eMedicine Specialties > Pediatrics: General Medicine > Parasitology
Cysticercosis: Treatment & Medication
Updated: Oct 7, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
Medical treatment of cysticercosis depends on the location of the cysts and the patient's symptoms. Patients with live parenchymal cysts can be treated with either albendazole or praziquantel, but corticosteroids and antiseizure medications are often required in addition. Consultation with a physician (neurologist or infectious diseases specialist) experienced in treating neurocysticercosis is recommended prior to planning a course of antiparasitic drug treatment. Many authorities consider albendazole to be preferred over praziquantel because of its higher eradication rate of parenchymal brain cysts.
- For treatment of neurocysticercosis, albendazole is orally administered at a dose of 15 mg/kg/d divided into 2 daily doses for 8-30 days (not to exceed 800 mg/d in children or 400 mg twice daily in adults). This regimen can be repeated if necessary. Praziquantel orally administered at a single dose of 5-10 mg/kg is highly effective in eradicating adult tapeworm infection. However, when this drug is used to treat neurocysticercosis, much higher doses and a longer duration of treatment is required. For neurocysticercosis, praziquantel is orally administered at a dose of 50-100 mg/kg/d divided into three daily doses for 30 days.
- Patients with nonviable (calcified) brain cysts should be treated only for their symptoms; anticonvulsants are used to treat seizures. Seizures most often recur for months and may indefinitely recur. Anticonvulsant medications must be continued until cysts have resolved and until the patient is seizure free for 1-2 years.
- No consensus has been reached regarding the role of antiparasitic drugs in patients with parenchymal cysts and inflammation (depicted as ring enhancement on neuroimages).
- Although taeniacidal drugs that may hasten radiologic resolution of cysts are available, treatment may worsen the inflammation and, thus, precipitate complications or death.
- Coadministration of corticosteroids (eg, dexamethasone, prednisone) is recommended to decrease the adverse effects of antiparasitic treatment.
- In all patients with multiple cysts and associated cerebral edema (cysticercal encephalitis), antiparasitic therapy should be deferred until the cerebral edema is controlled by corticosteroid therapy. In addition, antiparasitic drug therapy may cause permanent damage if used to treat ocular or spinal cysts, even when combined with corticosteroids. A careful ocular examination to rule out ocular cysts should be performed prior to initiating antiparasitic drug treatment.
Surgical Care
For cases that do not respond to medical therapy, shunt placement, removal of large solitary cysts for decompression, and the removal of mobile cysts that cause ventricular obstruction should be considered.
- Intraventricular cysts and hydrocephalus usually require surgical therapy and, often, the placement of intraventricular shunts. Adjunctive chemotherapy with antiparasitic agents and corticosteroids can reduce the rate of subsequent shunt failure.
- Neuroendoscopy may be used to remove certain ventricular cysts.
- Spillage of cyst contents during surgery is not associated with parasite dissemination, as it is with echinococcosis.
- Very large cysts that cause a mass effect may require surgical debridement.
- Ocular cysticercosis is treated with surgical excision of the cysts.
- The outcome is often poor. Thus, enucleation is frequently required.
- Treatment with antiparasitic drugs is contraindicated in ocular cysticercosis because the inflammatory response may worsen the outcome.
Consultations
- Consultation with a neurologist should be considered to recommend anticonvulsant medications and further neurologic assessment is indicated in patients with seizures or neurologic deficits.
- Consultation with a neurosurgeon may be indicated in patients with acute hydrocephalus or large intracerebral cysts with a mass effect, in those with suspected cysts in the ventricular system, or in those with spinal cysts.
- Consultation with an infectious diseases or tropical medicine specialist should be considered when planning antiparasitic drug treatment in patients suspected to have live parenchymal cysts.
- Consultation with an ophthalmologist to rule out intraocular cysts should be considered prior to initiating antiparasitic drug treatment.
Diet
- No special diet is indicated. Good sanitation is essential to prevent the spread of the disease.
Activity
- No limitations are necessary, unless activity is limited by the patient's symptoms.
Medication
Specific recommendations for treatment of neurocysticercosis remain controversial. Treatment depends on disease presentation. Observation, symptomatic treatment, antiparasitic treatment, and/or surgery may play a role.
Medical therapy may include antihelminthic medications (to reduce cysts) or anticonvulsant medications. Antihelminthic medications work only in noncalcified lesions and may not decrease long-term morbidity associated with cysticercosis. Initially, they may worsen the patient's condition because of the inflammatory response to the dying or dead cyst. Additionally, medical therapy may convert quiescent parenchymal lesions to active ones or may worsen ventricular, ocular, or spinal disease. Corticosteroids should be started 2-3 days before the initiation of antihelminthic drugs and continued during their use to decrease the inflammatory response to the dying cysts. In cases with evidence of hydrocephalus or ventricular or spinal disease, a ventricular shunt should be placed before medical therapy is initiated.
If one drug is not successful, a second drug may be used in a sequential manner. This treatment may eliminate more than 95% of the parenchymal cysticerci.
Albendazole is the drug of choice. Repeated courses of albendazole have been shown to be of benefit in patients who had a positive response to an initial course. Therapy for 1 week may be as beneficial as a 4-week course of therapy.
Antihelminthic agents
These are used to eradicate cysts in noncalcified brain lesions. Parasite biochemical pathways are different from those of the human host; thus, toxicity is directed to the parasite, egg, or larvae. The mechanism of action varies within the drug class. Antiparasitic actions may include the following:
- Inhibition of microtubules, which causes irreversible block of glucose uptake
- Inhibition of tubulin polymerization
- Depolarizing neuromuscular blockade
- Cholinesterase inhibition
- Increased cell membrane permeability, which results in intracellular calcium loss
- Vacuolization of the schistosome tegument
- Increased cell membrane permeability to chloride ions caused by alternations in the chloride channels
Albendazole (Albenza)
Broad-spectrum antihelminthic. It is cysticidal and destroys approximately 85% with a single course. Administer for 8-30 d with a fatty meal to improve absorption.
Adult
>60 kg: 400 mg PO bid after meals
<60 kg: 15 mg/kg/d PO divided bid after meals; not to exceed 800 mg/d, may repeat regimen if needed
Pediatric
Administer as in adults; safe in pediatric patients >1 y
Coadministration with carbamazepine may decrease effectiveness; dexamethasone, cimetidine, and praziquantel may increase toxicity
Documented hypersensitivity
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
Do not use in pregnant women unless no alternative is available; patients should avoid becoming pregnant until at least 1 mo after treatment; caution in breastfeeding; rare fatalities due to associated granulocytopenia or pancytopenia have occurred; determine blood counts prior to and q2wk during treatment (discontinue treatment if total WBC count and absolute neutrophil counts continue to decline); initiate corticosteroids to prevent cerebral edema; examine retina for lesions before treatment; may cause headache, nausea, vomiting, increased ICP, meningeal signs, elevated LFT results, dizziness, vertigo, and reversible alopecia; rarely causes leukopenia, granulocytopenia, pancytopenia, agranulocytosis, thrombocytopenia, agranulocytosis, rash, urticaria, allergic reaction, and acute renal failure
Praziquantel (Biltricide)
Cysticidal agent that destroys approximately 75% of cysts with a single course. Increases cell membrane permeability in susceptible worms, resulting in loss of intracellular calcium, massive contractions, and paralysis of musculature. Causes vacuolization and disintegration of the schistosome tegument, followed by attachment of phagocytes to the parasite and death. Tabs should be swallowed whole with some liquid during meals. Bitter taste can cause nausea or vomiting if tabs are held in the mouth.
Adult
10-12 mg/kg PO as a one-time dose for treatment of the adult tapeworm in the intestinal tract;
50-100 mg/kg/d PO divided q8h for at least 15 d in cysticercosis
Pediatric
<4 years: Not established
>4 years: 10-12 mg/kg PO as a one-time dose
Concomitant use with corticosteroids may decrease levels as much as 50%; some advocate use of praziquantel 100 mg/kg/d with cimetidine, which inhibits the cytochrome P450 system and increases the serum concentration; hydantoins may reduce serum 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
Patients should not drive or operate machinery on the day of or the day after treatment; discontinue breastfeeding from the day of treatment until 72 h after treatment; frequently causes malaise, headache, dizziness, abdominal pain, myalgias, nausea, vomiting, diarrhea, and mildly elevated liver enzyme levels
Niclosamide (Niclocide)
Used in the treatment of adult worms. No longer commercially available in the United States. Not absorbed and does not provoke an inflammatory response to cysticerci. Inhibits mitochondrial oxidative phosphorylation and glucose uptake in the parasite.
Adult
2 g (4 tab) PO as a single dose; tabs must be chewed
Pediatric
<11 kg: Not established
11-34 kg: 1 g (2 tabs) PO as a single dose; tabs must be chewed
>34 kg: 1.5 g (3 tabs) PO as a single dose; tabs must be chewed
None reported
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
May cause nausea, vomiting, abdominal pain, diarrhea, drowsiness, dizziness, headache, and pruritus
More on Cysticercosis |
| Overview: Cysticercosis |
| Differential Diagnoses & Workup: Cysticercosis |
 Treatment & Medication: Cysticercosis |
| Follow-up: Cysticercosis |
| Multimedia: Cysticercosis |
| References |
| « Previous Page | Next Page » |
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Further Reading
Keywords
cysticercosis, neurocysticercosis, giant cysticercosis, cysticercus cellulosae, cysticercus racemosus, adult-onset epilepsy, cysticerci, tapeworm infection, cysticercoids, neurocysticercosis, cysticerci, hydrocephalus, parkinsonism, treatment, diagnosis
