Neurocysticercosis

Neurocysticercosis platyhelminthes,cysticercus, albendazole, praziquantel tape worm seizure infestation

1. NEUROCYSTICERCOSIS Dr. Sagar Ghimire

2. Introduction Neurocysticercosis (NCC) is the infection of CNS caused by larval stage (Cysticercus cellulosae) of Taenia Solium , pig tapeworm. Most common parasitic disease of the nervous system Leading cause of Adult onset Epilepsy (30% in endemic regions) Out of 50 million cases of epilepsy worldwide 1/3 rd cases occur in region where T. Solium is endemic. Endemic in central and South America, sub-Saharan Africa, regions of far-east including Indian subcontinent, China and Indonesia

3. Epidemiology of T. Solium

4. Tapeworms Taenia Solium – The pork tapeworm Taenia Saginata – The beef tapeworm Diphyllobothrium Latum – The fish tapeworm Echinococcus Granulosus – The dog tapeworm Hymenolepis Nana – The dwarf tapeworm Dipylidium Caninum – the double-pored dog tapeworm

5. Life cycle of Taenia Solium 3m length 1000 proglottides 50,000 eggs

6. Gist of the lifecycle Autoinoculation

7. Clinical manifestations Neurocysticercosis

8. Two types : > Intestinal infection (Taeniasis) and Cysticercosis Taeniasis- may be asymptomatic, passage of proglottides Cysticercosis – most commonly in the Brain, CSF, Striated muscle, Tongue, Eye Neurologic Manifestation is Most common presenting mainly as Seizure Seizure – Generalized, Focal or Jacksonian type Features of raised ICP d/t Hydrocephalus – Headache, Nausea, Vomiting, Dizziness, Ataxia, Confusion, Vision disturbances May also cause Arachnoiditis, Chronic meningitis or even Stroke.

9. INVESTIGATIONS AEC (30-350 normal) raised if cyst leaking IgE level Stool Examination CSF examination CSF ELISA more sensitive than serum (85% sensitive and 95% specific) Enzyme Linked ImmunoelectroTransfer Blot (95% sensitive and 100% specific) – serum more specific than CSF CT Scan MRI USG for Ocular X-Ray

10. Diagnosis Of NCC(Criteria) Absolute Criteria Demonstration of cysticerci by histologic or microscopic examination of biopsy material Visualization of the parasite in the eye by fundoscopy Neuroradiologic demo of cystic lesions containing a characteristic scolex

11. 2. Major Criteria Neuroradiologic lesion suggestive of Neurocysticercosis Demonstration of antibodies to cysticerci in serum by enzyme-linked ImmunoelectroTransfer blot Resolution of intracranial cystic lesions spontaneously or after therapy with Albendazole or Praziquantel alone 3. Minor Criteria Lesions compatible with Neurocysticercosis detected by neuroimaging studies Clinical manifestation suggestive of NCC Demonstration of antibodies to cysticerci or cysticercal antigen in CSF by ELISA Evidence of Cysticercosis outside the CNS (e.g., cigar shaped soft-tissue like calcification)

12. Diagnosis confirmed if 1 Absolute criteria or, 2 Major criteria or, Probable Diagnosis if 1 major + 2 minor Major+Minor+Epidemiologic 3 Minor + Epidemiologic 4. Epidemiologic Criteria Residence in a Cysticercus endemic area Frequent travel to a Cysticercus-endemic area Household contact with an individual infected with Taenia Solium

13. Differential Diagnosis Congenital Dermoids Epidermoids Traumatic Subdural or Extradural Hematoma Inflammatory Abscess, Tuberculoma, Syphilitic Gumma, Fungal Gumma Neoplasm

14. PREVENTION Major method is adequate cooking of pork viscera/muscles to as low as 56˚C for 5 minutes Refrigerating Salting Freezing at -10˚C for 9 days Proper disposal of human feces Treatment of human intestinal inf Mass Chemotherapy

15. Treatment of NCC Initial symptomatic management of Seizures or Hydrocephalus Seizure control – Antiepileptic Treatment (for 1-2 years) Fundoscopy Parenchymal Cysticerci – Antiparasitic Treatment favored including: Albendazole (15 mg/kg/day for 8-28 days) Praziquantel (50-100 mg/kg/day in 3 divided doses for 15-30 days) Longer courses in multiple subarachnoid cysticerci High doses of corticosteroids Cimetidine and Glucocorticoids w/ Praziquantel

16. Treatment (contd..) Hydrocephalus – Reduction of ICP Obstructive Hydrocephalus – Endoscopic removal or a V/P shunt Sub arachnoid cysts or giant cysticerci – Glucocorticoids then surgery Diffuse cerebral edema and elevated ICP – Steroids main stay Spinal and Ocular lesions – Surgery preferred Intestinal Infection – Praziquantel (10 mg/kg) single dose

17. Prognosis In most cases, the prognosis is good. Seizures improve with anticysticercal drugs 22% develop recurrent seizures Others include headache, neurologic deficits related to strokes and hydrocephalus Patients with complications such as hydrocephalus, large cysts, multiple lesions, chronic meningitis, vasculitis donot respond well to treatment

18. 1. HARRISON’S 18 th edition 2.Parasitology K.D Chatterjee 3.Nelson’s textbook of pediatrics 4.Bruno et al journal References:

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