Clinical manifestations and diagnosis of cysticercosis
- A Clinton White, Jr, MD, FACP, FIDSA
A Clinton White, Jr, MD, FACP, FIDSA
- Paul R Stalnaker Distinguished Professor of Medicine and Director, Infectious Disease Division
- Department of Internal Medicine
- University of Texas Medical Branch
Cysticercosis is caused by the larval stage (metacestode) of the pork tapeworm Taenia solium. Clinical syndromes related to this parasite are divided into neurocysticercosis (NCC) and extraneural cysticercosis. Neurocysticercosis, in turn, is divided into parenchymal and extraparenchymal forms. Extraparenchymal forms include intraventricular, subarachnoid, intraocular, and spinal disease.
The clinical features and diagnosis of cysticercosis will be reviewed here. The epidemiology, life cycle, transmission and treatment of this infection are discussed separately. (See "Epidemiology, transmission, and prevention of cysticercosis" and "Treatment of cysticercosis" and "Intestinal tapeworms".)
Tissue cysticerci develop over a period of three to eight weeks following ingestion of T. solium eggs shed in the stool of a human tapeworm carrier. Cysticerci can develop at one or multiple sites; during the initial viable phase, cysticerci do not cause much inflammation in surrounding tissues. This phase of infection is usually asymptomatic, and cysticerci typically remain in this stage for many years. (See "Epidemiology, transmission, and prevention of cysticercosis".)
Taenia parasites have sophisticated means of evading destruction, and a number of mechanisms for host immune tolerance have been postulated. Metacestodes elaborate a variety of substances, including prostaglandins, taeniaestatin (a parasite serine proteinase inhibitor), paramyosin, sulfated polysaccharides, and secretory proteases, that inhibit or divert host inflammatory responses [1,2]. Parasite molecules may interfere with lymphocyte proliferation and macrophage function, thereby inhibiting normal cellular immune defenses [1,2]. Secreted proteases degrade host molecules including cytokines. In addition, humoral antibodies do not kill the mature metacestode.
Eventually (after a variable number of years) the cysts degenerate and lose their ability to modulate the host immune response . Host immune and inflammatory cells attack the cysticercus, which leads to the appearance of edema and/or contrast enhancement on imaging studies. This inflammatory response is associated with onset of seizures. Host inflammatory molecules such as substance P may be key mediators of seizures [4,5].
- White AC, Jr, Robinson P, Kuhn R. Taenia solium cysticercosis: Host-parasite interactions and the immune response. In: Immunopathogenetic Aspects of Disease Induced by Helminth Parasites, Freedman DO (Ed), Karger, Basel 1997. p.209.
- Garcia HH, Nash TE, Del Brutto OH. Clinical symptoms, diagnosis, and treatment of neurocysticercosis. Lancet Neurol 2014; 13:1202.
- Garcia HH, Coyle CM, White AC Jr. Cysticercosis. In: Tropical Infectious Diseases: Principles, Pathogens and Practice, 3rd ed, Guerrant RL, Walker DH, Weller PF (Eds), Saunders Elsevier, Philadelphia 2011. p.815.
- Stringer JL, Marks LM, White AC Jr, Robinson P. Epileptogenic activity of granulomas associated with murine cysticercosis. Exp Neurol 2003; 183:532.
- Robinson P, Garza A, Weinstock J, et al. Substance P causes seizures in neurocysticercosis. PLoS Pathog 2012; 8:e1002489.
- Nash TE, Del Brutto OH, Butman JA, et al. Calcific neurocysticercosis and epileptogenesis. Neurology 2004; 62:1934.
- Nash TE, Pretell EJ, Lescano AG, et al. Perilesional brain oedema and seizure activity in patients with calcified neurocysticercosis: a prospective cohort and nested case-control study. Lancet Neurol 2008; 7:1099.
- Bianchin MM, Velasco TR, Wichert-Ana L, et al. Characteristics of mesial temporal lobe epilepsy associated with hippocampal sclerosis plus neurocysticercosis. Epilepsy Res 2014; 108:1889.
- Rathore C, Thomas B, Kesavadas C, et al. Calcified neurocysticercosis lesions and antiepileptic drug-resistant epilepsy: a surgically remediable syndrome? Epilepsia 2013; 54:1815.
- Gupta RK, Awasthi R, Rathore RK, et al. Understanding epileptogenesis in calcified neurocysticercosis with perfusion MRI. Neurology 2012; 78:618.
- Rangel-Castilla L, Serpa JA, Gopinath SP, et al. Contemporary neurosurgical approaches to neurocysticercosis. Am J Trop Med Hyg 2009; 80:373.
- Sáenz B, Ruíz-Garcia M, Jiménez E, et al. Neurocysticercosis: clinical, radiologic, and inflammatory differences between children and adults. Pediatr Infect Dis J 2006; 25:801.
- Singhi P, Ray M, Singhi S, Khandelwal N. Clinical spectrum of 500 children with neurocysticercosis and response to albendazole therapy. J Child Neurol 2000; 15:207.
- Serpa JA, Graviss EA, Kass JS, White AC Jr. Neurocysticercosis in Houston, Texas: an update. Medicine (Baltimore) 2011; 90:81.
- Nash TE, Garcia HH. Diagnosis and treatment of neurocysticercosis. Nat Rev Neurol 2011; 7:584.
- del la Garza Y, Graviss EA, Daver NG, et al. Epidemiology of neurocysticercosis in Houston, Texas. Am J Trop Med Hyg 2005; 73:766.
- Dixon HB, Lipscomb FM. Cysticercosis: An analysis and follow-up of 450 cases, Her Majesty's Stationary Service, London 1961.
- Montano SM, Villaran MV, Ylquimiche L, et al. Neurocysticercosis: association between seizures, serology, and brain CT in rural Peru. Neurology 2005; 65:229.
- Fleury A, Gomez T, Alvarez I, et al. High prevalence of calcified silent neurocysticercosis in a rural village of Mexico. Neuroepidemiology 2003; 22:139.
- Prasad A, Gupta RK, Pradhan S, et al. What triggers seizures in neurocysticercosis? A MRI-based study in pig farming community from a district of North India. Parasitol Int 2008; 57:166.
- Medina MT, Durón RM, Martínez L, et al. Prevalence, incidence, and etiology of epilepsies in rural Honduras: the Salamá Study. Epilepsia 2005; 46:124.
- Garcia-Noval J, Moreno E, de Mata F, et al. An epidemiological study of epilepsy and epileptic seizures in two rural Guatemalan communities. Ann Trop Med Parasitol 2001; 95:167.
- Nash TE, Singh G, White AC, et al. Treatment of neurocysticercosis: current status and future research needs. Neurology 2006; 67:1120.
- Del Brutto OH, Santibañez R, Noboa CA, et al. Epilepsy due to neurocysticercosis: analysis of 203 patients. Neurology 1992; 42:389.
- Carpio A, Hauser WA. Prognosis for seizure recurrence in patients with newly diagnosed neurocysticercosis. Neurology 2002; 59:1730.
- Torres-Corzo J, Rodriguez-della Vecchia R, Rangel-Castilla L. Bruns syndrome caused by intraventricular neurocysticercosis treated using flexible endoscopy. J Neurosurg 2006; 104:746.
- Viola GM, White AC Jr, Serpa JA. Hemorrhagic cerebrovascular events and neurocysticercosis: a case report and review of the literature. Am J Trop Med Hyg 2011; 84:402.
- Callacondo D, Garcia HH, Gonzales I, et al. High frequency of spinal involvement in patients with basal subarachnoid neurocysticercosis. Neurology 2012; 78:1394.
- Barinagarrementeria F, Cantú C. Frequency of cerebral arteritis in subarachnoid cysticercosis: an angiographic study. Stroke 1998; 29:123.
- Jha S, Kumar V. Neurocysticercosis presenting as stroke. Neurol India 2000; 48:391.
- Garcia HH, Del Brutto OH, Nash TE, et al. New concepts in the diagnosis and management of neurocysticercosis (Taenia solium). Am J Trop Med Hyg 2005; 72:3.
- Alsina GA, Johnson JP, McBride DQ, et al. Spinal neurocysticercosis. Neurosurg Focus 2002; 12:e8.
- Bandres JC, White AC Jr, Samo T, et al. Extraparenchymal neurocysticercosis: report of five cases and review of management. Clin Infect Dis 1992; 15:799.
- Pushker N, Bajaj MS, Chandra M. Ocular and orbital cysticercosis. Acta Ophthalmol Scand 2001; 79:408.
- Rath S, Honavar SG, Naik M, et al. Orbital cysticercosis: clinical manifestations, diagnosis, management, and outcome. Ophthalmology 2010; 117:600.
- Del Brutto OH, Rajshekhar V, White AC Jr, et al. Proposed diagnostic criteria for neurocysticercosis. Neurology 2001; 57:177.
- Rajshekhar V, Chandy MJ. Validation of diagnostic criteria for solitary cerebral cysticercus granuloma in patients presenting with seizures. Acta Neurol Scand 1997; 96:76.
- Carpio A, Fleury A, Romo ML, et al. New diagnostic criteria for neurocysticercosis: Reliability and validity. Ann Neurol 2016; 80:434.
- Gabriël S, Blocher J, Dorny P, et al. Added value of antigen ELISA in the diagnosis of neurocysticercosis in resource poor settings. PLoS Negl Trop Dis 2012; 6:e1851.
- Webb CM, White AC Jr. Update on the Diagnosis and Management of Neurocysticercosis. Curr Infect Dis Rep 2016; 18:44.
- Lerner A, Shiroishi MS, Zee CS, et al. Imaging of neurocysticercosis. Neuroimaging Clin N Am 2012; 22:659.
- Hernández RD, Durán BB, Lujambio PS. Magnetic resonance imaging in neurocysticercosis. Top Magn Reson Imaging 2014; 23:191.
- Carrillo Mezo R, Lara García J, Arroyo M, Fleury A. Relevance of 3D magnetic resonance imaging sequences in diagnosing basal subarachnoid neurocysticercosis. Acta Trop 2015; 152:60.
- do Amaral LL, Ferreira RM, da Rocha AJ, Ferreira NP. Neurocysticercosis: evaluation with advanced magnetic resonance techniques and atypical forms. Top Magn Reson Imaging 2005; 16:127.
- Sharma T, Sinha S, Shah N, et al. Intraocular cysticercosis: clinical characteristics and visual outcome after vitreoretinal surgery. Ophthalmology 2003; 110:996.
- Bustos JA, Garcia HH, Dorregaray R, et al. Detection of muscle calcifications by thigh CT scan in neurocysticercosis patients. Trans R Soc Trop Med Hyg 2005; 99:775.
- Proaño-Narvaez JV, Meza-Lucas A, Mata-Ruiz O, et al. Laboratory diagnosis of human neurocysticercosis: double-blind comparison of enzyme-linked immunosorbent assay and electroimmunotransfer blot assay. J Clin Microbiol 2002; 40:2115.
- Gekeler F, Eichenlaub S, Mendoza EG, et al. Sensitivity and specificity of ELISA and immunoblot for diagnosing neurocysticercosis. Eur J Clin Microbiol Infect Dis 2002; 21:227.
- Wilson M, Bryan RT, Fried JA, et al. Clinical evaluation of the cysticercosis enzyme-linked immunoelectrotransfer blot in patients with neurocysticercosis. J Infect Dis 1991; 164:1007.
- Kojic EM, White AC Jr. A positive enzyme-linked immunoelectrotransfer blot assay result for a patient without evidence of cysticercosis. Clin Infect Dis 2003; 36:e7.
- Lee YM, Handali S, Hancock K, et al. Serologic diagnosis of human Taenia solium cysticercosis by using recombinant and synthetic antigens in QuickELISA™. Am J Trop Med Hyg 2011; 84:587.
- Garcia HH, Gilman RH, Catacora M, et al. Serologic evolution of neurocysticercosis patients after antiparasitic therapy. Cysticercosis Working Group in Peru. J Infect Dis 1997; 175:486.
- Garcia HH, Harrison LJ, Parkhouse RM, et al. A specific antigen-detection ELISA for the diagnosis of human neurocysticercosis. The Cysticercosis Working Group in Peru. Trans R Soc Trop Med Hyg 1998; 92:411.
- Garcia HH, Parkhouse RM, Gilman RH, et al. Serum antigen detection in the diagnosis, treatment, and follow-up of neurocysticercosis patients. Trans R Soc Trop Med Hyg 2000; 94:673.
- Garcia HH, Gonzalez AE, Gilman RH, et al. Circulating parasite antigen in patients with hydrocephalus secondary to neurocysticercosis. Am J Trop Med Hyg 2002; 66:427.
- Fleury A, Hernández M, Avila M, et al. Detection of HP10 antigen in serum for diagnosis and follow-up of subarachnoidal and intraventricular human neurocysticercosis. J Neurol Neurosurg Psychiatry 2007; 78:970.
- Rodriguez S, Dorny P, Tsang VC, et al. Detection of Taenia solium antigens and anti-T. solium antibodies in paired serum and cerebrospinal fluid samples from patients with intraparenchymal or extraparenchymal neurocysticercosis. J Infect Dis 2009; 199:1345.
- White AC Jr. New developments in the management of neurocysticercosis. J Infect Dis 2009; 199:1261.
- Michelet L, Fleury A, Sciutto E, et al. Human neurocysticercosis: comparison of different diagnostic tests using cerebrospinal fluid. J Clin Microbiol 2011; 49:195.
- Wang CH, Gao SF, Guo YP. Diagnostic significance of eosinophilia of the cerebrospinal fluid in cerebral cysticercosis. Chin Med J (Engl) 1993; 106:282.
- Gutierrez Y. Cysticercosis, Coenurosis, and Sparganosis. In: Diagnostic Pathology of Parasitic Infection with Clinical Correlation, Gutierrez Y (Ed), Oxford University Press, Oxford 2000. p.635.
- CLINICAL MANIFESTATIONS
- Parenchymal NCC
- Extraparenchymal NCC
- - Intraventricular cysts
- - Subarachnoid cysts
- - Spinal cysticercosis
- - Ocular cysticercosis
- Extraneural cysticercosis
- - Subcutaneous and intramuscular cysticercosis
- Laboratory tests
- Clinical approach
- Diagnostic tools
- - Imaging
- - Serology
- - Funduscopic exam
- - Spinal fluid studies
- - Pathology
- DIFFERENTIAL DIAGNOSIS
- SUMMARY AND RECOMMENDATIONS