Neurocysticercosis/cysticercosis and public health. Dr.Kedar Karki. Veterinary Public Health Office. Tripureswor.
Background: Cysticercosis is a systemic parasitic infestation caused by the pork tapeworm, Taenia solium. The symptoms of this illness are caused by the development of characteristic cysts (cysticerci) which most often affect the central nervous system (neurocysticercosis), skeletal muscle, eyes, and skin. Many individuals with cysticercosis never experience any symptoms (asymptomatic). The tapeworm responsible for causing cysticercosis is endemic to many parts of the developing world, including Latin America, Asia, and sub-Saharan Africa. The incidence of cysticercosis has increased in the United States due to increased immigration from developing countries, and it is estimated that about 1,000 new cases of cysticercosis are diagnosed annually in the United States. Neurocysticercosis is a leading cause of adult-onset seizures worldwide. Historically, the disease has been recognized since about 2000 B.C. by the Egyptians and later described in pigs by Aristotle. The disease was also recognized by Muslim physicians and is thought to be the reason for Islamic dietary prohibition of eating pork. In the 1850s, German investigators described the life cycle of T. solium. Causes of cysticercosis. Cysticercosis is caused by the dissemination of the larval form of the pork tapeworm, Taenia solium. When the eggs of Taenia solium are ingested by humans, the tapeworm eggs hatch and the embryos penetrate the intestinal wall and reach the bloodstream. The formation of cysts in different body tissues leads to the development of symptoms, which will vary depending on the location and number of cysts. Transmission of cysticercosis. Humans are the host for Taenia solium, and they may carry the tapeworm in their intestine, often without symptoms. The tapeworm eggs are periodically shed in the feces by the human reservoir, and typically pigs ingest the eggs in contaminated food or water. The pigs subsequently become infected and develop cysticerci in their body tissue. When humans eat infected raw or undercooked pork, the life cycle of the tapeworm is complete and the cycle continues. Human cysticercosis, however, develops after humans ingest Taenia solium eggs. The eggs are typically spread via food, water, or surfaces contaminated with infected feces. Oftentimes, the eggs may be spread from the hands of infected food handlers who do not clean their hands or from foods fertilized/irrigated with water containing infected human feces. Though the source of this fecal-oral transmission often occurs from other infected individuals, it is also possible for individuals who carry the
tapeworm to auto infect themselves. The life cycle of T. solium is shown below, and pictures of the cysts in tissues can be found in the last reference listed below. Symptoms of cysticercosis. The symptoms of cysticercosis may develop from several months to several years after the initial infection (incubation period). The symptoms will depend on the location and the number of cysticerci, though many individuals with cysticercosis will never develop any symptoms at all. The majority of patients with cysticercosis who present to a health-care provider have central nervous system involvement (neurocysticercosis or NCC). Symptoms of neurocysticercosis may include the following:
Nausea and vomiting
Weakness or numbness
Seizure (often the presenting symptom, occurs in about 70% of people with NCC)
Involvement of other body tissues may cause skeletal muscle swelling, subcutaneous cysts, and vision changes from cysts infecting the eyes. Diagnosis of cysticercosis.
The diagnosis of cysticercosis can sometimes be difficult, and it may require a combination of tests and imaging studies to make the diagnosis. In general, however, the patient's clinical presentation along with abnormal radiographic imaging results (CT scan of the brain/MRI of the brain) lead to the diagnosis of neurocysticercosis. Pictures of the cysts in the brain can be found in the first reference listed below.
Blood testing can sometimes be used as an adjunct in making the diagnosis, though it is not always helpful or accurate. These tests are usually done by specialist labs. Rarely, a biopsy from affected tissue may be needed to make the diagnosis. Stool studies are sometimes also obtained .b ecause they may contain identifiable parasite eggs Treatment for cysticercosis.
The treatment of cysticercosis depends on various factors, including the individual's symptoms, the location and number of cysticerci, and the stage of cyst development. Generally speaking, treatment is tailored to each individual patient and their particular presentation, and treatment regimens may include anthelmintic agents, corticosteroids, anticonvulsant medications, and/or surgery. Asymptomatic patients may not require any treatment at all. Controversy does exist as to which patients require treatment with the various medications. The most commonly used anthelmintic agents include albendazole and less commonly praziquantel. These antiparasitic medications are effective in eliminating viable cysticerci though they may cause reactive localized inflammation. Consequently, the use of these medications must be evaluated on a case-by-case basis. More than one course of treatment may be necessary to completely eliminate active cysts. Corticosteroids may also be used in conjunction with, or instead of, antiparasitic medications. Corticosteroids are used to decrease inflammation but are not active against the parasite. Again, treatment with these medications must be tailored to each individual case. Consultation with an infectious disease expert is recommended. Anticonvulsant medications are used in patients with neurocysticercosis experiencing seizures or at high risk for recurrent seizures. Various anticonvulsant medications, such as carbamazepine (Tegretol) or phenytoin (Dilantin), may be prescribed. Consultation with an experienced neurologist may be helpful to determine patient treatments. Surgical management may also be necessary in select cases of cysticercosis. Surgical removal of central nervous system cysts or placement of a brain shunt (to relieve pressure) is sometimes necessary in some cases of neurocysticercosis. Certain cases of cysticercosis involving the eyes or subcutaneous cysts may also require surgery Complications of cysticercosis. The potential complications of cysticercosis may include the following:
Cognitive problems Death
In general, the prognosis for the majority of patients with cysticercosis is excellent with proper management. Patients with NCC and seizures have a good prognosis if the patient obtains antiseizure medications and if the acute lesion clears on subsequent CT exams. Prevention of cysticercosis The prevention of cysticercosis can be achieved through various measures including the following:
Public education regarding the parasite and its route of transmission Avoidance of raw or undercooked pork (USDA says safe cooked pork reaches 160 degrees F) in endemic areas Avoidance of potential fecal-oral routes of transmission through hand washing, good personal hygiene, as well as through the proper handling and preparation of foods Meat inspection and the proper disposal of infected meat in endemic areas Improved sanitary measures for human waste disposal in endemic areas Screening contacts of infected individuals and instituting appropriate treatment Developing a vaccine for the prevention of cysticercosis, which may be used in the future; currently, there is no vaccine approved for use in humans