eMedicine Specialties > Pediatrics: General Medicine > Parasitology
Neurocysticercosis: Treatment & Medication
Updated: Sep 14, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
- Drug therapy for neurocysticercosis is controversial. Several nonrandomized case series have suggested faster resolution of lesions with treatment using both praziquantel and albendazole.16 Other controlled, randomized trials have not shown such a beneficial effect in intraparenchymal CNS cysticerci. Furthermore, anthelmintic therapy may exacerbate obstruction of CSF flow, precipitating hydrocephalus. Inflammatory response associated with drug therapy may impair vision in ocular disease and may increase the risk of paralysis with spinal cord lesions.
- Drug therapy for intraventricular cysts may prove efficacious and is currently recommended by many experts. A meta-analysis of cysticidal drug therapy with albendazole and praziquantel concluded that drug therapy results in better resolution of colloidal and vesicular cysticerci, lower risk for recurrence of seizures in patients with colloidal cysticerci, and a reduction in the rate of generalized seizures in patients with vesicular cysticerci.3
- Medical care depends on whether the disease is simple or complicated.
- Simple neurocysticercosis occurs in children living in nonendemic areas with only a single exposure to cysts. These children tend to have solitary cysts and fewer complications. They often can be treated symptomatically and have a favorable prognosis. In most cases, the cyst has died and cysticidal drugs are not necessary.
- Complicated neurocysticercosis occurs in children living in endemic areas who are constantly reexposed to ova. These children may have a less favorable prognosis because of complications from increased intracranial pressure and difficulty controlling in seizures.
Surgical Care
- Reserve neurosurgical intervention for cases of cysts that have failed to resolve with antihelminthic treatment and are causing severe neurologic sequelae. Resolution of lesions with medical management alone is superior and should be attempted first.
- In general, indications of surgery include cysts that compress the brain and cranial nerves locally, intracranial hypertension or edema refractory to medical treatment, intraventricular cysts, spinal cysts with cord or root compression, and ocular cysts. Recently, endoscopic approaches for ventricular cysts have been developed and are now the treatment of choice for ventricular cysts with hydrocephalus.11
- Shunting may be indicated if cysts have led to hydrocephalus.
Consultations
- Consult a neurologist for management of seizures, increased intracranial pressure, and any other neurologic sequelae of this disease.
- Consult an infectious disease specialist for help with a questionable diagnosis, eradication of the organism, and public health issues.
- Consult an ophthalmologist to examine the child for any signs of subretinal cysts.
- Consult a neurosurgeon if a biopsy or resection is called for or if the child requires shunting because of hydrocephalus.
Diet
- Avoid reinfection and reingestion of ova from the original source.
- No other specific diet is necessary.
Activity
- No activity restrictions are necessary.
Medication
Anticonvulsants are of universal benefit in stopping seizures and are successful in most cases. However, the use of antihelminthic medications is quite controversial. Many children with solitary cysts are found to have calcified or edematous lesions (ie, indicative of cyst death) on imaging studies and have had excellent resolution of their lesions without antihelminthic agents. However, studies on adults performed in 1992 showed a significant decrease in seizures in those treated. In a 2002 study of 176 cases in India by Talukdar et al, lesions disappeared regardless of albendazole therapy. In a double-blind, placebo-controlled trial of albendazole in 2004, the incidence of seizures was reduced by 46% (not significant), but seizures were reduced 67% with generalization.4 No evidence suggests that treatment affects the long-term seizure outcome.
Most experts treat children with viable cysts (ie, those that have not calcified or shown signs of edema on imaging studies) and/or multiple cysts. Treating children with severe edema with antihelminthic medications is not recommended because of risk of causing further swelling. Destruction of cysts by antihelminthic agents can cause inflammation that results in neurologic symptoms (eg, headache, vomiting, seizures), which usually occur within 24-48 hours of initiation of therapy. Prophylactic treatment with dexamethasone is beneficial in decreasing the severity of such acute symptoms.
A single dose of praziquantel (5-10 mg/kg) can be administered to individuals found to have T solium tapeworms in their stool.
In a recent study in children, a combination of albendazole and praziquantel was statistically comparable to sole therapy with albendazole in eradicating lesions and preventing seizures.10
Antihelminthics
These agents are used in children with viable or multiple cysts. They are used in patients with T solium tapeworms in their stool. Avoid use of antihelminthics in patients with severe edema. Parasite biochemical pathways are different from 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 causing irreversible block of glucose uptake
- Tubulin polymerization inhibition
- Depolarizing neuromuscular blockade
- Cholinesterase inhibition
- Increased cell membrane permeability, resulting in intracellular calcium loss
- Vacuolization of the schistosome tegument
- Increased cell membrane permeability to chloride ions via chloride channels alteration
Albendazole (Albenza)
Is produced by Glaxo Smith Kline and was made available in the United States in June 1996. Mechanism of action is via its inhibitory effect on tubulin polymerization, which results in the loss of cytoplasmic microtubules. Albendazole is available in 200-mg tabs. To avoid inflammatory response in the CNS, the patient must also be started on anticonvulsants and high-dose glucocorticoids.
Adult
400 mg PO bid for 30 d with meals
Alternatively, 3-day to 8-day course in adults with 3 or fewer cysts
Pediatric
15 mg/kg/d PO divided bid for 30 d with meals; not to exceed 800 mg/d
Recent data suggest a 1-wk course is as effective as a 4-wk course in children (Singhi, 2003)
Increase in serum and CSF metabolite concentrations with concomitant corticosteroids; possible increase in metabolism and decrease in efficacy with carbamazepine; possible increase in plasma levels when administered concurrently with dexamethasone and praziquantel
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
Administer with meals; adverse effects include headache, nausea, dizziness, vomiting, and abnormalities in liver functions; possibility of increased intracranial pressure as a result of cyst death; observe children for first 24-48 h for signs; rare adverse effects include alopecia, rash, fever, and pancytopenia; perform biweekly CBC counts and monitoring of LFTs during therapy
Praziquantel (Biltricide)
More expensive than albendazole and probably less effective. Available in 600-mg tabs. 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 schistosome tegument. This is followed by attachment of phagocytes to parasite and death.
Tabs should be swallowed whole with some liquid during meals. Keeping tabs in mouth is not advised because of bitter taste, which can produce nausea or vomiting.
Adult
50 mg/kg/d PO divided q6-8h for 15 d
Some evidence suggests that a 1-d course may be just as effective by administering 3 doses of 25 mg/kg at 2-h intervals after an overnight fast (Corona, NEJM, 1996)
Pediatric
<4 years: Not established
>4 years: 50 mg/kg/d PO divided q6-8h for 15 d
Substrate of CYP450; decrease in levels with concomitant corticosteroids, carbamazepine, and phenytoin; cimetidine may increase serum levels
Documented hypersensitivity; ocular cysticercosis
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adverse effects include dose-dependent, mild-to-moderate, and transient dizziness, headache, fatigue, limb pain, abdominal distress, and bloody diarrhea; advise patients not to drive during and 1 day after therapy because of dizziness; administer with meals, swallow whole (ie, do not chew or crush)
Corticosteroids
These agents are useful in patients with increased intracranial pressure as a result of anthelmintic-induced cyst death and resultant inflammation.
Dexamethasone (Decadron)
Begin therapy in children on the second or third day of antihelminthic therapy if symptoms arise.
Adult
4 mg IV q6h for no more than 3-4 d
Pediatric
1-1.5 mg/kg/d IV divided q4-6h for no more than 3-4 d; not to exceed 16 mg/d; tapering unnecessary unless used >4 d
Possible increased level of albendazole and decreased level of praziquantel with coadministration; possible decreased effect with concomitant use of barbiturates, phenytoin, and rifampin
Documented hypersensitivity; uncontrolled diabetes mellitus; systemic fungal infections
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
Possibility of sodium and fluid retention, hypertension, hyperglycemia, peptic ulcer, and headache; caution with hyperthyroidism, cirrhosis, nonspecific ulcerative colitis, osteoporosis, peptic ulcer, diabetes mellitus, and myasthenia gravis
Anticonvulsants
These agents are used to control seizures that result from cysts. Most experts taper doses for children after 1-2 years without further seizures. Others suggest that anticonvulsants can be tapered even sooner (6 mo).
Carbamazepine (Tegretol)
Appears to act by reducing polysynaptic responses and blocking posttetanic potentiation.
Adult
Initial dose: 200 mg PO bid; increase dose at weekly intervals (by 200 mg/d) until optimal response achieved
Usual dose: 800-1200 mg/d PO divided tid/qid
Pediatric
10-20 mg/kg/d PO divided bid/tid; increase weekly to achieve optimal clinical response, administered tid/qid
Substrate of CYP3A4 and CYP3A4 isoenzyme inducer; CYP3A4 inhibitors (eg, macrolides, loratadine) can increase levels; (CYP3A4 inducers (eg, phenytoin, theophylline) can decrease levels; not for concomitant use with MAOIs; mandatory discontinuation of MAOIs for at least 14 d before carbamazepine administration; possible decreased primidone, phenobarbital, and higher carbamazepine serum concentrations with concomitant use; possible increase in carbamazepine plasma levels and toxicity when administered concurrently with cimetidine, especially in first 4 wk of therapy
Documented hypersensitivity; bone marrow depression; known sensitivity to any tricyclic compounds; MAOIs
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Possible adverse drug reactions include dizziness, drowsiness, and abdominal pain; rarely, rash, agranulocytosis, aplastic anemia, and Stevens-Johnson reaction; regular CBC counts, hepatic function tests, and Tegretol levels needed
Phenytoin (Dilantin)
Primary site of action of hydantoins, such as phenytoin, appears to be the motor cortex, where it may inhibit the spread of seizure activity. May reduce the maximal activity of brainstem centers responsible for the tonic phase of grand mal seizures.
Adult
300 mg PO qhs
Pediatric
4-8 mg/kg/d PO divided bid/tid
Amiodarone, benzodiazepines, chloramphenicol, cimetidine, fluconazole, isoniazid, metronidazole, miconazole, omeprazole, phenacemide, phenylbutazone, succinimides, sulfonamides, trimethoprim, and valproic acid may increase toxicity with coadministration; conversely, possible decreased effects when administered concurrently with barbiturates, carbamazepine, diazoxide, rifampin, theophylline, antacids, and sucralfate; possible decreased effects of acetaminophen, amiodarone, carbamazepine, cardiac glycosides, corticosteroids, haloperidol, methadone, mexiletine, quinidine, theophylline, and valproic acid with coadministration
Documented hypersensitivity; sinoatrial block; sinus bradycardia; second-degree and third-degree AV block; Adams-Stokes syndrome
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Possible adverse reactions include gingival hyperplasia, nausea, and vomiting; rarely, Stevens-Johnson syndrome, nystagmus, slurred speech, and ataxia; check phenytoin levels regularly; discontinue if rash appears and do not resume use with exfoliative, bullous, or purpuric rash; caution with liver dysfunction; discontinue if hepatic dysfunction occurs
More on Neurocysticercosis |
| Overview: Neurocysticercosis |
| Differential Diagnoses & Workup: Neurocysticercosis |
 Treatment & Medication: Neurocysticercosis |
| Follow-up: Neurocysticercosis |
| Multimedia: Neurocysticercosis |
| References |
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References
Zee CS, Go JL, Kim PE, DiGiorgio CM. Imaging of neurocysticercosis. Neuroimaging Clin N Am. May 2000;10(2):391-407. [Medline].
Wallin MT, Kurtzke JF. Neurocysticercosis in the United States: review of an important emerging infection. Neurology. Nov 9 2004;63(9):1559-64. [Medline].
[Best Evidence] Del Brutto OH, Roos KL, Coffey CS, García HH. Meta-analysis: Cysticidal drugs for neurocysticercosis: albendazole and praziquantel. Ann Intern Med. Jul 4 2006;145(1):43-51. [Medline].
Garcia HH, Pretell EJ, Gilman RH. A trial of antiparasitic treatment to reduce the rate of seizures due to cerebral cysticercosis. N Engl J Med. Jan 15 2004;350(3):249-58. [Medline].
Pineda T, Eckstein C, Diethelm G, Cure J. Neurocysticercosis. Headache. May 2007;47(5):717-8. [Medline].
Sinha S, Sharma BS. Neurocysticercosis: A review of current status and management. J Clin Neurosci. Apr 24 2009;[Medline].
Chaoshuang L, Zhixin Z, Xiaohong W, Zhanlian H, Zhiliang G. Clinical analysis of 52 cases of neurocysticercosis. Trop Doct. Jul 2008;38(3):192-4. [Medline].
Jung H, Cardenas G, Sciutto E, Fleury A. Medical treatment for neurocysticercosis: drugs, indications and perspectives. Curr Top Med Chem. 2008;8(5):424-33. [Medline].
Ruiz-Garcia M, Gonzalez-Astiazaran A, Rueda-Franco F. Neurocysticercosis in children. Clinical experience in 122 patients. Childs Nerv Syst. Nov-Dec 1997;13(11-12):608-12. [Medline].
Leonard R, Adickes ED, Brumback RA. Neurocysticercosis. J Child Neurol. Jul 2006;21(7):589-90. [Medline].
St. Geme JW 3d, Maldonado YA, Enzmann D, et al. Consensus: diagnosis and management of neurocysticercosis in children. Pediatr Infect Dis J. Jun 1993;12(6):455-61. [Medline].
Rosenfeld EA, Byrd SE, Shulman ST. Neurocysticercosis among children in Chicago. Clin Infect Dis. Aug 1996;23(2):262-8. [Medline].
Almeida CR, Ojopi EP, Nunes CM, et al. Taenia solium DNA is present in the cerebrospinal fluid of neurocysticercosis patients and can be used for diagnosis. Eur Arch Psychiatry Clin Neurosci. Aug 2006;256(5):307-10. [Medline].
Pradhan S, Kathuria MK, Gupta RK. Perilesional gliosis and seizure outcome: a study based on magnetization transfer magnetic resonance imaging in patients with neurocysticercosis. Ann Neurol. 2000;48:181-187. [Medline].
Del Brutto OH, Castillo PR, Mena IX, Freire AX. Neurocysticercosis among patients with cerebral gliomas. Arch Neurol. Sep 1997;54(9):1125-8. [Medline].
Kaur S, Singhi P, Singhi S, Khandelwal N. Combination therapy with albendazole and praziquantel versus albendazole alone in children with seizures and single lesion neurocysticercosis: a randomized, placebo-controlled double blind trial. Pediatr Infect Dis J. May 2009;28(5):403-6. [Medline].
Del Brutto OH, Rajshekhar V, White AC. Proposed diagnostic criteria for neurocysticercosis. Neurology. Jul 24 2001;57(2):177-83. [Medline].
Fleury A, Hernandez M, Avila M, et al. Detection of HP10 antigen in serum for diagnosis and follow-up of subarachnoidal and intraventricular human neurocysticercosis. J Neurol Neurosurg Psychiatry. Sep 2007;78(9):970-4. [Medline].
Li J, Zhang WB, Wilson M, et al. A novel recombinant antigen for immunodiagnosis of human cystic echinococcosis. J Infect Dis. Dec 15 2003;188(12):1952-61. [Medline].
Marconi VC, Garcia HH, Katz JT. Neurocysticercosis. Curr Infect Dis Rep. Jun 2006;8(4):293-300. [Medline].
Motamedi G. Baylor Neurology Case of the Month #10. Baylor College of Medicine. Available at http://www.bcm.tmc.edu/neurol/challeng/pat10/summary.html. Accessed 1999.
Nash TE, Singh G, White AC, et al. Treatment of neurocysticercosis: current status and future research needs. Neurology. Oct 10 2006;67(7):1120-7. [Medline].
Odermatt P, Preux PM, Druet-Cabanac M. Treatment of neurocysticercosis: a randomised controlled trial. J Neurol Neurosurg Psychiatry. Sep 2008;79(9):978. [Medline].
Prasad KN, Prasad A, Verma A, Singh AK. Human cysticercosis and Indian scenario: a review. J Biosci. Nov 2008;33(4):571-82. [Medline].
Serpa JA, Yancey LS, White AC Jr. Advances in the diagnosis and management of neurocysticercosis. Expert Rev Anti Infect Ther. Dec 2006;4(6):1051-61. [Medline].
Shandera WX, Kass JS. Neurocysticercosis: current knowledge and advances. Curr Neurol Neurosci Rep. Nov 2006;6(6):453-9. [Medline].
Singhi P, Dayal D, Khandelwal N. One week versus four weeks of albendazole therapy for neurocysticercosis in children: a randomized, placebo-controlled double blind trial. Pediatr Infect Dis J. Mar 2003;22(3):268-72. [Medline].
Singhi P, Singhi S. Neurocysticercosis in children. J Child Neurol. Jul 2004;19(7):482-92. [Medline].
Strano SD. Exfoliative cytology in the diagnosis of breast disease. Br J Surg. Jan 1996;83(1):135. [Medline].
Swaiman KF. Cysticercosis. In: Pediatric Neurology: Principles and Practice. Vol 1. 2nd ed. St. Louis, Mo: Mosby; 1994:707-8.
Talukdar B, Saxena A, Popli VK. Neurocysticercosis in children: clinical characteristics and outcome. Ann Trop Paediatr. Dec 2002;22(4):333-9. [Medline].
Vazquez V, Sotelo J. The course of seizures after treatment for cerebral cysticercosis. N Engl J Med. Sep 3 1992;327(10):696-701. [Medline].
White AC Jr. New developments in the management of neurocysticercosis. J Infect Dis. May 1 2009;199(9):1261-2. [Medline].
Further Reading
Keywords
cysticercosis, taeniasis, tapeworm diseases, parasite, parasitic infection, tapeworm, tapeworm infection, larval infection, hydrocephalus, treatment, diagnosis
