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|Year : 2017 | Volume
| Issue : 4 | Page : 924-926
Be careful while using albendazole/praziquantel in neurocysticercosis
Ravindra Kumar Garg, Ravi Uniyal, Hardeep Singh Malhotra
Department of Neurology, King George Medical University, Lucknow, Uttar Pradesh, India
|Date of Web Publication||5-Jul-2017|
Ravindra Kumar Garg
Department of Neurology, King George Medical University, Lucknow - 226 003, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Garg RK, Uniyal R, Malhotra HS. Be careful while using albendazole/praziquantel in neurocysticercosis. Neurol India 2017;65:924-6
Chatterjee and co-workers have described a very interesting case of ulnar artery thrombosis following antiparasitic treatment in an epileptic patient with a single cysticercal lesion of the brain. Asymptomatic cysts were discovered near the proximal ulnar artery.
Neurocysticercosis is a common parasitic condition affecting the brain, spinal cord, eye, skin, muscles and other body parts. Neurocysticercosis is caused by the larval form of Taenia solium. In human brain, cysticercus larvae pass through four stages of evolution; each stage has a different amount of perilesional inflammation. These stages are vesicular, colloidal, granular-nodular and calcific. Inflammatory changes are often minimal in vesicular (viable) cysts. Intense inflammation is often associated with colloidal and granulo-nodular (degenerating) stages of cysts. A calcified lesion, though representing a dead parasite, may still produce an intense perilesional inflammation., Perilesional inflammation in and around the cysticerci is often responsible for symptoms. In the brain, perilesional inflammation presents with a sort of focal encephalitis and often manifests as seizures. In other locations, for example, in the spinal cord, the parasitic inflammation causes arachnoiditis; and, in the, eye, inflammatory changes can lead to retinal detachment and blindness. In the brain, perilesional inflammation can produce focal cerebritis, ependymitis and vasculitis. Praziquantel and albendazole are the two antiparasitic drugs that are effectively used in the treatment of symptomatic neurocysticercosis.,
Association of neurocysticercosis with cerebral vascular complications is well recognized. Vasculitis of the brain manifests with focal neurological deficits and severe disabilities. Cerebral infarction, transient ischemic attacks, and cerebral hemorrhage may occur in patients with neurocysticercosis. After demise of the cysticercal larvae, massive release of parasite antigens provokes an inflammatory reaction that affects surrounding brain tissues. Vessels in the region of inflammation are also affected (innocent bystander) resulting in arteritis and subsequently stroke. Cerebral infarction is much more frequent with the subarachnoidal and racemose forms of neurocysticercosis. Cystic contents have intense antigenic properties. In a report, the authors noted a severe inflammatory reaction within the ventricular system and basal cisterns after the intraoperative cysticerci ruptured while an endoscopic transventricular removal of cyst was being attempted.
Cysts are known to present in the brain and other body parts without producing symptoms for a long time. These asymptomatic cysts are liable to become symptomatic following treatment with antiparasitic drugs. A cyst may remain asymptomatic for a variable period of time ranging from one year to thirty years. In a study from Northern India, the prevalence of asymptomatic neurocysticercosis, in apparently healthy population, was estimated to be 15% of the population engaged in pig farming. Among family members of symptomatic neurocysticercosis patients, the prevalence of asymptomatic neurocysticercosis was as high as 29%. Significantly higher proportion of the asymptomatic population had vesicular stage of the parasite. There are several reports where even a single dose, taeniacidal use of antiparasitic drugs in patients with intestinal taeniasis unravelled a hidden cyst, making the patient symptomatic. In most of these reports, otherwise asymptomatic individuals developed seizures and/or headache after taking antiparasitic drugs (praziquantel or albendazole) for the purpose of deworming [Table 1].,,,,
|Table 1: Reports on cases of neurocysticercosis where deworming uncovered a lesion: A review|
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The common adverse effects seen in patients with symptomatic neurocysticercosis following antiparasitic therapy include fever, seizures, headache, nausea, vomiting, meningismus, increased intracranial pressure, altered sensorium and stroke. These adverse reactions are probably not due to a toxic effect of the drug but rather due to an inflammatory reaction produced by the host in response to a massive destruction of cysticerci and the release of cysticercal antigens.,, In isolated instances, even calcified neurocysticercosis lesions triggered severe inflammatory reactions during the antiparasitic therapy.
Subarachnoidal form and racemose form of neurocysticercosis are, in particular, more liable to develop adverse reactions because of their closeness to cerebrospinal fluid spaces. Catastrophic complications, in the form of raised intracranial pressure, hydrocephalus, chronic arachnoiditis and vasculitis, can even be life-threatening. The host's inflammatory reaction in response to an acute destruction of the parasite within the subarachnoid space may occlude the vessels surrounding the cyst. There are several reports available where antiparasitic treatment led to cerebral infarction or other inflammatory complications [Table 2].,,,,
|Table 2: Vascular complications and myositis in neurocysticercosis following antiparasitic treatment: Review of literature|
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Anti-inflammatory drugs, particularly corticosteroids, are used to control paradoxical aggravations of inflammation following antiparasitic therapy in patients with neurocysticercosis. In patients with giant subarachnoid cysticerci, ventricular cysts, spinal cysts, numerous cerebral parenchymal cysts and in patients with disseminated cysticercosis, corticosteroids must be administered before commencement of the course of antiparasitic drugs to avoid disastrous complications.
The case described by Chatterjee et al., also suggests that corticosteroids should always be administered along with antiparasitic therapy.
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Conflicts of interest
There are no conflicts of interest.
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