Albendazole therapy for subarachnoid cysticerci: clinical and neuroimaging analysis of 17 patients.

Seventeen patients with subarachnoid cysticerci received albendazole at doses of 15 mg/kg/day for eight days. All patients also received corticosteroids during the trial. Evaluation of the therapeutic response consisted of the comparison of the number of cysts shown by CT before and three months after treatment, and the evaluation of the clinical status of the patients before and after the trial. Before treatment, the 17 patients had 30 subarachnoid cysticerci, 11 of which were > 50 mm in diameter. Seventeen cysts were located at the convexity of cerebral hemispheres, seven at the sylvian fissure, five at the ambiens cisterns, and one at the cerebellopontine angle cistern. Fourteen patients had seizures, 10 had hemiparesis, three were demented, one had diminution of visual acuity, and one had hemifacial spasm. Brain CT obtained after therapy showed resolution of 27 cysts (90% effectiveness). Fourteen (82%) patients had total resolution of all cysts. All but three patients were asymptomatic. Remaining deficits included hemiparesis in two patients and diminution of visual acuity in one. It is concluded that albendazole is an effective treatment for subarachnoid cysticerci as it causes disappearance of most lesions on CT, and produces considerable improvement in the clinical manifestations of the patients.     

Therapy for neurocysticercosis

Therapy for neurocysticercosis has advanced during the last 20 years with the advent of albendazole (Zentel) and praziquantel (Cysticide). Albendazole is the current medication of choice for the treatment of neurocysticercosis and is recommended for symptomatic patients with multiple viable cysts in the brain parenchyma. Albendazole may also be useful in extraparenchymal cysticercosis, especially in the subarachnoid racemose form, when complete surgical resection of the cysts is usually impracticable. Currently, there is an intense debate over the value and safety of anticysticercal therapy. Causes for failure of anticysticercal therapy include high inter-individual variability in plasma concentration of albendazole sulfoxide and the complex interactions of several drugs with the albendazole metabolite. Furthermore, albendazole sulfoxide is an enantiomeric mixture of (+)- and (-)-albendazole sulfoxide with accumulation of the (+)-enantiomer in the cerebrospinal fluid. However, the question over which enantiomer is effective against cysticerci remains to be clarified.     

Albendazole trial at 15 or 30 mg/kg/day for subarachnoid and intraventricular cysticercosis

Thirty-six patients with subarachnoid and intraventricular cysticercosis were randomly assigned to receive albendazole at 15 or 30 mg/kg/day plus dexamethasone for 8 days. Results favored a higher dose, with larger cyst reduction on MRI at 90 and 180 days and higher albendazole sulfoxide levels in plasma. An albendazole course at 30 mg/kg/day combined with corticosteroids is safe and more effective than the usual dose. A single treatment was insufficient in intraventricular and giant cysts.     

Dexamethasone increases plasma levels of albendazole

Summary Therapy of neurocysticercosis with cysticidal drugs is frequently complicated by the exacerbation of symptoms that follows the inflammation triggered by the acute destruction of cysticerci. Treatment of such adverse reactions with dexamethasone is highly effective. However, it has been shown that dexamethasone lowers the plasma levels of praziquantel, thus reducing its cysticidal efficacy. We measured plasma levels of albendazole, another strong cysticidal drug, when dexamethasone was given simultaneously. We found that dexamethasone increased the plasma levels of albendazole by about 50% (P<0.002); hence, it seems that cysticercosis and the ensuing inflammation can be treated simultaneously with albendazole and dexamethasone without diminishing the efficacy of the cysticidal drug.     

Transitory alexia without agraphia: a disconnection syndrome due to neurocysticercosis

We describe a 65-year-old male who presented with acute onset inability to read, without any difficulty in writing. A clinical diagnosis of alexia without agraphia was made and the patient was subjected to routine investigations including contrast MRI. MRI showed a ring-enhancing lesion in left occipital area, suggestive of neurocysticercosis supported by quantitative enzyme-linked immunosorbant assay from purified cell fraction of taenia solium cysticerci (PCF-ELISA). Patient was treated with albendazole and prednisolone for one week. The clinical manifestation as well as the radiological finding resolved after treatment.     

Bilateral cysticercosis of the optic nerve.

Bilateral cysticercosis of the optic nerves affected a man who presented with features suggestive of optic neuritis. Ultrasonography revealed bilateral sonolucent cystic lesions with central echo-dense, highly reflective structures behind the optic nerve heads. A subretinal cyst was present in one eye. Magnetic resonance imaging of the brain and orbit revealed multiple cysticerci in the brain, orbit, and eye. The subretinal cyst was removed by pars plana vitrectomy, and the other cysts resolved on treatment with albendazole.     

Symptomatic human neurocysticercosis

Abstract. Objective: To evaluate the relevance of exposure and host biological factors in the heterogeneity of the clinical, radiological and inflammatory picture of neurocysticercosis (NCC). Methods: 105 Mexican symptomatic NCC patients confirmed by imaging were studied before they received any specific treatment. The relationships studied were those between a) the patients characteristics (gender, age and level of exposure), b) the type of clinical picture and c) the radiological and inflammatory characteristics of the disease (number, aspect, localization of the parasites, and CSF leukocytecounts). Results: Results Seizures were the most frequent symptom and multiple subarachnoid cysticerci the most frequent localization. Symptomatology related to the developmental stage, number and localization of the parasites as well as the CSF leukocyte-counts. The total number of cysticercal lesions and of vesicular cysticerci increased with age,whereas the number of colloidal cysticerci decreased. CSF leukocyte-counts were higher in women than in men. Levels of exposure did not correlate with the clinical and radiological pictures. Conclusions: The variability found in the number, stage, localization and inflammation in the parasite lesions is strongly associated with the heterogeneity of NCC symptoms. The increased number of vesicular cysticerci and the decreased number of degenerating cysticerci with aging, as well as the prominence of inflammation in women suggest that immuno-endocrinological factors may play a role in susceptibility and pathogenesis. The data also show that with increasing age and exposure there is no increment in severity, a suggestion that there might be ways of regulating pathogenicity.     

Disseminated Cysticercosis

Disseminated cysticercosis is a rare form of cysticercosis in which the cysticerci spread out through the whole body. We report the first case of a 39-year-old Mongolian with disseminated cysticercosis. He visited our hospital with generalized tonic-clonic seizure. After extensive investigation from brain computed tomography (CT), spine magnetic resonance imaging (MRI), whole body MRI and pathologic biopsy, he was diagnosed as having cysticercosis involving the brain, subcutaneous tissue, and skeletal muscles through the whole body. We treated him with the albendazole in which case the followed MRI showed that numbers of cystic lesions were copiously decreased. We report an unsual case of disseminated cysticercosis treated with medical therapy.     

Short course of albendazole therapy for neurocysticercosis

Albendazole is now used for therapy of neurocysticercosis; however, duration of treatment has usually been empirically determined. In this study we shortened the length of therapy from one month in previous reports, to one week. Twelve patients with parenchymal brain cysticercosis were treated with albendazole for eight days at daily doses of 15 mg/kg of body weight. After three months of treatment the number of cysts on computed tomography had decreased from 185 to six; a 97% reduction in the number of lesions. Total remission of all cysts was seen in nine patients. Two cases had been unsuccessfully treated before with praziquantel, in both instances albendazole therapy was effective with 100% improvement. Our results indicated that a short course of albendazole is highly effective for treatment of neurocysticercosis.     

Plasma and CSF levels of albendazole and praziquantel in patients with neurocysticercosis

Albendazole or praziquantel were measured in plasma and cerebrospinal fluid (CSF) in 29 patients with neurocysticercosis. Mean levels of albendazole in plasma were 0.918 microgram/ml and in CSF were 0.392 microgram/ml and levels of praziquantel were 1.640 micrograms/ml in plasma and 0.398 microgram/ml in CSF, after doses of 15 and 50 mg/kg, respectively. Drug concentrations in CSF were 43% for albendazole and 24% for praziquantel. The drug levels obtained for both drugs showed ample individual variations that were not related to age, sex, presence of inflammation in the subarachnoid space, or therapeutic effectiveness; such variations seem to be due to individual differences in pharmacokinetics. Both drugs were effective and the doses currently used of each drug seem to be optimal for therapy of neurocysticercosis.     

Neurocysticercosis: Current knowledge and advances

Neurocysticercosis is the most common cause of acquired seizures worldwide. Most cases of this larval stage infection of the pork tapeworm Taenia solium occur in the developing world, although increasing numbers of cases are being recognized in the United States, particularly among Hispanic immigrants. The ability of the pathogen to persist for years within the host is the subject of immunologic and biochemical investigation. The major presenting symptom is seizures, although symptoms of obstructive hydrocephalus occur if cysts are located near the ventricles or in the subarachnoid spaces. Diagnosis is dependent on clinical, radiologic, and serologic data. Therapy with antiparasitic agents, especially albendazole, is effective in large burden disease or disease within sensitive neuraxis sites (the ventricles, the subarachnoid spaces). When patients with radiologically enhancing disease are given cysticidal therapy, there appears to be a reduction in seizure recurrences. Surgery is indicated for disease in selected anatomic sites. Longterm prevention requires attention to pork husbandry and general sanitation, including the potential use of mass human chemotherapy and porcine vaccination.     

Medical management of neurocysticercosis.

Neurocysticercosis is the most common parasitic disease of the central nervous system. Praziquantel and albendazole, the two antiparasitic drugs, have been reported to be effective against cysticercosis. Both the drugs effectively destroy the cerebral parenchymal cystic lesions. However, albendazole is possibly more effective in subarachnoidal, ventricular and spinal forms of cysticercosis, and frequently obviates the need for surgery. Initially, longer courses of albendazole and praziquantel had been advocated. Now even shorter treatment regimens are found equally effective. Complete course of praziquantel therapy can be administered in a single day with comparable efficacy instead of conventional treatment of 15 days. Similarly, one week therapy of albendazole is as effective as 30 days' treatment regimen. Recently, there is an intense debate whether anticysticercal treatment is useful and safe. Opponents of anticysticercal therapy argue that effectiveness of therapy is possibly a reflection of natural course of the disease. It has been observed that even if cysticercal lesions are left untreated, they either disappear spontaneously or calcify. Anticysticercal therapy is potentially risky, it may aggravate cerebral oedema, and may produce vasculitis and stroke, and several deaths have also been reported. To minimise these risks, concomitant corticosteroids should be administered especially, if there is a massive parasitic load. It is better to avoid anticysticercal treatment in patients with cysticercotic encephalitis. Doubts have been expressed that anticysticercal therapy really affects ultimate long-term clinical outcomes (e.g. control of seizure and possibility of seizure free state after discontinuation of antiepileptic drugs). So far, definite evidences in this regard, based on finding of well planned placebo-controlled studies, are lacking and an opinion that, there is an urgent need for such a study, has been expressed. Measures for effective prevention like provision for safe drinking water and safe excreta disposal should be emphasisfxed.     

Single parenchymal brain cysticercus in the acute encephalitic phase: definition of a distinct form of neurocysticercosis with a benign prognosis.

Fifty four patients with a single parenchymal brain cysticercus in the acute encephalitic phase were studied to outline the features of this form of the disease. Seizures were the presenting symptom in all cases. Twenty six patients had a single seizure and 28 had several seizures before admission. Neurological examination was normal in 45 patients and showed focal signs in nine. All patients had a single enhancing CT lesion; all but three lesions were < 20 mm. Anticonvulsants were started in every patient. Forty five patients were followed up for 18 (SD 6) months. Thirty seven of these 45 patients received albendazole. Four weeks after the trial, CT showed resolution of lesions in all cases. The remaining eight patients refused albendazole, and CT showed persistence of lesions by 16 weeks in six cases. At the end of the follow up, all patients who received albendazole were free of seizures as opposed to three of eight patients who did not receive the drug. Focal signs improved in the nine patients with these signs (all received albendazole). Recognition of this form of neurocysticercosis permits early treatment with albendazole that greatly improves the prognosis.     

囊虫性脑膜炎(附63例临床分析)

目的 分析63例囊虫性脑膜炎的临床资料，以加强对此病的认识，提高临床医师病的诊断率。方法 选取囊虫性脑膜炎患者63例，对其起病形式、临床症状与体征、辅助检查等进行分析。结果 患者多生活在囊虫病高发地区（95％）；慢性或亚急性起病（95％）；表现为反复发作性头痛（60％），可伴有发热（27％）或痴呆（15％），脑膜刺激征阳性（63％）；血嗜酸性细胞增加（50％）；CSF以淋巴细胞为主（47％），蛋白可升高，囊虫抗体阳性；皮下结节活检被证实为囊虫；非脑囊虫病的典型影像学表现，可伴有脑积水（49％）。结论 囊虫性脑膜炎是一种少见浆液性脑膜炎，应与结核性脑膜炎、霉菌性脑膜炎、梅毒性脑膜炎及原发或继发的脑膜癌变等鉴别。     

Randomized controlled trial of albendazole in new onset epilepsy and MRI confirmed solitary cerebral cysticercal lesion: effect on long-term seizure outcome

No trials to date have focused on long-term seizure outcome in solitary cerebral cysticercal lesion (SCCL), which is believed to produce a relatively benign form of epilepsy. This is a prospective randomized controlled study to evaluate the effect of Albendazole on long-term seizure outcome in patients with MRI-confirmed solitary cerebral cysticercal lesion (SCCL). One hundred and twenty-three patients with new-onset seizures and SCCL on contrast MRI were randomized to treatment with albendazole and followed for up to five years with serial MRI and clinical evaluation. At final analysis 103 patients (M-54, F-49) with a mean age of 18.6+/-10.7 years and follow-up period more than 12 months were included. The mean follow-up duration was 31.4+/-14.8 months (12-64). At one month follow-up more patients receiving albendazole were seizure-free (62% versus 49% for controls). Subsequently there was no significant difference in overall seizure outcome between the two groups. There was no correlation between seizure semiology, albendazole therapy and long-term seizure outcome. Baseline MRI showed active lesions in all; 23% remained active at 12 months with no difference between the albendazole and control groups. Patients whose lesions resolved at 12 months showed better seizure outcome. Reduction in mean cyst area was greater in the albendazole group as compared to the controls and the difference at six months was significant (p<0.05). At three months follow-up perilesional edema also resolved faster in albendazole group (p<0.05). Thus, albendazole did not alter the long-term seizure outcome in patients with SCCL and epilepsy. However, albendazole hastened resolution of SCCL on MRI, but interestingly 23% of lesions were still active 12 months after treatment.     

Therapy for neurocysticercosis. Comparison between albendazole and praziquantel.

Praziquantel and albendazole have been recently described as effective drugs for treatment of intraparenchymal brain cysticercosis. We performed a prospective study comparing the efficacy of these drugs. Twenty-two patients were treated with praziquantel and 21 with albendazole. In addition, 16 patients were treated with symptomatic drugs only and used as controls. Treatment was discontinued in two patients receiving praziquantel and one patient receiving albendazole owing to acute decompensation of the increased intracranial pressure, and one of them died. Albendazole and praziquantel were effective when compared with the control group. However, albendazole was significantly more effective than praziquantel in reducing the total number of cysts in the computed tomographic scans (88% vs 50%). Despite these results, however, analysis of clinical course showed a high frequency of neurologic sequelae. Considering the risks and fallibility of anticysticercal therapy, the real solution for this serious disease continues to be prophylaxis of infestation.     

Does albendazole affect seizure remission and computed tomography response in children with neurocysticercosis? A Systematic review and meta-analysis

A recent trial suggested that albendazole reduces seizures in adults with neurocysticercosis. There is still no consensus regarding optimal management of neurocysticercosis in children. The authors conducted a systematic review and meta-analysis to assess the efficacy of albendazole in children with neurocysticercosis, by searching the Cochrane Databases, MEDLINE, EMBASE, and LILACS. Three reviewers extracted data using an intent-to-treat analysis. Random effects models were used to estimate relative risks. Four randomized trials were selected for meta-analysis, and 10 observational studies were selected for qualitative review. The relative risk of seizure remission in treatment versus control was 1.26 (1.09, 1.46). The relative risk of improvement in computed tomography in these trials was 1.15 (0.97, 1.36). Review of observational studies showed conflicting results, likely owing to preferential administration of albendazole to sicker children.     

Selective sensitivity of cysts to praziquantel and albendazole in a case of cerebral cysticercosis]

A case of neurocysticercosis in a Za?rian patient with clinical and neuro-radiological follow-up is reported. Treatment with praziquantel resulted in the regression of only some of the cysts. Subsequent treatment with albendazole was effective, eliminating most of the remaining lesions. This case illustrates a selective sensitivity of cysts to praziquantel and albendazole in a single patient.     

Subarachnoid hemosiderin deposition after subarachnoid hemorrhage on T2*-weighted MRI correlates with the location of disturbed cerebrospinal fluid flow on computed tomography cisternography

A 72-year-old male was admitted with subarachnoid hemorrhage associated with a ruptured cerebral aneurysm. The aneurysm was treated with clipping soon after radiological examination. Eight weeks after the treatment, the patient suffered from secondary hydrocephalus resulting from blockage of the subarachnoid space due to subarachnoid granulation. Previous pathological examination revealed the granulation was associated with hemosiderin deposition. We investigated subarachnoid hemosiderin deposition in this patient using T2FNx01-weighted (T2FNx01-w) magnetic resonance image (MRI), a sensitive method for hemosiderin detection. computed tomography (CT) cisternography demonstrated that cerebrospinal fluid (CSF) flow was disturbed adjacent to sites of subarachnoid hemosiderin deposition on T2FNx01-w MRI. Placement of a ventriculo-peritoneal shunt contributed to neurological improvement. In this case, T2FNx01-w MRI was an effective means of diagnosing the location of disturbed CSF flow associated with subarachnoid hemosiderin deposition.     

Drug-induced psychosis associated with albendazole-ivermectin combination therapy

We report a case that experienced psychosis after combination therapy of albendazole and ivermectin. This case report represents the first report of psychosis caused by this combination therapy and its treatment with clonazepam.