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COMMENTARY
Year : 2016  |  Volume : 64  |  Issue : 5  |  Page : 1060-1062

Disseminated cysticercosis: Many issues are still unresolved


Department of Neurology, King George Medical University, Lucknow, Uttar Pradesh, India

Date of Web Publication12-Sep-2016

Correspondence Address:
Ravindra K Garg
Department of Neurology, King George Medical University, Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.190246

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How to cite this article:
Garg RK, Malhotra HS, Kumar N. Disseminated cysticercosis: Many issues are still unresolved. Neurol India 2016;64:1060-2

How to cite this URL:
Garg RK, Malhotra HS, Kumar N. Disseminated cysticercosis: Many issues are still unresolved. Neurol India [serial online] 2016 [cited 2019 Nov 12];64:1060-2. Available from: http://www.neurologyindia.com/text.asp?2016/64/5/1060/190246




Sardhana et al., describe two interesting cases of disseminated cysticercosis. Both the patients had extensive dissemination of cysts and both received antiepileptic medication. None of the patient received albendazole and/or praziquantel.[1]

Neurocysticercosis is a frequently encountered parasitic infection of the brain and the most common cause of seizures among adults in India. Cysticercosis is caused by the larvae of Taenia solium, a tapeworm. Humans are infected after eating contaminated food containing the eggs of the tapeworm. Through blood circulation, eggs reach the various body parts. Occasionally, dissemination of cysticercus larvae is massive and virtually every body structure is affected.

What is disseminated cysticercosis? Widely disseminated cysticercosis is known for over a century but its exact definition is still not known. We propose that the diagnosis of disseminated cysticercosis can be considered to be confirmed if there are multiple vesicular cystic lesions present in the brain and cysts are demonstrated in at least two other body parts.[2] Other body parts most frequently affected are the skin, skeletal muscles, lungs, eyes, liver, and rarely, heart. Magnetic resonance imaging of the whole body is an invaluable tool in disseminated cysticercosis that can image the whole body at high speed.[3],[4] High-resolution ultrasound is useful in noninvasively demonstrating subretinal cysticercosis and cysticercal cysts at other unusual locations.

Why is disseminated cysticercosis common in India? Latest PubMed data revealed that a majority of reports related to disseminated cysticercosis are from India. Out of the 88 items searched with the key word (on 21 April 2016) “disseminated cysticercosis,” 65 items were from India. Both environmental (poor hygienic and sanitary conditions) and genetic factors are possibly responsible for this occurrence.

What is the natural course of disseminated cysticercosis? The exact course in disseminated cysticercosis is not precisely known. Individual cysts either get inflamed and or get calcified. Cysts are known to remain in the brain, unchanged even after several years. Del Brutto and Campos have described two forms of neurocysticercosis with a massive lesion load. These forms are “encephalitic” and “nonencephalitic.” The encephalitic form is seen in children and young females. This form is characterized by marked brain edema and signs of raised intracranial tension. In the nonencephalitic form, there are innumerable viable uninflamed cysts and such patients often present with epilepsy.[5] Genetic factors are possibly responsible for the conversion of massive neurocysticercosis to an encephalitic condition known as “cysticercus encephalitis.”

What should be the treatment of massively disseminated cysticercosis? Should antiparasitic treatment be used? Currently, two antiparasitic drugs, namely, albendazole and praziquantel are recommended for the treatment of neurocysticercosis. Corticosteroids are often used to treat cerebral parenchymal inflammatory changes that occur following the demise of cysts. Initial experience of using praziquantel in patients with disseminated cysticercosis, presenting with uncontrolled seizures, progressive dementia, muscular pseudohypertrophy, and with signs of raised intracranial tension, was disastrous. In a series by Wadia et al., all three patients died after treatment with praziquantel. All three patients, in fact, had encephalitic form of disseminated cysticercosis.[6] Subsequently, in a few isolated case reports, treatment with albendazole resulted in a dramatic and complete disappearance of all cerebral lesions. Even skin lesions disappear following antiparasitic therapy. A limited experience suggests that albendazole in these patients should be continued for 4 weeks.[7],[8] Prior treatment with corticosteroids helps in reducing possible inflammatory reactions. Recently, a combination of albendazole and praziquantel was found to be effective in comparison to a single drug therapy in patients with parenchymal brain cysticercosis with ≤20 viable cysts. Complete cyst clearance was seen in 75% (12 of 16) of the patients with a combination therapy whereas only 25% (4 of 16) patients had complete cyst clearance in the subgroup of patients who received only albendazole. The role of albendazole and praziquantel combination therapy is worth trying in patients with massively infected disseminated cysticercosis.[9]

In conclusion, the treatment of disseminated cysticercosis is currently far from satisfactory. A randomized study is urgently needed to assess the efficacy of the currently available drugs. The role of combination therapy and the repeated courses of antiparasitic drugs also needs to be evaluated. In most of the patients with disseminated cysticercosis, quality of life is often poor.

 
  References Top

1.
Sardana V, Ojha P, Sharma D, Sharma SK, Saxena S, Rai NN. Disseminated cysticercosis. Neurol India 2016;64:1058-60.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
2.
Garg RK. Diagnostic criteria for neurocysticercosis: Some modifications are needed for Indian patients. Neurol India 2004;52:171-7.  Back to cited text no. 2
[PUBMED]  Medknow Journal  
3.
Kumar J, Gorghate S. Disseminated cysticercosis: Whole body MRI. BMJ Case Rep 2015;2015. pii: bcr2015211283.  Back to cited text no. 3
    
4.
Kumar A, Goenka AH, Choudhary A, Sahu JK, Gulati S. Disseminated cysticercosis in a child: Whole-body MR diagnosis with the use of parallel imaging. Pediatr Radiol 2010;40:223-7.  Back to cited text no. 4
[PUBMED]    
5.
Del Brutto OH, Campos X. Massive neurocysticercosis: Encephalitic versus non-encephalitic. Am J Trop Med Hyg 2012;87:381.  Back to cited text no. 5
[PUBMED]    
6.
Wadia N, Desai S, Bhatt M. Disseminated cysticercosis. New observations, including CT scan findings and experience with treatment by praziquantel. Brain 1988;111:597-614.  Back to cited text no. 6
[PUBMED]    
7.
Kobayashi K, Nakamura-Uchiyama F, Nishiguchi T, Isoda K, Kokubo Y, Ando K, et al. Rare case of disseminated cysticercosis and taeniasis in a Japanese traveller after returning from India. Am J Trop Med Hyg 2013;89:58-62.  Back to cited text no. 7
[PUBMED]    
8.
Duvignaud A, Receveur MC, Pistone T, Malvy D. Disseminated cysticercosis revealed by subcutaneous nodules in a migrant from Cameroon. Travel Med Infect Dis 2014;12:551-2.  Back to cited text no. 8
[PUBMED]    
9.
Garcia HH, Lescano AG, Gonzales I, Bustos JA, Pretell EJ, Horton J, et al. Cysticidal efficacy of combined treatment with praziquantel and albendazole for parenchymal brain cysticercosis. Clin Infect Dis Mar 2016;62:1375-9.  Back to cited text no. 9
    




 

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