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Pediatric Neurocysticercosis Workup

  • Author: Vinod K Dhawan, MD, FACP, FRCPC, FIDSA; Chief Editor: Russell W Steele, MD  more...
 
Updated: Mar 03, 2015
 

Laboratory Studies

Laboratory diagnosis of neurocysticercosis is facilitated by serological and imaging studies.[18, 19]

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.[20]

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%).[21]

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. Detection of antigen in the CSF using a monoclonal antibody-based ELISA has been shown to increase the diagnostic sensitivity.[22]

ELISA can aid in diagnosis in cases with few lesions and relatively mild disease.

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Imaging Studies

CT scanning

CT scanning shows the cyst and granuloma stages of neurocysticercosis.[23] 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. See the images below.

Case 2: MRI of a 40-year-old patient with a single Case 2: MRI of a 40-year-old patient with a single parietal calcified cyst.
Case 2: CT scan of a 40-year-old patient with a si Case 2: CT scan of a 40-year-old patient with a single parietal calcified cyst.

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. This gliosis was associated with seizure recurrence after at least 2 years of antiepileptic medications were tapered and then discontinued.

See the images below.

MRI of multiple cysts. Image courtesy of the Cente MRI of multiple cysts. Image courtesy of the Centers for Disease Control and Prevention.
Case 3: MRI of a 47-year-old man with 2 right pari Case 3: MRI of a 47-year-old man with 2 right parietal cysts, one with edema.
Case 3: MRI of a 47-year-old man with 2 right pari Case 3: MRI of a 47-year-old man with 2 right parietal cysts, one with edema, after the larger cyst had involuted.

Radiography

Soft tissue radiography can be performed to look for extraneural cysts.[24]

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.

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Other Tests

Electroencephalography

Perform electroencephalography (EEG) in children with recalcitrant seizures.

Occasionally, evidence of periodic lateralized epileptiform discharges (PLEDs) is present.

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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.

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Contributor Information and Disclosures
Author

Vinod K Dhawan, MD, FACP, FRCPC, FIDSA Professor, Department of Clinical Medicine, University of California, Los Angeles, David Geffen School of Medicine; Chief, Division of Infectious Diseases, Rancho Los Amigos National Rehabilitation Center

Vinod K Dhawan, MD, FACP, FRCPC, FIDSA is a member of the following medical societies: American College of Physicians, American Medical Association, American Society for Microbiology, Infectious Diseases Society of America, Royal College of Physicians and Surgeons of Canada

Disclosure: Received honoraria from Pfizer Inc for speaking and teaching.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Russell W Steele, MD Clinical Professor, Tulane University School of Medicine; Staff Physician, Ochsner Clinic Foundation

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, Southern Medical Association

Disclosure: Nothing to disclose.

Additional Contributors

Ashir Kumar, MD, MBBS FAAP, Professor Emeritus, Department of Pediatrics and Human Development, Michigan State University College of Human Medicine

Ashir Kumar, MD, MBBS is a member of the following medical societies: Infectious Diseases Society of America, American Association of Physicians of Indian Origin

Disclosure: Nothing to disclose.

Acknowledgements

Leslie L Barton, MD Professor Emerita of Pediatrics, University of Arizona College 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. 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.

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Case 1: Coronal image MRI of a 6-year-old boy from Peru with single right frontal cyst.
Case 1: Axial image MRI of a 6-year-old boy from Peru with single right frontal cyst.
Case 2: MRI of a 40-year-old patient with a single parietal calcified cyst.
Case 2: CT scan of a 40-year-old patient with a single parietal calcified cyst.
Case 3: MRI of a 47-year-old man with 2 right parietal cysts, one with edema.
Case 3: MRI of a 47-year-old man with 2 right parietal cysts, one with edema, after the larger cyst had involuted.
Case 4: CT scan of 28-year-old woman with occipital headaches and diplopia; imaging reveals a superior cerebellar cyst, mild ventricular dilatation, and old calcifications in the right insular region. Image courtesy of Gholam Motamedi, MD.
Case 4: MRI of 28-year-old woman with occipital headaches and diplopia; MRI discerns prepontine and suprasellar lesions, as well as the superior cerebellar cyst. Image courtesy of Gholam Motamedi, MD.
MRI of multiple cysts. Image courtesy of the Centers for Disease Control and Prevention.
MRI of an 87-year-old patient from Europe with bitemporal lesions found incidentally. Image courtesy of Jon Poling, MD.
Two parietal lesions observed on autopsy specimen.
MRI of a 40-year-old woman with severe epilepsy and a left temporal single cyst.
MRI of a 21-year-old woman with left temporal lobe epilepsy and a single cyst.
 
 
 
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