Clinical characteristics and management of neurocysticercosis patients: a retrospective assessment of case reports from Europe

OBJECTIVES

Neurocysticercosis (NCC) is a parasitic disease caused by the larval stage of the tapeworm Taenia solium. NCC mainly occurs in Africa, Latin America and South-East Asia and can cause a variety of clinical signs/symptoms. Although it is a rare disease in Europe, it should nonetheless be considered as a differential diagnosis. The aim of this study was to describe clinical characteristics and management of patients with NCC diagnosed and treated in Europe.

METHODS

We conducted a systematic search of published and unpublished data on patients diagnosed with NCC in Europe (2000-2019) and extracted demographic, clinical and radiological information on each case, if available.

RESULTS

Out of 293 identified NCC cases, 59% of patients presented initially with epileptic seizures (21% focal onset); 52% presented with headache and 54% had other neurological signs/symptoms. The majority of patients had a travel or migration history (76%), mostly from/to Latin America (38%), Africa (32%) or Asia (30%). Treatment varied largely depending on cyst location and number. The outcome was favorable in 90% of the cases.

CONCLUSIONS

Management of NCC in Europe varied considerably but often had a good outcome. Travel and migration to and from areas endemic for T. solium will likely result in continued low prevalence of NCC in Europe. Therefore, training and guidance of clinicians is recommended for optimal patient management.

Extracellular Vesicles Enriched in hsa-miR-301a-3p and hsa-miR-1293 Dynamics in Clear Cell Renal Cell Carcinoma Patients: Potential Biomarkers of Metastatic Disease

Clear cell renal cell carcinoma (ccRCC) is the most aggressive subtype of kidney cancer and up to 40% of patients submitted to surgery with a curative intent will relapse. Thus, the aim of this study was to analyze the applicability of an Extracellular vesicle (EV) derived miRNA profile as potential prognosis biomarkers in ccRCC patients. We analyzed a nine-miRNA profile in plasma EVs from 32 ccRCC patients with localized disease (before and after surgery) and in 37 patients with metastatic disease. We observed that the levels of EV-derived hsa-miR-25-3p, hsa-miR-126-5p, hsa-miR-200c-3p, and hsa-miR-301a-3p decreased after surgery, whereas hsa-miR-1293 EV-levels increased. Furthermore, metastatic patients presented higher levels of hsa-miR-301a-3p and lower levels of hsa-miR-1293 when compared to patients with localized disease after surgery. Functional enrichment analysis of the targets of the four miRNAs that decreased after surgery resulted in an enrichment of terms related to cell cycle, proliferation, and metabolism, suggesting that EV-miRNA enrichment in the presence of the tumor could represent an epigenetic mechanism to sustain tumor development. Taken together, these results suggest that EVs content varies depending on the presence or absence of the disease and that an increase of EV-derived hsa-miR-301a-3p, and decrease of EV-derived hsa-miR-1293, may be potential biomarkers of metastatic ccRCC.

Epidemiology and surveillance of human (neuro)cysticercosis in Europe: is enhanced surveillance required?

OBJECTIVES

To report on relevant national surveillance systems of (N)CC and taeniasis (the infection with the adult tapeworm) in the European Union/European Economic Area and to assess the magnitude of (N)CC occurrence by retrieving information on cases for the period 2000-2016.

METHODS

(N)CC cases were retrieved via national reporting systems, a systematic literature search, contact with clinicians and a search for relevant 'International Statistical Classification of Diseases and Related Health Problems' (ICD)-based data.

RESULTS

Mandatory notification systems for (N)CC were found in Hungary, Iceland and Poland. Ten cases were reported in Poland and none in Hungary and Iceland. Through the systematic literature review and information given by clinicians, 263 individual and 721 aggregated (N)CC cases from 19 European countries were identified. ICD-based data were obtained from five countries. From 2000 to 2016, a total of 3489 cases (N)CC cases were coded: 832 in Italy, eight in Latvia, 357 in Portugal, 2116 in Spain and 176 in Sweden.

CONCLUSION

Despite being classified as a possible eradicable disease, (N)CC is still diagnosed across Europe, yet its true extent and impact remain unclear.

One Health-ness Evaluation of Cysticercosis Surveillance Design in Portugal

The increasing occurrence of human cysticercosis, a zoonotic neglected disease, is challenging the traditional prevention and control paradigm and calling for One Health (OH) solutions in industrialized countries. OH solutions for health interventions are increasingly being used to capture expected and unexpected outcomes across people, animals, and the environment. The Network for Evaluation of One Health (NEOH) proposes an evidence-based framework, relying on systems and mixed methods approaches to evaluate the One Health-ness. In this case study, this tool is used to evaluate the design of the Observatory of Taeniasis and Cysticercosis, as an example of intersectorial collaboration for surveillance in Portugal. The OH Initiative (drivers and expected outcomes) and its system (boundaries, aim, dimensions, actors, and stakeholders) were described. The different aspects of this Initiative were scored with values from 0 (=no OH approach) to 1 (=perfect OH approach). The OH index was 0.31. Its OH ratio is 1.98. Overall scores were as follows: OH thinking 0.75; OH planning 0.60; OH working 0.60; OH sharing 0.35; OH learning 0.50; and systemic organization 0.50. Operational levels of the Initiative are the main strengths, indicating a comprehensive multidimensional innovative approach and transdisciplinarity. Critical issues in the supporting infrastructure were observed, related to communication, learning and organizational gaps in the project, with the evaluation being conducted as the project is being designed and implemented. The strengths and weaknesses detected may be used to refine the Initiative. This case study therefore exemplifies and supports OH assessment also for ongoing projects, at design and early implementation stages for guiding and guaranteeing an OH-oriented perspective.

First molecular detection of Leishmania infantum in Sergentomyia minuta (Diptera, Psychodidae) in Alentejo, southern Portugal

Protozoan parasites, such as Leishmania spp., are the causative agents of many insect-borne infectious diseases with medical and veterinary importance. Leishmaniasis, caused by Leishmania spp., is transmitted by female phlebotomine sand flies. In the Alentejo region of Portugal, located at the north of Algarve, cases of human and canine leishmaniasis caused by Leishmania infantum have been notified. However, no recent studies regarding the sand fly fauna in the region are available. We therefore aimed to explore the phlebotomine sand fly species found in both, Évora and Beja Districts, to gain an insight about the leishmaniasis epidemiology in these areas. After the identification of the insect species, PCR molecular tests were used to assess L. infantum infection rate in the sand fly captured females, together with the analysis of blood meal sources of the insect vectors. One Sergentomyia minuta female was positive for L. infantum infection and another for human blood as a meal source. The occurrence of this phlebotomine species infected with L. infantum may suggest that, in the Mediterranean basin, leishmaniasis epidemiology is changing. Also, if the importance of S. minuta for the zoonotic and anthroponotic cycle of leishmaniasis is later proven, the strategies to control its vector will inevitably to be rethought.

Epidemiology of taeniosis/cysticercosis in Europe, a systematic review: Western Europe

BACKGROUND

Taenia solium and Taenia saginata are zoonotic parasites of public health importance. Data on their occurrence in humans and animals in western Europe are incomplete and fragmented. In this study, we aimed to update the current knowledge on the epidemiology of these parasites in this region.

METHODS

We conducted a systematic review of scientific and grey literature published from 1990 to 2015 on the epidemiology of T. saginata and T. solium in humans and animals. Additionally, data about disease occurrence were actively sought by contacting local experts in the different countries.

RESULTS

Taeniosis cases were found in twelve out of eighteen countries in western Europe. No cases were identified in Iceland, Ireland, Luxembourg, Norway, Sweden and Switzerland. For Denmark, Netherlands, Portugal, Slovenia, Spain and the UK, annual taeniosis cases were reported and the number of detected cases per year ranged between 1 and 114. Detected prevalences ranged from 0.05 to 0.27%, whereas estimated prevalences ranged from 0.02 to 0.67%. Most taeniosis cases were reported as Taenia spp. or T. saginata, although T. solium was reported in Denmark, France, Italy, Spain, Slovenia, Portugal and the UK. Human cysticercosis cases were reported in all western European countries except for Iceland, with the highest number originating from Portugal and Spain. Most human cysticercosis cases were suspected to have acquired the infection outside western Europe. Cases of T. solium in pigs were found in Austria and Portugal, but only the two cases from Portugal were confirmed with molecular methods. Germany, Spain and Slovenia reported porcine cysticercosis, but made no Taenia species distinction. Bovine cysticercosis was detected in all countries except for Iceland, with a prevalence based on meat inspection of 0.0002-7.82%.

CONCLUSIONS

Detection and reporting of taeniosis in western Europe should be improved. The existence of T. solium tapeworm carriers, of suspected autochthonous cases of human cysticercosis and the lack of confirmation of porcine cysticercosis cases deserve further attention. Suspected cases of T. solium in pigs should be confirmed by molecular methods. Both taeniosis and human cysticercosis should be notifiable and surveillance in animals should be improved.

The role of Rhipicephalus sanguineus sensu lato saliva in the dissemination of Rickettsia conorii in C3H/HeJ mice

Animal models have been developed for the study of rickettsial pathogenesis. However, to understand what occurs during the natural route of rickettsial transmission via the tick bite, the role of tick saliva should be considered in these models. To address this, we analysed the role of tick saliva in the transmission of Rickettsia conorii (Rickettsiales: Rickettsiaceae) in a murine host by intradermally (i.d.) inoculating two groups of susceptible C3H/HeJ mice with this Rickettsia, and infesting one group with nymphal Rhipicephalus sanguineus sensu lato (Ixodida: Ixodidae) ticks. Quantification of bacterial loads and mRNA levels of interleukin-1β (IL-1β), IL-10 and NF-κB was performed in C3H/HeJ lung samples by real-time quantitative polymerase chain reaction (PCR) and real-time reverse transcriptase PCR, respectively. Lung histology was examined to evaluate the pathological manifestations of infection. No statistically significant difference in bacterial load in the lungs of mice was observed between these two groups; however, a statistically significant difference was observed in levels of IL-1β and NF-κB, both of which were higher in the group inoculated with rickettsiae but not infected with ticks. Lung histology in both groups of animals revealed infiltration of inflammatory cells. Overall, this study showed that i.d. inoculation of R. conorii caused infection in the lungs of C3H/HeJ mice and tick saliva inhibited proinflammatory effects.

Quantitative study of Rickettsia massiliae in Rhipicephalus sanguineus organs

Rickettsia massiliae, belonging to the spotted fever group of Rickettsia, is a human pathogen causing a similar course of disease to that caused by R. conorii, the originally recognized etiologic agent of Mediterranean spotted fever. In view of this similarity, we performed an ultrastructural study of R. massiliae in organs of Rhipicephalus sanguineus ticks, in order to advance knowledge of the complex dynamics at the tick-pathogen interface in rickettsioses. Adult R. massiliae-infected Rh. sanguineus ticks were fed on uninfected Hartley strain guinea pigs, and five females were collected daily throughout their feeding period up to day 6, and analyzed by quantitative real-time PCR and electron microscopy. An increase in rickettsial content was observed in the salivary glands, particularly in the first two days of feeding, and a plateau was observed between days 3 and 6. Rickettsial organisms were observed in all tick organs analyzed, in higher numbers in the fed state, and statistically significant differences were observed in measurements of the periplasmic layer of R. massiliae in salivary glands of fed and unfed Rh. sanguineus ticks, with increased thickness in the former case. This study provides insight into the interface between R. massiliae and Rh. sanguineus ticks, highlighting the need for analysis of R. massiliae to fully ascertain its place as an important pathogenic agent of a spotted fever rickettsiosis.

The emergence of Taenia solium cysticercosis in Eastern and Southern Africa as a serious agricultural problem and public health risk

Pig production has increased significantly in the Eastern and Southern Africa (ESA) region during the past decade, especially in rural, resource-poor, smallholder communities. Concurrent with the increase in smallholder pig keeping and pork consumption, there have been increasing reports of porcine cysticercosis in the ESA region. This article reviews the findings concerning the presence and impact of porcine cysticercosis in seven of the ESA countries. Most of the reported findings are based on surveys utilising lingual palpation and post-mortem examination, however, some also used serological assays. In Tanzania, community-based studies on porcine cysticercosis indicate a prevalence of 17.4% in the northern highlands district of Mbulu and a prevalence range of 5.1-16.9% in the southern highlands. In Kenya recent surveys in the southwestern part of the country where smallholder pig keeping is popular indicate that 10-14% of pigs are positive for cysticercosis by lingual examination. Uganda has the most pigs in Eastern Africa, most of which are kept under smallholder conditions. Preliminary surveys in 1998 and 1999 at slaughterhouses in Kampala indicated a prevalence of porcine cysticercosis between 0.12 and 1.2%, however, a rural survey in northern Uganda in 1999 indicated 34-45% of pigs slaughtered in selected villages were infected. Additionally, a new survey of 297 pigs slaughtered in Kampala in 2002 indicated that pigs from the central region of the country were negative for cysticercosis while 33.7% of the pigs coming from the rural Lira district in the north were positive. Interestingly 8 piglet foetuses removed from an infected slaughtered sow coming from Lira district were all found to harbour cysts of T. solium providing evidence of congenital transmission of porcine cysticercosis. In Mozambique, abattoir records indicate that porcine cysticercosis is present in all provinces of the country. A serological survey on pigs in rural Tete Province found 15% of pigs positive. In Zimbabwe, a retrospective study in official abattoirs around the country from 1994 to 2001 reported a mean prevalence of 0.34% which is in contrast to a post-mortem survey in 1999, which showed that the prevalence of porcine cysticercosis in rural west Zimbabwe where smallholder pig keeping is popular was 28.6%. In Zambia, abattoir records reported porcine cysticercosis in six of the nine provinces. Routine meat inspection of 1316 pigs at a slaughter slab in Lusaka showed that 20.6% of the pigs had cysticercosis whereas serological testing of 874 pigs at the same abattoir indicated that 56.6% were found to have circulating antigens of Taenia solium. Field surveys based on lingual palpation in Southern and Eastern Provinces of Zambia revealed prevalences of 8.2-28.4 and 5.2%, respectively. South Africa has the largest number of pigs in Southern Africa and cysticercosis has been recognised as a problem in the country for many decades. There is strong evidence supporting the high prevalence of neurocysticercosis infecting humans from resource-poor areas of the country where pigs are being raised under smallholder conditions. In spite of this community-based surveys on porcine cysticercosis have never been conducted in South Africa and the last slaughterhouse survey was conducted nearly 40 years ago. The prevalences of porcine cysticercosis found in these ESA countries rank among the highest in the world and the disease is emerging as an important constraint for the nutritional and economic well being of resource-poor smallholder farming communities. The current findings suggest the widespread presence of human tapeworm carriers and thus a high risk of human cysticercosis in both rural areas and urban centres in the ESA region. More research is required in the region to assess the extent and public health and economic impact of T. solium infection in order to determine whether and what prevention and control efforts are needed.

Seroprevalence of human cysticercosis in Maputo, Mozambique

We carried out a serosurvey for cysticercosis among people visiting the Central Hospital of Maputo, the capital of Mozambique, between January and June 1993. A standardized questionnaire was designed to obtain information on demographic, socioeconomic, environmental, and behavioral characteristics related to the transmission of the infection. Four hundred eighty-nine individuals were tested for anti-cysticercosis antibodies: 222 blood donors and patients from the Department of Orthopedics, 148 patients from the Department of Neurology, and 119 patients from the Department of Psychiatry. The overall positivity rate was 12.1% (59 of 489). Anti-cysticercus antibodies was detected in 14.9% of the blood donors and patients from the Department of Orthopedics, 11.5% of the patients from the Department of Neurology, and 7.6% of the patients from the Department of Psychiatry. Living in poor sanitary conditions seems to be an important factor related to human cysticercosis in Maputo, Mozambique.

Ewing's sarcoma in children: twenty-five years of experience at the Instituto Portugês de Oncologia de Francisco Gentil (I.P.O.F.G.)

Fifty children with Ewing's sarcoma were consecutively treated from 1962 to 1987 and retrospectively analyzed at the I.P.O.F.G. of Lisbon. At first diagnosis, 10 cases had distant metastases. The remaining 40 patients had clinically localized disease, and different protocols were followed over the years. The best results were obtained with chemotherapy and radiotherapy with or without surgery; and for these children the two-year survival rate was 42.8% vs. 8.3% for the group of patients submitted to local treatment alone. Besides the treatment modality, other factors influenced the prognosis, such as inflammatory signs, sex, tumor volume, and tumor site as well as evidence of distant metastases.

Morphologic and morphometric studies on tumor necrosis produced by radiotherapy, and hyperthermia singly and in combination

The purpose of the present study was to evaluate the therapeutic effects of hyperthermia associated with radiotherapy on neoplasia. Two transplanted experimental tumors (undifferentiated carcinoma of mouse breast and sarcoma 37) were used. A protocol was followed that included, for both models, four groups of animals: 1) control group; 2) radiotherapy group; 3) hyperthermia group; 4) radiotherapy associated with hyperthermia group. The animals were sacrificed after therapy according to a different schedule for each type of tumor. The morphology of the neoplasia in every group of treated tumors was compared with that of the control group. For quantitative evaluation of the necrosis, we studied the ratio of the tumor necrotic areas (N) to a tumor standard area (T). From the results obtained, the following conclusions were made: 1) Necrosis produced by combined treatment was significantly greater than that obtained by using one only; 2) necrosis appeared early after treatment and remained relatively unchanged; 3) The damaging effect of the hyperthermia occurred earlier than that produced by radiotherapy when these methods were used separately, thus suggesting distinct mechanisms of tumor necrosis.

Haemostatic and antialgic effects of the 25 MV photon beam concentrated dose in the treatment of carcinoma of the cervix

The authors present the results of a preliminary study on the use of a concentrated dose of 13 Gy in 48 hours in the treatment of cancer of the cervix, especially for haemostatic and antialgic purposes and mostly as a first part of a split course of radiotherapy. In 13 patients with early stages of the disease, the method was used as an emergency treatment with good response in 84.6% of the cases without serious complications. In 43 patients with advanced disease, the concentrated dose was generally repeated for palliation and relieved symptoms in about 72% of the cases but with complications in 16.3%. The authors recommend this method only when absolutely necessary to stop severe haemorrhage and suggest that patients with good response to the first flash course should continue treatment with conventional fractionation, bearing in mind the tolerance of the normal tissues.

Palliative telecobalt-60 with concentrated dose in TNM classification T4 of the breast

A method is presented of rapid, palliative radiotherapy for carcinoma of the breast, composed of two sessions of 6.5 or 8.5 Gy delivered at a 48-hour interval. The radiobiological equivalence of this unconventional technique is presented. Our preliminary results in a series of 80 patients were published in 1978. The present report is based on the analysis of 112 patients with T4 of the breast submitted to the "flash" dose, from March 1978 to December 1981. The method was used not only for relief of symptoms such as pain and hemorrhage, but also as part of intensive radiotherapy in all patients with good response and with no manifestation of distant dissemination so that they were able to resume treatment 2.5 or 3 weeks later, with conventional fractionation. Some of these patients became operable. About half of the cases had castration and/or hormone therapy and/or chemotherapy. In the group of patients with T4M0, 59.8% were alive after more than 1 year, and of them, 43.7% had no evidence of disease. These encouraging results suggest that this method be advocated in T4 of the breast because of its rapidity and good tolerance with no significant complications.

Hodgkin disease clinical stages I, II, and III (A, B): results of radiotherapy with or without chemotherapy

Between 1961 and 1976, 387 patients with Hodgkin disease were examined, evaluated, and treated at the Instituto Portugues de Oncologia de Francisco Gentil. After reviewing histological and clinical staging presentation, the authors retrospectively analyzed the results obtained with 303 patients classified in clinical stages I, II, and III (A, B) who were treated with or without chemotherapy in two time periods (before and after 1970) according to individual therapeutic modalities. The improvement of the 5-year survival rates in the last period was associated with the introduction of extended-field irradiation and multidrug chemotherapy (MOPP). However, the incidence of serious complications was higher in the group of patients subjected to combined field irradiation and MOPP. The authors suggest a stricter protocol based on the current recommendations for the treatment of Hodgkin disease in order to achieve better results with minimum possible hazards.

[Stage I and II cancer of the cervix. Report on the results of treatment in 1,015 patients (author's transl)]

The results of treatment in 1,015 stage I and II patients with cancer of the cervix are presented. The 5 year survival and recurrence rates were calculated in relation to the treatment applied. Two groups of stage Ib and IIa patients were available, one of them having been treated with radiotherapy, and the other one with radical hysterectomy and pelvic lymphadenectomy after previous intra cavitary radiumtherapy. The difference in the survival rates between the two stage Ib groups is not statistically signficant. We did not try to make a statistical comparison between the two stage IIa groups because the combined therapy group includes only patients with very early lesions. Most stage IIb patients were treated with radiotherapy. The postoperative mortality was 2.2%. There were no deaths related to treatment in the group of patients treated with radiotherapy alone. Ninety percent of the recurrences appeared within 3 years after completion of treatment.

Management and results of endometrial carcinoma treated at Instituto Português de Oncologia de Francisco Gentil

The experience of 260 patients with endometrial carcinoma was reviewed. The influence of factors such as age, stage of disease, grade and degree of myometrial penetration on the survival was presented, showing that survival decreases in elderly patients, in patients with advanced stage of disease, when the tumor is undifferentiated, and when the tumor deeply penetrates the myometrium. The methods of therapy, fall into three main groups: surgery, radiotherapy, and combined therapy, the latter yielding the best 5-year survival rate, in all stages. The incidence of vaginal recurrences was low, probably due to the fact that 68.8% of the patients were treated by a combined therapeutic modality.