Journal of Infection (2008) 56, 65e73

www.elsevierhealth.com/journals/jinf

ELISA in the evaluation of therapeutic response

to albendazole in neurocysticercosis
Nuzhat Husain a,*, Nitin Shukla a, Raj Kumar a, Mazhar Husain b,
Arun Chaturvedi c, Girdhar G. Agarwal d, Rakesh K. Gupta e
a

Department of Pathology, King Georges Medical University, Lucknow 226003, Uttar Pradesh, India
Department of Neurosurgery, King Georges Medical University, Lucknow-3, Uttar Pradesh, India
c
Department of Surgical Oncology, King Georges Medical University, Lucknow-3, Uttar Pradesh, India
d
Department of Statistics, University of Lucknow, Lucknow-7, Uttar Pradesh, India
e
Department of Radiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences,
Lucknow-14, Uttar Pradesh, India
b

Accepted 27 September 2007

Available online 7 November 2007

KEYWORDS
Neurocysticercosis;
ELISA;
Albendazole;
IgG;
IgM;
CT scan

Summary Background: Immunological tests are frequently used in the diagnosis of neurocysticercosis (NC), but scant literature is available on the efficacy of these tests in the assessment
of therapeutic response. An ELISA using the Cysticercus fasciolaris larval stage of T. taeniaeformis has been evaluated in the post-treatment follow-up of NC in a cohort of 165 cases.
Methods: Cases (n Z 165) with at least one active cyst documented by computed tomography
and a positive pre-treatment serum ELISA for IgG and/or IgM antibodies were treated with albendazole. CT scan and ELISA tests were repeated at 6 months in 148 cases who returned for
follow-up.
Results: A radiological response was observed in 132 of 148 cases at follow-up. Sixteen cases
were non-responders. Amongst the responders, 111/128 (IgG) and 93/117 (IgM) respectively
had converted to negative antibody titers at 6 months. Thirteen of 16 and 12 of 15 non-responders continued to show high anti-Cysticercus IgG and IgM titers. IgG ELISA, IgM ELISA
and combined IgG and IgM results exhibited a sensitivity (%) of 81.3, 80.0 and 100, a specificity
(%) of 86.7, 79.5 and 72.0, a positive predictive value (PV%) of 97.4, 96.9 and 30.2, and a
negative PV(%) of 97.4, 96.9, 100 respectively.
Conclusion: IgG ELISA is a sensitive and specific tool to assess treatment response. A negative
ELISA result for both IgG and IgM antibodies denotes a cure. While ELISA cannot replace the
visual confirmation provided by radiological imaging in follow-up, the addition of an ELISA test
may help overcome the limitations in interpretation of CT scans.
2007 The British Infection Society. Published by Elsevier Ltd. All rights reserved.

Abbreviations: NC, neurocysticercosis; ELISA, enzyme linked immunosorbent assay; EITB, enzyme immuno transfer blot; CT, computerized
tomography; OD, optical density; EU, ELISA units.
* Corresponding author. Tel.: 91 522 225 7640 (O), 230 8077 (R); fax: 91 522 225 7606.
E-mail address: drnuzhathusain@hotmail.com (N. Husain).
0163-4453/$30 2007 The British Infection Society. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.jinf.2007.09.014

66

N. Husain et al.

Introduction

Sample size justification

Neurocysticercosis (NC) is the commonest parasitic disease

of the central nervous system (CNS) and is caused by
lodging of Taenia solium larvae in the brain parenchyma,
meninges, ventricles or spinal cord. The disease frequently
presents with epilepsy, headache, focal deficit, encephalitis or meningitis symptoms. Racemose intraventricular cysts
may present as hydrocephalus and rarely massive infection
of brain parenchyma by multiple cysts may result in dementia. Epidemiological studies have revealed that a large fraction of cases are asymptomatic.1 The estimated mortality
of the disease worldwide is 50,000 per year and more
than 20 million people are infected with cysticerci in the
CNS.2 Diagnostic dilemmas exist. Diagnostic criteria have
been enumerated with degrees of certainty and include radiological, serological, clinical and epidemiological features.3 Definitive diagnosis can be established when the
scolex is visualized as an eccentric nodule on a computed
tomographic (CT) scan. Ring enhancing cystic lesions on
CT may also be seen in tuberculosis, a frequent differential
diagnosis in regions endemic for tuberculosis, other than
small abscess or glioma. Serological diagnosis is based on
the detection of anti-cysticercal antibodies by enzyme
linked immunosorbent assay (ELISA) or enzyme immunotransfer blot assay (EITB). Most immunodiagnostic tests utilize membrane or scolex antigens or their purified
derivatives from Cysticercus cellulosae, the human pathogen.4e6 We have for the first time used membrane antigen
of C. fasciolaris (the rat pathogen) in anti-IgG and anti-IgM
ELISA for the immunodiagnosis of NC.7
While immunoassays have been frequently evaluated
and are established in current clinical use as diagnostic
procedures, only few studies with limited subjects are
available on the evaluation of ELISA and EITB assays in the
estimation of therapeutic response in NC.8e10 Currently,
response to therapy is monitored in clinical practice by repeat CT scans or magnetic resonance (MR) imaging of the
brain. The current study was envisaged to evaluate the efficacy of ELISA in the assessment of response to albendazole therapy in cases of NC and the effect of the test on
clinical decision-making.

A required sample size of 140 was calculated prior to the

study assuming a sensitivity of 90% with a precision of 5%
and confidence levels of 95%.

Materials and methods

Study design and participants
A cohort study was carried out in a tertiary hospital setting
at King Georges Medical University, Lucknow, India. One
hundred and sixty-five cases fulfilled the study inclusion
criteria of a positive commercial ELISA, experimental IgG
and/or IgM ELISA, viable and active cysts on CT scan
qualifying for albendazole therapy, and gave their consent
for entry into the study from September 2003 to January
2005. These cases included 65 females and 100 males with
a mean (SD) age of 20.2 (12.1) years, ranging from
2e65 years. Mean (SD) duration of symptoms at the time
of presentation was 48.2 (22.4) days. Out of 165 recruited
cases 4 cases died, 3 were removed and 10 were lost to follow-up, finally leaving 148 cases that came for a follow-up,
including 59 females and 89 males.

Clinical assessment
In a pre-treatment clinical assessment 121 of 165 cases
presented with generalized seizures. Focal fits were present
in the 42 cases. Epilepsy was accompanied by other
symptoms such as vomiting and headache in 112 cases and
papilledema in 10 cases. In two cases the disease was
asymptomatic. Post-treatment assessment showed recurrent
seizures were present in 24 cases and persistent headache in
47 cases. One case with hemiplegia and dementia had
persistent symptoms and was a non-responder.

Radiological evaluation
Pre-treatment evaluation
CT scans were evaluated independently by two clinicians/
radiologists blinded to the ELISA results for the presence
of ring enhancing lesions with or without visualization
of scolex. Agreement confirmed the diagnosis. In cases of
disagreement a blinded third opinion was sought. Definitive diagnostic criteria were used.3 Pre-treatment staging of disease was done into viable innocuous cyst with no
enhancement on post contrast study, early degenerating
cyst (active), healed lesion (calcified lesion) as designated
by CT and/or MRI. Only cases with viable and active lesions were registered for the study. Pre-treatment analysis
in 165 cases that entered the study showed 12 cases with
two cysts, 30 cases with more than two cysts and 123
cases with a single cyst. Scolex could be visualized in
the CT scans of 72 cases. At least one active cyst was
present in all cases undergoing therapy. No evidence of
calcification was seen in these cysts. Only cases with parenchymal cysts were included in the study. MRI scans
were done in 3 cases to confirm the diagnosis. MR spectroscopy was done in 5 patients.
Post-treatment response
To assess response to treatment CT was repeated at 6 months
15 days after commencement of therapy. CT scans were
evaluated independently by two clinicians/radiologists in
terms of the decrease in the number and size of cysts, calcification and disappearance of lesions. Post-treatment analysis of 148 cases that came in follow-up, showed multiple cysts
in 39 cases and single cyst in 109. These cases were categorized as responders (n Z 132) and non-responders (n Z 16)
on the basis of repeat CT evaluation. The responders were
further categorized into responders with complete response
(n Z 32), where complete resolution of the lesion occurred
either as a normal scan (n Z 30) (Fig. 1a,b) or as a small
non-edematous focus of calcification (n Z 2); partial responders (n Z 100) showed a decrease in the size of the
cyst (n Z 95), decrease in the number (n Z 12), minimum
or absent edema (n Z 96). Focal calcification of the lesion
was also evident in 55 partial responders. Non-responders
(n Z 16) showed no significant change in the lesion

ELISA in follow up of neurocysticercosis

67

Figure 1 (a) Axial contrast enhanced CT of a responder presented with seizures shows coalescent ring enhancing lesions in the
right frontal region with presence of scolex. (b) A follow-up non-contrast enhanced CT after 6 months of therapy shows residual
calcification. There was no enhancement around the calcified lesion on post-contrast study (image not shown). (c) Contrast
enhanced CT shows evidence of multiple cysts with scolices in both cerebral hemispheres with variable perifocal edema. (d)
Follow-up CT of case in (c) showing an increase in the number of lesions.

(n Z 13), or appearance of new active lesions on CT (with

persistence of the lesion already present) (n Z 3) (Fig. 1c,d).
Experimental ELISA
Two tests for detection of anti-cysticercus IgG and IgM
antibodies were done. All tests were run in triplicate and
mean OD taken as test OD. A variation of less than 10% in
the OD of 3 wells was acceptable or else the test was
repeated. A serum adjusted to the cut-off titer was run in
each batch for standardization of OD. Pooled negative and
positive control sera were run in each batch. Multiple
checks were exercised for consistency of results. All tests
were repeated on two different occasions to evaluate
reproducibility of results, which was 99.6%. ELISA titers
equal to or more than 50 ELISA Units (EU) were considered

as positive, while ELISA titers less than 50 EU were taken

as negative. Post-treatment ELISA was done at 6 months
15 days after commencement of therapy. Post-treatment
ELISA results were evaluated in terms of a change in the titer of the anti-cysticercus antibodies in IgG and IgM ELISA,
as well as a change in positive to negative ELISA results following treatment. The crude membrane extract was prepared from mature cysticerci developing in rat liver,
60 days after infestation of male Duchrey rats with ova of
T. taeniaeformis.7 The membrane extract was prepared
by dissecting membranes from scolices and adherent liver
tissue on ice followed by sonication and centrifugation at
4  C for 30 min. The supernatant adjusted to a concentration of 150 mg/dl was used as the antigen concentrate.
Membrane extract at a dilution of 1:1000 was coated

68
overnight on polystyrene microtiter plates, blocked with 2%
bovine serum albumin in carbonate buffer for 1 h, washed
with phosphate buffer saline with 1% Tween 20 (PBS-T),
treated with 1:1000 dilution of serum for 1 h, washed 5
times in PBS-T, incubated with either anti human IgM or
IgG (Dakopatts, Denmark) for 2 h. After washing 5 times
with PBS-T, color was developed using substrate tetramethyl benzidine for 15 min. The reaction was stopped
with 5 N sulfuric acid and optical density measured at
450 nm in an ELISA reader. Institutional ethical clearance
was obtained for the work and all norms of animal ethics
were followed.
Therapeutic intervention
Anti-helminthic therapy was given in the form of albendazole 15 mg/kg body weight for 4 weeks, along with steroids
and a single, or a combination, of antiepileptic drugs in
doses adequate for seizure control. The steroids were tapered within 1 month. Cases with numerous multiple cysts
were admitted and albendazole was given under supervision. No adverse effects were observed.
Commercial ELISA
Commercially available ELISA kit from UBI, Hauppauge, New
York, USA, detecting IgG antibodies against cysticercosis was
also used in the pre-treatment and post-treatment phase to
evaluate the antibody titer of cases. The test was performed
according to the instruction leaflet supplied with the kit.

Data analysis
SPSS version 11 was used in the statistical analysis. The
sensitivity, specificity of IgG, IgM and combined ELISA in
predicting response to treatment, taking CT scan as the
gold standard was calculated in the post-treatment phase.
The sensitivity of the individual tests was calculated in
terms of the ability of the test to predict the nonresponders to therapy (CT positive at follow-up viz. true
positives) and the specificity in terms of test negativity in
true responders (CT negative at follow-up viz. true negatives). Positive and negative predictive values and likelihood ratios (LRs) were also calculated. Comparison
of independent means was performed using a two-sample
t-test, and the ManneWhitney test for non-normally distributed variables. All significance tests were two-tailed.

Results
ELISA results
IgG ELISA
Pre-treatment IgG ELISA was positive in 144/148 cases that
came in for follow-up. Analysis of post-treatment results
was done in these 144 cases. Mean (SD) pre-treatment IgG
titers in all cases were 122.03 (48.99). Cases with multiple
cysts (n Z 39) had a mean (SD) pre-treatment titer of 138.39
(49.08) in IgG ELISA, while cases with single cyst (n Z 105)
had a lower mean pre-treatment titer 91.6 (41). At the
6 month follow-up, 111/128 responders were diagnosed
by a negative ELISA, while 13 of 16 responders continued
to have positive ELISA titers (Fig. 2a). Scatter graphs of

N. Husain et al.
pre- and post-treatment titers in ELISA done in individual
cases, show a definite trend of decrease in titers in
responders (Fig. 3a) and persistent high titers in nonresponders (Fig. 3b). The mean titer of antibodies in preand post-treatment cases in response groups is shown in
Table 1.
IgM ELISA
IgM ELISA was positive in 132/148 cases that came in for followup. Post-treatment analysis of the results was done in these
132 cases. Mean (SD) pre-treatment IgM titers were 90.77
(40.6). Cases with multiple cysts (n Z 38) had a mean (SD) pretreatment titer of 88.49 (41.7) in IgM ELISA. Cases with single
cyst (n Z 94) had a mean (SD) pre-treatment titer of 88.45
(37.39). At the 6 month follow up, 12/15 non-responders
tested true positive, while a false positive result was obtained
in 24/117 responders (Fig. 2b). Scatter graphs of pre- and posttreatment titers in ELISA in individual cases show a trend of
decrease in titers in responders (Fig. 3c) and persistent high
titers in non-responders (Fig. 3d). The mean titer in each
group, as well as the change in titer, is shown in Table 1.
Combined IgG and IgM ELISA
One hundred and forty-eight cases had either IgG or IgM, or
both antibodies to cysticercosis. In 128 cases both ELISA
tests were positive. Both tests showed negative results in
95/132 responders and 0/16 non-responders (Table 2). It is
significant to note here that none of the non-responders
showed negative results for both ELISA tests. Both tests remained positive in 11/16 non-responders, in 1 case IgM was
positive and in 4 cases IgG continued to be positive. In 31
responders either one of the ELISA tests was false positive,
IgG was positive in 13, whereas IgM was positive in 18 cases.
In 6 cases both IgG and IgM titers were in the positive range.
These included 2 cases categorized as complete responders
and 4 cases with partial response.
Commercial ELISA
All cases (n Z 165) had a positive initial ELISA in the pretreatment phase. While at follow-up ((n Z 148) out of total
responders (n Z 132)), 108 had a negative commercial
ELISA and 12 of 16 non-responders had a positive ELISA.
ELISA in single vs. multiple cysts
Single cysts were more frequent (n Z 109) than multiple
cysts (n Z 39). Significant difference was observed in the
proportion of cases with single cyst, which responded to
therapy (95/109), compared to cases with multiple cysts
showing therapeutic response (37/39) with IgG ELISA. Cases
with multiple cysts showed significantly higher pre-treatment IgG ELISA titer, compared to cases with single cyst.
In IgM ELISA the high pre-treatment titers of cases with single vs. multiple cysts were not significantly different. The
post-treatment IgG and IgM titers following therapy in responders with single or multiple cysts were significantly
lower than the pre-treatment titers, while non-responders
did not show a significant change (Tables 3a and b).

Statistical analysis
IgG ELISA had a higher sensitivity of 81.3% and specificity
of 86.7% in the assessment of therapeutic response in

ELISA in follow up of neurocysticercosis

69

(a)

Pretreatment IgG ELISA

POSITIVE
(n=144)

Responders
(n=128)

Non Responders
(n=16)

Complete
Response
n=32
IgG ELISA
Positive
n=6

Partial
Response
n=96

IgG ELISA
Negative
n=27

(b)

IgG ELISA
Positive
n=8

IgG ELISA
Negative
n=88

Pretreatment IgM ELISA

POSITIVE
(n=132)
Responders
(n=177)
Complete
Response
n=36

IgM ELISA
Positive
n=4

Figure 2

IgG ELISA
Negative
n=3

IgG ELISA
Positive
n=13

Non responders
(n=15)
Partial
Response
n=81

IgM ELISA
Negative
n=32

IgM ELISA
Positive
n=5

IgM ELISA
Positive
n=12

IgM ELISA
Negative
n=3

IgM ELISA
Negative
n=76

(a) IgG ELISA in assessment of treatment response; (b) IgM ELISA in assessment of treatment response.

neurocysticercosis, compared to IgM ELISA with sensitivity

and specificity of 80.0% and 79.5%, respectively. The likelihood ratio of a negative IgG ELISA in diagnosing response to
therapy was 0.22, while the likelihood ratio of positive ELISA
in diagnosing non-responders was 6.1. The likelihood ratio of
a negative IgM ELISA was 0.25, while the likelihood ratio of
positive ELISA was 3.9 (Table 4). The predictive value (PV%)
of a response was 97.4, 96.9 and 30.2, and PV (%) of no response was 97.4, 96.9 and 100. When both ELISA results
were combined, to interpret positive cases as having both
tests positive and negative cases as having both tests negative, a sensitivity and NPV of 100% was observed (Table 4).

Discussion
ELISA is a simple and economical test, which compliments
CT/MRI scans in the immunodiagnosis of NC. Lesions in
neuroimaging may appear as single or multiple enhancing
cystic lesions, with or without calcification. Several differential diagnosis need to be ruled out, including small
arachnoid cysts, porencephaly, cystic astrocytoma and
colloid cysts (in cases of intraventricular cysticercus) for
non-enhancing lesions.11 In India, CNS tuberculoma forms
a major differential diagnosis for ring-enhancing lesions,
other than early gliomas, toxoplasmosis, metastases and arterio-venous malformations. A positive immunodiagnostic
test for NC increases the likelihood of diagnosis. However,
results should be interpreted with caution. MR spectroscopy, magnetization transfer and diffusion MR imaging

contribute to differentiation of tuberculoma from NC.12,13

as proved in 3 cases in our study. Three cases with single lesions were re-evaluated after clinical deterioration following commencement of therapy. Two were diagnosed as
tubercular granulomas on magnetization transfer MR and
MR spectroscopy and one as a glioma (biopsy confirmed it
as an astrocytoma). These 3 cases were removed from the
study for further specific management.
Post-treatment radiological evolution of the lesions in
NC has been described14 and they are known to decrease in
number and size, or resolve totally or cause gliosis and calcification. In the current study, to assess the response a clinician and radiologist were approached independently and
were blinded to the ELISA results. During the pre-treatment
phase they detailed the location of the cyst, size of the
cyst, number of cysts and edema, graded on a 1e3 scale.
After 6 months their observations of the CT, based on the
decrease in size (measurable), number, disappearance of
the cyst, appearance of any new cyst(s) and edema, were
recorded in a structured format using the same scale. However, in cases of multiple cysts, the findings were recorded
on the basis of the target lesion(s) diagnosed on the pretreatment CT. The pre- and the post-treatment findings
were finally compared to grade cases as responders or
non-responders. The diagnosis of the two was taken as final and in the case of disagreement a third opinion was
sought. However, observations of the clinician and radiologist were in concordance and there was no disagreements
in any of the cases. Disappearance of the lesion cannot
be the sole criterion of response because cysts are known

70

N. Husain et al.

300

300

250

250

200

200

Titres (EU)

Titres (EU)

Responders

150
100
50

150
100
50

0
0

50

100

150

50

No. of Cases

150

(c)

Non-Responders

300

300

250

250

200

200

Titres (EU)

Titres (EU)

(a)

100

No. of Cases

150

150

100

100

50

50

0
0

10

15

20

10

No. of cases

No. of cases

(b)

(d)

IgG

IgM

15

Pre-treatment titers
Post-treatment titers

Figure 3 Scatter plots showing pre-treatment and post-treatment ELISA titers in: (a) IgG ELISA in responders; (b) IgG ELISA in
non-responders; (c) IgM ELISA in responders; (d) IgM ELISA in non-responders.

Table 1

Comparison of mean titers among responders and non-responders in IgG ELISA and IgM ELISA

Therapeutic
response

Responders
(n, mean, SD)

Pre-treatment
IgG
128, 120.5, 48.2
IgM
117, 94.2, 34.2
Post-treatment
IgG
128, 29.4, 22.4
IgM
117, 28.5, 28.4
Difference in pre-treatment and post-treatment mean titers
IgG
128, 91.1, 47.0
IgM
117, 65.7, 41.9
a

Values obtained by two sample t-test.

Non-responders
(n, mean, SD)

p (95% CI for mean

differencea)

16, 103.2, 54.1

15, 92.8, 27.4

0.18 (8.3, 42.9)

0.87 (16.7, 19.6)

16, 81.5, 39.7

15, 73.9, 37.7

<0.001 (65.0, 39.0)

<0.001 (61.4, 29.3)

16, 21.8, 53.5

15, 18.9, 50.0

<0.001 (44.3, 94.3)

<0.001 (23.6, 70.0)

ELISA in follow up of neurocysticercosis

71

Table 2 Comparison of ELISA for IgG, IgM and combined

ELISA with gold standard
CT scan (gold standard)

IgG ELISA
Positive
Negative
IgM ELISA
Positive
Negative
Combined ELISA
Positive
Negative

Responder

Non-responder

17
111

13
3

24
93

12
3

37
95

16
0

to resolve gradually over time. Decrease in size or number

of cysts, presence of calcification or disappearance of
edema, all represent radiological evidence of a response.
There is controversy regarding the use of anti-parasitic
therapy for NC. Solitary cysts are frequently not treated
since they are known to resolve spontaneously. Treatment
with albendazole has, however, proved to reduce the
incidence and severity of seizures in the post-treatment
phase.8 It may be interesting to compare pre- and posttreatment titers in untreated cases to observe if changes
in ELISA results are similar to those observed in the treated
cases. We have not considered the solitary cysticercus granulomas resolving without treatment in this study and plan
to do so in the future.
The humoral immune response may be of importance,
not only in the elimination of the parasite, but also in the
genesis of the illness. Garcia et al.15 have described baseline serologic responses in a cohort of 49 cases of NC. An assay, detecting 7 purified reactive antigens in immunoblot,
was used at 3 months and 1 year of therapy. They concluded that persistent positive immunoblot results do not
indicate active infection. We have also observed persistent
IgG sero-positivity in 17/128 of radiological responders and
24/117 IgM responders in ELISA. However, the disappearance of either or both IgG and IgM antibodies denotes
Table 3a Comparison of mean titers among single cyst
and multiple cysts subjects for IgG ELISA and IgM ELISA
(responders)
Single cyst
(n Z 95, mean, SD)

Multiple cysts
(n Z 37 mean, SD)

Pre-treatment
IgM
88.2, 37.9
83.0,
IgG 130.2, 47.6
82.8,
Post-treatment
IgM
32.7, 27.5
13.6,
IgG
33.1, 21.5
17.2,
Difference in pre-treatment
and post-treatment mean titers
IgM
55.6, 42.4
69.4,
IgG
97.1, 48.6
65.7,
a

p-valuea

41.1
46.6

0.49
<0.001

23.4
21.6

<0.001
<0.001

45.7
42.1

0.10
0.001

Two samples independent t-test was used for this

comparison.

Table 3b Comparison of mean titers among single cyst

and multiple cysts subjects for IgG Elisa and IgM Elisa
(non-responders)
Single cyst
(n Z 14 mean,
SD)

Multiple cysts
(n Z 2 mean,
SD)

Pre-treatment
IgM
89.6, 25.4
73.1,
IgG
110.1, 50.2
55.3,
Post-treatment
IgM
75.5, 38.6
75.2,
IgG
83.7, 41.7
65.7,
Difference in pre-treatment
and post-treatment mean titers
IgM
14.1, 48.2
2.1,
IgG
26.4, 53.6
10.4,

p-value
ManneWhitney
one-sided

90.9
77.0

0.5
0.2

33.0
20.3

0.4
0.2

123.9
56.6

0.5
0.2

a cure. Persistent sero-positivity in cured patient may be

due to lesions missed on CT scan, lesions at non-CNS locations or due to the slow evolution of immunological response and residual antibodies. It is interesting to note
that in reported EITB studies a greater number of reactive
bands are found in severe disease and they decrease as
the disease evolves.15 However, the test became negative
in only 3/13 cases cured and in none of the 28 cases not
cured. It appears, therefore, that the high sensitivity of
EITB assays limits their use in evaluating the treatment response. In another study of 8 cases on praziquantel therapy,
Estanol et al.9 found that level of IgG in ELISA rose significantly in CSF, but not in blood. The levels of complement
and IgM, IgA, IgE did not change significantly, either in serum or in CSF. Their data support the theory that specific
antibodies are produced intrathecally and are not derived
from the serum pool through a ruptured bloodebrain barrier in CSF.9 Ito et al. reported a drop in titer of antibodies
after surgical resection in a single case.16
Antigen ELISA has been used by Nguekam et al. for
detection of circulating cysticercus antigen in patients
with NC receiving an 8-day albendazole therapy.17 Three
cured cases showed disappearance of circulating antigen at
1 month. Two other cases responding to a second course of
albendazole also became sero-negative. The authors have
reported an excellent correlation in disappearance of circulating antigen to success of treatment. In a serologic follow
up of 69 NC patients by ELISA after praziquantel therapy,
Cho et al.10 have reported an increase in antibody titer, in
some cases initially, followed by a steady declining tendency. Our study involved cases undergoing albendazole
treatment. We did a single, one-time measurement of antibody titers at 6 months after the commencement of albendazole therapy. Our study sample was adequately powered to
make valid conclusions. The results suggest that IgG alone,
or a combined interpretation of IgG and IgM ELISA, can give
a reasonably accurate prediction of the evolution of NC.
Most immunodiagnostic assays for NC have utilized
membrane, scolex, and cyst fluid antigen of C. cellulosae.4,6,18 Alternative sources of antigen from related species have been used, including T. saginata19 and T.
crassiceps.20e22 We used, for the first time, larval antigens
of T. taeniaeformis antigen in ELISA for the detection of

72
Table 4

N. Husain et al.
Performance characteristics of ELISA compared with CT scan (gold standard)

Test

Sensitivity
(95% CI)

Specificity
(95% CI)

Positive
predictive
value (95% CI)

Negative
predictive
value (95% CI)

LR (95% CI)
Positive test

Negative test

IgG ELISA (n Z 144) 81.2 (62.1, 100.0) 86.8 (80.8, 92.6) 43.3 (25.6,61.1) 97.4 (94.4, 100.0) 6.1 (3.7, 10.1) 0.2 (0.1, 0.6)
IgM ELISA (n Z 132) 80.0 (60.0, 100.0) 79.4 (72.2, 86.8) 33.3 (17.9, 48.7) 96.9 (93.4, 100.0) 3.9 (2.5, 6.0) 0.3 (0.1, 0.7)
Combined ELISA
100.0 (79.0, 100.0) 71.9 (64.3, 79.6) 30.2 (17.8,42.5) 100.0 (96.0, 100.0) 3.6 (2.7, 4.7) 0.0
(n Z 148)
LR, likelihood ratio; CI, confidence interval.

antibodies to cysticercus with a sensitivity of 93.54% and

a specificity of 84.2%.7 In immunoblot assays we a found
marked antigenic similarity between C. cellulosae and C.
fasciolaris (unpublished data).
Besides the diagnostic dilemmas, treatment protocols
for NC are also riddled with controversies regarding the
efficacy of anti-helminthics in the radiological cure and
long-term seizure control in neurocysticercosis. Results
from randomized trials using albendazole, as reviewed by
the Cochrane collaboration,23 were inconclusive because of
the variable types of disease studied and protocols used.
However, a well-designed clinical trial with 120 NC patients
in Peru provided the first real evidence that albendazole
was safe and effective in controlling seizures of NC.24 We
used albendazole as an anti-helminthic for a period of
4 weeks. Response of treatment was good, with 132/148
cases responding to therapy. All cases studied had parenchymal cysticercosis.
It can be concluded that IgG ELISA has a higher sensitivity and specificity, compared to IgM ELISA in the detection
of treatment response in NC. A negative ELISA result for
both IgG and IgM antibodies denotes a cure. Persistent
antibody levels may be present in some cases with
radiological cure due to cysts not being visualized on CT
scan or a slow decrease in antibody titers after healing.
Since the ELISA test is considerably cheaper and less
resource intensive than radio-imaging techniques, it can
be used for periodic screening in cases undergoing therapy
or in regions where funds and resources are limited. If
a patient tests negative in both IgG and IgM ELISA and also
shows clinical improvement, a repeat CT can be avoided.
While ELISA cannot replace the visual details provided by
radio-imaging on follow-up, where fund constraints are not
an issue the addition of an ELISA test can help overcome the
limitations in interpreting the CT and would also increase
the accuracy of assessment of the therapeutic response.

Acknowledgements
International Clinical Epidemiology Network, Inc., Boston
University, and USAID as co-funders and co-contributors to
the research.

References
1. Fleury A, Gomez T, Alvarez I, Meza D, Huerta M, Chavarria A,
et al. High prevalence of calcified silent neurocysticercosis in
a rural village of Mexico. Neuroepidemiology 2003;22:139e45.

2. Gemmel M, Matyas Z, Pawlowsky Z. Guidelines for surveillance, prevention and control of Taeniasis/cysticercosis.
Geneva: WHO; 1983.
3. Del Brutto OH, Raj Shekhar V, White Jr AC, Tsang VC, Nash TE,
Takayanagui OM, et al. Proposed diagnostic criteria for neurocysticercosis. Neurology 2001;57:177e83.
4. Diwan AR, Cokervan-Vann M, Brown P, Subianto DB, Yolken R,
Desowitz R, et al. Enzyme-linked immunosorbent assay (ELISA)
for the detection of antibody to cysticerci of Taenia solium.
Am J Trop Med Hyg 1986;31:364e9.
5. Coker-Vann M, Brown P, Gajdusek DC. Serodiagnosis of human
cysticercosis using a chromatofocused antigenic preparation of
Taenia solium cysticerci in an enzyme-linked immunosorbent
assay (ELISA). Trans R Soc Trop Med Hyg 1984;78:492e6.
6. Malla N, Kaur M, Kaur U, Ganguly NK, Mahajan RC. Evaluation
of enzyme linked immunosorbent assay for the detection of anticysticercus antibodies in cerebrospinal fluid from patients
with neurocysticercosis. J Hyg Epidemiol Microbiol Immunol
1992;36:181e90.
7. Husain N, Jyotsna, M Bagchi, Husain M, Mishra MK, Gupta S.
Evaluation of Cysticercus fasciolaris antigen for the immunodiagnosis of neurocysticercosis. Neurol India 2001;49:375e9.
8. Garcia HH, Gilman RH, Catacora M, Verastegui M, Gonzalez AE,
Tsang VC. Serologic evolution of neurocysticercosis patients
after antiparasitic therapy. J Infect Dis 1997;175:486e9.
9. Estanol B, Juarez H, Irigoyen Mdel C, Gonzalez-Barranco D,
Corona T. Humoral immune response in patients with cerebral
parenchymal cysticercosis treated with praziquantel. J Neurol
Neurosurg Psychiatry 1989;52:254e7.
10. Cho SY, Kim SK, Kang SY. Serologic follow-up study in neurocysticercosis patients by ELISA after praziquantel treatment.
Korean J Parasitol 1986;23:159e70.
11. Carpio A. Neurocysticercosis: an update. Lancet Infect Dis
2002;2:751e62.
12. Shukla-Dave, Amita Shukla, Roy R, Husain N, Paul L,
Venkatesh SK, et al. Prospective evaluation of in vivo proton
MR spectroscopy in differentiation of similar appearing intracranial cystic lesions. Magn Reson Imaging 2001;19:103e10.
13. Gupta RK, Prakash M, Mishra AM, Husain M, Prasad KN,
Husain N. Role of diffusion weighted imaging in differentiation
of intracranial tuberculoma and tuberculous abscess from cysticercus granulomasda report of more than 100 lesions. Eur
J Radiol 2005;55:384e92.
14. Zhao S, Xu K. Changes in computed tomogram in cerebral parenchymal cysticercosis treated with albendazole. Zhongguo Ji
Sheng Chong Xue Yu Ji Sheng Chong Bing Za Zhi 1999;17:390e3.
15. Garcia HH, Parkhouse RM, Gilman RH, Montenegro T, Bernal T,
Martinez SM, et al. Serum antigen detection in the diagnosis,
treatment, and follow-up of neurocysticercosis patients. Trans
R Soc Trop Med Hyg 1998;92:411e4.
16. Ito A, Nakao M, Ito Y, Yuzawa I, Morishima H, Kawano N, et al.
Neurocysticercosis case with a single cyst in the brain showing
dramatic drop in specific antibody titers within 1 year after curative surgical resection. Parasitol Int 1999;48:95e9.

ELISA in follow up of neurocysticercosis

17. Nguekam, Zoli AP, Ongolo-Zogo P, Dorny P, Brandt J, Geerts S.
Follow-up of neurocysticercosis patients after treatment using
an antigen detection ELISA. Parasite 2003;10:65e8.
18. Molinari JL, Garcia-Mendoza E, de la Garza Y, Ramirez JA,
Sotelo J. Discrimination between active and inactive neurocysticercosis by metacestode excretory/secretory antigens of
Taenia solium in an enzyme-linked immunosorbent assay. Am
J Trop Med Hyg 2002;66:777e81.
19. Morakote
N,
Nawacharoen
W,
Sukonthasun
K,
Thammasonthi W, Khamboonruang C. Comparison of cysticercus extract, cyst fluid and Taenia saginata extract for use in
ELISA for serodiagnosis of neurocysticercosis. Southeast Asian
J Trop Med Public Health 1992;23:77e81.
20. Larralde C, Sotelo J, Montoya RM, Palencia G, Padilla A,
Govezensky T, et al. Immunodiagnosis of human cysticercosis
in cerebrospinal fluid. Antigens from murine Taenia crassiceps
cysticerci effectively substitute those from porcine Taenia solium. Arch Pathol Lab Med 1990;114:926e8.

73
21. Pardini AX, Peralta RH, Vaz AJ, Machado LR, Peralta JM. Use of
Taenia crassiceps cysticercus antigen preparations for detection of antibodies in cerebrospinal fluid samples from patients
with neurocysticercosis (Taenia solium). Clin Diagn Lab Immunol 2002;9:190e3.
22. Espindola NM, Iha AH, Fernandes I, Takayanagui OM, Machado
Ldos R, Livramento JA, et al. Cysticercosis immunodiagnosis
using 18- and 14-kilodalton proteins from Taenia crassiceps cysticercus antigens obtained by immunoaffinity chromatography.
J Clin Microbiol 2005;43:3178e84.
23. Salinas R, Prasad K. Drugs for treating neurocysticercosis
(tapeworm infection of the brain). Oxford: Cochrane
database of systematic reviews (2) (update software 2000:
CD000215).
24. Garcia HH, Pretell EJ, Gilman RH, Martinez SM, Moulton LH, Del
Brutto OH, et al. A trial of antiparasitic treatment to reduce
the rate of seizures due to cerebral cysticercosis. N Engl J
Med 2004;350:249e58.