Gaps in treatment of epileptic seizures in a Zambian rural area.

BACKGROUND: Epilepsy is a multifactorial neurological disorder, including parasitic infections of the brain such as neurocysticercosis (NCC). People with epileptic seizures (PWES) in low and middle-income countries often do not receive appropriate treatment, which besides epileptic seizures, may also lead to reduced quality of life and possibly death. The objective of this study was to describe gaps in treatment of epileptic seizures in a Zambian rural area. METHODS: A cross-sectional study was conducted in Sinda district of Zambia between August and October 2018. PWES identified from clinic records and with the help of community healthcare workers were recruited. Two questionnaires, one to PWES and the other to local healthcare workers, were administered to describe the treatment gap. RESULTS: A total of 146 PWES and 43 healthcare workers were interviewed. Of the 146 PWES, 131 had taken anti-seizure medication (ASM) at some point since their seizure onset, of which 49.6% were on current treatment. Only 18.3% were on continuous ASM, an overall treatment gap of 83.6%. Over 55% of healthcare workers did not know the relationship between epilepsy and NCC. The risk factors associated with lack of appropriate treatment were stock-outs of ASMs, lack of diagnostic equipment, poor patient follow-up, and PWES opting for traditional medicine. CONCLUSION: The treatment gap is substantial in Sinda district. The causes are multifactorial, involving shortcomings at the level of healthcare facilities, communities, and individuals. Directed training of healthcare workers and significant improvements in the supply and dispensing of ASMs will be key in substantially reducing the gap.

Mielopatía dorsal aguda como presentación atípica de una neurocisticercosis espinal / Acute dorsal myelopathy as an atypical presentation of spinal neurocysticercosis

La neurocisticercosis espinal es una enfermedad infecciosa poco frecuente. Su presentación puede ser extraespinal o intraespinal y la mayoría de casos es de evolución subaguda o crónica. Se presenta el caso de una paciente mujer de 55 años, natural y procedente de Lima, Perú, con cuadro clínico de una paraparesia aguda secundaria a una mielopatía dorsal por lesiones quísticas de cisticercosis espinal. La paciente recibió tratamiento médico y quirúrgico con una evolución clínica y de imágenes favorable. Es importante considerar en nuestro contexto epidemiológico, la cisticercosis espinal como diagnóstico diferencial, ante un cuadro clínico de mielopatía aguda, ya que el adecuado enfoque diagnóstico y tratamiento oportuno de esta rara entidad pueden mejorar el pronóstico de los pacientes.

Spinal neurocysticercosis is an infectious and rare disease. Its presentation can be extraspinal or intraspinal and most cases are of subacute or chronic evolution. We report the case of a 55-year-old female patient from Lima, Peru with a 2-day history of acute paraparesis secondary to dorsal myelopathy due to cystic lesions of spinal cysticercosis. The patient received medical and surgical treatment with a favorable clinical and imaging evolution. In our epidemiological context, it is important to consider a spinal cysticercosis as a differential diagnosis when faced with a clinical picture of acute myelopathy, since the appropriate diagnostic approach and timely treatment of this rare entity can improve the prognosis of patients.

The many facets of disseminated parenchymal brain cysticercosis: A differential diagnosis with important therapeutic implications.

Neurocysticercosis (NCC), the infection of the nervous system by the cystic larvae of Taenia solium, is a highly pleomorphic disease because of differences in the number and anatomical location of lesions, the viability of parasites, and the severity of the host immune response. Most patients with parenchymal brain NCC present with few lesions and a relatively benign clinical course, but massive forms of parenchymal NCC can carry a poor prognosis if not well recognized and inappropriately managed. We present the main presentations of massive parenchymal NCC and their differential characteristics.

Parasitic Infections of the Nervous System.

PURPOSE OF REVIEW: This article reviews how parasites affect the human nervous system, with a focus on four parasitic infections of major public health importance worldwide, two caused by protozoa (malaria and toxoplasmosis) and two by helminths (neurocysticercosis and schistosomiasis). RECENT FINDINGS: Parasitic infections in humans are common, and many can affect the central nervous system where they may survive unnoticed or may cause significant pathology that can even lead to the death of the host. Neuroparasitoses should be considered in the differential diagnosis of neurologic lesions, particularly in individuals from endemic regions or those with a history of travel to endemic regions. SUMMARY: Cerebral malaria is a significant cause of mortality, particularly in African children, in whom infected red blood cells affect the cerebral vessels, causing severe encephalopathy. Neurocysticercosis is the most common cause of acquired epilepsy worldwide and has varied clinical presentations, depending on the number, size, and location of the parasites in the nervous system as well as on the host's inflammatory response. Toxoplasmosis is distributed worldwide, affecting a significant proportion of the population, and may reactivate in patients who are immunosuppressed, causing encephalitis and focal abscesses. Schistosomiasis causes granulomatous lesions in the brain or the spinal cord.

Post-Infective Hydrocephalus.

BACKGROUND: Post-infective hydrocephalus (PIH) arises as a complication of any CNS infection, and can be either communicating or noncommunicating. OBJECTIVE: The aim of this article is to study the various causes of PIH and its pathophysiology and treatment. MATERIAL AND METHODS: The literature was searched for articles describing the causes of PIH. RESULTS: Common causes of PIH are CNS tuberculosis (TB), neurocysticercosis, and perinatal or neonatal infection. TBM is most likely to result in hydrocephalus out of all these manifestations of CNS TB, and hydrocephalus is more likely to occur early in the course, typically 4-6 weeks after the onset of TBM, and is more common among children as compared to adults. A trial of medical management (antitubercular therapy, steroids, and decongestants) can be given to patients with communicating hydrocephalus. Ventriculoperitoneal shunt is the most employed method of CSF diversion in these patients. Though traditionally considered contraindicated, many recent studies have found ETV to be a reasonable option in patients with PIH. HCP in patients with neurocysticercosis can be associated with intraventricular cysts and racemose cysts in the basal subarachnoid cisterns. Surgical intervention is required either for cyst removal or CSF diversion. Endoscopic approaches can be used to remove the intraventricular cysts, which takes care of the HCP. PIH in infants can result either from antenatal infections (TORCH infections) or postnatal infections such as meningitis. CONCLUSIONS: Management of PIH can be challenging. Management has to be individualized.

Case Report: Neurocysticercosis Acquired in Australia.

Neurocysticercosis (NCC) is a disease caused by infection of the central nervous system with the larval stage of the tapeworm Taenia solium. This disease is endemic in many parts of the world, including Africa, Asia, and Latin America, where animal husbandry practices are common such that pigs reared for human consumption ingest feces from humans infected with T. solium. Neurocysticercosis is rarely acquired in economically affluent regions, including North America, Central Europe, Japan, and Australasia, and in countries where pork consumption is discouraged by religious or social practices. In these countries, NCC is usually diagnosed in immigrants or returning travelers who have spent time in endemic regions. Here, we report a case of NCC in a 25-year-old woman presenting with worsening visual symptoms in association with headache, diagnosed previously as a migraine with visual aura. This person had always lived in Australia and had never traveled overseas to a country endemic for T. solium. The unusual features of the clinical presentation and epidemiology are highlighted to raise physicians' awareness that attention needs to be paid to the risk of autochthonous infection occurring in non-endemic countries.

Co-infection of neurocysticercosis with Japanese encephalitis: coincidence or synchronism?

We report the case of an eight-year-old boy who presented with an acute encephalitis and was confirmed to have Japanese encephalitis (JE). In addition, we found the vesicular stage of neurocysticercosis (NCC). The co-occurrence of JE and NCC was thought to be synergistic as there is some evidence that in presence of NCC, the neuroinvasiveness and virulence of JE is greater and associated with poor outcome.

Systematic Review and Meta-Analysis of Management Strategies and Outcomes in Adult Spinal Neurocysticercosis.

OBJECTIVE: Spinal involvement in neurocysticercosis is rare and can lead to debilitating injury if not diagnosed and treated early. We aim to provide the reader with a thorough analysis of the best available evidence regarding patient characteristics, optimal treatment modality, and outcomes in cases of spinal neurocysticercosis. METHODS: A systematic review of the literature using PubMed, Google Scholar, and Web of Science electronic databases was made according to the PRISMA guidelines. An illustrative case of intramedullary-cervical spinal disease is also presented for illustrative purposes. RESULTS: A total of 46 reports of 103 patients fitting the screening criteria were identified. Isolated spinal involvement was seen in 46.15% of patients. Most infections (76.92%) had an intradural extramedullary localization, with 43.27% of cases involving >1 spinal cord level. The most common presenting symptoms were motor deficits (77.88%), pain syndromes (64.42%), and sensory deficits (53.85%). Combined surgical resection and pharmacologic therapy was the most frequently used treatment modality (49.04%) and had the highest proportion of patients reporting symptomatic improvement at follow-up (78.43%). Combination therapy had a significantly higher rate of neurologic recovery compared with surgery alone (P = 0.004) or medical treatment (P = 0.035). CONCLUSIONS: Spinal involvement in neurocysticercosis should be considered in patients from or who traveled to endemic areas presenting with ring-enhancing lesions. Combined treatment with surgery followed by cysticidal and steroid medication seems to be superior to surgery or medical treatment in isolation and seems to provide the highest chances of recovery.

Update on the major imported helminth infections in travelers and migrants.

Helminth infections cause considerable morbidity worldwide and may be frequently underdiagnosed especially in areas of lower endemicity. Patients may harbor latent infections that may become symptomatic years or decades after the initial exposure and timely diagnosis may be critical to prevent complications and improve outcomes. In this context, disease in special populations, such as immunosuppressed patients, may be of particular concern. Heightened awareness and recent diagnostic developments may contribute to the correct management of helminth infections in nonendemic regions. A review of the main helminth infections in travelers and migrants (strongyloidiasis, taeniasis-neurocysticercosis and schistosomiasis) is presented, focusing on epidemiology, developments in diagnosis, treatment and prevention.

Neurocysticercosis.

Neurocysticercosis (NCC) is one of the common parasitic central nervous system (CNS) infections. Improperly cooked pork and eggs of the tapeworm Taenia solium, entering the body through the feco-oral route, are the common sources of its infection. Affected person may remain asymptomatic for long periods and can present with a variety of neurological manifestations, including focal neurological deficits and generalized seizures. Neuroimaging along with serological test can aid in its diagnosis. Treatment of NCC varies from case to case and must always be individualized based on the patients' condition. Common therapeutic strategies include surgery and treatment with drugs, such as antiparasitic agents (albendazole) and corticosteroids (hydrocortisone), apart from other agents which are based on the patient presentation. Proper prevention strategy has to be followed to control the spread of infection within and among the individuals. We herewith present a case of NCC in a tertiary care hospital of Hyderabad, India.

Neurocysticercosis cases identified at Sanglah Hospital, Bali, Indonesia from 2014 to 2018.

Neurocysticercosis (NCC) was first reported in the province of Bali, Indonesia in 1975. Since this time, sporadic cases have been reported annually. This study reports information on 29 NCC cases (20 males and 9 females) admitted to a referral hospital in Denpasar, Bali from 2014 until 2018. Twenty-four cases were from Bali, 2 were from the province of East Nusa Tenggara, and 3 were from the Democratic Republic of Timor-Leste. Mean patient age was 37.2 years and 69.0% (20/29) were male. Epileptic seizures were the most common clinical manifestation (65.5%, 19/29). Serology (ELISA) was used in 14 cases (48.2%, 14/29), but only 6 cases, including one case with an inactive calcified lesion, were positive (42.9%, 6/14). Two cases underwent surgical resection after their lesions were initially misdiagnosed as brain tumors. These hospital-based findings are discussed along with the present status of NCC in Bali.

Neurocysticercosis and HIV Infection: what can we learn from the published literature?

OBJECTIVE: Infections caused by the human immunodeficiency virus (HIV) and by the larvae of Taenia solium (i.e., cysticercosis) are still widespread in many developing countries. Both pathologies modify host immune status and it is possible that HIV infection may modulate the frequency and pathogeny of cysticercosis of the central nervous system (i.e., neurocysticercosis [NCC]). To describe published cases of NCC among HIV-positive patients and to evaluate whether the characteristics of NCC, including frequency, symptoms, radiological appearance, and response to treatment differed between HIV-positive and HIV-negative patients. METHODS: Forty cases of NCC/HIV co-infected patients were identified in the literature. Clinical and radiological characteristics, as well as response to treatment, were compared with non-matching historical series of NCC patients without HIV infection. RESULTS: Most of these patients had seizures and multiple vesicular parasites located in parenchyma. Clinical and radiological characteristics were similar between HIV-positive and HIV-negative patients with NCC, as well as between immunocompromised and non-immunocompromised HIV-positive patients. CONCLUSION: Our review did not reveal clear interactions between HIV and NCC. This may be partially due to the small number of cases and reliance on published research. A systematic, multi-institutional effort aiming to report all the cases of this dual pathology is needed to confirm this finding and to clarify the possible relationship between both pathogens.

Neurocysticercosis and HIV Infection: what can we learn from the published literature? / Neurocisticercosis e infección por VIH: ¿Qué se puede aprender de la literatura reportada?

ABSTRACT Infections caused by the human immunodeficiency virus (HIV) and by the larvae of Taenia solium (i.e., cysticercosis) are still widespread in many developing countries. Both pathologies modify host immune status and it is possible that HIV infection may modulate the frequency and pathogeny of cysticercosis of the central nervous system (i.e., neurocysticercosis [NCC]). Objective: To describe published cases of NCC among HIV-positive patients and to evaluate whether the characteristics of NCC, including frequency, symptoms, radiological appearance, and response to treatment differed between HIV-positive and HIV-negative patients. Methods: Forty cases of NCC/HIV co-infected patients were identified in the literature. Clinical and radiological characteristics, as well as response to treatment, were compared with non-matching historical series of NCC patients without HIV infection. Results: Most of these patients had seizures and multiple vesicular parasites located in parenchyma. Clinical and radiological characteristics were similar between HIV-positive and HIV-negative patients with NCC, as well as between immunocompromised and non-immunocompromised HIV-positive patients. Conclusion: Our review did not reveal clear interactions between HIV and NCC. This may be partially due to the small number of cases and reliance on published research. A systematic, multi-institutional effort aiming to report all the cases of this dual pathology is needed to confirm this finding and to clarify the possible relationship between both pathogens.

RESUMO Las infecciones causadas por el virus de inmunodeficiencia humana (VIH) y la larva de la Tenia solium siguen estando diseminadas en países en vías de desarrollo. Ambas patologías modifican el estado inmune y es posible que la infección por el VIH module la frecuencia y la patología de la neurocisticercosis (NCC). Objetivo: Describir los casos publicados de NCC en los pacientes VIH positivos y evaluar si las características de la NCC, incluyendo frecuencia, síntomas, presentación radiológica, respuesta a tratamiento, difieren entre los sujetos VIH positivos y VIH negativos. Métodos: Cuarenta casos con coinfección NCC/VIH fueron identificados en la literatura. Se compararon sus características clínico-radiológicas, así como su respuesta al tratamiento con diferentes series de casos históricos no pareados. Resultados: La mayoría de los pacientes NCC/VIH tenían epilepsia y múltiples parásitos vesiculares en el parénquima. Las características clínico-radiológicas de la NCC así como la evolución de los pacientes fueron similares entre pacientes VIH positivos y negativos, así como entre pacientes VIH inmunocomprometidos y no inmunocomprometidos. Conclusión: No encontramos interacciones claras entre VIH y NCC. Este resultado puede haber sido influenciado por el pequeño número de casos y la parcialidad de la información publicada. Un esfuerzo multiinstitucional, sistemático encaminado a reportar todos los casos de esta patología dual es necesario para confirmar estos resultados y esclarecer la relación entre patógenos.

Neurocysticercosis: mimics and chameleons.

Neurocysticercosis is the most common parasitic neurological disease worldwide, yet in Europe, it remains relatively uncommon, with many practitioners rarely seeing a case. However, immigration and international travel mean that it is becoming increasingly recognised and diagnosed in developed countries. Being a treatable condition, it is essential to be familiar with the diagnosis and to appreciate its mimics and breadth of its possible clinical presentations.

Neurocysticercosis and epilepsy in sub-Saharan Africa.

Neurocysticercosis is a public health problem and the leading cause of epilepsy in developing countries especially in sub-Saharan Africa (SSA). In this paper, the authors review the epidemiology of cysticercosis and neurocysticercosis, as well as the non-specific clinical manifestations which render clinical diagnosis challenging especially in the sub-Saharan African context. Special attention is given to the association of epilepsy and neurocysticercosis, the former being the most common symptom of the later, and the role of the later in epileptogenesis is discussed. The state of the art guidelines regarding diagnostic tests and treatment options are discussed and proposals for prevention are made, given the specific socio-culturaland economic context of the endemic countries, mostly in SSA.

Pediatric Neurocysticercosis.

Neurocysticercosis is the most common helminth infection of nervous system in humans caused by the encysted larvae of Taenia solium. It is a major cause of epilepsy in tropical areas and the most common cause of focal-onset seizures in North Indian children. Children with neurocysticercosis have pleomorphic manifestations depending on the location, number and viability of the cysts and host response. In endemic areas, neurocysticercosis should be clinically suspected in any child with recent-onset seizures, headache or focal motor deficits where there is no other suggestion of an underlying neurological disorder. Diagnosis of neurocysticercosis is essentially based on neuroimaging; visualization of a scolex is diagnostic. Management includes use of cysticidal drugs usually albendazole, which seems to be effective for lesion resolution and seizure remission, use of steroids and anti-epileptic drugs. Single lesions portend good prognosis with resolution of lesions in >60% of the cases within 6 mo and good seizure control. Prognosis is guarded in cysticercus encephalitis, racemose and extraparenchymal neurocysticercosis.