Cysticercosis: Difference between revisions
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Revision as of 04:30, 28 August 2014
Background
- Parasitic infection caused by larval stage of Taenia solium (pork tapeworm)
- Occurs when humans (definitive host) ingest poorly cooked pig (intermediate host) that is infected with larvae (cysticerci)
- Estimated 50-100 million people infected worldwide
- 1,000 new cases in US per year, mostly in immigrants from Latin America but also seen in those from Asia or Africa
- More than 80% of those affected are asymptomatic
- Cysts can reside anywhere in body
Clinical Features
Divided into extraneural cysticercosis (outside CNS) and neurocysticercosis (which can be parenchymal, extraparenchymal or both)
- Extraneural cysticercosis
- Subcutaneous tissue: nodules that are not cosmetically pleasing, but usually asymptomatic
- Muscle: asymptomatic or sometimes painful due to surrounding inflammation
- Cardiac cysts are rare: arrhythmias/conduction abnormalities
- Neurocysticercosis (NCC)
- Parenchymal NCC
- Most common presentation of NCC
- Most cases are asymptomatic and discovered incidentally after resolution of infection (see image below)
- Those with symptoms usually present with seizures (focal or generalized)
- Focal neurologic deficit
- Extraparenchymal NCC: more often present with headaches, vomiting, hydrocephalus
- Intraventricular cysts: can get lodged in ventricular outflow tracts and cause obstructive hydrocephalus and increased ICP causing nausea, vomiting, AMS, papilledema
- Subarachnoid cysts: can cause inflammatory response leading to arachnoiditis which may result in hydrocephalus, meningitis, stroke, and vasculitis
- Ocular (1-3% of cases): diplopia if EOM involvement, vision loss or pain if intra-ocular
- Spinal (1% of cases): radicular pain, paresthesias, cauda equina symptoms
- Parenchymal NCC
Differential Diagnosis
- Brain abscess
- Vasculitis
- Tuberculomas or Mycotic granulomas
- Primary brain tumors or metastases
Workup
- Imaging is usually best
- CT head (calcifications/edema); MRI (cysts +/- scolex, edema)
- X-rays or CT for extraneural cysticercosis
- EITB assay for anticysticercal antibody
- Serum (more sensitive) or CSF studies (less common)
- Labs
- Usually not helpful
- Eosinophilia not seen unless cyst is leaking/ruptured
- Depending on presentation, involvement of the following services may be needed:
- Neurology: for seizures refractory to meds
- Neurosurgery: hydrocephalus, mass effect, herniation
- Infectious disease: if starting antiparasitic therapy
- Ophthalmology: if suspect ocular involvement or if starting antibiotics and need to confirm no ocular involvement
Management
- Asymptomatic: observation
- Subcutaneous or intramuscular: typically observation
- If just one lesion or cosmetic issue, surgical excision
- Otherwise: NSAIDs
- Symptomatic NCC
- Anticonvulsants (keppra, dilantin, newer agents)
- Antihelminthic therapy and steroids
- Treat if edema, mass effect, or vasculitis
- Don’t treat if old calcifications on CT without edema
- Before starting these meds, need to check for:
- positive PPD
- co-infection w/ Strongyloides (steroids can cause to disseminate)
- ocular involvement (inflammation associated with dying organisms can result in vision loss by causing chorioretinitis, retinal detachment, or vasculitis)
- Pts started on therapy get admitted to watch for any adverse events initially
- First line: Albendazole 15mg/kg/day divided in 2 doses
- Second line: Praziquantel: 50-100mg/kg/day divided in 3 doses
- Steroids: Prednisone 1mg/kg/day or Dexamethasone 0.1mg/kg/day
- If hydrocephalus present, CSF diversion with ventriculostomy or VP shunt by Neurosurgery and/or surgical resection of cysts.
- Ocular
- Intra-ocular: surgery
- Extra-ocular muscle involvement: albendazole and steroids
- Spinal intramedullary: possibly surgery
Disposition
- Home if asymptomatic or no complications w/ good pain control
- Admit if starting antihelminthic therapy for further testing as listed above and to monitor initial side effects of drug therapy
- ICU for uncontrolled seizures, AMS, increased ICP
Sources
- Mansur MM and Cunha BA. “Cysticercosis.” www.emedicine.medscape.com. Oct 2012.
- Khosla, A and Smirniotopoulos. “CNS Imaging in Cysticercosis.” www.emedicine.medscape.com. Oct 2012.
- White AC, Weller PF and Baron EL. “Treatment of cysticercosis.” www.uptodate.com. Jul 2014.
- White AC, Weller PF and Baron EL. “Clinical manifestations and diagnosis of cysticercosis.” www.uptodate.com. Jul 2014.
- Rosen’s Emergency Medicine