Anthelmintics for people with neurocysticercosis.

BACKGROUND: Neurocysticercosis is a parasitic infection of the central nervous system by the larval stage of the pork tapeworm and is a common cause of seizures and epilepsy in endemic areas. Anthelmintics (albendazole or praziquantel) may be given alongside supportive treatment (antiepileptics/analgesia) with the aim of killing these larvae (cysticerci), with or without corticosteroid treatment. However, there are potential adverse effects of these drugs, and the cysticerci may eventually die without directed anthelminthic treatment. OBJECTIVES: To assess the effects of anthelmintics on people with neurocysticercosis. SEARCH METHODS: We searched the Cochrane Infectious Diseases Group Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, LILACS, the WHO ICTRP, and ClinicalTrials.gov, up to 21 October 2020. SELECTION CRITERIA: Randomized controlled trials comparing anthelmintics and supportive treatment (+/- corticosteroids) with supportive treatment alone (+/- corticosteroids) for people with neurocysticercosis. DATA COLLECTION AND ANALYSIS: Two review authors independently screened the title and abstract of all articles identified by the search. We obtained full-text articles to confirm the eligibility of all studies that passed screening. One review author extracted data, which a second review author checked. Two review authors assessed the risk of bias of each trial and performed GRADE assessments. In cases of disagreement at consensus discussion stage between review authors, we consulted a third review author. We calculated risk ratios (RR) for dichotomous variables, with 95% confidence intervals (CIs) for pooled data from studies with similar interventions and outcomes. MAIN RESULTS: We included 16 studies in the review. Only two studies investigated praziquantel and did not report data in a format that could contribute to meta-analysis. Most results in this review are therefore applicable to albendazole versus placebo or no anthelmintic. The aggregate analysis across all participants with neurocysticercosis did not demonstrate a difference between groups in seizure recurrence, but heterogeneity was marked (RR 0.94, 95% CI 0.78 to 1.14; 10 trials, 1054 participants; I2 = 67%; low-certainty evidence). When stratified by participants with a single cyst or multiple cysts, pooled analysis suggests that albendazole probably improves seizure recurrence for participants with a single cyst (RR 0.61, 95% CI 0.4 to 0.91; 5 trials, 396 participants; moderate-certainty evidence). All studies contributing to this analysis recruited participants with non-viable, intraparenchymal cysts only, and most participants were children. We are uncertain whether or not albendazole reduces seizure recurrence in participants with multiple cysts, as the certainty of the evidence is very low, although the direction of effect is towards albendazole causing harm (RR 2.05, 95% CI 1.28 to 3.31; 2 trials, 321 participants; very low-certainty evidence). This analysis included a large study containing a highly heterogeneous population that received an assessment of unclear risk for multiple 'Risk of bias' domains. Regarding radiological outcomes, albendazole probably slightly improves the complete radiological clearance of lesions (RR 1.22, 95% CI 1.07 to 1.39; 13 trials, 1324 participants; moderate-certainty evidence) and the evolution of cysts (RR 1.27, 95% CI 1.10 to 1.47; 6 trials, 434 participants; moderate-certainty evidence). More adverse events appeared to be observed in participants treated with either albendazole or praziquantel compared to those receiving placebo or no anthelmintic. The most commonly reported side effects were headache, abdominal pain, and nausea/vomiting. AUTHORS' CONCLUSIONS: For participants with a single cyst, there was less seizure recurrence in the albendazole group compared to the placebo/no anthelmintic group. The studies contributing to this evidence only recruited participants with a non-viable intraparenchymal cyst. We are uncertain whether albendazole reduces seizure recurrence for participants with multiple cysts. We also found that albendazole probably increases radiological clearance and evolution of lesions. There were very few studies reporting praziquantel outcomes, and these findings apply to albendazole only.

Observed or Predicted Albendazole Hepatotoxicity as an Indication for a Resection Procedure in Hepatic Hydatid Disease - A Short Series of Cases.

OBJECTIVE: To highlight the role of albendazole hepatotoxicity in the choice between drainage versus a resection procedure in hepatic hydatidosis. Methods: The charts of four patients were reviewed retrospectively. In three patients, albendazole caused more than 10-fold increases in transaminase levels and was stopped. One patient had concomitant autoimmune hepatitis. Results: In the first case, two large hydatid cysts involving the right and the left hepatic veins were detected. First, left lateral sectionectomy and ligation of the right posterior portal vein branches were performed. Hypertrophy of the remnant liver allowed a safe right posterior sectionectomy two months later. In the second patient, a 9-cm cyst in segments 6 and 7 was treated with pericystectomy. The third patient had a 6-cm centrally located cyst. Pericystectomy, removal of small vesicles from the anterior section bile duct, common bile duct exploration with a T-tube placement were performed. In the patient with auto-immune hepatitis, pericystectomy was chosen for two objectives: 1) to eliminate a cavity prone to recurrence in an immunosuppressed patient 2) to avoid albendazole that may complicate the interpretation of liver function tests. The postoperative period and early follow up of all patients was uneventful. The second and the fourth patients have been followed for 56 and 17 months respectively and no recurrence has been detected. Conclusions: A resection procedure eliminates the cavity and the need for adjuvant albendazole treatment. This is a vital advantage for the small subset of patients with severe albendazole hepatotoxicity.

Three day albendazole therapy in patients with a solitary cysticercus granuloma: a randomized double blind placebo controlled study.

A solitary cysticercus granuloma is a benign form of neurocysticercosis. Several reports have suggested albendazole is effective in early resolution of these lesions. A short duration (7 days) albendazole therapy has been found to be effective in treatment. In this study, we evaluated a "three day course" of albendazole in a prospective randomized double- blind trial. Sixty-seven consecutive patients who presented with new-onset seizures and a solitary cysticercus granuloma were randomly allocated to receive either albendazole (15 mg/kg/day for 3 days) or placebo. All patients were treated with antiepileptic drugs. Patients were followed up for 6 months. A repeat CT of the brain was obtained at the end of 6 months of follow-up. The end points were complete resolution of the lesion on CT scan and total seizure control at 6 months follow-up. In the albendazole group complete resolution of lesions was noted in 28 of 33 patients (84.8%), while in the control group only 14 of 34 patients (41.2%) had complete resolution of the lesion (p = 0.001). Partial resolution of lesion was seen in 2 patients (6%) in the albendazole group and 4 patients (11.8%) in the control group (p = 0.06). The lesion remained unchanged in 9 cases (26.5%) in the control group only. The lesion became calcified in 7 (20.6%) and 3 (9.1%) patients in the control and albendazole groups, respectively (p = 0.187). Seizure recurrence occurred in 3 patients (9.1%) in the albendazole and 1 patient (2.9%) in the control group (p = 0.239). The three days course of albendazole was effective in resolving lesions, but there was no significant difference in seizure recurrence rates between the two treatment groups.

Monocular blindness during therapy for cerebral neurocysticercosis.

Neurocysticercosis is endemic in India, cerebral and ocular manifestations being common. A 32 yr old man on treatment with Albendazole for cerebral neurocysticercosis for 10 days presented with 3 days of painful uniocular blindness. He had only light perception in the left eye, left pupil was non-reactive to light and left disc was edematous. B-scan of eye revealed retinal detachment due to sub retinal cyst and CT brain showed multiple parenchymal cysticerci. The natural history of ocular neurocysticercosis or enhanced sub-retinal inflammation due to Albendazole therapy could have resulted in the retinal detachment in this case.

Drug-Induced Liver Failure Requiring Liver Transplant: Report and Review of the Role of Albendazole in Managing Echinococcal Infection.

Albendazole is often used as adjunctive therapy in the treatment of echinococcal infection to reduce cyst viability before and prevent recurrence after surgical treatment. In this report, we present a 38-year-old Iraqi woman with Echinococcus initiated on albendazole therapy who developed acute liver failure 6 weeks after treatment. Investigation for common viral and autoimmune causes of liver injury was unremarkable, and a liver biopsy revealed changes consistent with severe, drug-induced liver injury. Despite discontinuation of albendazole, liver function continued to deteriorate, prompting rescue with an orthotopic liver transplant. Often used perioperatively in the management of Echinococcus infection, albendazole can induce idiosyncratic severe liver injury, mandating close monitoring for hepatotoxicity.

A trial of antiparasitic treatment to reduce the rate of seizures due to cerebral cysticercosis.

BACKGROUND: Neurocysticercosis is the main cause of adult-onset seizures in the developing world. Whether therapy with antiparasitic agents results in improved seizure control has been questioned because of the lack of adequate, controlled studies. METHODS: We conducted a double-blind, placebo-controlled trial in which 120 patients who had living cysticerci in the brain and seizures treated with antiepileptic drugs were randomly assigned to receive either 800 mg of albendazole per day and 6 mg of dexamethasone per day for 10 days (60 patients) or two placebos (60 patients). The patients were followed for 30 months or until they had been seizure-free for 6 months after the doses of the antiepileptic drugs had been tapered. The efficacy of treatment was measured as the decrease in the number of seizures after treatment. RESULTS: In the albendazole group, there was a 46 percent reduction in the number of seizures (95 percent confidence interval, -74 to 83 percent) during months 2 to 30 after treatment. This reduction, which was not statistically significant, was composed of a nonsignificant reduction of 41 percent in the number of partial seizures (95 percent confidence interval, -124 to 84 percent) and a significant 67 percent reduction in the number of seizures with generalization (95 percent confidence interval, 20 to 86 percent). Most of the difference in the number of partial seizures was attributable to a few patients who had many seizures during follow-up. The proportions of patients who had partial seizures during follow-up were similar in the two groups (19 of 57 in the albendazole group and 16 of 59 in the placebo group), but the patients in the placebo group had a greater tendency to have seizures with generalization (22 of 59, vs. 13 of 57 in the albendazole group; risk ratio, 1.63; 95 percent confidence interval, 0.91 to 2.92). More of the intracranial cystic lesions resolved in the albendazole group than in the placebo group. With the sole exception of abdominal pain, side effects did not differ significantly between the two groups. CONCLUSIONS: In patients with seizures due to viable parenchymal cysts, antiparasitic therapy decreases the burden of parasites and is safe and effective, at least in reducing the number of seizures with generalization.

Calcified neurocysticercosis lesions trigger symptomatic inflammation during antiparasitic therapy.

We report a patient with neurocysticercosis who developed numerous cerebral edematous lesions while undergoing cysticidal therapy. These lesions outnumbered viable cystic lesions seen before therapy. Most new lesions were subsequently found to be associated with former calcifications not seen on initial MR imaging. Calcified neurocysticercosis lesions can trigger inflammatory reactions during therapy, and the number and location of calcified neurocysticercosis lesions may influence treatment decisions.

Comparative Evaluation of Liposomal Albendazole and Tablet-Albendazole Against Hepatic Cystic Echinococcosis: A Non-Randomized Clinical Trial.

In this study, we aimed to compare the clinical efficacy of liposomal albendazole (L-ABZ) and tablet-albendazole (T-ABZ) for the treatment of human hepatic cystic echinococcosis (CE). Sixty patients with single cyst (CE1) or daughter cyst (CE2) were included in this study and were nonrandomly divided into the L-ABZ group (n = 30, 10  mg/kg per day, p.o., b.i.d.) and T-ABZ group (n = 30, 12-20 mg/kg per day, p.o., b.i.d.), respectively. The treatment duration lasted for 6 months, during which dynamic follow-up was carried out to evaluate the clinical efficacy through calculating the total effective rates (TERs). Measurement data and numerous data were analyzed by the chi-square test. Two-sided tests were performed for all the statistical tests. In our study, 2 patients were lost in the follow-up in the L-ABZ group. One patient was lost in the follow-up in the T-ABZ group, and 1 patient was withdrawal from the study due to receiving surgery. Significant difference was identified in the 3-month TERs of L-ABZ group and T-ABZ group (33.3% vs 76.7%, P < 0.05). Also, remarkable difference was noted in the 6-month TERs in the L-ABZ group and T-ABZ group (66.7% vs 93.3%, P = 0.01). No statistical difference was noticed in the incidence rate of adverse reactions in both groups (P > 0.05). Based on our study, both T-ABZ and L-ABZ are effective for treating human CE. The TER in the L-ABZ group is superior to that of T-ABZ.

Disseminated muscular cysticercosis with myositis induced by praziquantel therapy.

Cysticercosis, the infestation with the encysted larval stage of Taenia solium, is increasingly recognized as a major problem in most countries in Latin America, Asia, and Africa, involving mainly the central nervous system. Muscle involvement is also common, although it usually remains asymptomatic. We describe a case of disseminated muscular cysticercosis followed by myositis (fever, diffuse myalgia, weakness of the lower limbs, and inflammatory reaction around dying cysticerci) induced by praziquantel therapy, an event not described previously.

Nitazoxanide in the treatment of Taenia saginata and Hymenolepis nana infections.

Nitazoxanide , a nitrothiazole derivative, was tested in 22 patients infected with Taenia saginata and 18 infected with Hymenolepis nana. A single 25 mg/kg body weight dose was effective against T. saginata, while twice this dose level (50 mg/kg), also as a single dose, was required for treating H. nana infection. Tolerance of the drug was good at both dose levels used.

Comparative clinical studies of nitazoxanide, albendazole and praziquantel in the treatment of ascariasis, trichuriasis and hymenolepiasis in children from Peru.

Three randomized clinical studies were conducted in 2000 to evaluate the efficacy of nitazoxanide paediatric suspension compared to albendazole in the treatment of ascariasis and trichuriasis and praziquantel in the treatment of hymenolepiasis in children from Cajamarca, Peru. Nitazoxanide was administered at a dose of 100 mg (age 1-3 years) or 200 mg (age 4-11 years) twice daily for 3 days, albendazole as a 400-mg single dose and praziquantel as a 25-mg/kg single dose. Post-treatment parasitological examinations were carried out on 3 faecal samples, each collected on a different day between 21 and 30 days following initiation of treatment. Nitazoxanide cured 89% (25/28), 89% (16/18) and 82% (32/39) of the cases of ascariasis, trichuriasis and hymenolepiasis respectively compared with 91% (32/35), 58% (11/19) and 96% (47/49) for the comparator drugs. Each of the drugs produced egg reduction rates in excess of 98%. There were no significant adverse events or abnormalities in haematology or clinical chemistry values or urinalysis.

Treatment of hydatid disease.

Hydatid disease caused by Echinococcus granulosus presents medical, veterinary and economic problems worldwide. Hydatidosis can be treated by medical, surgical and percutaneous modalities. Benzoimidazole carbamates are effective against E. granulosus. Although mebendazole, the first benzoimidazole used, has some beneficial effects on the disease in selected patients, it has also been associated with treatment failure in some cases, perhaps because of its poor absorption. Albendazole, a more recently developed benzoimidazole, is more effective than mebendazole. Praziquantel, an isoquinoline derivative, has recently shown value in the treatment of human echinococcal disease and its use in combination with albendazole is recommended in some patients. Ultrasound guided cyst puncture is another choice of treatment which has been used successfully in selected patients, although anaphylactic and allergic reactions due to spillage of the cyst contents have occurred. Surgical therapy in echinococcal hydatid disease is indicated for large cysts with multiple daughter cysts, superficially located single liver cysts which have a risk of rupture, complicated cysts such as those accompanied by infection, compression or obstruction, and cysts located in vital organs or which are exerting pressure on adjacent vital organs. However, surgical therapy carries high risk of mortality, morbidity or recurrence. Therefore, medical therapy may be an alternative option in uncomplicated cysts and in patients at high risk from surgery. The adjuvant use of drugs with surgery and percutaneous treatment can also be recommended for some patients.

Continuous long-term albendazole therapy in intraabdominal cystic echinococcosis.

OBJECTIVE: To assess the therapeutic effects of long-term albendazole therapy in intraabdominal cystic echinococcosis. METHODS: Fifteen patients with a total of 45 cysts were treated with albendazole with dosage regimen of 20 mg.kg-1.d-1 for an average of 2.5 years. Repeated CT and ultrasound scannings (US) were performed after the end of therapy. The duration of follow-up was 3.6 years on average. The number, size and morphology of cysts were compared before and after treatment. RESULTS: The hydatid cysts were classified according to location and CT patterns into hepatic simple cysts, hepatic cysts with daughter cysts, hepatic/abdominal cysts and splenic cysts. The hepatic simple cysts responded most favorably to albendazole therapy, with an overall cure rate of 88.7%. The disappearance of cysts was observed in 43.0% of cases (15/35). Sixteen cysts (45.7%) became solidified or calcified, among which 8 cysts were completely calcified, 6 showed egg shell-like calcification of the cystic walls, and 2 showed solidification and calcification of cyst contents. Four patients had large hepatic cysts containing daughter cysts; the daughter cysts all disappeared after treatment, but one patient relapsed with the reappearance of daughter cysts at 4-year follow-up. Two splenic cysts also calcified. Two patients had peritoneal cysts; one calcified and the other one reduced in size. Among 15 patients treated, 9 were cured and 6 were improved. There was no serious toxic reactions with continuous long-term therapy in a small series of patients. CONCLUSIONS: Continuous long-term albendazole treatment of intraabdominal cystic echinococcosis is safe and effective in the treatment of hepatic simple cysts, and some daughter cysts, peritoneal secondary cysts and splenic cysts. No serious toxic reactions were found.

Perioperative benzimidazole therapy in human hydatid liver disease.

Primary treatment of liver hydatidosis is surgical, but the recurrence rate is about 10%. To minimize the risk of recurrence, 67 consecutive patients with liver hydatidosis were prospectively treated by mebendazole or albendazole for 5 days before surgery. During the operation the viability of the protoscoleces was assessed. Seventeen patients who had viable protoscoleces at the time of the operation received the same benzimidazole one extra month postoperatively, while the remaining 50 patients who had dead protoscoleces didn't receive postoperative therapy. None of the patients developed recurrence of the disease after a follow-up period of 15-67 months (average 41 months). These results suggest that a 5-day preoperative benzimidazole therapy either combined or not with a monthly postoperative course according to the viability of the protoscoleces at the time of operation, may erase the risk of recurrence after surgical treatment of the liver hydatidosis.

Metabolic acidosis induced by cetrimide-chlorhexidine solution in hydatid cyst surgery.

A patient with a large hydatid cyst of the left lobe of the liver developed metabolic acidosis following rather liberal use of cetrimide-chlorhexidine solution as a scolicidal agent. The progress and management of this complication are described in the patient is being reported.

Treatment of taeniasis with Puag-Haad: a crude extract of Artocarpus lakoocha wood.

Thirty-nine patients with tapeworm infection were treated with five grams of crude aqueous extract of Artocarpus lakoocha wood, "Puag-Haad". Seven of them vomited the drug immediately. Of the 32 patients, segments with scolices of Taenia saginata and of Taenia solium were recovered from 24 and 2 patients respectively. The side effects were vomiting and nausea.

[A short praziquantel regimen for the treatment of parenchymatous neurocysticercosis]. / Esquema corto de praziquantel para el tratamiento de la neurocisticercosis parenquimatosa.

OBJECTIVE: Fifteen-day praziquantel therapy for parenchymal neurocysticercosis has been shown to be effective. Plasma and cerebrospinal fluid concentrations of praziquantel peak two hours after administration. Maintenance of high concentrations of the drug for six hours may be an adequate therapy for the disease. METHODS: Thirty patients with parenchymal neurocysticercosis were treated with three oral doses of praziquantel(25 mg/kg) at two-hour intervals. Intramuscular dexamethasone (10 mg/day) was administered for three days after the praziquantel treatment. RESULTS: Cysts disappeared in 21 patients and showed a decrease in number of 30 to 60% in seven patients. Two patients remained without change. Considering the total number of cysts, this therapy showed a 70.7% eradication rate. Two patients had seizures, six reported headache, and nausea was frequently reported. Patients under antiepileptic treatment did not have seizures. CONCLUSION: The cost and duration of treatment with praziquantel were significantly reduced and the inflammation that follow the destruction of the parasite was treated sequentially.

NTZ trials for cryptosporidiosis.

AIDS: A phase I/II dose-ranging study of nitazoxanide (NTZ), a new drug for cryptosporidiosis, is opening this month at Cornell/New York Hospital. Previous rodent studies have shown NTZ had greater anti-cryptosporidiosis activity than paromomycin, at substantially lower doses, and a Malian trial (500mg twice daily) showed clinical improvement and clearance of cryptosporidia in two-thirds of those participating. Doubt, however, has risen that NZT's antidiarrheal effect may be due to its activity against other, concurrent parasitic infections, which may have been the primary cause of diarrhea in the people under study.^ieng

Necessity of lung resection in neglected cases of pulmonary hydatidosis.

In pulmonary hydatid disease, lung resection is not a desirable treatment. Two young boys, aged 9 and 15, presented at our institution, the 9-year-old with a destroyed lung as the result of a delayed diagnosis of a giant cyst; the second with a massive hemoptysis as the result of preoperative albendazole use. Both children underwent a lobectomy for the treatment of pulmonary hydatidosis. Delayed diagnosis and use of albendazole, respectively, were considered the causes necessitating lung resection in these cases of giant and complicated pulmonary hydatid disease.