Case Presentation:

41 year old male with acute seizures

Christine Ruh
PharmD Candidate 2013
University of Rhode Island
General Medicine Rotation
Roger Williams Medical Center

Objectives
Patient case
Neurocysticercosis

Epidemiology
Disease Course
Pathophysiology
Presentation
Treatment

Patient Plan

Subjective
CC: 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.

Subjective- contd
PMH:

Type 2 diabetes mellitus

Seizure disorder unspecified
Hypertension (Stage II)
Dyslipidemia

Allergies: NKDA
Surgical Hx: none
FH: not significant
SH:
Smokes occasionally, denies alcohol/ drug use
Lives at home with wife, daughter

Medications: Outpatient
Medication

Regimen

Indication

Insulin glargine

2o units SubQ QHS

Type 2 diabetes mellitus

Metformin

1000 mg PO BID

Type 2 diabetes mellitus

Lisinopril

20 mg PO daily

Hypertension

Metoprolol tartrate

25 mg PO BID

Hypertension

Simvastatin

20 mg PO QHS

Dyslipidemia

Objective- contd
Physical Exam

General: NAD, AAO x 3

HEENT: No LAD
Neck: Supple
Cardiac: S1/ S2 normal, No murmurs apparent
Respiratory: Lungs clear to auscultation bilaterally
Abdominal: Soft, nontender, nondistended. + BS, organomegaly
Skin: No changes, no rashes
Extremities: No edema
Neurological: Cranial nerves 2 to 12, grossly
nonfocal

Objective- contd
Chemistry

Value

CBC

Value

Sodium

139

WBC

6.3

Potassium

4.0

Hgb

14.2

Chloride

95

Hct

41.2

Carbon Dioxide

32

Plt

198

BUN

12

Creatinine

1.0

Vitals

Value

Glucose

90

Temperature

98.6 C

Pulse

18

Measurement

Value

HR

72

Height

65 in

BP

130/72

Weight

65.9 kg

CrCl

90.6 mL/min

CM MRI

Neurocysticercosis

Epidemiology
1800-2000 cases annually in US
New York, Oregon, Texas, Illinois

Latin America, India, Africa, China

Most common CNS parasitic disease
Leading cause of acquired epilepsy

1 of 5 Neglected Parasitic Infection by CDC

Chagas disease, cysticercosis, toxocariasis,
toxoplasmosis, trichomoniasis

CDC Parasites-Cysticercosis- Homepage. http://www.cdc.gov/nchs/. January 20, 2013.

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.

Lifecycle of Taenia solium

www.cdc.gov

Disease Course- contd

Acquired through tape worm Taenia solium
Consumption improperly cooked pork
Fecal- oral (human to human)

Affects many organs

Mainly CNS: subarachnoid space, spinal cord,
ventricles
Eyes
Muscles

Pictures of Taenia solium

Scolex

Eggs

Pathophysiology
Parasite
Direct effect, obstruction

Inflammatory response
Edema

Scarring
Fibromas, 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.

Presentation
Extraneural cysticercosis
Few symptoms
Small, painless nodules
Months to years become inflamed
Eventually disappear

Ophthalmic cysticercosis
1-3% of cases
Visual disturbances

Neurocysticercosis
Epileptic seizures 50-80% of patients with cysts
50% recurrence rate after first seizure
Intracranial HTN, hydrocephalus, stroke, motor impairments,
headaches
Garcia HH, Gonzalez AW, Evans CA, and Gilman RH. Taenia solium cysticercosis. The Lancet 2003; 361: 547-56.

Diagnosis
Head CT scan or MRI
Stages the disease
Vesicular cysticerci: no inflammation, small, welldefined
Colloidal and granular cysticerci: ill-defined, edema,
ring

Enzyme-linked immunoelectrotransfer blot (EITB)

Species-specific antigens
50% false-negatives
May be false-positive in people exposed w/o the
disease
Del Brutto OH. Neurocysticercosis: A Review. The Scientific World Journal, Vol. 2012. Article ID 159821, 8 pages, 2012.
doi:10.1100/2012/159821.

Treatment
Albendazole (Albenza)
MOA: prevents parasite-specific ATP production
Give w/ corticosteroids to prevent cerebral HTN
Start anti-seizure medication w/in 1 week
Take with high fat meal to increase absorption

Use in neurocysticercosis is controversial

Carpio 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.

5 deaths in placebo, 2 in treatment- not statistically

significant
Immunocompromised patients excluded
Other studies have demonstrated efficacy

Conclusions
Criteria

Inclusion: New onset seizure w/in 2 months, cysts

identified by imaging
Exclusion: TB, syphilis, ocular cysticercosis,
calcifications only

Results

174 randomized, 77 each group completed trial

Decrease in active cysts, largest change in 1 month
No change in seizure activity

Double Blind RCT

8 days 400 mg BID albendazole + 4 weeks
prednisone taper
Placebo +4 weeks prednisone taper

Methods

Effects of albendazole treatment on

neurocysticercosis: a randomised controlled trial

Treatment- contd
Praziquantel (Biltricide)
MOA: increase intracellular calcium
concentrations leading to wall detachment
Very bitter taste: take with water to prevent vomiting
Off label w/ cysticercosis
May exacerbate seizures

H. 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

Lack of UGH Neurology scale validation

Small study , needs comparison against other trials
May be a good option to reduce frequency and duration

Conclusions
Criteria

Inclusion: Neurocysticercosis diagnosed

Exclusion: Uncontrolled seizures on phenytoin,
increased intracranial pressure, TB, tumors

Results

189 randomized: 66 completed PPP, 63 P

73% improvement in frequency and duration
epileptic attacks with PPP group

Double blind RCT

Pheytoin, 400 mg daily for 5 days prednisone, 25
mg/kg for 4 doses in 1 day praziquantel
Placebo +4 weeks prednisone taper+ pheytoin

Methods

Clinical Trial Of Praziquantel And Prednisone In Rural Patients With

Neurocysticercosis Presenting With Recurrent Epileptic Attacks

Treatment- contd
Neurosurgery
Reserved for patients with abscess, infections, life
threatening
Ventriculoperitoneal shunt
Resection

Anti-epileptics
Monotherapy
Solitary cysticercus granulomas: temporary AED
Calcified 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;80:373-38
Murthy JMK. Seizures associated with solitary cysticercus granulomas: Antiepileptic drugs for how long? Neurology India. 2006;54:141-42.

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

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

Prevention
Wash hands with soap and water
Wash and peel vegetables and fruits in developing
countries
Avoid raw foods that cannot be peeled

Drink bottled water or boil water for 1 minute in

developing countries
Do not use ice cubes
Filter water and use iodine tablets

Improve access to clean water

Vaccinations and de-worming for pigs from Taenia
solium

Back to CM- Plan

Neurocysticercosis
Start phenytoin 100 mg PO TID for seizures
Monitor:
Level: 10-20 mcg/mL
Abrupt cessation may cause seizures
Liver function tests

F/U outpt neurosurgeon

CM Plan- contd
Type 2 Diabetes
Continue insulin glargine 20 units SubQ QHS and
metformin 1000 mg PO BID

Hypertension (Stage II)

Continue metoprolol tartrate 25 mg PO BID and
lisinopril 20 mg PO daily

Dyslipidemia
Continue simvastatin 20 mg PO QHS

Thank You!