Treatment

Medical treatment is with albendazole (preferred) or praziquantel. Albendazole is more effective, and when corticosteroids are given concurrently, the plasma level of albendazole increases but that of praziquantel decreases. Antheimintic treatment is most effective for parenchymal cysts; less effective for intraventricular, subarachnoid, or racemose cysts; and has no effect on and is not needed for granulomatous or calcified cysts. It remains to be fully established that medical treatment is preferable to symptomatic treatment followed by normal death of the parasites. Some clinicians wait 3 months, with selected patients to see if cysts will spontaneously disappear without treatment. Drug treatment is withheld during the acute phase of cysticercotic encephalitis if intracranial hypertension is present.

Treatment should be conducted in hospital. In less than a week after starting treatment, inflammatory reactions around dying parasites may be manifested by meningismus, headache (analgesics may be sufficient for mild symptoms), vomiting, hyperthermia, mental changes, and convulsions: decompensation with death is very rare. It remains controversial whether to give steroids concomitantly to avoid or diminish this reaction or to use them only if marked symptoms appear or increase. Even when steroids are given prospectively, the inflammatory reaction may occur. Prednisone, 30 mg in two or three divided doses, starting 1-2 days before use of the drug and continuing at diminishing doses for about 14 days afterward, is one regimen. The reaction usually subsides in 48-72 hours, but continuing severity may require steroids in higher dosage and mannitol. Anticonvulsants must be continued during drug treatment and probably for an indefinite time afterward.

Following treatment, 50% cure rates (disappearance of cysts and clearing of symptoms) have been reported both for albendazole and praziquantel. Of the remaining patients, many have amelioration of symptoms, including intracranial hypertension and seizures.

In ocular eysticercosis, treatment with albendazole plus corticosteroids kills the cysts, reducing subretinal cysts to a small scar and allowing for easy extraction of vitreous cysts.

Specific measures:

1. Albendazole

• A dosage of 15 mglkg/d in divided doses with meals for 8 days is as effective as the former 30- day course. Albendazole should be taken with a fatty meal to increase absorption.

2. Praziguantel

• Give 50 mglkg/d for 15 days in three divided doses. Phenytoin, phenobarbital, and corticosteroids, when administered with praziquantel, reduce serum levels of the latter; high doses of praziquantel have been tried in these circumstances.

3. Surgery

• Surgery has successfully removed orbital, cistemal, and ventricular cysts and, if accessible, cerebral, meningeal, or spinal cord cysts. When hydrocephalus is present, surgical shunt is required even when the parasites have been destroyed.

General measures:

Symptomatic treatment of neurocysticercosis is based on the use of steroids and mannitol for cerebral edema and anticonvulsants for seizures.

Prognosis

The fatality rate for untreated neuroeysticercosis is about 50%; survival time from onset of symptoms ranges from days to many years. Drug treatment has reduced the mortality rate to about 5-15%. Surgical procedures to relieve intracranial hypertension along with use of steroids to reduce edema improve the prognosis for those not effectively treated with the drugs.