Neurocysticercosis Clinical Practice Guidelines (2018)

Infectious Diseases Society of America and American Society of Tropical Medicine and Hygiene

Reviewed and summarized by Medscape editors

May 11, 2018

The clinical practice guidelines on neurocysticercosis were released by the Infectious Diseases Society of America and the American Society of Tropical Medicine and Hygiene in April 2018.[1]

Although there is a wide range of clinical manifestations of NCC, the 2 most common clinical presentations are with seizures and increased intracranial pressure.

Initial evaluation should include careful history, physical examination, and neuroimaging studies.

Recommend serologic testing with enzyme-linked immunotransfer blot (EITB) as a confirmatory test in patients with suspected NCC. Enzyme-linked immunosorbent assay (ELISA) tests using crude antigens should be avoided because of poor sensitivity and specificity.

Recommend both a brain magnetic resonance imaging (MRI) and a non-contrast computed tomography (CT) scan for classifying patients with newly diagnosed NCC.

Suggest screening for latent tuberculosis infection in patients likely to require prolonged corticosteroids.

Suggest screening or empiric therapy for Strongyloides stercoralis in patients likely to require prolonged corticosteroids.

Recommend that all patients with NCC undergo a fundoscopic examination before initiation of anthelminthic therapy.

Suggest that patients with NCC who have probably acquired NCC in a non-endemic area have their household members be screened for tapeworm carriage. Remark: This is a public health issue and can often be addressed by the local health department.

Recommend that patients treated with albendazole for more than 14 days be monitored for hepatotoxicity and leukopenia.

No additional monitoring is needed for patients receiving combination therapy with albendazole and praziquantel beyond that recommended for albendazole monotherapy.

In patients with untreated hydrocephalus or diffuse cerebral edema, we recommend management of elevated intracranial pressure alone and not antiparasitic treatment. Remarks: The management of patients with diffuse cerebral edema should be anti-inflammatory therapy such as corticosteroids, whereas hydrocephalus usually requires a surgical approach.

In the absence of elevated intracranial pressure, we recommend the use of antiparasitic drugs in all patients with VPN.

For patients with one to two viable parenchymal cysticerci, we recommend albendazole monotherapy for 10–14 days compared with either no antiparasitic therapy or combination antiparasitic therapy. Remarks: The usual dose of albendazole is 15 mg/kg/day divided into two daily doses for 10–14 days with food. We recommend a maximum dose of 1,200 mg/day.

We recommend albendazole (15 mg/kg/day) combined with praziquantel (50 mg/kg/day) for 10–14 days rather than albendazole monotherapy for patients with more than two viable parenchymal cysticerci.

We suggest re-treatment with antiparasitic therapy for parenchymal cystic lesions persisting for 6 months after the end of the initial course of therapy.

We suggest that MRI be repeated at least every 6 months until resolution of the cystic component.

We recommend antiepileptic drugs for all patients with single enhancing lesions (SEL) and seizures.

In patients who have been seizure free for 6 months, we suggest tapering off and stopping antiepileptic drugs after resolution of the lesion in patients with SEL without risk factors for recurrent seizures.

We suggest albendazole therapy rather than no antiparasitic therapy for all patients with SEL.

We recommend MRI with three-dimensional (3D) volumetric sequencing to identify intraventricular and subarachnoid cysticerci in patients with hydrocephalus and suspected neurocysticercosis (NCC).

We recommend that patients with hydrocephalus from SAN be treated with shunt surgery in addition to medical therapy.

We recommend corticosteroid treatment of patients with SN with evidence of spinal cord dysfunction (eg, paraparesis or incontinence) or as adjunctive therapy along with antiparasitic therapy.

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