Editorial
Treatment of neurocysticercosis
According to a joint report by the UN’s Food and
Agriculture Organization and WHO, Research priorities
for helminth infections, neurocysticercosis is the most
important preventable cause of epilepsy with an
estimated 2 million people having epilepsy, in the
developing world. It is caused by the pork tapeworm
Taenia solium, belonging to cyclophyllid cestodes in
the family of Taeniidae. The larval or cysticercus stage
of this intestinal zoonotic parasite can infect human
beings as well as pigs, and if the infection reaches
the brain, can cause a wide range of debilitating
neurological problems.
Despite the huge social costs and global effects
associated with neurocysticercosis, roughly 50 million
people in the world have the infection and 50–70% of
all individuals with symptomatic cysticercosis have
epileptic seizure. Information is generally scarce about
the source of these parasites, how they live in the
human body, and most importantly how they cause
illness. The paucity of diagnostic methods and the lack
of consistent intervention studies as part of integrated
helminth control strategies means this infection is still
neglected. The disease is most commonly recorded in
members of agricultural societies with poor sanitary
conditions and economies based on breeding pigs
with low hygiene standards. However, the disease has
been increasingly reported in the developed world
because of immigration from endemic countries. In
the USA, almost 2000 people are diagnosed with
neurocysticercosis every year according to the UN
report.
Although the clinical features of neurocysticercosis
are well understood and the availability of antiparasitic
drugs is good, the treatment remains controversial.
Much of the controversy arose from the seizure
occurrence and other neurological disorders caused
by inflammation associated with the antiparasitic
treatment. For years, the main debate among experts
has been on the usefulness and potential dangers of
cysticidal treatment, steroids, and antiepileptic drugs.
In the past 10 years, data from different controlled trials
have suggested that treatment with praziquantel or
albendazole with corticosteroids increases radiological
clearance in people with few and uninflamed cysts.
In these trials, the primary outcome was partial or
www.thelancet.com/infection Vol 14 August 2014
complete cyst resolution. Other controlled studies
have shown that with high load of cysts radiological
clearance might be lower. In these studies, the presence
Zephyr/Science Photo Library
of inflamed cysts reduced the benefits of anticysticercal
treatment with albendazole. Findings of other
studies have shown that compared with albendazole
alone, combined treatment with praziquantel and
albendazole are better and quicker.
See Comment page 658
In this issue of The Lancet Infectious Diseases,
See Articles page 687
Hector Garcia and colleagues report the results For more on the UN report see
of a three-group randomised trial in which the http://www.fao.org/3/a-i3649e.
pdf
standard albendazole dose (maximum 800 mg per
For more on neurocysticercosis
day), an increased albendazole dose (maximum see PLoS Negl Trop Dis 2012;
1200 mg per day), and a combination of albendazole published online May 29.
DOI:10.1371/journal.
and praziquantel (in standard doses) were tested. pntd.0001500
However, as pointed out in the linked Comment For more on trials promoting
albendazole see
by Gagandeep Singh and Arthur Clinton White, a Arch Intern Med 1995;
complete resolution of cysts was not associated 155: 1982–88
with complete resolution of seizures. According to For trials on combination of
praziquantel and albendazole
a new evidence-based guideline from the American see Trop Med Parasitol 1993;
Academy of Neurology published April 9, 2013, the 44: 192–94
combination of albendazole plus a corticosteroid For more on the guidelines see
Neurology 2013; published online
should be considered for adults and children with April 9. DOI:10.1212/
WNL.0b013e31828c2f3e
parenchymal neurocysticercosis. In view of the
complexity of the disease and the different forms
in which it can manifest, it will be important for
guidelines to distinguish between the different forms
of neurocysticercosis.
Although the trial by Garcia and colleagues
represents a big advance in the treatment of
parenchymal cysticercosis, new trials with seizure
outcome will be welcome. Clearance of seizures should
be the ultimate goal of any type of intervention in the
treatment of neurocysticercosis. Decreased numbers
of seizures would mean a better quality of life for
patients. The efficacy of antiepileptic drugs in treating
or decreasing the occurrence of subsequent seizures
secondary to parenchymal neurocysticercosis is also
unclear. Future studies will also be need to establish
the appropriate use of adjuvant corticosteroids. Public
health efforts together with global collaborations
will be of fundamental importance to deliver better
diagnostic methods and therapeutic interventions
to eradicate this still neglected neuroinfection.
■ The Lancet Infectious Diseases
657