eMedicine Specialties > Emergency Medicine > Infectious Diseases
Cysticercosis: Treatment & Medication
Updated: Apr 28, 2009
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Treatment
Prehospital Care
Patients present with seizure activity, altered mental status, headache, or other neurologic complaints. Prehospital treatment involves standard supportive care including ensuring that adequate airway support, oxygenation, ventilation, and perfusion are maintained. Administration of anticonvulsants may be necessary for prolonged or repeated seizure activity. Empiric naloxone may be given for coma. Hypoglycemia should be corrected.
Emergency Department Care
- Secure airway, oxygenation, circulation, adequate glucose delivery, and proper monitoring.
- Administer supportive care for those presenting with seizure activity.
- Correct metabolic abnormalities.
- Anticonvulsants are reliably effective in controlling seizures secondary to cysticercosis. Most patients will respond to first-line agents.
- Steroids, osmotic agents, and/or diuretics are indicated with evidence of increased ICP.
- Analgesics may be administered for pain control.
- Initiate diagnostic procedures, including blood work and imaging.
- Consult appropriate specialists.
Consultations
- Consultations may include neurosurgery, neurology, infectious diseases, and ophthalmology. Neurosurgical procedures are frequently required to relieve intracranial pressure. Biopsy or surgical removal of lesions may be necessary.
Medication
Antihelminthic agents are the mainstay of definitive treatment. Controversy exists as to whether antiparasitic treatment of cysticercosis is necessary in most cases. Some authors claim that patients do well without antiparasitic therapy since symptomatology is produced by pericystic inflammation, which portends imminent involution of the parasite. This suggests that the presence of clinical symptoms is predictive of a subsequent self-limited disease course.
In addition, the calcific lesions of "inactive" disease may not be clinically silent but rather epileptogenic and can thereby confer significant morbidity. A randomized controlled study of 300 patients with neurocysticercosis over several years found that those treated with a course of albendazole plus corticosteroids and anticonvulsants developed significantly more lesional calcification on follow-up imaging than those treated with anticonvulsants alone.4 During the first year, this treatment group also had a significantly higher incidence of seizures and thereafter displayed a trend toward such. These investigators concluded that antihelminthic treatment may result in more long-term seizure activity since complete resolution of lesions may be more likely when cysts are allowed to spontaneously resolve. They therefore recommend treatment with anticonvulsants alone, with careful clinical and radiologic follow up.
Despite lively controversy surrounding the matter, a preponderance of the literature positively supports treatment with antihelminthics.5,6 Several randomized controlled trials have demonstrated benefit of antihelminthic therapy, particularly in reducing the number of active cysts. Benefit seems to be greatest during the first weeks of therapy. As mentioned previously, treatment with antihelminthic medication will initially worsen clinical symptoms as faltering parasite defenses lead to increasing perilesional inflammation. Therefore, in nearly all trials, antiparasitic medication has been combined with steroid therapy. In addition, patients are usually maintained on concomitant anticonvulsant therapy for an indefinite period of time.
Caution is particularly warranted in patients with significant pretreatment encephalitis, hydrocephalus, or vasculitis, since treatment may cause increasing inflammation as cysts involute, leading to worsening clinical states. CSF shunting may be indicated before medical treatment begins since intracranial hypertension may worsen upon administration of antiparasitics.
Anthelmintics
Parasite biochemical pathways differ sufficiently from those of the human host so as to allow selective interference by chemotherapeutic agents in relatively small doses. Many patients may require more than one course of treatment to entirely eliminate active cysts.
The more effective agent, albendazole, has upstaged praziquantel as the traditional therapeutic agent. Subarachnoid and intraventricular neurocysticercosis (NCC) may be relatively more resistant to treatment. In these cases, repeat courses of medication are usually needed, and there is limited evidence that higher-dose albendazole treatment (30 mg/kg/d) may be beneficial.7
Praziquantel (Biltricide)
Increases cell membrane permeability in susceptible worms, resulting in a loss of intracellular calcium, massive contractions, and paralysis of their musculature. In addition, produces vacuolization and disintegration of the schistosome tegument. This is followed by attachment of phagocytes to the parasite and death.
Adult
50 mg/kg/d PO divided tid for 2 wk
Pediatric
<4 years: Not established
>4 years: Administer as in adults
Hydantoins may reduce serum praziquantel concentrations, possibly leading to treatment failure
Documented hypersensitivity; ocular cysticercosis
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Destruction of parasite within eyes can cause irreparable lesions (ocular cysticercosis should not be treated with praziquantel); caution while driving or performing other tasks requiring alertness on the day of and following treatment; minimal increases in liver enzymes reported; when schistosomiasis or fluke infection associated with cerebral cysticercosis, hospitalize patient for duration of treatment
Albendazole (Albenza)
Broad-spectrum anthelmintic that decreases ATP production by the worm causing energy depletion, immobilization, and finally, death.
Adult
15 mg/kg/d PO divided bid/tid for 2 wk
Pediatric
10 mg/kg PO qid
Coadministration with carbamazepine may decrease efficacy; dexamethasone, cimetidine, and praziquantel may increase toxicity
Documented hypersensitivity; ocular cysticercosis
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Discontinue use if LFTs increase significantly (resume when levels decrease to pretest values)
Corticosteroids
A temporary increase in pericystic inflammation often is observed during treatment of NCC, as the dying parasite no longer can escape host defenses. For this reason, it is often recommended that corticosteroids be administered in combination with, or instead of, antihelminthics. This practice is controversial and should be tailored to the individual patient according to the number and location of cysticerci. Steroids are more likely indicated in cases involving extraparenchymal cysts.
Prednisone (Orasone, Meticorten, Deltasone)
May decrease inflammation by reversing increased capillary permeability and suppressing PMN activity.
Adult
1 mg/kg/d PO
Pediatric
Not established
Coadministration with estrogens may decrease prednisone clearance; concurrent use with digoxin may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics
Documented hypersensitivity; viral, fungal, tubercular skin, or connective tissue infections; peptic ulcer disease; hepatic dysfunction; GI disease
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur with glucocorticoid use
Dexamethasone (Decadron, Dexone)
For various allergic and inflammatory diseases. Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability.
Adult
4-6 mg IV q4-6h
Pediatric
Not established
Effects decrease with coadministration of barbiturates, phenytoin, and rifampin; dexamethasone decreases effect of salicylates and vaccines used for immunization
Documented hypersensitivity; active bacterial or fungal infection
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Increases risk of multiple complications, including severe infections; monitor adrenal insufficiency when tapering drug; abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections are possible complications of glucocorticoid use
Anticonvulsants
Anticonvulsant therapy should proceed as in other epileptiform states. Benzodiazepines are first-line agents for active prolonged or repeated seizures. They should generally be followed by a more definitive anticonvulsant such as phenytoin. Barbiturates may be needed in more refractory cases.
Lorazepam (Ativan)
Sedative hypnotic with short onset of effects and relatively long half-life. By increasing the action of gamma-aminobutyric acid (GABA), which is a major inhibitory neurotransmitter in the brain, may depress all levels of CNS, including limbic and reticular formation. Important to monitor blood pressure after administering dose. Adjust as necessary.
Adult
0.05-0.15 mg/kg IV
Pediatric
Not established
Toxicity of benzodiazepines in CNS increases when used concurrently with alcohol, phenothiazines, barbiturates, and MAOIs
Documented hypersensitivity; preexisting CNS depression; hypotension; narrow-angle glaucoma
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in renal or hepatic impairment, myasthenia gravis, organic brain syndrome, or Parkinson's disease
Phenytoin (Dilantin)
May act in motor cortex, where it may inhibit spread of seizure activity. Activity of brainstem centers responsible for tonic phase of grand mal seizures may also be inhibited. Dose to be administered should be individualized. Administer larger dose before retiring if dose cannot be divided equally.
Adult
18 mg/kg IV loading dose followed by 100-150 mg/dose at 30-min intervals; not to exceed 1500 mg/24 h
Pediatric
Not established
Amiodarone, benzodiazepines, chloramphenicol, cimetidine, fluconazole, isoniazid, metronidazole, miconazole, phenylbutazone, succinimides, sulfonamides, omeprazole, phenacemide, disulfiram, ethanol (acute ingestion), trimethoprim, and valproic acid may increase phenytoin toxicity; phenytoin effects may decrease when taken concurrently with barbiturates, diazoxide, ethanol (chronic ingestion), rifampin, antacids, charcoal, carbamazepine, theophylline, and sucralfate; phenytoin may decrease effects of acetaminophen, corticosteroids, dicumarol, disopyramide, doxycycline, estrogens, haloperidol, amiodarone, carbamazepine, cardiac glycosides, quinidine, theophylline, methadone, metyrapone, mexiletine, oral contraceptives, valproic acid
Documented hypersensitivity; sinoatrial block, second- and third-degree AV block, sinus bradycardia, or Adams-Stokes syndrome
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Perform blood counts and urinalyses when therapy is begun and at monthly intervals for several months thereafter to monitor for blood dyscrasias; discontinue use if a skin rash appears and do not resume use if rash is exfoliative, bullous, or purpuric; rapid IV infusion may result in death from cardiac arrest, marked by QRS widening; caution in acute intermittent porphyria and diabetes (may elevate blood sugar level); discontinue use if hepatic dysfunction occurs
Phenobarbital (Solfoton, Luminal, Barbita)
Elevates seizure threshold, limits the spread of seizure activity, sedative.
Adult
10-30 mg/kg IV loading dose followed by 5 mg/kg/dose q15-30min; not to exceed 40 mg/kg
Pediatric
Not established
May decrease effects of chloramphenicol, digitoxin, corticosteroids, carbamazepine, theophylline, verapamil, metronidazole, and anticoagulants (patients stabilized on anticoagulants may require dosage adjustments if added to or withdrawn from their regimen); coadministration with alcohol may produce additive CNS effects and death; chloramphenicol, valproic acid, and MAOIs may increase phenobarbital toxicity; rifampin may decrease phenobarbital effects; induction of microsomal enzymes may result in decreased effects of oral contraceptives in women (must use additional contraceptive methods to prevent unwanted pregnancy; menstrual irregularities may also occur)
Documented hypersensitivity; severe respiratory disease; marked impairment of liver function; nephritic patients
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
In prolonged therapy, evaluate hematopoietic, renal, hepatic, and other organ systems; caution in fever, hyperthyroidism, diabetes mellitus, and severe anemia since adverse reactions can occur; caution in myasthenia gravis and myxedema
More on Cysticercosis |
| Overview: Cysticercosis |
| Differential Diagnoses & Workup: Cysticercosis |
 Treatment & Medication: Cysticercosis |
| Follow-up: Cysticercosis |
| Multimedia: Cysticercosis |
| References |
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References
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Further Reading
Keywords
cysticercosis, undercooked pork, tapeworm, pork tapeworm, tapeworm treatment, tapeworm symptoms, tapeworm causes, neurocysticercosis, NCC, larval cysts, Taenia solium infestation, T solium, cysticerci
