Controversies in the management of cysticercosis.

Commentaries Controversies in the Management of Cysticercosis Cysticercosis, an infection caused by larvae of the pork tapeworm Taenia solium in human tissues , is a common cause of neurologic disease in most non-Muslim developing countries, where it accounts for more than one-third of adult-onset epilepsy cases (1). Cysticercosis is increasingly diagnosed in patients in industrialized nations; persons who have never left the United States as well as visitors to disease-endemic regions are at risk. Traditionally considered an exotic disease, this infection now accounts for up to 2% of neuro-logic/neurosurgical admissions in southern Cali-fornia (2) and more than 1,000 cases per year in the United States (3). Further away from disease-endemic regions, an outbreak of cysticercosis among orthodox Jews living in New York City was reported after food was contaminated with T. solium eggs by immigrant cooks infected with the pork tapeworm (4); these carriers may have been completely unaware of their infections. Neurocysticercosis has been reported in AIDS patients, but immuno-suppression does not appear to increase the incidence of this infection. Once cysticercosis is diagnosed, treatment may be necessary, but optimal therapy and particularly the role of cestocidal drugs is controversial. In this commentary, we discuss current options in the treatment of established cysticercosis. The clinical and pathologic features of neuro-cysticercosis vary, depending on the inflam-matory response around cysticerci, their number, size, and location. The presence of viable, living cysti-cerci in the central nervous system usually does not cause symptoms (5). In contrast, inflammation around degenerating cysticerci may have severe consequences, including focal encephalitis, edema, and vasculitis. The most frequent symptom is epilepsy. However, neurocysticercosis can cause a wide variety of clinical syndromes—from chronic meningitis and cranial nerve palsies to spinal infarction and symptoms due to either a mass effect or, particularly in racemose disease, raised intracranial pressure. Such variable clinical features necessitate further investigations to make a diagnosis before treatment. The diagnosis may be made by excision biopsy of subcutaneous cysticerci, which are found in 4% to 25% of patients with neurocysticercosis (the percentages are higher in Asia than in Latin America). However, radiologic and serologic tests are usually required for diagnosis unless biopsy of a central nervous system lesion is possible. Computed tomography visualizes living cysticerci as hypodense lesions not enhanced with intravenous contrast; a small, hyperdense scolex may be observed within a living cyst (6). Degenerating cysticerci which are more often symptomatic are isodense or hyperdense, and …