Albendazole therapy for solitary persistent cysticercus granuloma

Use of Albendazole therapy for the treatment of patients having persisting intracranial solitary cysticercus granuloma is controversial. Most of the times these patients are treated empirically with variety of drugs for variable period. Some authors advocate biopsy before definitive treatment. 25 patients having radiologicaly persistent solitary cysticercus granuloma (>6 months) were given 15 days course of oral albendazole (15 mg/kg body wt). Cranial CT scan was repeated one month after the completion of albendazole therapy. It was evaluated for complete resolution, partial response (> 50% decrease in size of lesion) or no change as compared to previous scan. 12 patients (48%) showed complete resolution, 4 patients (16%) showed a partial response, while 9 patients (36%) did not show any change on follow up. Albendazole therapy may be useful for patients having persistent cysticercus granuloma.     

猪囊尾蚴特异性DNA片段的分离及聚合酶链检测方法的建立

目的分离猪囊尾蚴特异性ＤＮＡ技术片段并建立猪囊尾蚴聚合酶链反应（ＰＣＲ）检测方法。方法应用随意引物聚合酶链反应（ＡＰＰＣＲ）技术分离猪囊尾蚴特异性ＤＮＡ片段，根据其核苷酸序列设计引物，建立ＰＣＲ方法。结果应用ＡＰＰＣＲ技术从不同患者囊尾蚴结节活检标本中扩增得到基本一致的ＤＮＡ带谱。经Ｓｏｕｔｈｅｒｎ印迹杂交证实随意扩增所得片段与猪囊尾蚴ＤＮＡ同源。对其中一个片段再次扩增并克隆测序。依据测序结果设计合成引物，分别以猪囊尾蚴、猪和人组织ＤＮＡ作模板，仅有前者ＰＣＲ阳性，并可检出低至１０ｐｇ的猪囊尾蚴ＤＮＡ。结论猪囊尾蚴ＤＮＡＰＣＲ检测方法的建立为猪囊尾蚴感染的临床诊断和病原流行病学调查提供了实验基础。     

Economic evaluation of seizures associated with solitary cysticercus granuloma

BACKGROUND: Patients with solitary cysticercus granuloma (SCG) develop acute symptomatic seizures because of the inflammatory response of the brain and the seizures are self-limiting. Thus seizure disorder associated with SCG provides a good model to study the total cost of illness (COI). MATERIALS AND METHODS: COI of new-onset seizures associated with SCG was studied in 59 consecutive patients registered at the epilepsy clinic. Direct treatment-related costs and indirect costs, man-days lost and wages lost were evaluated. The relative cost was calculated as the percentage of per capita gross national product (GNP) at current prices for the year 1997-1998. RESULTS: The total COI, for treating seizure disorder associated with SCG per the period of CT resolution of the lesion per patient was INR 7273.7 (US$ 174.66, I$ 943.16) and he/she would be spending 50.9% of per capita GNP The direct cost per patient was INR 5916 (US$ 137.14, 41.4% of per capita GNP). If the patient had received only AEDs for the period of resolution of CT lesion, the cost would be INR 5702.48 (US$132.2, 40% of per capita GNP). The extra expenditure on albendazole and steroid was INR 213.72 (US$ 4.95), 3.6% of the total direct cost and 20.7% of the medication cost. Indirect cost (average wage loss) per patient was INR 1312.7 (US$ 30.42) and it accounted for 9% of per capita GNP. The one-time expenditure at present costs (adjusted for inflation) to the nation to treat all the prevalence cases is to the tune of INR 1.184 billion (US$ 2.605) and 0.0037% of GNP. CONCLUSIONS: This study suggests that seizure disorder associated with SCG, a potentially preventable disorder, is a good model to study the total COI. The one-time expenditure at present costs to the nation to treat all the prevalence cases of seizure disorder associated with SCG is to the tune of INR 1.184 billion (US$ 2.605 million) and 0.0037% of GNP.     

Evaluation of cysticercus fasciolaris antigen for the immunodiagnosis of neurocysticercosis.

Cysticercus cellulosae antigen has been frequently used to detect antibodies for immunodiagnosis of neurocysticercosis. We have, for the first time, used membrane extract of cysticercus fasciolaris, the larval stage of Taenia taeniaeformis, in ELISA, with successful results. IgM and IgG antibodies against cysticercus were measured in serum from cases of neurocysticercosis (217), normal and diseased controls (89). 203 sera from cases of neurocysticercosis were positive for either or both IgG and IgM antibodies while 157/217 cases showed IgM and 158/217 showed IgG antibodies. Ten controls showed false postivity in IgG ELISA. Eight of these cases also had IgM antibodies. The test had an overall sensitivity of 93.54% and a specificity of 84.2% with a positive predictive value of 93.54% and a negative predictive value of 84.2%. Cysticercus fasciolaris can be conveniently produced in the experimental laboratory host, Rattus rattus, and would be of practical value in the immunodiagnosis of cysticercosis in humans.     

Cutaneous reactions in patients with solitary cysticercus granuloma on phenytoin sodium

Several medical conditions are believed to be associated with an increased risk of cutaneous adverse reactions to anti-epileptic drugs. The aim of this study was to study the frequency and nature of cutaneous reactions in a cohort of patients being treated with phenytoin sodium for seizures, who were divided into those with a solitary cysticercus granuloma (SCG) and those with a condition other than SCG, to determine if the presence of SCG increases the risk of cutaneous adverse reaction to phenytoin. A cohort of 117, consecutively begun on treatment with phenytoin for seizure control, were followed up prospectively for the development of cutaneous reactions. There were 63 patients with SCG upon imaging and 54 patients to whom phenytoin was administered for seizures due to causes other than SCG or multiple neurocysticercosis. Cutaneous reactions were significantly more common (p = 0.02) in patients with SCG (9/63 patients; 14.3%) than in controls (2/54 patients; 3.7%). The spectrum of skin reactions in patients with SCG included benign skin rash (n = 3), anticonvulsant hypersensitivity syndrome (n = 4), Stevens-Johnson syndrome (n = 1), and urticaria (n = 1). Individuals with seizures due to SCG have a high incidence of cutaneous adverse reactions to phenytoin. This fact should be kept in mind when initiating them on treatment with this anti-epileptic drug.     

Validation of diagnostic criteria for solitary cerebral cysticercus granuloma in patients presenting with seizures

Objective - To evaluate a set of clinical and computed tomographic (CT) criteria (previously described by us) to predict the diagnosis of a solitary cerebral cysticercus granuloma (SCCG) at initial presentation, in patients presenting with seizures. Material and methods - The diagnostic criteria were applied prospectively to patients presenting with seizures and solitary lesion on the CT scan. The clinical diagnostic criteria were as follows: seizures should be the presenting complaint; there should be no evidence of persistent raised intracranial pressure, progressive neurological deficit or an active systemic disease. The CT diagnostic criteria were: evidence of a solitary contrast enhancing lesion measuring 20 mm or less in its maximal dimension without a shift of the midline structures due to the surrounding oedema. A diagnosis of SCCG was made only when all the clinical and CT criteria were fulfilled. Over a period of 36 months, we managed 401 patients presenting with seizures and a solitary mass on the CT scan; 215 met the criteria for the diagnosis of an SCCG. Results - Of the 215 patients initially diagnosed to have an SCCG, 197 were ultimately determined to have that diagnosis (true positive diagnosis) while 16 were excluded because of lack of follow-up CT assessment. Two of the 215 patients with the initial diagnosis of an SCCG subsequently had histological diagnosis of a secondary metastasis and a pyogenic abscess (false positive diagnosis). Our set of diagnostic criteria for SCCG had a sensitivity of 99.5%; specificity of 98.9%; a positive predictive value of 99%; and a negative predictive value of 99.5%. The likelihood ratios for the positive and negative tests were 92.99 and 0.005 respectively. Conclusions - Our diagnostic criteria help in not only accurately identifying an SCCG but also in differentiating it from a solitary tuberculoma and other brain masses. However, confirmation of the diagnosis of an SCCG is only obtained at follow-up evaluation and therefore careful clinical and CT re-evaluation is essential in all patients initially diagnosed to have an SCCG.     

Cerebral cysticercus granuloma associated with a subdural effusion.

The association of a solitary cerebral cysticercus granuloma with a subdural effusion is being reported. The granuloma and the effusion resolved following albendazole therapy. We speculate that the spread of the inflammatory changes around the granuloma to the subdural space could have led to the development of the subdural effusion.     

New solitary cysticercus granulomas causing recurrent symptoms in patients with resolved solitary granulomas

Recurrence of symptoms in a patient with a resolved solitary cerebral cysticercus granuloma (SCCG) is uncommon. Recurrent seizures in these patients are generally attributed to an epileptogenic scar or calcific residue of the granuloma. We report two patients with recurrent seizures and one patient with headache; all three patients were previously diagnosed to have SCCG and had complete resolution of the granuloma on follow-up imaging. Computed tomography (CT) at the time of recurrent symptoms showed a SCCG at a site different from the initial lesion, but in the same cerebral hemisphere in all the three patients. Since a new lesion can cause recurrent symptoms in patients with a resolved SCCG, repeat imaging should be performed in all these patients. We also postulate that recurrent cysticercal lesions in patients who have previously had a SCCG, tend to be solitary.     

Cerebellopontine angle cysticercus and concurrent vascular compression in a case of trigeminal neuralgia

The authors present the case of a 59-year-old woman with an 8 months history of lancinating pain and hyphestesia on the right side of the face along with hearing impairment. She had poor tolerance to carbamazepine. A non-enhancing cystic image was observed at the right cerebellopontine angle on magnetic resonance imaging. The patient underwent surgery. Through a right retromastoid minicraniectomy and under microscopic magnification the VII and VIII cranial nerve complex was found involved by multiple adhesions around a cysticercus. After the cyst was removed a loop of the anteroinferior cerebellar artery was identified compressing the V right nerve at its root entry zone. Decompression was performed by the insertion of a Teflon implant. The postoperative course was uneventful and trigeminal neuralgia (TN) disappeared after surgery. Five previous cases of cranial nerve hyperactive dysfunction syndromes, four of trigeminal neuralgia and one of hemifacial spasm associated to cerebellopontine angle cysticercosis are briefly commented. We suggest that in some of these cases microvascular compression was probably present, and during surgery of cerebellopontine angle cysticercus by either trigeminal neuralgia or hemifacial spasm, vascular compression must be carefully searched and treated when found.     

Outcome of short-term antiepileptic treatment in patients with solitary cerebral cysticercus granuloma

OBJECTIVES: The duration of antiepileptic drug (AED) therapy in cases of solitary cerebral cysticercus granuloma (SCCG) presents a major dilemma and the efficacy of short-term (6 months) vs long-term (2 years) AED therapy has been studied. MATERIALS AND METHODS: Prospective randomized study of short-term vs long-term AED treatment with SCCG has been undertaken. A total of 206 subjects with new onset seizures with SCCG were randomized into two groups: group A (98 patients) were treated for 6 months and group B (108 patients) were treated for 2 years with AED therapy. The patients were evaluated periodically during and at least 18 months after the tapering of drugs. RESULTS: Partial seizures with or without secondary generalization has been found to be the commonest manifestation occurring in 80.6% of patients with SCCG. In group A 66.3% and in group B 57.4% patients showed complete resolution of computerized tomographic lesion and rest had punctated residual calcification. Statistically, no significant difference in the recurrence of seizures was found in two groups with disappearance of lesion but the difference between calcified residua and complete resolution subset was significant. In patients having residual calcification, 42.2% in group A and 21.7% in group B had recurrence of seizures and the difference was statistically significant (Z = 1.97, P < 0.05). CONCLUSIONS: The study revealed that SCCG with epilepsy is a benign self-limiting disease. A longer duration of therapy is not warranted in patients having total resolution of lesion. Calcified lesion was found to be the most common cause of recurrence of seizures. Higher recurrence rate was observed in short-term therapy in patients having calcified lesions and may require long-term AED treatment.     

Unusual cause for bilateral trigeminal neuralgia: unilateral racemous cysticercus of cerebellopontine angle. Case report

We report the case of a 42-year-old woman with a racemous cystecercus in the right cerebellopontine angle (CPA), who presented with bilateral trigeminal neuralgia. The parasite was completly removed via a right suboccipital craniotomy. On the first postoperative day, the patient indicated that the pain disappeared. The neuralgia was caused by two probable mechanisms: a distortion of the brain stem and compression of the nerve against an arterial loop at the entry zone or arachnoiditis caused by the parasite in the both CPA cisternae. This case demonstrates the advisability of obtaining imaging studies in all patients with trigeminal neuralgia before starting any management. We must always remind that the cysticercus may be a differential diagnosis of CPA lesions.