Cysticercosis medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Cysticercosis is generally treated with combination of both anti parasitic drugs and anti inflammatory drugs. Symptomatic treatment is the mainstay therapy for neurocysticercosis. Surgerical removal sometimes necessary to treat Ophthalmic Cysticercosis and Subcutaneous Cysticercosis.
Medical Therapy
Not all cases of cysticercosis are treated and the use of albendazole and praziquantel is controversial.
Neurocysticercosis
Neurocysticercosis most often presents as headaches and acute onset seizures, thus the immediate mainstay of therapy is anticonvulsant medications. Once the seizures have been brought under control, antihelminthic treatments may be undertaken. The decision to treat with antiparasitic therapy is complex and based on the stage and number of cysts present, their location, and the patient's specific clinical presentation.[1] Antiparasitic treatment should be given in combination with corticosteroids and anticonvulsants to reduce inflammation surrounding the cysts and lower the risk of seizures. Albendazole is generally preferable over praziquantel due to its lower cost and fewer drug interactions.[2]
Asymptomatic cysts, such as those discovered incidentally on neuroimaging done for another reason, may never lead to symptomatic disease and in many cases do not require therapy.
Calcified cysts have already died and involuted. Further antiparasitic therapy will be of no benefit.
Ophthalmic cysticercosis
In ophthalmic disease, surgical removal is necessary for cysts within the eye itself while antihelminth drugs with steroids alone might be sufficient to treat cysts outside globe.Treatment recommendations for subcutaneous cysticercosis includes surgery, praziquantel and albendazole.
Subcutaneous cysticercosis
In general, subcutaneous disease does not need specific therapy. Painful or bothersome cysts can be surgically excised.
Antimicrobial Regimen
Neurocysticercosis
- Neurocysticercosis treatment
- 1. Parenchymal neurocysticercosis
- 1.1 Single lesions[3]
- Preferred regimen: Albendazole 15 mg/kg/day PO bid for 3-8 days AND Prednisone 1 mg/kg/day PO qid for 8-10 days followed by a taper
- 1.2 Multiple cysts
- Preferred regimen: Albendazole 15 mg/kg/day PO bid for 8-15 days and high-dose steroids
- Preferred regimen: Praziquantel 50 mg/kg/day PO tid AND Albendazole 15 mg/kg/day PO bid
- 1.3 Cysticercal encephalitis [3]
- Cysticercal encephalitis (diffuse cerebral edema associated with multiple inflamed cysticerci) is a contraindication for antiparasitic therapy, since enhanced parasite killing can exacerbate host inflammatory response and lead to diffuse cerebral edema and potential transtentorial herniation. Most cases of cysticercal encephalitis improve with corticosteroid therapy
- 1.4 Calcified cysts
- Radiographic evidence of parenchymal calcifications is a significant risk factor for recurrent seizure activity; these lesions are present in about 10 percent of individuals in regions where neurocysticercosis is endemic. Seizures in these patients should be treated with antiepileptic therapy.
- 2. Extraparenchymal NCC
- 2.1 Subarachnoid cysts
- Preferred regimen: Albendazole 15 mg/kg/day PO bid for 28 days AND (Prednisone up to 60 mg/day PO OR Dexamethasone (up to 24 mg/day)) along with the antiparasitic therapy. The dose can often be tapered after a few weeks. However, in cases for which more prolonged steroid therapy is required, methotrexate can be used as a steroid-sparing agent
- 2.2 Giant cysts
- Giant cysticerci are usually accompanied by cerebral edema and mass effect, which should be managed with high-dose corticosteroids (with or without mannitol).
- 2.3 Intraventricular cysts
- Emergent management with CSF diversion via a ventriculostomy or placement of a ventriculo-peritoneal shunt
- Treatment of residual hydrocephalus may be managed with endoscopic foraminotomy and endoscopic third ventriculostomy; this approach may also allow debulking of cisternal cysticerci
- 2.4 Ocular cysticercosis
- Surgical excision is warranted in the setting of intraocular cysts
- Cysticercal involvement of the extraocular muscles should be managed with albendazole and corticosteroids.
- 2.5 Spinal cysticercosis
- Medical therapy with corticosteroids and antiparasitic drugs
Contraindicated medications
Ocular cysticercosis is considered an absolute contraindication to the use of the following medications:
References
- ↑ White, Jr., A. Clinton (2009). "New developments in the management of neurocysticercosis". The Journal of Infectious Diseases. 199 (9): 1261. doi:10.1086/597758. PMID 19358667.
- ↑ Dimitrios K. Matthaiou, Georgios Panos, Eleni S. Adamidi,Matthew E. Falagas “Albendazole versus Praziquantel in the Treatment of Neurocysticercosis: A Meta-analysis of Comparative Trials” PLoS Negl Trop Dis. 2008 March; 2(3): e194
- ↑ 3.0 3.1 García HH, Evans CA, Nash TE, Takayanagui OM, White AC, Botero D; et al. (2002). "Current consensus guidelines for treatment of neurocysticercosis". Clin Microbiol Rev. 15 (4): 747–56. PMC 126865. PMID 12364377.