated in epidemiological models to simulate the temporal transmission of the parasite and the effects of control interventions on its life cycle. These estimates are also of high importance to assess the disease burden since incidence data are needed to make regional and global projections of morbidity and mortality related to cysticercosis.

Epidemiology and management of cysticercosis and Taenia solium taeniasis in Europe, systematic review 1990-2011

BACKGROUND

Cysticercosis is caused by the invasion of human or pig tissues by the metacestode larval stage of Taenia solium. In Europe, the disease was endemic in the past but the autochthonous natural life cycle of the parasite is currently completed very rarely. Recently, imported cases have increased in parallel to the increased number of migrations and international travels. The lack of specific surveillance systems for cysticercosis leads to underestimation of the epidemiological and clinical impacts.

OBJECTIVES

To review the available data on epidemiology and management of cysticercosis in Europe.

METHODS

A review of literature on human cysticercosis and T. solium taeniasis in Europe published between 1990-2011 was conducted.

RESULTS

Out of 846 cysticercosis cases described in the literature, 522 cases were autochthonous and 324 cases were imported. The majority (70.1%) of the autochthonous cases were diagnosed in Portugal from 1983 and 1994. Imported cases of which 242 (74.7%) diagnosed in migrants and 57 (17.6%) in European travellers, showed an increasing trend. Most of imported cases were acquired in Latin America (69.8% of migrants and 44.0% of travellers). The majority of imported cases were diagnosed in Spain (47.5%), France (16.7%) and Italy (8.3%). One third of neurosurgical procedures were performed because the suspected diagnosis was cerebral neoplasm. Sixty eight autochthonous and 5 imported T. solium taeniasis cases were reported.

CONCLUSIONS

Cysticercosis remains a challenge for European care providers, since they are often poorly aware of this infection and have little familiarity in managing this disease. Cysticercosis should be included among mandatory reportable diseases, in order to improve the accuracy of epidemiological information. European health care providers might benefit from a transfer of knowledge from colleagues working in endemic areas and the development of shared diagnostic and therapeutic processes would have impact on the quality of the European health systems.

A high oxfendazole dose to control porcine cysticercosis: pharmacokinetics and tissue residue profiles

Oxfendazole (OFZ) is efficacious for porcine cysticercosis at 30 mg/kg. OFZ is not registered to be used at this dose. The assessment of the OFZ and metabolites [(fenbendazole sulphone (FBZSO2), fenbendazole (FBZ)] plasma pharmacokinetic and tissue residue profiles after its oral administration to pigs and the withdrawal period for human consumption were reported. Forty-eight pigs allocated into two groups received OFZ (30 mg/kg) orally as a commercial (CF) or as experimental formulation (SMF). Samples (blood, muscle, liver, kidney and fat) were collected over 30 days post-treatment and analyzed by HPLC. OFZ was the main compound recovered in plasma, followed by FBZSO2 and low FBZ concentrations. OFZ AUC0-LOQ (209.9±33.9 μg·h/ml) and Cmax (5.40±0.65 μg/ml) parameters for the CF tended to be higher than those for the SMF (AUC0-LOQ: 159.4±18.3 μg h/ml, Cmax: 3.80±0.35 μg/ml). The highest total residue (OFZ+FBZSO2+FBZ) concentrations were quantified in liver, followed by kidney, muscle and fat tissue. FBZSO2 residue levels were the highest found in muscle (0.68±0.39 μg/g) and fat (0.69±0.39 μg/g). In liver and kidney the highest residues corresponded to FBZ (5.29±4.36 μg/g) and OFZ (2.86±0.75 μg/g), respectively. A withdrawal time of 17 days post-treatment was established before tissues are delivered for human consumption.

A dot-ELISA using a partially purified cathepsin-L-like protein fraction from Taenia solium cysticerci, for the diagnosis of human neurocysticercosis

Human neurocysticercosis (NCC), caused by the cestode Taenia solium, is responsible for a significant amount of neurological morbidity and epilepsy in developing countries. The disease remains highly endemic in many areas, despite several efforts and interventions to control it. A simple, cheap and fast diagnostic assay that is suitable for use in field conditions is highly desired. In immunodiagnostics based on western immunoblots or standard ELISA, a cathepsin-L-like protein purified from the cysticercus fluid has previously performed well as an antigen. In a recent study in Peru, the same 53/25-kDa antigen was therefore used in the development of a dot-ELISA that could be employed for mass screenings under field conditions. The assay was standardized and tested not only against sera from a large group of NCC cases but also against sera from patients with other common parasitic infections, so that sensitivity and specificity could be assessed. For NCC, the assay gave better sensitivity in the detection of individuals with extraparenchymal cysts (94·4%-100%) or multiple parenchymal cysts (74·6%-80·0%) than in the detection of individuals with single parenchymal cysts (29·4%-45·1%). The assay also showed a high specificity for NCC (99·0%-100%), with a very low level of cross-reactivity with other parasitic infections. The dot-ELISA developed in this study is a highly specific, simple, cheap and rapid test for NCC that could be used under field conditions, even in the low-resource settings that are common in developing countries.

Immunoinformatics prediction of linear epitopes from Taenia solium TSOL18

Cysticercosis is a public health problem in several developing countries. The oncosphere protein TSOL18 is the most immunogenic and protective antigen ever reported against porcine cysticercosis, although no specific epitope has been identified to account for these properties. Recent evidence suggests that protection might be associated with conformational epitopes. Linear epitopes from TSOL18 were computationally predicted and evaluated for immunogenicity and protection against porcine cysticercosis. A synthetic peptide was designed based on predicted linear B cell and T cell epitopes that are exposed on the surface of the theoretically modeled structure of TSOL18. Three surface epitopes from TSOL18 were predicted as immunogenic. A peptide comprising a linear arrangement of these epitopes was chemically synthesized. The capacity of the synthetic peptide to protect pigs against an oral challenge with Taenia solium proglottids was tested in a vaccine trial. The synthetic peptide was able to produce IgG antibodies in pigs and was associated to a reduction of the number of cysts, although was not able to provide complete protection, defined as the complete absence of cysts in necropsy. This study demonstrated that B cell and T cell predicted epitopes from TSOL18 were not able to completely protect pigs against an oral challenge with Taenia solium proglottids. Therefore, other linear epitopes or eventually conformational epitopes may be responsible for the protection conferred by TSOL18.

Neurocysticercosis: unraveling the nature of the single cysticercal granuloma

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.

Control of Taenia solium

Control or eradication of Taenia solium cysticercosis has been achieved to date only in Europe and North America. Significant improvements in sanitary conditions and developing functional slaughterhouse control systems were primarily responsible for control in these regions. Conversely, in endemic areas of developing countries control is limited by economic and sanitary conditions: the life cycle of T. solium is sustained because pigs have access to infected faeces, and cysticercosis-infested pork is available for consumption. Interventional trials with massive human cestocidal chemotherapy, treatment of both human and porcine populations with antihelminthic drugs and/or immunotherapy and health education have shown improvements in specific settings but not yet proven to be sustainable in the long-term. In order to ensure sustainability, any given control strategy towards elimination/eradication of porcine cysticercosis should incorporate economic incentives.

Failure of one-day praziquantel treatment in patients with multiple neurocysticercosis lesions

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.

Proposed diagnostic criteria for neurocysticercosis

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.

Neurocysticercosis and oncogenesis

Recent studies suggest that neurocysticercosis may be a risk factor for human cancer. Pathogenetic mechanisms explaining possible oncogenic effects of cysticerci include the following: (a) parasite-induced modulation of the host immune response that may be associated with loss of regulatory mechanisms implicated in the immunological surveillance against cancer; (b) transfer of genetic material from the parasite to the host, causing DNA damage and malignant transformation of host cells, and (c) chronic inflammation with liberation of nitric oxide and inhibition of tumor suppressor genes. Further research is needed to confirm the potential role of cysticercosis in the development of cancer. These studies should determine the presence of cysticercotic factors responsible for the transfer of genetic material and potential mutations in the tumor suppressor genes in proliferating astrocytes surrounding cysticercotic lesions. Additionally, the complex interaction between the immune state of the host with variable cytokine release and the presence of inflammatory cells releasing nitric oxide that cause DNA damage and impair tumor suppressive mechanisms needs to be investigated.

Heavy nonencephalitic cerebral cysticercosis in tapeworm carriers. The Cysticercosis Working Group in Perú

We describe 11 patients with massive brain infection with viable cysticerci, undetectable inflammatory reaction on CNS imaging, and an unexpectedly high (82%) prevalence of tapeworm infection. With the exception of two individuals with heavy parasite loads, patients had a relatively benign clinical course and tolerated the use of cysticidal drugs. This group of patients represents a particular presentation of neurocysticercosis, different from the previously described syndromes of cysticercotic encephalitis and disseminated systemic cysticercosis.

Clinical significance of neurocysticercosis in endemic villages. The Cysticercosis Working Group in Peru

Cerebral cysticercosis is the main cause of late-onset epilepsy in most developing countries. Data on the neuroepidemiology of cysticercosis in endemic populations is scarce. In an endemic village on the northern coast of Peru, 49 individuals with neurological symptomatology (41 epileptic and 8 non-epileptic) were screened for antibodies to Taenia solium, using a serum electroimmunotransfer blot assay. Fifteen subjects were seropositive, 14 (34%) of those with epilepsy but only one (13%) of those who were non-epileptic. A history of passing proglottides was associated with positive serology. Thirteen of the 15 seropositive individuals underwent cerebral computed tomography; only 7 (54%) were abnormal. A randomly selected sample of 20 pigs from the village was also tested, and 6 (30%) were seropositive. This study demonstrated the importance of cysticercosis in the aetiology of epilepsy in endemic villages and the close relationship between porcine and human infection.