Cysticercosis medical therapy: Difference between revisions
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__NOTOC__ | __NOTOC__ | ||
{{Cysticercosis}} | {{Cysticercosis}} | ||
{{CMG}} | {{CMG}};{{AE}}{{AY}} | ||
==Overview== | ==Overview== | ||
Cysticercosis is generally treated with combination of both anti parasitic drugs and anti inflammatory drugs. Symptomatic treatment is the mainstay therapy for neurocysticercosis. | Cysticercosis is generally treated with combination of both [[Antiparasitic|anti parasitic]] drugs and [[Anti-inflammatory drug|anti inflammatory drugs]]. Symptomatic treatment is the mainstay therapy for neurocysticercosis. Surgical removal sometimes necessary to treat ophthalmic cysticercosis and subcutaneous cysticercosis. | ||
==Medical Therapy== | ==Medical Therapy== | ||
===Neurocysticercosis=== | ===Neurocysticercosis=== | ||
Neurocysticercosis most often presents as [[headache]]s and acute onset [[seizure]]s, thus the immediate mainstay of therapy is [[anticonvulsant]] medications. Once the seizures have been brought under control, [[antihelminthic]] treatments may be undertaken. The decision to treat with | *Neurocysticercosis most often presents as [[headache]]s and acute onset [[seizure]]s, thus the immediate mainstay of therapy is [[anticonvulsant]] medications. *Once the seizures have been brought under control, [[antihelminthic]] treatments may be undertaken. | ||
*The decision to treat with antihelminthic therapy is complex and based on the stage and number of cysts present, their location, and the patient's specific clinical presentation.<ref>{{cite journal|title=New developments in the management of neurocysticercosis|doi=10.1086/597758|year=2009|author=White, Jr., A. Clinton|journal=The Journal of Infectious Diseases|volume=199|pages=1261|pmid=19358667|issue=9}}</ref> | |||
Asymptomatic cysts, such as those discovered incidentally on neuroimaging done for another reason, may never lead to symptomatic disease and in many cases do not require therapy. | *Antihelminthic therapy should be given in combination with [[corticosteroids]] and anticonvulsants to reduce inflammation surrounding the cysts and lower the risk of [[seizures]]. | ||
*[[Albendazole]] is generally preferable over [[praziquantel]] due to its lower cost and fewer drug interactions.<ref name="nine">Dimitrios K. Matthaiou, Georgios Panos, Eleni S. Adamidi,Matthew E. Falagas “Albendazole versus Praziquantel in the Treatment of Neurocysticercosis: A Meta-analysis of Comparative Trials” PLoS Negl Trop Dis. 2008 March; 2(3): e194</ref> | |||
Calcified cysts have already died and [[Involution_(medicine)|involuted]]. Further | *Asymptomatic cysts, such as those discovered incidentally on [[neuroimaging]] done for another reason, may never lead to symptomatic disease and in many cases do not require therapy. | ||
=== | *[[Calcification|Calcified]] cysts have already died and [[Involution_(medicine)|involuted]]. Further [[antihelminthic]] therapy will be of no benefit. | ||
In ophthalmic disease, surgical removal is necessary for cysts within the [[eye]] itself | ===Ocular cysticercosis=== | ||
*In ophthalmic disease, surgical removal is necessary for cysts within the [[eye]] itself. | |||
*Cysts outside the globe can be treated with [[Antihelminthic|antihelminthic drugs]] alone. | |||
===Subcutaneous cysticercosis=== | ===Subcutaneous cysticercosis=== | ||
In general, subcutaneous disease does not need specific therapy. Painful or bothersome cysts can be surgically excised. | *In general, the subcutaneous disease does not need specific therapy. Painful or bothersome cysts can be surgically excised. | ||
*Treatment recommendations for subcutaneous cysticercosis includes surgery, [[praziquantel]] and [[albendazole]]. | |||
===Antimicrobial Regimen=== | ===Antimicrobial Regimen=== | ||
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::::* Preferred regimen: [[Albendazole]] 15 mg/kg/day PO bid for 3-8 days {{and}} [[Prednisone]] 1 mg/kg/day PO qid for 8-10 days followed by a taper | ::::* Preferred regimen: [[Albendazole]] 15 mg/kg/day PO bid for 3-8 days {{and}} [[Prednisone]] 1 mg/kg/day PO qid for 8-10 days followed by a taper | ||
:::* 1.2 '''Multiple cysts''' | :::* 1.2 '''Multiple cysts''' | ||
::::* Preferred regimen: [[Albendazole]] 15 mg/kg/day PO bid for 8-15 days and high-dose steroids | ::::* Preferred regimen: [[Albendazole]] 15 mg/kg/day PO bid for 8-15 days and [[Steroids|high-dose steroids]] | ||
::::* Preferred regimen: [[Praziquantel]] 50 mg/kg/day PO tid {{and}} [[Albendazole]] 15 mg/kg/day PO bid | ::::* Preferred regimen: [[Praziquantel]] 50 mg/kg/day PO tid {{and}} [[Albendazole]] 15 mg/kg/day PO bid | ||
:::* 1.3 '''Cysticercal encephalitis''' <ref name="pmid12364377">{{cite journal| author=García HH, Evans CA, Nash TE, Takayanagui OM, White AC, Botero D et al.| title=Current consensus guidelines for treatment of neurocysticercosis. | journal=Clin Microbiol Rev | year= 2002 | volume= 15 | issue= 4 | pages= 747-56 | pmid=12364377 | doi= | pmc=PMC126865 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12364377 }} </ref> | :::* 1.3 '''Cysticercal encephalitis''' <ref name="pmid12364377">{{cite journal| author=García HH, Evans CA, Nash TE, Takayanagui OM, White AC, Botero D et al.| title=Current consensus guidelines for treatment of neurocysticercosis. | journal=Clin Microbiol Rev | year= 2002 | volume= 15 | issue= 4 | pages= 747-56 | pmid=12364377 | doi= | pmc=PMC126865 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12364377 }} </ref> | ||
::::* Cysticercal encephalitis (diffuse cerebral edema associated with multiple inflamed cysticerci) is a contraindication for antiparasitic therapy, since enhanced parasite killing can exacerbate host inflammatory response and lead to diffuse cerebral edema and potential transtentorial herniation. Most cases of cysticercal encephalitis improve with corticosteroid therapy | ::::* [[Encephalitis|Cysticercal encephalitis]] (diffuse [[cerebral edema]] associated with multiple [[inflamed]] cysticerci) is a contraindication for [[Antiparasitic|antiparasitic therapy]], since enhanced parasite killing can exacerbate host [[inflammatory response]] and lead to diffuse [[cerebral edema]] and potential [[transtentorial herniation]]. Most cases of [[Encephalitis|cysticercal encephalitis]] improve with [[corticosteroid]] therapy | ||
:::* 1.4 '''Calcified cysts ''' | :::* 1.4 '''Calcified cysts ''' | ||
::::* Radiographic evidence of parenchymal calcifications is a significant risk factor for recurrent seizure activity; these lesions are present in about 10 percent of individuals in regions where neurocysticercosis is endemic. Seizures in these patients should be treated with antiepileptic therapy. | ::::* Radiographic evidence of [[parenchymal]] [[Calcification|calcifications]] is a significant risk factor for recurrent [[seizure]] activity; these lesions are present in about 10 percent of individuals in regions where neurocysticercosis is [[endemic]]. [[Seizures]] in these patients should be treated with [[Antiepileptic|antiepileptic therapy]]. | ||
::* 2. '''Extraparenchymal NCC''' | ::* 2. '''Extraparenchymal NCC''' | ||
:::* 2.1 '''Subarachnoid cysts''' | :::* 2.1 '''Subarachnoid cysts''' | ||
::::* Preferred regimen: [[Albendazole]] 15 mg/kg/day PO bid for 28 days {{and}} ([[Prednisone]] up to 60 mg/day PO {{or}} [[Dexamethasone]] (up to 24 mg/day)) along with the antiparasitic therapy. The dose can often be tapered after a few weeks. However, in cases for which more prolonged steroid therapy is required, methotrexate can be used as a steroid-sparing agent | ::::* Preferred regimen: [[Albendazole]] 15 mg/kg/day PO bid for 28 days {{and}} ([[Prednisone]] up to 60 mg/day PO {{or}} [[Dexamethasone]] (up to 24 mg/day)) along with the [[Antiparasitic|antiparasitic therapy]]. The dose can often be tapered after a few weeks. However, in cases for which more prolonged [[steroid therapy]] is required, [[methotrexate]] can be used as a steroid-sparing agent | ||
:::* 2.2 '''Giant cysts''' | :::* 2.2 '''Giant cysts''' | ||
::::* Giant cysticerci are usually accompanied by cerebral edema and mass effect, which should be managed with high-dose corticosteroids (with or without mannitol). | ::::* Giant cysticerci are usually accompanied by [[cerebral edema]] and [[mass effect]], which should be managed with [[Corticosteroids|high-dose corticosteroids]] (with or without [[mannitol]]). | ||
:::* 2.3 ''' Intraventricular cysts''' | :::* 2.3 ''' Intraventricular cysts''' | ||
::::* Emergent management with CSF diversion via a ventriculostomy or placement of a ventriculo-peritoneal shunt | ::::* Emergent management with [[CSF]] diversion via a [[ventriculostomy]] or placement of a [[Ventriculoperitoneal shunt|ventriculo-peritoneal shunt]] | ||
::::* Treatment of residual hydrocephalus may be managed with endoscopic foraminotomy and endoscopic third ventriculostomy; this approach may also allow debulking of cisternal cysticerci | ::::* Treatment of residual [[hydrocephalus]] may be managed with [[Foraminotomy|endoscopic foraminotomy]] and [[Ventriculostomy|endoscopic third ventriculostomy]]; this approach may also allow debulking of cisternal cysticerci | ||
:::* 2.4 ''' Ocular cysticercosis''' | :::* 2.4 ''' Ocular cysticercosis''' | ||
::::* Surgical excision is warranted in the setting of intraocular cysts | ::::* Surgical excision is warranted in the setting of intraocular cysts | ||
::::* Cysticercal involvement of the extraocular muscles should be managed with albendazole and corticosteroids. | ::::* Cysticercal involvement of the [[extraocular muscles]] should be managed with [[albendazole]] and [[corticosteroids]]. | ||
:::* 2.5 '''Spinal cysticercosis''' | :::* 2.5 '''Spinal cysticercosis''' | ||
::::* Medical therapy with corticosteroids and antiparasitic drugs | ::::* Medical therapy with [[corticosteroids]] and [[Antiparasitic|antiparasitic drugs]] | ||
====Contraindicated medications==== | ====Contraindicated medications==== | ||
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==References== | ==References== | ||
{{Reflist|2}} | {{Reflist|2}} | ||
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Ahmed Younes M.B.B.CH [2]
Overview
Cysticercosis is generally treated with combination of both anti parasitic drugs and anti inflammatory drugs. Symptomatic treatment is the mainstay therapy for neurocysticercosis. Surgical removal sometimes necessary to treat ophthalmic cysticercosis and subcutaneous cysticercosis.
Medical Therapy
Neurocysticercosis
- Neurocysticercosis most often presents as headaches and acute onset seizures, thus the immediate mainstay of therapy is anticonvulsant medications. *Once the seizures have been brought under control, antihelminthic treatments may be undertaken.
- The decision to treat with antihelminthic therapy is complex and based on the stage and number of cysts present, their location, and the patient's specific clinical presentation.[1]
- Antihelminthic therapy should be given in combination with corticosteroids and anticonvulsants to reduce inflammation surrounding the cysts and lower the risk of seizures.
- Albendazole is generally preferable over praziquantel due to its lower cost and fewer drug interactions.[2]
- Asymptomatic cysts, such as those discovered incidentally on neuroimaging done for another reason, may never lead to symptomatic disease and in many cases do not require therapy.
- Calcified cysts have already died and involuted. Further antihelminthic therapy will be of no benefit.
Ocular cysticercosis
- In ophthalmic disease, surgical removal is necessary for cysts within the eye itself.
- Cysts outside the globe can be treated with antihelminthic drugs alone.
Subcutaneous cysticercosis
- In general, the subcutaneous disease does not need specific therapy. Painful or bothersome cysts can be surgically excised.
- Treatment recommendations for subcutaneous cysticercosis includes surgery, praziquantel and albendazole.
Antimicrobial Regimen
Neurocysticercosis
- Neurocysticercosis treatment
- 1. Parenchymal neurocysticercosis
- 1.1 Single lesions[3]
- Preferred regimen: Albendazole 15 mg/kg/day PO bid for 3-8 days AND Prednisone 1 mg/kg/day PO qid for 8-10 days followed by a taper
- 1.2 Multiple cysts
- Preferred regimen: Albendazole 15 mg/kg/day PO bid for 8-15 days and high-dose steroids
- Preferred regimen: Praziquantel 50 mg/kg/day PO tid AND Albendazole 15 mg/kg/day PO bid
- 1.3 Cysticercal encephalitis [3]
- Cysticercal encephalitis (diffuse cerebral edema associated with multiple inflamed cysticerci) is a contraindication for antiparasitic therapy, since enhanced parasite killing can exacerbate host inflammatory response and lead to diffuse cerebral edema and potential transtentorial herniation. Most cases of cysticercal encephalitis improve with corticosteroid therapy
- 1.4 Calcified cysts
- Radiographic evidence of parenchymal calcifications is a significant risk factor for recurrent seizure activity; these lesions are present in about 10 percent of individuals in regions where neurocysticercosis is endemic. Seizures in these patients should be treated with antiepileptic therapy.
- 2. Extraparenchymal NCC
- 2.1 Subarachnoid cysts
- Preferred regimen: Albendazole 15 mg/kg/day PO bid for 28 days AND (Prednisone up to 60 mg/day PO OR Dexamethasone (up to 24 mg/day)) along with the antiparasitic therapy. The dose can often be tapered after a few weeks. However, in cases for which more prolonged steroid therapy is required, methotrexate can be used as a steroid-sparing agent
- 2.2 Giant cysts
- Giant cysticerci are usually accompanied by cerebral edema and mass effect, which should be managed with high-dose corticosteroids (with or without mannitol).
- 2.3 Intraventricular cysts
- Emergent management with CSF diversion via a ventriculostomy or placement of a ventriculo-peritoneal shunt
- Treatment of residual hydrocephalus may be managed with endoscopic foraminotomy and endoscopic third ventriculostomy; this approach may also allow debulking of cisternal cysticerci
- 2.4 Ocular cysticercosis
- Surgical excision is warranted in the setting of intraocular cysts
- Cysticercal involvement of the extraocular muscles should be managed with albendazole and corticosteroids.
- 2.5 Spinal cysticercosis
- Medical therapy with corticosteroids and antiparasitic drugs
Contraindicated medications
Ocular cysticercosis is considered an absolute contraindication to the use of the following medications:
References
- ↑ White, Jr., A. Clinton (2009). "New developments in the management of neurocysticercosis". The Journal of Infectious Diseases. 199 (9): 1261. doi:10.1086/597758. PMID 19358667.
- ↑ Dimitrios K. Matthaiou, Georgios Panos, Eleni S. Adamidi,Matthew E. Falagas “Albendazole versus Praziquantel in the Treatment of Neurocysticercosis: A Meta-analysis of Comparative Trials” PLoS Negl Trop Dis. 2008 March; 2(3): e194
- ↑ 3.0 3.1 García HH, Evans CA, Nash TE, Takayanagui OM, White AC, Botero D; et al. (2002). "Current consensus guidelines for treatment of neurocysticercosis". Clin Microbiol Rev. 15 (4): 747–56. PMC 126865. PMID 12364377.