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ESSENTIALS OF DIAGNOSIS
Exposure to T solium through fecal contamination of food.
Focal CNS lesions; seizures, headache.
Brain imaging shows cysts; positive serologic tests.
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General Considerations
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Cysticercosis is due to tissue infection with cysts of T solium that develop after humans ingest food contaminated with eggs from human feces, thus acting as an intermediate host for the parasite. Prevalence is high where the parasite is endemic, in particular Mexico, Central and South America, the Philippines, and Southeast Asia. An estimated 20 million persons are infected with cysticerci yearly, leading to about 400,000 persons with neurologic symptoms and 50,000 deaths. Antibody prevalence rates up to 10% are recognized in some endemic areas, and the infection is one of the most important causes of seizures in the developing world and in immigrants to the United States from endemic countries. In Latin America, it is estimated that 0.5–1.5 million people are affected by epilepsy secondary to cysticercosis.
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A. Symptoms and Signs
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Neurocysticercosis can cause intracerebral, subarachnoid, and spinal cord lesions and intraventricular cysts. Single or multiple lesions may be present. Lesions may persist for years before symptoms develop, generally due to local inflammation or ventricular obstruction. Presenting symptoms include seizures, focal neurologic deficits, altered cognition, and psychiatric disease. Symptoms develop more quickly with intraventricular cysts, with findings of hydrocephalus and meningeal irritation, including severe headache, vomiting, papilledema, and visual loss. A particularly aggressive form of the disease, racemose cysticercosis, involves proliferation of cysts at the base of the brain, leading to alterations of consciousness and death. Spinal cord lesions can present with progressive focal findings.
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Cysticercosis of other organ systems is usually clinically benign. Involvement of muscles can uncommonly cause discomfort and is identified by radiographs of muscle showing multiple calcified lesions. Subcutaneous involvement presents with multiple painless palpable skin lesions. Involvement of the eyes can present with ptosis due to extraocular muscle involvement or intraocular abnormalities.
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B. Laboratory Findings and Imaging
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Diagnosis generally requires consideration of both laboratory and imaging findings. The updated Del Brutto diagnostic criteria, which include laboratory and imaging findings, have demonstrated good sensitivity and specificity.
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CSF examination may show lymphocytic or eosinophilic pleocytosis, decreased glucose, and elevated protein. Serology plays an important role in diagnosis; both antibody and antigen detection assays are available. ELISAs and related immunoblot assays have excellent sensitivity and specificity, but sensitivity is lower with only single or calcified lesions.
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With neuroimaging by CT or MRI, multiple parenchymal cysts are most typically seen. Parenchymal calcification is also common. Performing both CT and MRI is ideal because CT is better for identification of calcification and MRI for smaller and ventricular lesions. Typical findings can be highly suggestive of the diagnosis.
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