JCM Accepted Manuscript Posted Online 6 June 2018

J. Clin. Microbiol. doi:10.1128/JCM.00424-18

Copyright © 2018 American Society for Microbiology. All Rights Reserved.

1 Laboratory diagnosis of neurocysticercosis / Taenia solium

2 Hector H. Garcia,a,b Seth E. O'Neal,c John Noh,d and Sukwan Handali,d for The
3 Cysticercosis Working Group in Peru.
4
5 Cysticercosis Unit, Instituto Nacional de Ciencias Neurologicas, Lima, Peru;a
6 Universidad Peruana Cayetano Heredia, Lima, Peru;b School of Public Health,
7 Oregon Health & Science University – Portland State University, Portland,
8 Oregon, USA;c Division of Parasitic Diseases and Malaria, Centers for Disease
9 Control and Prevention, Atlanta, Georgia, USA.d

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10
11
12 Other members of the CWGP include Robert H. Gilman, Armando E. Gonzalez,
13 and Victor C.W.Tsang, PhD (Coordination Board); Silvia Rodriguez, MSc;
14 Manuel Martinez, MD; Isidro Gonzales, MD, Herbert Saavedra, MD (Instituto
15 Nacional de Ciencias Neurológicas, Lima, Perú); Manuela Verastegui, PhD;
16 Javier A. Bustos, MD, MPH; Mirko Zimic, PhD; Holger Mayta, PhD; Yesenia
17 Castillo, MSc; Yagahira Castro, MSc (Universidad Peruana Cayetano Heredia,
18 Lima, Perú); Maria T. Lopez, DVM, PhD; Cesar M. Gavidia, DVM, PhD (School
19 of Veterinary Medicine, Universidad Nacional Mayor de San Marcos, Lima,
20 Perú); Luz M. Moyano, MD; Ricardo Gamboa, MSc, Claudio Muro, Percy
21 Vilchez, MSc (Cysticercosis Elimination Program, Tumbes, Perú); Theodore E.
22 Nash, MD; Siddhartha Mahanty, MD, PhD (NIAID, NIH, Bethesda, MD); Jon
23 Friedland (Imperial College, London, UK).
24
25 Disclaimer. The findings and conclusions in this report are those of the author(s)
26 and do not necessarily represent the official position of the Centers for Disease
27 Control and Prevention
28
29 Corresponding Author. Hector H. Garcia, MD, PhD. Center for Global Health,
30 Universidad Peruana Cayetano Heredia, H. Delgado 430, SMP, Lima 31, Perú.
31 Tel +511 3287360, Fax +511 3284038, email hgarcia@jhsph.edu
32
33
34 Running head. Serological diagnosis of neurocisticercosis
35
36 Word count 3322 (abstract 123) Tables None Figures 3
37
38 Competing Interests – The authors have no competing interests to declare.
39
40
41 ABSTRACT
42
43 Neurocysticercosis accounts for approximately 30% of all epilepsy cases in most
44 developing countries. Immunodiagnosis of cysticercosis is complex and strongly
45 influenced by the course of infection, the disease burden and cyst location, and
46 the immune response of the host. The main approach to immunodiagnosis

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47 should thus be to evaluate whether the serological results are consistent with the
48 diagnosis suggested by imaging. Antibody detection is performed using lentil-
49 lectin purified parasite antigens in an enzyme-linked immunoelectrotransfer blot
50 format while antigen detection uses a monoclonal antibody-based ELISA.
51 Promising new assay configurations have been developed for detection of both
52 antibody and antigen, including assays based on synthetic or recombinant
53 antigens that may reduce costs and improve assay reproducibility, and multiplex
54 bead based assays that may provide simultaneous quantitative results for
55 several target antigens or antibodies.
56
57
58
59 Keywords. Taenia solium, cysticercosis, neurocysticercosis, antigen, antibody,
60 EITB, Western blot, ELISA, Peru.
61
62 Taenia solium taeniasis/cysticercosis
63 Taenia solium, the pork tapeworm, is endemic in most developing countries
64 where pigs are raised. The coexistence of domestic pig raising and poor sanitary
65 conditions allows the establishment of the parasite life cycle, in which pigs get
66 infected with the larval, cystic stage (cysticercus) by ingesting infective Taenia
67 eggs excreted in the stools of a human carrying the adult intestinal tapeworm.

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68 Humans, in turn, get infected with the adult tapeworm stage by ingesting cysts in
69 poorly cooked pork. Humans may also host the larval stage and acquire
70 cysticercosis by fecal-oral contamination.(1) While cysts in most tissues are
71 asymptomatic and rarely noticed, cysts in the nervous system
72 (neurocysticercosis, NCC) are a major cause of epilepsy and other neurological
73 morbidity in endemic regions.(2, 3) Cases of NCC are seen in non-endemic
74 regions with increasing frequency because of travel and migration. In the US,
75 more than 1,800 NCC-related hospitalizations are estimated to occur per year.
76 Hospitalization costs for cysticercosis exceed those for malaria and all other
77 neglected tropical diseases combined.(4)
78
79 Cysticercosis infection. Very little is known regarding the usual evolution of
80 human cysticercosis infections. In the pig model, the embryos contained in
81 ingested tapeworm eggs are released, cross the intestinal mucosa, migrate
82 through the circulatory system, and develop into cysticerci that reach their
83 definitive size in 3 to 4 months. Cysticerci are typically found in muscle and
84 subcutaneous tissue and less frequently in the nervous system.(5) There is no
85 reason to suspect that this initial process is different in humans than in pigs.
86
87 Neurocysticercosis: parasite stages, localization, clinical manifestations.
88 It is generally accepted that, although human cysticercosis affects multiple
89 tissues, the parasite is usually destroyed by the host’s immune system, surviving
90 mainly in immunologically privileged sites like the brain or the eye. Infection of
91 the nervous system is more likely to result in prominent symptoms, and therefore
92 more likely to be diagnosed than infections of other tissues. Despite this, it is
 93 likely that most infections remain undiagnosed for months or years. Evidence
94 from a large series of NCC cases occurring in British soldiers who served in India
95 for a defined period demonstrated that in a significant proportion of cases,
96 neurological symptoms present years after infection.(6)
97
98 The process by which embryos invade the central nervous system has not been

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99 clearly elucidated. However, once infection is established, the evolution of
100 cysticerci in the human nervous system follows a somewhat predictable course.
101 Viable intraparenchymal brain cysts develop into rounded vesicles comprised of
102 a thin parasitic membrane filled with a clear, cerebrospinal (CSF)-like fluid, and
103 containing a retracted tapeworm head (scolex). There is evidence that the
104 parasite employs multiple active immune evasion mechanisms to avoid
105 recognition.(7) Pericystic inflammation at this initial stage is minimal or
106 nonexistent. At some point, the host's immune system detects the parasite and
107 launches a cellular response with local, perilesional inflammation that gradually
108 leads to the death of the cyst. The fluid inside the cyst becomes turbid and
109 dense, the cyst shrinks, and remnant parasite tissue is eventually cleared or
110 replaced with a residual calcification (Figure 1).
111
112 In contrast, cysts that develop in the subarachnoid spaces may not result in
113 rounded vesicles. Without the constraints of surrounding brain parenchyma, the
114 cyst membrane may infiltrate and grow into neighboring spaces and cavities,
115 resulting in large cystic structures or cyst clumps invading wide areas of the
116 subarachnoid space (Figure 2). This is frequently accompanied by a profuse
117 inflammatory reaction characterized by CSF pleocytosis, elevated protein
118 concentration, and low glucose. Cysts in the ventricles are usually individual
119 vesicles that frequently do not cause symptoms, although in some cases cysts
120 may block CSF circulation leading to hydrocephalus.
121
122 The location of the parasites in the human nervous system determines the
123 clinical manifestations of the infection. Parenchymal brain cysts primarily
124 manifest with seizures and epilepsy, although headache, focal signs, and
125 cognitive deficits are not uncommon. Ventricular and subarachnoid cysts present
126 as space-occupying lesions with or without hydrocephalus, and with headache
127 and intracranial hypertension as the most frequently associated symptoms.
128
129 Evolution of the immunological diagnosis in NCC. Initial attempts at

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130 immunodiagnosis date back to complement fixation described by Weinberg 1909
131 and later adapted by Nieto in Mexico in the early 1940's.(8) Hemagglutination
132 and radioimmunoassay were used for many years despite suboptimal sensitivity
133 and specificity.(9) Soon after the advent of the enzyme-linked immunosorbent
134 assay (ELISA), several teams applied this technique to cysticercosis with good
135 results,(10-13) although cross-reactions with other helminth infections (including
136 Echinococcus, Hymenolepis, and Schistosoma, among others) were frequent. In
137 1989, the introduction of the enzyme-linked immunoelectrotransfer blot using
138 lentil-lectin bound glycoproteins (LLGP-EITB) significantly improved the
139 performance of immunodiagnosis.
140
141 All of the above assays are based on the detection of antibodies, taking
142 advantage of the multiplier effect of the antibody production system in the host.
143 Detection of antigen was deemed poorly efficient (14,15) until the use of
144 monoclonal antibodies (Mabs) allowed improved ELISA assays. Two assays for
145 veterinary use, detecting T. saginata cysticercosis in cattle were developed in
146 Europe using Mabs against Taenia saginata, one using the HP10 Mab from
147 Edimburgh(16) and the other using the B158-B60 antibodies from Antwerp.(17)
148 These Mabs are cross-reactive with T. solium in pigs and T. ovis in sheep, but
149 not with other common cestodes that infect humans such as Hymenolepis nana
150 or Echinococcus granulosus. These assays were initially reported to be useful to
151 support diagnosis of NCC using CSF,(15) and were subsequently demonstrated
152 to be have similar utility for serum(18-21) and urine.(22,23)
153
154
155 ANTIBODY DIAGNOSIS
156 Assays. The reference assay for antibody detection is the LLGP-EITB.(9) This
157 assay uses a lentil-lectin purified glycoprotein antigen mixture that is separated
158 by gel electrophoresis, transferred onto nitrocellulose paper, and then cut into
159 strips. A strip is placed in a well containing the sample (usually serum or CSF)
160 and incubated overnight. Conjugated goat anti-human IgG antibody is then

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161 added to reveal antigen-antibody reactions that appear as dark bands on the
162 strip. Reactions to one or more of the seven LLGP antigens are considered
163 positive.
164
165 In clinical settings, the diagnostic performance of the LLGP-EITB performed in
166 serum samples is very high, approaching 98% sensitivity and 100% specificity in
167 patients with more than one viable brain cysticercosis cyst.(9) In patients with a
168 single viable or degenerating cyst, sensitivity is lower (60 to 70%).(24) The
169 presence of circulating antibodies detectable by LLGP-EITB in patients with only
170 calcified lesions is extremely variable, and likely affected by the burden of the
171 original infection and the time since resolution. Currently, the LLGP-EITB assay
172 is available through the CDC Parasitic Disease Reference Laboratory for clinical
173 diagnosis in US cases.
174
175 Antibody-detection ELISA assays have mostly used semi-purified somatic
176 parasite or cyst fluid antigens. Their performance in general is poor, with
177 suboptimal sensitivity and frequent cross-reactions with other common cestode
178 infections such as hymenolepiasis or hydatid disease.(25) Some authors suggest
179 that antibody detection in ELISA is more specific and substantially more sensitive
180 when performed in CSF rather than in sera. In research settings, good test
181 accuracies have been obtained in several platforms of ELISAs (traditional ELISA,
182 FAST-ELISA, and QuickELISA) using recombinant or synthetic antigens (26-28)
183 although these assays have not yet become commercially available.
184
185 Antigens. A systematic list of antigens used for antibody diagnosis in
186 cysticercosis can be found in Rodriquez S (2012).(24) In short, the first antigen
187 characterized was the dominant Antigen B which was described in Mexico in
188 1980. As the use of antigen B did not demonstrate much advantage over other
189 antigen sources, further characterization of antigenic proteins were carried out.
190 After the LLGP antigens were characterized and applied in the EITB format, this

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191 assay became the reference assay for serodiagnosis. Other assays based on the
192 LLGP antigens have been developed.(9,26-31) The LLGPs belong to three
193 families, including the GP50, T24, and 8kDa families.
194
195 The GP50 protein is a glycosylated and GPI-anchored membrane protein.
196 The native protein migrates at 50 kDa, but the predicted molecular weight of the
197 mature protein is 28.9. Expressed in a baculovirus expression system,
198 recombinant GP50 in a EITB assay showed 100% specificity for cysticercosis
199 and 90% sensitivity for cysticercosis positive serum samples reactive with the
200 GP50 component of LLGP.(30)
201
202 The T24 protein is an integral membrane protein that belongs to the
203 tetraspanin superfamily. It migrates at a position corresponding to 24-kDa and as
204 a homodimer at 42-kDa. A portion of T24, the large, extracellular loop domain,
205 was expressed in an immunologically reactive form in insect cells and also in
206 bacterial cells. When tested in a EITB assay with several well-defined batteries of
207 serum samples (ranging from 149 to 249 NCC cases, as well as from 131 to 401
208 negative controls), this protein, T24H, has a sensitivity of 94% for detecting
209 cases of cysticercosis with two or more viable cysts, and a specificity of
210 98%.(27,29,31)
211
212 The 8kDa proteins are the diagnostic proteins found at 14, 18, and 21 kDa
213 lentil lectin bound fraction from urea-solubilized cysticerci, and are also found in
214 the bands at 24 and 39 to 42 kDa of LLGP. The 8kDa family is likely comprised
215 of extracellular secreted proteins that accumulate in the cyst fluid. This family
216 consists of 4 clades of proteins (TsRS1, TsRS2, Ts14, and Ts18) and from each
217 representative clade, a synthetic peptide have been produced and evaluated as
218 diagnostic antigens.
219
220 Samples. Serum samples are preferred for antibody diagnosis. CSF has the
221 advantage of being in more direct contact with the CNS infection, but its

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222 collection requires a lumbar puncture, an invasive and moderately painful
223 procedure that is poorly accepted in some cultures. In general, antibody
224 detection by EITB is similarly sensitive in serum than in CSF, and antibody
225 detection by ELISA seems higher in CSF.(32) CSF examination may however
226 complement the serological diagnosis and as well as add information such as cell
227 counts and CSF biochemistry. Antibodies can be also found in saliva
228 samples.(32)
229
230 Antibody profiles by type of NCC. The presence of specific antibodies does
231 not definitively indicate active cysticercosis infection, since antibodies can result
232 from exposure to the parasite, and from infections that did not establish or were
233 resolved in very early stages. In fact, a positive LLGP-EITB result can be found in
234 up to 20-25% of some rural endemic populations where all of these scenarios are
235 present.(33) Moreover, in endemic settings, transient antibody responses have
236 been reported to be relatively common in both humans and pigs, suggesting that
237 exposure is frequent and does not necessarily result in sustained
238 seropositivity.(34) However, the strength of the antibody response, and the
239 particular profile of individual LLGP reactions, can provide useful information in
240 the clinical setting. Positive antibody responses in asymptomatic people from
241 endemic populations are usually characterized by weak reactions against GP50
242 only, or to GP50 and GP42-39. In contrast, antibody reactions in clinical cases
243 are much stronger and frequently involve all the LLGP families. We have been
244 able to dilute a serum sample from a patient with subarachnoid NCC 16 times
245 before the EITB became negative (Figure 3). A recent study described the
246 associations between LLGP-EITB antibody banding patterns and brain imaging
247 findings in 548 NCC cases. Samples with a negative result or with only
248 antibodies to GP50 were associated with non-viable or single viable parenchymal
249 cysticerci, and samples with low molecular weight antibodies (8kDa family) were
250 more likely to have extraparenchymal NCC or multiple viable intraparenchymal
251 cysts.(35)
252

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253 Longevity of antibody responses in NCC. One of the drawbacks of antibody
254 detection is that the lifespan of the antibody response is extremely variable and
255 likely dependent on the immune history of the host, the burden of infection, and
256 other variables. Thus, some individuals with infections involving multiple cysts
257 may have persistently detectable antibodies on LLGP-EITB years after
258 successful anti-parasitic treatment, while others may become seronegative after
259 nine months or so.(36) While seroreversion to negative is a marker of cure,
260 waning of the antibody response over less than a year is not the norm in most
261 patients. Antibodies to the 8-kDa antigens are the first to disappear, followed by
262 antibodies to GP24 and GP42-39. Antibodies to GP50 are the most persistent.
263 Patients presenting with only calcified NCC lesions may still have persistently
264 positive reactions; the positive EITB result in these cases does not necessarily
265 imply the presence of undetected viable parasitic cysts, particularly in cases with
266 weak or decreasing antibody responses. On the other hand, strong LLGP-EITB
267 reactions (4-7 bands) in a patient with calcified NCC may indicate the presence
268 of viable cysts, although the predictive value is lower than that of antigen
269 detection.(35)
270
271 ANTIGEN DETECTION
272 Diagnosis by antigen detection is limited by the amount of circulating antigens
273 that are produced or released from the parasites, unlike the antibody responses
274 that have been amplified by the host's immune system.
275
276 Assays. The introduction of Mab-based antigen detection ELISA assays
277 improved the specificity of the tests and allowed their use for the diagnosis of
278 human NCC. These assays use a sandwich ELISA technique with one Mab as
279 capture antibody and a different Mab as the detection antibody.
280
281 Antibodies. Two assays have been described in the literature. One of them uses
282 HP10 and HP6 antigens, and another assay from a different group utilizes MABs
283 B158 and B60. All of these MABs were developed against Taenia saginata but

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284 cross-react with Taenia solium, allowing the diagnosis of viable cysticercosis.
285 The HP10 and HP6 monoclonal antibody pairs were developed by injecting
286 antigens from viable cysts into mice and were screened against lentil lectin
287 adherent glycoproteins from T. saginata cysts.(16,17) The HP10 monoclonal
288 antibody is an IgM class antibody and recognizes an epitope present on a
289 heterogeneous group of phosphorylcholine-bearing, lentil-lectin adherent,
290 trichloroacetic acid soluble glycoproteins present on the surface and in the
291 secretions of the T. saginata cysticerci.(16)
292
293 The B158 and B60 monoclonal antibodies were developed against the
294 excretory secretory antigens of T. saginata viable cysticerci. These monoclonal
295 antibodies are IgM antibody class and recognize bands at 87 kDa, and 100 kDa
296 of somatic extract of adult T. saginata and also the 65 kDa from excretory-
297 secretory antigens of T. saginata cysticerci.(17) The performance of these
298 assays appears to be comparable. One commercial version of the B158 assay
299 (Cysticercosis AG Elisa, ApDia, Turnhout, Belgium) is available in the US.
300
301 Samples. Antigen detection was initially reported using CSF, but later also
302 reported to be possible using serum and urine. While there is no published
303 controlled data, antigen levels seem to be higher in CSF than in serum. As
304 mentioned above for antibody detection, serum is the preferred sample.
305 The same advantages (sample being in more direct contact with the CNS
306 infection) and disadvantages (more invasive and less acceptable) apply
307 regarding CSF versus the other samples types.
308
309 Antigen profiles by type of NCC. Detectable levels of circulating antigen
310 demonstrate the presence of live parasite cysts in the host. Patients with only
311 calcified NCC should therefore be antigen-negative, and a positive result in this
312 scenario should make the clinician suspect that viable lesions have been missed
313 by imaging. Results of antigen testing are frequently negative in patients with a
314 degenerating cyst or with one or a few viable parenchymal cysts, and

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315 consistently positive in patients with several viable parenchymal cysts. Levels of
316 circulating antigen are very high in patients with subarachnoid NCC, to the extent
317 of frequently saturating the assay detection limit.
318
319 Longevity of antigen responses in NCC. Unlike circulating antibodies, antigen
320 levels drop fairly quickly after a successful course of anti-parasitic therapy in
321 which all viable parasites are destroyed. Resolution of extensive subarachnoid
322 NCC may, however, take several courses of anti-parasitic treatment.
323
324 Role of immunological diagnosis in the diagnosis of NCC. Understanding
325 how immunological assays can best contribute to the diagnosis of NCC is not as
326 intuitive as it may sound. To begin with, brain imaging is a key part of the
327 evaluation of a patient suspected to have NCC and should be used to establish
328 the diagnosis, define key characteristics of infection, and determine medical or
329 surgical treatment approaches. The diagnosis suggested by imaging needs to be
330 considered when evaluating serological results. For example, it is important to
331 consider that the levels of antigens and antibodies vary enormously depending
332 on the stage and number of the parasites present. In general, it is to be expected
333 that most patients with viable infections would be seropositive for both antibodies
334 and antigens. However, patients with a single lesion may test negative for either,
335 and patients with low infection burden may be antigen-negative but positive for
336 antibodies. Patients with only calcified lesions are typically antigen negative and
337 many of them will also be antibody negative, although a proportion of them will
338 continue having detectable levels of circulating antibodies due to the persistence
339 of the response months or years after the parasites have died. Subarachnoid
340 NCC is commonly associated with very high levels of circulating antigens and
341 antibodies and thus a negative or weak result should raise questions about the
342 diagnosis.
343
344 Role of immunological diagnosis to screen for cysticercosis or NCC
345 infections. A frequent question is whether immunodiagnostic assays should be

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346 used to identify people suspected of having NCC in endemic areas where
347 confirmatory brain imaging is not possible. We contend that the utility of this
348 approach is limited, as immunodiagnosis using the tests that are currently
349 available would not modify the clinical management for the vast majority of
350 people with either asymptomatic or symptomatic NCC. In addition, most experts
351 will not prescribe anti-parasitic treatment in the absence of brain imaging,
352 because the risks associated with the resulting inflammatory response depend
353 greatly on the number and location of viable cysts present.
354
355 On the population level, most individuals with asymptomatic NCC will have only
356 calcified disease. While it is not known what proportion of these will develop
357 epilepsy or other neurological symptoms, clinical management is limited to the
358 administration of antiepileptic drugs or other symptomatic measures regardless
359 of serologic status. A smaller proportion of individuals with NCC will have viable
360 or degenerating cysts. Again, an unknown but likely small proportion will go on to
361 develop symptoms, and the prognosis with or without anti-parasitic treatment is
362 favorable. An even smaller proportion, however, will have a large CNS cyst
363 burden (many cysts) or early subarachnoid NCC involvement, with substantial
364 risk of disease progression or complications. In our assessment, the only
365 potential contribution of an immunological screening test for NCC would be to
366 identify this small subset, as early intervention could potentially improve
367 prognosis and reduce long-term costs. These potential benefits have yet to be
368 demonstrated. Clinical management of these patients also requires brain
369 imaging.
370
371 The scenario is similar for individuals with symptomatic NCC. The majority will
372 have epilepsy secondary to parenchymal brain cysticercosis, and should be
373 managed with antiepileptic drugs regardless of serologic status. There is no
374 indication for anti-parasitic treatment in the sizable proportion of clinical cases
375 presenting with calcified NCC only. Although symptomatic individuals with few
376 viable cysts may benefit from anti-parasitic drugs, the clinical prognosis with

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377 symptomatic management is again favorable, and blind use of anti-parasitic
378 treatment in cases with cysts in delicate locations such as the brainstem, or
379 individuals with large cyst burdens may be deleterious or even lethal. Those with
380 severe neurologic manifestations such as intracranial hypertension require
381 referral for brain imaging, and neurosurgery will be indicated independent of
382 whether the symptoms are due to NCC or not. As mentioned above, the utility of
383 screening may be limited to identifying those individuals with a heavy cyst burden
384 or subarachnoid involvement.
385
386 Future trends in immunological diagnosis. The limited availability of the LLGP
387 EITB is a serious drawback. Preparation of the antigens used on the test strips
388 requires a complex purification process that is both expensive and difficult to
389 standardize, as well as dependent on the availability of parasite material.
390 Because of this complex and labor-intensive process, adaptation to a titering
391 version does not seem a practical alternative. In recent years, however,
392 representative proteins for all three antigenic protein families have been
393 developed in either recombinant (rGP50, rT24) or synthetic (sTSRS1,
394 sTS18var1, sTSRS2var1, sTs14) forms that may reduce costs and improve
395 assay reproducibility. Standardized EITB assays using these new antigens are
396 now available in the research setting,(26-31) but require validation in a variety of
397 endemic settings to better understand their performance and limitations. These
398 efforts are currently underway.
399
400 Another drawback is that the result is qualitative and requires considerable
401 experience for correct interpretation of the banding profile. A quantitative,
402 multiplex bead-based assay such as the Luminex™ platform, offers the
403 possibility of simultaneously detecting cysticercosis antigens and also to quantify
404 the antibody response to each specific cysticercosis antigen. A quantitative
405 assay would provide an estimate of the intensity of the antibody response
406 (improving diagnostic accuracy) and would also allow direct comparison of
407 antibody levels between samples (providing a guide for monitoring therapy or

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408 follow the evolution of the infection). This platform assay also allows the
409 possibility of combining testing for cysticercosis with other diseases, which could
410 be beneficial for integrated control programs. With respect to antigen detection,
411 new mAbs that are specific to Taenia solium and that have greater binding
412 capacity to improve detection sensitivity, are needed.
413
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478 Gonzalez AE, Gilman RH, Tsang VCW, Brandt J. 2005. Drop in antigen
479 levels following successful treatment of subarachnoid neurocysticercosis.
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500 24. Rodriguez S, Wilkins P, Dorny P. 2012. Immunological and molecular
501 diagnosis of cysticercosis. Pathogens and Global Health 106:286-298.
502 25. Garcia HH, Castillo Y, Gonzales I, Bustos JA, Saavedra H, Jacob L, Del
503 Brutto OH, Wilkins PP, Gonzalez AE, Gilman RH, CWGiP. 2018. Low
504 sensitivity and frequent cross-reactions in commercially available antibody
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507 26. Lee YM, Handali S, Hancock K, Pattabhi S, Kovalenko VA, Levin A,
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509 Tsang VC. 2011. Serologic diagnosis of human Taenia solium
510 cysticercosis by using recombinant and synthetic antigens in QuickELISA.
511 Am J Trop Med Hyg 84:587-93.
512 27. Hernández-González A, Noh J, Perteguer MJ, Garate T, Handali S. 2017.
513 Comparison of T24H-his, GST-T24H and GST-Ts8B2 recombinant
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515 diagnosis of neurocysticercosis. Parasites and Vectors 10:237.
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517 VCW. 2003. Characterization of the 8-kilodalton antigens of Taenia solium
518 metacestodes and evaluation of their use in an enzyme-linked
519 immunosorbent assay for serodiagnosis. Journal of Clinical Microbiology
520 41:2577-86.
521 29. Noh J, Rodriguez S, Lee YM, Handali S, Gonzalez AE, Gilman RH, Tsang
522 VCW, Garcia HH, Wilkins PP. 2014. Recombinant protein- and synthetic
523 peptide-based immunoblot test for diagnosis of neurocysticercosis.
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525 30. Hancock K, Pattabhi S, Greene RM, Yushak ML, Williams F, Khan A,
526 Priest JW, Levine MZ, Tsang VCW. 2004. Characterization and cloning of
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529 31. Hancock K, Pattabhi S, Whitfield FW, Yushak ML, Lane WS, Garcia HH,
530 Gonzalez AE, Gilman RH, Tsang VCW. 2006. Characterization and
531 cloning of T24, a Taenia solium antigen diagnostic for cysticercosis.
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537 58:18-24.
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540 Cysticercosis Working Group in Peru. 2005. Neurocysticercosis:
541 association between seizures, serology, and brain CT in rural Peru.

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542 Neurology 65:229-33.
543 34. Garcia HH, Gonzalez AE, Gilman RH, Palacios LG, Jimenez I, Rodriguez
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551 VCW, Garcia HH. 2017. Antibody banding patterns of the Enzyme-linked
552 Immunoelectrotransfer Blot (EITB) and brain imaging findings in patients
553 with neurocysticercosis. Clinical Infectious Diseases
554 doi:10.1093/cid/cix774.
555 36. Garcia HH, Gilman RH, Catacora M, Verastegui M, Gonzalez AE, Tsang
556 VCW, Martinez M, Altamirano J, Trelles L, Cuba JM, Alvarado M, Alban G,
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558 Barron E. 1997. Serologic evolution of neurocysticercosis patients after
559 antiparasitic therapy. Journal of Infectious Diseases 175:486-489.
560 FIGURE LEGENDS
561
562
563 Figure 1. Macroscopic views of cysticerci in different stages of involution.
564
565
566 Figure 2. Basal subarachnoid neurocysticercosis (magnetic resonance imaging).
567
568

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569 Figure 3. Sustained EITB response despite sequential (two-fold) dilutions of a
570 strong positive serum sample.
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