A case study on Neurocysticercosis.pptx

It contains a detailed description of the disease and case study

1. A Case Presentation On NEUROCYSTICERCOSIS Presented by P J Hemanth Reddy 19Y01T0018 Pharm.D VIth year CESCOP

2. NEUROCYSTICERCOSIS Neurocysticercosis is a preventable parasitic infection caused by larval cysts (enclosed sacs containing the immature stage of a parasite) of the pork tapeworm (Taenia Solium). The larval cysts can infect various parts of the body causing a condition known as cysticercosis. Larval cysts in the brain cause a form of cysticercosis called neurocysticercosis which can lead to seizures. Neurocysticercosis, which affects the brain and is the most severe form of the disease, can be fatal. Neurocysticercosis is considered a Neglected Parasitic Infection, one of a group of diseases that results in significant illness among those who are infected. A person gets neurocysticercosis by swallowing microscopic eggs passed in the feces of a person who has an intestinal pork tapeworm

3. EPIDEMIOLOGY The greatest burden of T. Solium-induced disease is due to neurocysticercosis, which is estimated to contribute to approximately 30% of epilepsy cases in areas where the disease is endemic. Neurocysticercosis is also an important cause of hydrocephalus in endemic areas The total number of people with symptomatic or asymptomatic neurocysticercosis is estimated to be 2.56– 8.30 million from the data available

4. ETIOLOGY The most common parasitic disease of the brain caused by the cestode Taenia Solium or pork tapeworm. PATHOPHYSIOLOGY A person gets neurocysticercosis by swallowing microscopic eggs passed in the feces of a person who has an intestinal pork tapeworm.

5. Abnormal physical findings, which occur in 20% or less of patients with neurocysticercosis, depend on where the cyst is located in the nervous system and include the following: Cognitive decline Dysarthria Extraocular movement palsy or paresis Hemiparesis or hemiplegia, which may be related to stroke Hemisensory loss Movement disorders Hyper/hyporeflexia Gait disturbances Meningeal signs CLINICAL PRESENTATIONS

6. Imaging studies Neurocysticercosis is commonly diagnosed with the routine use of diagnostic methods such as computed tomography (CT) and magnetic resonance imaging (MRI) of the brain. Lab studies CSF analysis for neurocysticercosis is indicated in every patient presenting with new-onset seizures or neurologic deficit in whom neuroimaging shows a solitary lesion but does not offer a definitive diagnosis. DIAGNOSIS Other tests are as follows: Stool examination: 10-15% of neurocysticercosis patients have taeniasis Brain biopsy: Necessary only in extreme cases

7. PHARMACOTHERAPY NO Recommendations S trength Quality of evidence Treatment of neurocysticercosis with anthelmintic and anti-inflammatory therapy PICO 2&3 Anthelmintic therapy in combination with corticosteroids, should be given to individuals with symptomatic neurocysticercosis and viable parenchymal brain cysts for better outcomes in terms of cyst resolution and seizure control. strong moderate PICO 4&5 Anthelmintic therapy with ALBb, in combination with corticosteroids, should be given to individuals with symptomatic neurocysticercosis and a single enhancing lesion (SEL) for better outcomes in terms of cyst resolution and seizure control. Conditional Moderate to very low Treatment of neurocysticercosis-related epilepsy with antiepileptic drugs (AEDs) PICO 6 Withdrawal of AEDs should be considered 6 months after the last seizure in individuals with a SEL and epilepsy with low risk of seizure recurrence (defined as patients with a resolved granuloma, no residual calcification and who are seizure free). Conditional Low AED therapy should be continued in people with a SEL that persists on neuroimaging and those with a SEL that resolves with residual calcification. Remarks: There is limited evidence on the optimal duration of AED therapy for a SEL; however, it appears to be a few weeks after complete resolution of the SEL. Conditional Moderate PICO 7 AED therapy should be continued for at least 2 years in people with single or multiple calcified neurocysticercosis and epilepsy. These patients should be closely monitored if treatment is withdrawn. Conditional Very low

8. PHARMACOTHERAPY Indications for surgical intervention and recommended procedures are as follows: Hydrocephalus due to an intraventricular cyst: Placement of a ventricular shunt, followed by surgical extirpation of the cyst and subsequent medical treatment   Multiple cysts in the subarachnoid space: Urgent surgical extirpation Obstruction due to arachnoiditis: Placement of a ventricular shunt followed by administration of steroids and subsequent medical therapy

9. A 29 years old fe male pati ent was admitted in f e male medical ward with IP No: 81804 under the consultant doctor Dr. Noorjahan MD, with chief complaints of H eadache on right side ∵ week with Paresthesia on right half of the body ∵ week . And she also had H/O similar complaints in the past 8 years ago . The personal History & Habits shows Mixed diet , Normal Sleep , Normal appetite and with Regular Bowel & Bladder habits with no significant Family history . SOAP NOTES DEMOGRAPHIC DATA SUBJECTIVE EVIDENCE Patient name: xxxxxx Gender: Female Age: 29 years IP.no: 81804 DOA: 02/09/2024 Department: FM-I Consultant Doctor: Dr. Noorjahan MD

10. SOAP NOTES OBJECTIVE EVIDENCE Complete blood picture 31/08 03/09 Units WBC 9.5 6.5 cells/µL RBC 4.71 4.12 cells/µL HB 10.2🔻 8.8 🔻 gm/d L PLT 4.14 3.48 plt / µL Serum Electrolytes Na+ 138 mmol/L K+ 4 mmol/L Cl- 103 mmol/L Renal function test Results Units Blood Urea 20 mg/dl Sr Creatinine 0.8 mg/dl Liver function test Total.Br 0.8 mg/dl Direct.Br 0.1 mg/dl SGPT 14 U/L SGOT 19 U/L ALP 92 IU/Lit T.proteins 7.1 gm/dl Sr.Albumin 3.8 gm/dl

11. SOAP NOTES OBJECTIVE EVIDENCE ASSESSMENT: Based on subjective and objective evidence the patient was diagnosed with Neurocysticercosis . CT-Brain Multiple calcified granulomas noted B/L Cerebral hemisphere few of them showing perilesional oedema noted in left frontal lobe. Suggested clinical correlation with MRI- brain and contrast correlation. MRI-Brain & MR- Angiogram & MR-Venogra m Imp: Probably Neurocysticercosis. Small foci of Blooming noted in left capsuloganglionic region. -S/o Micro bleeds

12. PLANNING S.No Brand Name Generic Name Indication Dose ROA Frequency Duration 1. Tab. Naproxen Naproxen Analgesi c 500mg PO BD D1 To D3 2. Tab. Pantop Pantoprazole Antisecretory 40mg PO OD D1 To D3 3. Tab. Levipil Levetiracetam Antiepileptic 500mg PO BD D1 To D3 4. Tab . Gabaneuron Gabapentin Nortriptyline Neuropathic pain agent 400+10 mg PO OD D1 To D3 5. Inj . Dexa Dexamethasone Anti-inflammatory 8➡️4 mg IV Stat➡️ TID D3 6. Tab. Albendazole Albendazole Antihelminthic 40mg PO TID D3

13. PROGRESS CHART Prognosis Treatment Day-1 ( 02/09/24) O/E Patient - C/C BP- 120/80 mm H g Spo2- 98% c̅ RA RS- B/L BAE + GCS= E4-V5-M6 Temp- N PR - 90 bpm P/A- Soft CVS- S1S2 + 🔺 NEUROCYSTICERCOSIS Rx Tab. Naproxen 500mg PO BD 1-0-1 Tab. P antop 40mg PO OD 1-0-0 Tab. Levipil 500mg PO BD 1-0-1 Tab. Gabaneur on-NT PO OD 0-1-0 Day-2 (03/09/24) No fresh complaints O/E PT- C/C Temp- N PR - 93 bpm BP- 120/80 mmHg RS- B/L BAE + Spo2- 98% c̅ RA RBS-143 mg/dl FBS- 81 mg/dl Rx. Continue same treatment

14. PROGRESS CHART Prognosis Treatment Day- 3 (04/09/24) ℅ ↓ Headache O/E PT- C/C Temp- N PR - 92 bpm BP- 110/80 mmHg RS- B/L BAE + Spo2- 98% c̅ RA FBS- 86 mg/dl P/A- Soft CVS- S1S2 + Rx. Continue same treatment ADD Inj. Dexamethasone 8mg IV STAT ➡️ after 24hr 4mg IV TID Tab. Albendazole 400mg PO TID

15. MECHANISM OF ACTION Mechanism of Action ADRs MP Naproxen: Inhibits synthesis of prostaglandins in body tissues by inhibiting at least 2 cyclooxygenase (COX) isoenzymes, COX-1 and COX-2 May inhibit chemotaxis, alter lymphocyte activity, decrease proinflammatory cytokine activity, and inhibit neutrophil aggregation; these effects may contribute to anti-inflammatory activity Abdominal pain, Constipation, Dizziness, Nausea, Edem a RFT, CBP, electrolytes Pantoprazole: It binds to H+/K+ ATPase Pump and thereby inhibiting gastric acid and basal acid secretion. Headache Stomach pain Monitor GI symptoms Levetiracetam: It may inhibit voltage- dependent N-type calcium channels; may bind to synaptic proteins that modulate neurotransmitter release; through displacement of negative modulators may facilitate GABAergic inhibitory transmission Asthenia, Headache, Somnolence, Drowsiness, Anorexia , Weakness Seizure activity, LFT, RFT Dexamethasone: It inhibits pro-inflammatory cytokines and mediators, stabilizes cell membranes, and reduces capillary permeability. This action helps control inflammation, immune response, and edema, especially in neurological and autoimmune conditions. Skin irritation, HTN Improvement in the condition

16. MECHANISM OF ACTION Mechanism of Action ADRs MP Albendazole: Causes degeneration of cytoplasmic microtubule in intestinal and tegmental cells of intestinal helminths. Nausea, Vomiting, Headache, Abdominal pain Monitor for GI functions Gabaneuron: Gabapentin: Mechanism for analgesic and anticonvulsant activity unknown Nortriptyline: Neurotransmitter (especially norepinephrine and serotonin) reuptake inhibitor; increases concentration of neurotransmitter in the CNS Dryness in mouth, Decreased white blood cell count, Peripheral edema, Weakness Improvement in headache

17. PHARMACIST INTERVENTION RATIONALITY : The given treatment was found to be Rational . DRUG INTERACTIONS: Naproxen + Dexamethasone = May result in ↑ed risk of gastrointestinal ulcers and GI bleeding. PATIENT COUNSELING REGARDING DISEASES Neurocysticercosis is major cause of acquired seizures and epilepsy, it is caused by infection with the larval cyst of the tapeworm Taenia solium. REGARDING DRUGS Tab. Naproxen 500mg should be taken thrice a day to treat headache. Tab. Pantop 40 mg should be taken once a day to prevent gastric irritation. Tab. Levipil 500mg should be taken twice a day to prevent from seizure activity. Tab. Gabaneuron 400+10 mg should be taken once a day to treat headache. Tab. Albendazole 400 mg should be taken thrice a day to treat tapeworm infections.

18. Adequate sleep and stress reduction is important to prevent seizures activity Adequate hydration is essential, especially if the patient experiencing symptoms like nausea or vomiting. Implement strategies to manage symptoms like headache, neck pain such as relaxation techniques, meditation. Educate patient on preventive measures including proper hygiene, sanitation practice, safe food to reduce the risk of reinfection and transmission. Neurological rehabilitation strategies such as physical therapy, occupational therapy may be beneficial Foods that are rich in high antioxidants are helpful in reducing the inflammation. Avoid raw or undercooked food. PATIENT COUNSELING LIFESTYLE MODIFICATIONS

19. Reference https://www.ncbi.nlm.nih.gov/books/NBK573846/ https://www.who.int/publications/i/item/9789240032231 https://www.cdc.gov/dpdx/cysticercosis/index.html https://emedicine.medscape.com/article/1168656-overview?form=fpf https://my.clevelandclinic.org/health/diseases/23534-cysticercosis

20. P J Hemanth Reddy Thank you