In the Journals

Neurocysticercosis requires multidisciplinary approach, new guidelines say

Experts have released new guidelines recommending a variety of tests for diagnosing neurocysticercosis, as well as a multidisciplinary approach to treating the parasite-borne and potentially serious brain disease.

The guidelines, published in Clinical Infectious Diseases by the Infectious Diseases Society of America (IDSA) and the American Society of Tropical Medicine & Hygiene (ASTMH), address a range of different forms the disease can take.

“Forms of the infection can range from single cysts that may be relatively harmless to blockages in the ventricles that cause pressure and fluid on the brain that can be deadly if they’re not surgically removed,” guideline co-author A. Clinton White, MD, a professor of infectious diseases at the University of Texas Medical Branch in Galveston, said in a news release. “Neurocysticercosis is an important problem in the United States, and the right diagnosis and treatment are critical, which is why it requires management by a team that includes infectious disease specialists, neurologists and often neurosurgeons.”

It is estimated that more than 2,000 neurocysticercosis cases are diagnosed annually in the U.S., the guideline authors noted. The disease is common among immigrants to the U.S. from endemic regions, including Latin America, sub-Saharan Africa and parts of Asia.

“However, many doctors remain confused about how to best manage this infection,” White told Infectious Disease News.

The group of guideline authors assembled by the IDSA an ASTMH sought to lessen that confusion with its recommendations. In addition to infectious disease specialists, it included neurologists and neurosurgeons, White added.

In general, cysticercosis is an infection with cysts caused by the larva form of the pork tapeworm Taenia solium. Neurocysticercosis is a cysticercosis infection involving the central nervous system.

Patients with neurocysticercosis most often present clinically with seizures or increased intracranial pressure, the authors said. Other symptoms include nausea, vomiting, dizziness and an altered mental state.

“[Our] first observation is that neurocysticercosis represents a spectrum of disease,” White said. “In all forms of disease, symptomatic management — including anti-epileptic drugs for seizures and surgery for hydrocephalus — are critically important and should be the initial focus of management.”

The guidelines recommend both a computed tomography (CT) and an MRI exam when clinicians suspect a patient has neurocysticercosis. To confirm an infection, an enzyme-linked immunotransfer blot (EITB) is preferred over an enzyme-linked immunosorbent assay (ELISA), the guidelines add, because EITB is more sensitive.

Neurocysticercosis treatment depends on the form the infection takes. The range of treatment options includes steroids, anti-epileptic drugs (AEDs), anti-parasitic drugs and surgery, the guidelines say.

Once the CT and MRI exams identify the form of the infection, clinicians can decide on which therapeutic option to take. Patients who have epileptic seizures can benefit from AEDs, whereas a patient with a single live brain cyst can benefit from steroids or anti-parasitics. A combination of anti-parasitics should be used in those with several viable cysts, the authors said.

“Parenchymal cystic lesions respond more quickly when treated with steroids and anti-parasitic drugs, in most cases albendazole.” White said. “In patients with more than two cystic lesions, the response is better to combination therapy.”

The blocking of a ventricle by a cyst can be fatal, and the guidelines call for a neuroendoscopy — a minimally invasive surgery to remove the cyst. Patients with hydrocephalus — a build-up of cerebrospinal fluid in the brain — may need a shunt to drain the fluid.

The treatment options provide effective remedies for a severe infection, the authors concluded.

“Neurocysticercosis is a serious problem, but with optimal diagnosis and treatment, patients can be managed effectively,” White said. – by Joe Green

Disclosures: White reports that he has received royalties from UpToDate. Please see the guidelines for all other authors’ relevant financial disclosures.

Experts have released new guidelines recommending a variety of tests for diagnosing neurocysticercosis, as well as a multidisciplinary approach to treating the parasite-borne and potentially serious brain disease.

The guidelines, published in Clinical Infectious Diseases by the Infectious Diseases Society of America (IDSA) and the American Society of Tropical Medicine & Hygiene (ASTMH), address a range of different forms the disease can take.

“Forms of the infection can range from single cysts that may be relatively harmless to blockages in the ventricles that cause pressure and fluid on the brain that can be deadly if they’re not surgically removed,” guideline co-author A. Clinton White, MD, a professor of infectious diseases at the University of Texas Medical Branch in Galveston, said in a news release. “Neurocysticercosis is an important problem in the United States, and the right diagnosis and treatment are critical, which is why it requires management by a team that includes infectious disease specialists, neurologists and often neurosurgeons.”

It is estimated that more than 2,000 neurocysticercosis cases are diagnosed annually in the U.S., the guideline authors noted. The disease is common among immigrants to the U.S. from endemic regions, including Latin America, sub-Saharan Africa and parts of Asia.

“However, many doctors remain confused about how to best manage this infection,” White told Infectious Disease News.

The group of guideline authors assembled by the IDSA an ASTMH sought to lessen that confusion with its recommendations. In addition to infectious disease specialists, it included neurologists and neurosurgeons, White added.

In general, cysticercosis is an infection with cysts caused by the larva form of the pork tapeworm Taenia solium. Neurocysticercosis is a cysticercosis infection involving the central nervous system.

Patients with neurocysticercosis most often present clinically with seizures or increased intracranial pressure, the authors said. Other symptoms include nausea, vomiting, dizziness and an altered mental state.

“[Our] first observation is that neurocysticercosis represents a spectrum of disease,” White said. “In all forms of disease, symptomatic management — including anti-epileptic drugs for seizures and surgery for hydrocephalus — are critically important and should be the initial focus of management.”

The guidelines recommend both a computed tomography (CT) and an MRI exam when clinicians suspect a patient has neurocysticercosis. To confirm an infection, an enzyme-linked immunotransfer blot (EITB) is preferred over an enzyme-linked immunosorbent assay (ELISA), the guidelines add, because EITB is more sensitive.

Neurocysticercosis treatment depends on the form the infection takes. The range of treatment options includes steroids, anti-epileptic drugs (AEDs), anti-parasitic drugs and surgery, the guidelines say.

Once the CT and MRI exams identify the form of the infection, clinicians can decide on which therapeutic option to take. Patients who have epileptic seizures can benefit from AEDs, whereas a patient with a single live brain cyst can benefit from steroids or anti-parasitics. A combination of anti-parasitics should be used in those with several viable cysts, the authors said.

“Parenchymal cystic lesions respond more quickly when treated with steroids and anti-parasitic drugs, in most cases albendazole.” White said. “In patients with more than two cystic lesions, the response is better to combination therapy.”

The blocking of a ventricle by a cyst can be fatal, and the guidelines call for a neuroendoscopy — a minimally invasive surgery to remove the cyst. Patients with hydrocephalus — a build-up of cerebrospinal fluid in the brain — may need a shunt to drain the fluid.

The treatment options provide effective remedies for a severe infection, the authors concluded.

“Neurocysticercosis is a serious problem, but with optimal diagnosis and treatment, patients can be managed effectively,” White said. – by Joe Green

Disclosures: White reports that he has received royalties from UpToDate. Please see the guidelines for all other authors’ relevant financial disclosures.