eMedicine Specialties > Pediatrics: General Medicine > Parasitology

Neurocysticercosis: Differential Diagnoses & Workup

Author: Vinod K Dhawan, MD, FACP, FRCP(C), Professor, Department of Clinical Medicine, University of California, Los Angeles, David Geffen School of Medicine; Professor of Medicine, Charles Drew University of Medicine and Science; Chief, Division of Infectious Diseases, MLK-Harbor Hospital
Coauthor(s): Eric HW Kossoff, MD, Assistant Professor, Departments of Pediatrics and Neurology, Associate Director of Pediatric Neurology Residency Program, Johns Hopkins School of Medicine
Contributor Information and Disclosures

Updated: Sep 14, 2009

Differential Diagnoses

Amebic Meningoencephalitis
Schistosomiasis
Astrocytoma
Toxocariasis
Craniopharyngioma
Toxoplasmosis
Cytomegalovirus Infection
Trichinosis
Lyme Disease
Tuberculosis
Medulloblastoma
von Hippel-Lindau Disease
Meningitis, Bacterial
Sarcoidosis

Other Problems to Be Considered

Brain abscess
Hydatid disease
Meningitis, aseptic
Tuberous sclerosis

Workup

Laboratory Studies

  • Enzyme-linked immunotransfer blot assay
    • If neurocysticercosis is suspected on the basis of clinical and radiographic evidence, an enzyme-linked immunotransfer blot (EITB) assay of a patient's serum may confirm the diagnosis.
    • Specificity is 100% and sensitivity is 90% for children with more than 2 lesions. Sensitivity is only 50-70% in children with just one lesion (the majority); therefore, the usefulness of this test may be limited.
    • EITB can be ordered by sending serum to the state public health department laboratory in the area or to the Centers for Disease Control and Prevention (CDC). One private laboratory in the United States (Specialty Laboratories; Los Angeles, California) also performs the test. The CDC Web site provides further information.
  • HP10 antigen testing: Detection of the metacestode HP10 antigen in serum is a useful tool for diagnosis and follow-up of patients with severe forms of neurocysticercosis treated with cysticidal drugs.
  • Polymerase chain reaction: More recently, T solium DNA has been observed in the cerebrospinal fluid (CSF) of patients. The polymerase chain reaction amplification of the parasite DNA in the CSF enabled the investigators in correct identification of 29 cases (96.7%).13
  • Stool samples
    • Examine stools from patients and their contacts for ova and parasites. Obtain 3 consecutive daily stool specimens.
    • The presence of ova may be the sole diagnostic confirmation in some children, but more importantly, detecting ova in children with neurocysticercosis is worthwhile as a public health measure to prevent further exposure to the tapeworm ova.
    • Stool test for T solium ova is rarely positive.
  • Enzyme-linked immunosorbent assay
    • Enzyme-linked immunosorbent assay (ELISA) can be used on serum and CSF.
    • ELISA can aid in diagnosis in cases with few lesions and relatively mild disease.
    • Sensitivity is approximately 75-80%.

Imaging Studies

  • CT scanning
    • CT scanning shows the cyst and granuloma stages of neurocysticercosis. These cysts can be solitary or multiple and are usually 5-20 mm in diameter.
    • Perform CT scanning on all children considered for the diagnosis. Most likely, CT scanning is performed upon presentation of a child with new-onset focal seizures. CT scanning can be performed without contrast.
    • Approximately 75% of children who are affected with neurocysticercosis have a solitary lesion. Lesions are located most often in the cortex or at the gray-white junction. Approximately one half of lesions have a punctate high density within the ring (scolex). Between 10-20% of children have no abnormality (also observed in MRI studies).
    • CT scanning is superior to MRI study in detecting calcification, which can be useful in differentiating the punctate cyst of neurocysticercosis in the granuloma wall from other causes of granulomas; however, calcification is observed less frequently in children than in adults.
    • CT scanning can also detect edema around the cyst, which is associated with the death of the organism.
    • CT scanning can be performed quickly, which is important when caring for young children.
  • MRI
    • MRI is the best imaging test overall for the diagnosis. Perform MRI in all patients for whom the clinical history and CT scan findings suggest neurocysticercosis. Use gadolinium contrast.
    • MRI is useful for lesions of the spinal cord, posterior fossa, brainstem, subarachnoid, and ventricles.
    • Use of contrast also shows larval death, visible as enhancement of the cyst wall, which indicates that the cyst has changed into a granuloma. In addition, MRI (as well as CT scanning) shows any vasogenic edema around the cyst, indicative of the body's inflammatory response to organism death.
    • MRI can be used as follow-up imaging to document improvement based on both a decrease in the granuloma diameter and a resolution of vasogenic edema.
    • A 2000 study of 108 patients by Pradhan et al indicated the prognostic usefulness of gliosis as observed in a T1-weighted magnetization transfer spin-echo MRI.14 This gliosis was associated with seizure recurrence after at least 2 years of antiepileptic medications were tapered and then discontinued.
  • Radiography
    • Soft tissue radiography can be performed to look for extraneural cysts.
    • Radiography is rarely helpful. Perform radiography only when all other tests have failed to provide a diagnosis.
    • For unknown reasons, children in the United States with neurocysticercosis rarely have cysts in subcutaneous or intramuscular tissue.
    • Skull radiography can be performed, although they are rarely helpful with the advent of the MRI. Occasionally, separation of the cranial sutures can be observed, which indicates increased intracranial pressure.

Other Tests

  • Electroencephalography
    • Perform electroencephalography (EEG) in children with recalcitrant seizures.
    • Occasionally, evidence of periodic lateralized epileptiform discharges (PLEDs) is present.

Procedures

  • Lumbar puncture
    • In approximately 50% of cases, a lumbar puncture can reveal pleocytosis (often lymphocytic, but occasionally eosinophilic), decreased glucose, increased protein, and elevated opening pressure. A lumbar puncture can help exclude other infectious or malignant diagnoses.
    • Serum EITB is more sensitive than the CSF EITB assay, so CSF testing is not usually indicated.
  • Brain biopsy: Brain biopsy can be performed in cases where the diagnosis remains questionable and the lesion has not resolved. The procedure may be indicated in areas of low prevalence.

More on Neurocysticercosis

Overview: Neurocysticercosis
Differential Diagnoses & Workup: Neurocysticercosis
Treatment & Medication: Neurocysticercosis
Follow-up: Neurocysticercosis
Multimedia: Neurocysticercosis
References
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References

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Further Reading

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Keywords

cysticercosis, taeniasis, tapeworm diseases, parasite, parasitic infection, tapeworm, tapeworm infection, larval infection, hydrocephalus, treatment, diagnosis

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Contributor Information and Disclosures

Author

Vinod K Dhawan, MD, FACP, FRCP(C), Professor, Department of Clinical Medicine, University of California, Los Angeles, David Geffen School of Medicine; Professor of Medicine, Charles Drew University of Medicine and Science; Chief, Division of Infectious Diseases, MLK-Harbor Hospital
Vinod K Dhawan, MD, FACP, FRCP(C) is a member of the following medical societies: American College of Physicians, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, and Royal College of Physicians and Surgeons of Canada
Disclosure: Pfizer Inc None None

Coauthor(s)

Eric HW Kossoff, MD, Assistant Professor, Departments of Pediatrics and Neurology, Associate Director of Pediatric Neurology Residency Program, Johns Hopkins School of Medicine
Eric HW Kossoff, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Pediatrics, American Epilepsy Society, and Child Neurology Society
Disclosure: Nothing to disclose.

Medical Editor

Ashir Kumar, MBBS, MD, FAAP, Professor, Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University; Consulting Staff, Department of Pediatrics, EW Sparrow Hospital
Ashir Kumar, MBBS, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics, American Association of Physicians of Indian Origin, American Federation for Clinical Research, American Society for Microbiology, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Leslie L Barton, MD, Professor, Program Director, Department of Pediatrics, University of Arizona School of Medicine
Leslie L Barton, MD is a member of the following medical societies: American Academy of Pediatrics, Association of Pediatric Program Directors, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society
Disclosure: Nothing to disclose.

CME Editor

Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine
Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility
Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; sanofi pasteur Honoraria Speaking and teaching; Baxter Healthcare Honoraria Speaking and teaching

Chief Editor

Russell W Steele, MD, Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine
Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association
Disclosure: None None None

 
 
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