NCC Dr. Shatdal Chaudhary

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Cysticercosis / Neurocysticercosis:

Cysticercosis / Neurocysticercosis Dr Shatdal Chaudhary, M.D. Associate Professor Department of Internal Medicine Universal College Of Medical Sciences, Bhairahawa, Nepal

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Cestodes: Tape worm, Segmented worms Humans are definite host Living in GIT, T saginata, D latum, H nana Humans are intermediate host Echinococcosis, Sparganosis, Coenurosis Both Taenia solium

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Cysticercosis Larval form in the tissues (Cyst with scolex)

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T saginata Ingestion of raw or undercooked beef meat C/F Diagnosis Cellophane tape swab Tx Praziquantel 10 mg/kg Niclosamide 2 gm

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T solium : Two form of infection Taeniasis Cysticesosis

Life cycle of T. solium. :

Life cycle of T. solium .

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Life cycle of T solium . The adult parasite inhabits the small intestine in a human being. (2) T solium eggs are shed into faeces. (3) The eggs are disseminated to the environment through faeces. (4) A pig is infected by ingestion of parasite eggs in human faeces. (5) Human beings acquire intestinal infection by ingestion of undercooked infected pork. (6) People are also infected by ingestion of T solium eggs by contact with carriers


NEUROCYSTICERCOSIS Neurocysticercosis (NCC) invasion of the nervous system by the larval stage of pork tapeworm, Taenia solium . Important public health problem in developing and developed countries.

Transmission and epidemiology :

Transmission and epidemiology  Worldwide distribution, endemic in Latin America, Indian subcontinent, China, most of African and Asian countries. Absent from Israel, certain Asian countries where pig-rearing is not allowed for religious reasons.

Transmission and epidemiology:

Transmission and epidemiology US and European countries - becoming more common due to carrier immigrants. India – seroprevalence is between 2-3% in general population 40% of localization related seizures are due to NCC, or single enhancing CT lesion consistent with cysticercal granuloma (Pal et. al. 2000). ~50,000 deaths world wide annually

Transmission and epidemiology:

Transmission and epidemiology Close contact between pigs with poor sanitation, personal hygiene and sewage disposal system and lack of water supply. Man - definitive host, adult tape worm. Gravid proglottids - highly infective fertile eggs are shed in the feaces. Feco-oral route, raw vegetables or water or even through infected fingers of self or food handlers  

Pathology and pathogenesis:

Pathology and pathogenesis Survival in pigs - absence of significant inflammatory response in the host. Thin walled oval cysts -1cm in diameter, invaginated scolex, a white nodule,one side of the cyst. Cyst wall – an outer eosinophilic layer an inner cellular layer, and an innermost layer of loose connective tissue.

Pathology and pathogenesis Contd…….:

Pathology and pathogenesis Contd ……. Escapes hosts immune surveillance mechanism by Secreting a protease inhibitor called taeniastatin – inhibits complement activation. The parasite wall – covered with sulphated polysaccharides - shed intermittently and activate complement away from cyst wall.

Pathology and pathogenesis:

Pathology and pathogenesis Inhibit the classical pathway of complement activation, Elaborate prostaglandins , low molecular weight molecules which decrease inflammation. Approximately 3-8% of individuals dying of other causes show presence of viable cysticerci in their brains on autopsy in endemic areas.

Pathology and pathogenesis:

Pathology and pathogenesis Stages of evolution (Carpio et al 1994.). 1. Vesicular stage - minimal inflammatory response 2. Colloidal stage – inflammation mononuclear cells 3. Granular nodular stage - gradual replacement by fibrotic tissue, collapse of cell wall 4. Calcific stage replacement of the wall with calcium

Pathology and pathogenesis:

Pathology and pathogenesis Parenchymal cysts generally associated with seizures, Extraparenchymal cysts may be present in the ventricles or the subarachnoid space, raised intracranial pressure and deteriorating mental status.

Pathology and pathogenesis:

Pathology and pathogenesis Intraventricular - Persistent or intermittent raised intracranial pressure due to blockage of aqueduct of Sylvius or foramina of Lushka and Magendie. Arachnoiditis ,meningitis, hydrocephalous, vasculitis with stroke.

Localization of parasite in CNS:

Localization of parasite in CNS Parenchymal Brain Spinal cord Eye Extraparenchymal Ventricular Subarachnoid

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BRAIN small cyst single or multiple , tend to lodge in areas of high vascular supply SPINAL Inside the leptomeningeal space or intramedullary meningeal inflammation & fibrosis-severe

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C/F Taeniasis Cysticercosis: Can be found in any part of the body Commonly brain, CSF, skeletal muscle, subcutaneous tissue and eye C/F depends on site, Number, degree of inflammation and scarring


CLINICAL MANIFESTATION PARENCHYMAL Epilepsy-partial with secondary generalisation other types Pyramidal tract signs, sensory deficit, involuntary movement, cerebellar ataxia, signs of brainstem dysfunction, intellectual deterioration, dementia and psychosis

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SUBARACHNOID Headache, vomiting, vertigo, CN dysfunction, gait disturbances, mental deterioration, infarction of brain parenchyma INTRAVENTRICULAR Most Common- subacute or intermittent syndrome of intracranial hypertension, sudden death with acute hydrocephalus-some cases

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SPINAL Non specific Leptomeningeal- root pain, progressive weakness of insidious onset Intramedullary-thoracic segments OCULAR Progressive decrease of visual acquity- d/t parasite in eye or uveitis, endophthalmitis

Diagnostic criteria for neurocysticercosis modified Del Brutto Criteria:

Diagnostic criteria for neurocysticercosis modified Del Brutto Criteria Absolute   A. Histologic demonstration of the parasite from biopsy of a brain or spinal cord lesion     B. Cystic lesions showing the scolex on CT or MRI     C. Direct visualization of sub retinal parasites by fundoscopic examination

Diagnostic criteria for neurocysticercosis:

Diagnostic criteria for neurocysticercosis Major     A. Lesions highly suggestive of neurocysticercosis on neuroimaging studies     B. the detection of anticysticercal antibodies by Enzyme-linked immunoelectrotransfer blot      C. Resolution of intracranial cystic lesions after therapy with albendazole or praziquantel    

Diagnostic criteria for neurocysticercosis:

Diagnostic criteria for neurocysticercosis Minor     A. Lesions compatible with neurocysticercosis on neuroimaging studies     B. Clinical manifestations suggestive of neurocysticercosis     C. Positive CSF ELISA for detection of anticysticercal antibodies or cysticercal antigens     D. Cysticercosis outside the central nervous system

Diagnostic criteria for neurocysticercosis:

Diagnostic criteria for neurocysticercosis Epidemiologic     Evidence of a household contact with an individual infected T. solium infection     Individuals coming from or living in an area where cysticercosis is endemic     History of frequent travel to disease-endemic areas

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DEFINITIVE One absolute criteria Two major + one minor + One epidemiological criteria PROBABLE One major + Two minor criteria One major + One minor + One epidemiological criteria Three minor + One epidemiological criteria POSSIBLE One major criteria Two minor criteria One minor + One epidemiological criteria

CT patterns of parenchymal NCC:

CT patterns of parenchymal NCC 1. Small calcifications or granulomas. Rounded areas of low density showing little or no enhancement after intravenous contrast (vesicular cysts) 3. Scattered hypodense or isodense lesions surrounded by oedema and ring like enhancement after contrast (colloidal cysts). These lesions represent the acute encephalitis of parenchymal NCC. 4. Diffuse brain oedema associated with narrowing of lateral ventricles and multiple ring like areas of abnormal contrast enhancement in the parenchyma( this is the CT appearance of cysticercotic encephalitis ).

Calcifications (noncontrasted CT) :

Calcifications (noncontrasted CT)

Giant cyst (contrasted CT) :

Giant cyst (contrasted CT)

Viable cysts contrasted MRI:

Viable cysts contrasted MRI

Cyst with perilesional contrast enhancement (contrasted MRI) :

Cyst with perilesional contrast enhancement (contrasted MRI)

Enhancing lesion (contrasted MRI) :

Enhancing lesion (contrasted MRI)

Cysticercotic encephalitis (contrasted MRI) :

Cysticercotic encephalitis (contrasted MRI)

Basal subarachnoid cysticercosis (contrasted MRI) :

Basal subarachnoid cysticercosis (contrasted MRI)


IMMUNODIAGNOSIS Suspected NCC- CSF- degree of inflammation- elevation of protein and cell count ELISA- poor sensitivity and specificity EITB(enzyme linked immuno-electrotransfer blot) 100% sensitive, 98% specific Antigen specific IgM in CSF (87% sensitive,95% specific) Complement fixation

Differential Diagnosis:

Differential Diagnosis Tuberculoma – basal meningitis, communicating hydrocephalus and calcifying parenchymal granulomas. Metastasis - lung, breast, kidney, colon, melanoma Brain abscess- thin uniform wall, homogeneous centre & florid surrounding oedema Other infections: Toxoplasmosis, Cryptococcosis Lymphoma-solid enhancing periventricular tumour with ependymal spread (immunocompetent); ring enhancing in AIDS Brain tumour – multicentric glioma-diffusely infiltrating Infarct- gyriform,ring like or solid enhancement Contusions/haematomas-subacute stage


TREATMENT Single therapeutic approach – not justifiable d/t pleomorphic nature Decisive factor- activity of disease, location of parasite Two mainstay – medical & surgical Medical (cysticidal drugs) Albendazole (15mg/kg/day for 8-28 days) Praziquantel (50mg/kg/day for 15-30 days) Surgical – intraventricular & subarachnoid NCC Antioedema measures (steroids) Antiepileptic drugs

Prevention and public health aspects:

Prevention and public health aspects Proper disposal of human waste Treatment of water contaminated with human faeces before its use in irrigation of vegetables cultivation Proper cooking of pork Public education of life cycles of T. solium In endemic areas measures such as compulsary and repeated treatment of Taenia carriers and domestic or industrial freezing of pork Production of vaccine against T. solium

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