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Albendazole therapy for solitary persistent cysticercus granuloma.
Correspondence Address:
Use of Albendazole therapy for the treatment of patients having persisting intracranial solitary cysticercus granuloma is controversial. Most of the times these patients are treated empirically with variety of drugs for variable period. Some authors advocate biopsy before definitive treatment. 25 patients having radiologicaly persistent solitary cysticercus granuloma (>6 months) were given 15 days course of oral albendazole (15 mg/kg body wt). Cranial CT scan was repeated one month after the completion of albendazole therapy. It was evaluated for complete resolution, partial response (> 50% decrease in size of lesion) or no change as compared to previous scan. 12 patients (48%) showed complete resolution, 4 patients (16%) showed a partial response, while 9 patients (36%) did not show any change on follow up. Albendazole therapy may be useful for patients having persistent cysticercus granuloma.
Solitary cysticercus granuloma is a common cause of epilepsy in india [Figure 1a].[1],[2],[3] Use of albendazole in these lesions is controversial.[4],[5] We studied effect of albendazole on 25 patients having solitary cysticercus granuloma for more than 6 months.
25 patients having solitary cysticercus granuloma were enlisted for the study. All patients satisfied the criteria for diagnosis of solitary cysticercus granuloma laid down recently.[6] At entry, all patients had radiological proof of persistence of lesion for a minimum period of 6 months. After clinical evaluation all patients were subjected to a battery of tests including mantoux test, cysticercus serology and chest x-ray. All patients were subjected to a cranial CT scan at entry into study and one month after completing the course of albendazole. After initial CT scan, all patients were given oral albendazole (15 mg/kg body weight) for a period of 15 days. Post albendazole CT scan was evaluated for total resolution or significant reduction in the size of lesion. A decrease in size of more then 50% was taken as significant [Figure 1b]. Any decrease in size of lesion of less then 50% or a decrease in oedema without any change in the size of the lesion was taken as non significant; and such cases were included in the category of no change in size of lesion. During the trial, patients continued to be on antiepileptics and none of the patients required steroid administration. Results were compared using chisquare test wherever applicable. A 'p' value of <0.05 was considered significant. Study was approved by institutional ethics committee.
The study group comprised of 25 patients, 11 male and 14 females. Mean age of the patients was 22.42+1.29 years with a range of 8-51 years. Granuloma was persisting for a mean of 8.8+6.31 months with a range of 6-36 months. While 4 (16%) patients presented with partial seizures, 5(20%) had generalised seizures. However, majority 16(64%) presented with partial seizures with secondary generalisation. Cysticercus serology done by indirect haemagglutination method was positive in 6 (24%) and negative in 19 (76%) patients. Chest X-rays were normal in all the patients. Mantoux test was positive in 4(16%) and negative in 21(84%) of the patients. Evaluation of post albendazole scans revealed a total resolution in 12(84%) cases, while 4 patients (16%) showed a significant reduction on follow up neuroimaging [Figure 1a]. 9 patients (36%) did not show any change is compared to the previous scan.
Management of solitary cysticercus granuloma has remained controversial since the time of recognition of this entity. Majority of the lesions are known to disappear spontaneously.[4],[7] However, there is a subgroup of patients where the lesion may persist for months to years. Modalities available for management of these patients are few with no precise guidelines. Some authors recommend stereotactic/open biopsy to pin point the pathological nature of the lesion. This approach heralds a significant morbidity as compared to albendazole therapy, which is safe and of short duration. Use of albendazole in patients with single small enhancing CT lesion (SSECTL) has remained controversial. Now a days this lesion is thought to be the presentation of solitary cysticercus granuloma.[6] Rawlings et al were first to use this therapy and showed good result in two patients.8 Rajshekhar used it in 11 patients and reported a resolution in 4 patients.[5] Our study is comparable to the study done by Rajshekhar except for the inclusion criteria of minimum persistence of lesion, which was 3 months in his study and 6 months in our study. Study done by Padma et al[4] is not comparable because in that study albendazole was given to all the patients at the time of presentation, while in the present study the drug was given to patients having a radiological evidence of persistence of lesion for at least 6 months. In the present study, 64% patients showed a response to albendazole, 48% showed a complete resolution while 16% showed a partial response. The results of therapy are better in the present study in comparison to Rajshekhar's report where 36% (4 out of 11) showed a response. The average duration of lesion was 7.7 months responders, in comparison to non - responders who had a mean period of persistence of lesion of 11.1 months in the present study. But this difference was not statistically significant (p= 0.3). The therapy was uneventful in most of the cases.
Albendazole therapy is likely to be useful for solitary cysticercus granuloma persisting for more then 6 months. As the therapy is safe and of short duration, it is worth trying before undertaking longer treatments like antituberculous therapy or subjecting patients to hazardous procedures like open or stereotactic brain biopsy. This study however, is a small uncontrolled study A larger study with a good control group, may be able to provide the final answer.
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