Case Presentation: Neurocysticercosis

Case Presentation:41 year old male with acute seizuresChristine RuhPharmD Candidate 2013University of Rhode IslandGeneral Medicine RotationRoger Williams Medical Center

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ObjectivesPatient caseNeurocysticercosisEpidemiologyDisease CoursePathophysiologyPresentationTreatmentPatient Plan

SubjectiveCC: Recurrent seizures

HPI: CM 41 YO M from Guatemala who presents recurrent seizures consisting of 3 episodes of staring.

Hx of seizures 2001. Episode involved convulsing with LOC. Postictal state 1 min.

Seizure free until 2009. Presented w/ tonic-clonic seizure. Started phenytoin for 2 months, self D/C.

Denies sick contacts, fever, N/V/D/C, ab pain, appetite changes, weight loss.

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Subjective- contdPMH:Type 2 diabetes mellitusSeizure disorder unspecifiedHypertension (Stage II)DyslipidemiaAllergies: NKDASurgical Hx: noneFH: not significantSH: Smokes occasionally, denies alcohol/ drug useLives at home with wife, daughter

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Medications: Outpatient Medication RegimenIndicationInsulin glargine2o units SubQ QHSType 2 diabetes mellitusMetformin1000 mg PO BIDType 2 diabetes mellitusLisinopril20 mg PO daily HypertensionMetoprolol tartrate25 mg PO BIDHypertensionSimvastatin 20 mg PO QHSDyslipidemia

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Objective- contdPhysical ExamGeneral: NAD, AAO x 3HEENT: No LADNeck: SuppleCardiac: S1/ S2 normal, No murmurs apparentRespiratory: Lungs clear to auscultation bilaterally Abdominal: Soft, nontender, nondistended. + BS, - organomegalySkin: No changes, no rashesExtremities: No edema Neurological: Cranial nerves 2 to 12, grossly nonfocal

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Objective- contdChemistryValueSodium139Potassium4.0Chloride 95Carbon Dioxide32BUN12Creatinine 1.0Glucose90

CBCValueWBC6.3Hgb14.2Hct41.2Plt198

VitalsValueTemperature98.6 CPulse18HR72BP130/72

MeasurementValueHeight65 inWeight65.9 kgCrCl90.6 mL/min

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CM MRI

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Neurocysticercosis

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Epidemiology 1800-2000 cases annually in USNew York, Oregon, Texas, IllinoisLatin America, India, Africa, ChinaMost common CNS parasitic diseaseLeading cause of acquired epilepsy 1 of 5 Neglected Parasitic Infection by CDCChagas disease, cysticercosis, toxocariasis, toxoplasmosis, trichomoniasisCDC Parasites-Cysticercosis- Homepage. http://www.cdc.gov/nchs/. January 20, 2013.

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World Map of Cysticercosis

Del Brutto OH. Neurocysticercosis: A Review. The Scientific World Journal, Vol. 2012. Article ID 159821, 8 pages, 2012. doi:10.1100/2012/159821.

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Lifecycle of Taenia solium

www.cdc.gov

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Disease Course- contdAcquired through tape worm Taenia soliumConsumption improperly cooked porkFecal- oral (human to human)Affects many organsMainly CNS: subarachnoid space, spinal cord, ventriclesEyesMuscles

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ScolexEggs

Pictures of Taenia solium

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Pathophysiology ParasiteDirect effect, obstructionInflammatory responseEdemaScarringFibromas, granulomas, calcifications Kimura-Hayama ET, Higuera JA, CoronapCedillo R, Chavez-Macias L, Perochena A, Quiroz-Rojas LY, et al. Neurocysticercosis: Radilogic- Pathologic Correlation. RadioGraphics. 2010; 33: 1705-19.

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Presentation Extraneural cysticercosisFew symptomsSmall, painless nodulesMonths to years become inflamedEventually disappearOphthalmic cysticercosis 1-3% of casesVisual disturbancesNeurocysticercosis Epileptic seizures 50-80% of patients with cysts50% recurrence rate after first seizureIntracranial HTN, hydrocephalus, stroke, motor impairments, headachesGarcia HH, Gonzalez AW, Evans CA, and Gilman RH. Taenia solium cysticercosis. The Lancet 2003; 361: 547-56.

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Diagnosis Head CT scan or MRIStages the diseaseVesicular cysticerci: no inflammation, small, well-definedColloidal and granular cysticerci: ill-defined, edema, ringEnzyme-linked immunoelectrotransfer blot (EITB)Species-specific antigens50% false-negatives May be false-positive in people exposed w/o the diseaseDel Brutto OH. Neurocysticercosis: A Review. The Scientific World Journal, Vol. 2012. Article ID 159821, 8 pages, 2012. doi:10.1100/2012/159821.

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TreatmentAlbendazole (Albenza)MOA: prevents parasite-specific ATP production Give w/ corticosteroids to prevent cerebral HTN Start anti-seizure medication w/in 1 weekTake with high fat meal to increase absorptionUse in neurocysticercosis is controversial

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Effects of albendazole treatment on neurocysticercosis: a randomised controlled trialCarpio A, Kelvin EA, Bagiella E, Leslie D, Leon P, Andrews H. Effects of albendazole treatment on neurocysticercosis: a randomised controlled trial. J Neurol Neurosurg Psychiatry 2008;79:1050-55.

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Treatment- contdPraziquantel (Biltricide)MOA: increase intracellular calcium concentrations leading to wall detachmentVery bitter taste: take with water to prevent vomitingOff label w/ cysticercosisMay exacerbate seizures

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Clinical Trial Of Praziquantel And Prednisone In Rural Patients With Neurocysticercosis Presenting With Recurrent Epileptic AttacksH. Foyaca-Sibat , L..F. Ibaez-Valds : Clinical Trial Of Praziquantel And Prednisone In Rural Patients With Neurocysticercosis Presenting With Recurrent Epileptic Attacks. The Internet Journal of Neurology. 2002 Volume 1 Number 2. DOI: 10.5580/52d

Excellent see previous advice21

Treatment- contdNeurosurgery Reserved for patients with abscess, infections, life threateningVentriculoperitoneal shuntResectionAnti-epileptics Monotherapy Solitary cysticercus granulomas: temporary AEDCalcified lesions: indefinite AED

Rangel-Castilla L, Serpa JA, Gopinath SP, Graviss EA, Diaz-Marchan P, and White AC. Contemporary neurosurgical approaches to neurocycticercosis. Am J Trop Med Hyg. 2009;80:373-38Murthy JMK. Seizures associated with solitary cysticercus granulomas: Antiepileptic drugs for how long? Neurology India. 2006;54:141-42.

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Treatment- contdCorticosteroids Symptomatic relief of headaches 2 mg/kg/ day prednisolone 2-3 days before starting alebendazole, continue 3-4 additional daysIV dexamethasone w/ S/Sx of intracranial pressure Long term use w/ extensive edema

Singhi P. Neurocysticercosis. Ther Adv Neurol Disord. 2011;4:67-81.

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Prevention Wash hands with soap and waterWash and peel vegetables and fruits in developing countriesAvoid raw foods that cannot be peeledDrink bottled water or boil water for 1 minute in developing countriesDo not use ice cubes Filter water and use iodine tabletsImprove access to clean waterVaccinations and de-worming for pigs from Taenia solium

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Back to CM- PlanNeurocysticercosisStart phenytoin 100 mg PO TID for seizuresMonitor:Level: 10-20 mcg/mL Abrupt cessation may cause seizuresLiver function testsF/U outpt neurosurgeon

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CM Plan- contdType 2 DiabetesContinue insulin glargine 20 units SubQ QHS and metformin 1000 mg PO BIDHypertension (Stage II)Continue metoprolol tartrate 25 mg PO BID and lisinopril 20 mg PO dailyDyslipidemiaContinue simvastatin 20 mg PO QHS

Thank You!

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