Cysticercosis Follow-up

Updated: Oct 05, 2015
  • Author: Mossammat M Mansur, MD, MBBS; Chief Editor: Pranatharthi Haran Chandrasekar, MBBS, MD  more...
  • Print
Follow-up

Further Outpatient Care

The initial brain reimaging should be performed two months after therapy completion.

Parasite antigen levels typically fall by 3 months after successful treatment.

For patient monitoring, the imaging should be performed on a biannual basis to monitor the cysts.

If the cysts are growing in the absence of therapy, antiparasitic therapy should be considered.

In patients with seizures due to neurocysticercosis without calcification, perform imaging studies every 3-6 months. If calcification develops, lifelong anticonvulsant therapy is indicated, and further imaging studies can be performed as needed.

If results of imaging studies show normalization and seizures are under control after 2 years of therapy, anticonvulsants may be tapered, and further imaging can be performed as needed.

Patients with calcified lesions and a seizure disorder should be maintained on anticonvulsants indefinitely, and they should undergo imaging studies only as needed.

Monitor anticonvulsant serum levels to prevent toxicity.

Next:

Further Inpatient Care

ICU monitoring is necessary in patients with uncontrolled seizures, elevated ICP, or severe extraparenchymal disease.

If antiparasitic therapy is provided, patients should be hospitalized and monitored during the initial phase.

  • As cysticerci die, neurologic symptoms may worsen because of an increased inflammatory response.
  • Most symptoms associated with antiparasitic therapy develop within 3-5 days of beginning therapy.
  • Antiparasitic therapy may then be completed in an outpatient setting.

Prior initiation of therapy with antiparasitic medications or corticosteroids, the following steps should be taken:

  • Apply a purified protein derivative (PPD) skin test. Patients in whom the PPD result is positive should be treated with isoniazid along with pyridoxine (vitamin B6) for the duration of their steroid treatment.
  • Because many patients with cysticercosis also have risk factors for strongyloidiasis, these patients should be treated with ivermectin (200 μg/kg administered in two single doses two weeks apart before steroids are initiated.
  • An ophthalmologist should perform an eye examination to exclude ocular cysticercosis.
Previous
Next:

Inpatient & Outpatient Medications

Discharge medications may include steroids, anticonvulsants, antiparasitics, and cimetidine.

The anticonvulsants carbamazepine and phenytoin are first-choice treatments.

Previous
Next:

Transfer

Patients with extraparenchymal neurocysticercosis should be treated at hospitals with active neurosurgical and neurological services because emergency procedures such as shunt placement or ventriculostomy may be required in patients with worsening hydrocephalus.

Arrange transfer if the facility is unable to provide neurologic or neurosurgical care.

Previous
Next:

Deterrence/Prevention

Educate patients regarding routes of transmission of cysticerci ova.

Meat inspection has been effective at preventing transmission of tapeworms in developed countries but has been uniformly unsuccessful in developing countries.

In areas of endemic cysticercosis, avoid undercooked pork to reduce the risk of intestinal infection.

Be vigilant about avoiding potential fecal-oral transmission to reduce the risk of neurocysticercosis while in endemic areas. Individuals traveling to such areas should observe the following guidelines:

  • Eat only fruits and vegetables that you have peeled yourself.
  • Thoroughly wash (with water from a clean source) all food prior to ingestion.
  • Maintain good personal hygiene and wash hands prior to food preparation.

Mass chemotherapy has been used to interrupt transmission in some areas of endemic infection, but disease usually returns within a few years.

Mass anthelminthic therapy yields only limited success and may cause adverse neurologic events in individuals with undiagnosed neurocysticercosis who receive these drugs.

Consider identifying human carriers of tapeworms, possibly based on a history of proglottid passage, and instituting targeted treatment.

Serologic screening of the contacts of patients should also be considered in the management of cysticercosis, particularly in nonendemic countries when transmission may have occurred within a household (eg, via food prepared by a household worker from an endemic country).

Vaccines for prevention of cysticercosis have proven effective for other Taenia species and are in development for T solium.

Transmission of cysticercal infections to pigs can be prevented with the following measures:

Changing pig-raising practices in endemic areas by confining the animals and preventing them from roaming freely to avoid contact with infectious ova excreted in human feces

Improving sanitary conditions and proper disposal of human stool

Possibly vaccinating pigs (Preliminary studies suggest this may be feasible.)

Previous
Next:

Complications

Parenchymal disease causes seizures but few long-term complications. However, studies suggest that childhood infection may be associated with learning disabilities and cognitive dysfunction.

Extraparenchymal disease may cause elevated ICP, resulting in herniation and death.

Vasculitis associated with cisternal neurocysticercosis may cause strokes, communicating hydrocephalus, and death.

Previous
Next:

Prognosis

Most patients with parenchymal cysticercosis either remain asymptomatic or develop a self-limited seizure disorder.

Among patients who develop intracerebral calcifications, most have recurrent seizures unless treated with anticonvulsants. If treated with anticonvulsants, the seizures are generally easily controlled.

Ventricular neurocysticercosis usually requires shunting. Neurosurgery may be complicated by focal neurologic damage. Shunt revisions are often needed unless patients are treated with corticosteroids or antiparasitic drugs. However, even with treatment, some still require subsequent revision. Prior to the use of corticosteroids and antiparasitic drugs, subarachnoid disease was associated with a 90% 10-year fatality rate, even with shunting. With current management, fatalities appear to be rare.

Good evidence indicates that, once infected, patients are immune to reinfection.

Previous
Next:

Patient Education

Patients and their family members should be educated on how to decrease the source of egg carriers by emphasizing improvement in sanitation, separation of pigs from humans, and food-preparation hygiene in endemic areas.

Family members should be queried about symptoms suggestive of tapeworm infection, such as passing proglottids. They should be treated if symptoms are present.

Family members should also be screened.

Patients with seizures and their families should know proper seizure first-aid.

Patients who have had seizures should know about possible driving restrictions, which, in the United States, vary from state to state.

Patients who have received a VP shunt should be educated about the signs and symptoms of elevated ICP (possible shunt failure) and meningitis (secondary infection of indwelling hardware).

For excellent patient education resources, please see eMedicineHealth's Infections Center.

Previous