Correspondence

Case 8-1993: Cysticercosis

N Engl J Med 1993; 329:813September 9, 1993

Article

To the Editor:

Case 8-1993 (Feb. 25 issue)1 describes a patient with subarachnoid cysticercosis who was treated with praziquantel without the simultaneous administration of glucocorticoids. This approach contrasts with that currently recommended for the management of this form of the disease2. Although both praziquantel and albendazole are effective against parenchymal brain cysticerci, the latter is the drug of choice for subarachnoid cysts3. Albendazole and praziquantel have different mechanisms of action. Praziquantel destroys the scolex of the cysticercus by producing spastic paralysis of the parasite's musculature. In contrast, albendazole inhibits the uptake of glucose by parasitic membranes, causing energy depletion. Such differences explain why albendazole (and not praziquantel) is effective against subarachnoid cysticerci, which are usually composed of several membranes without a scolex. Moreover, albendazole reaches a higher concentration in cerebrospinal fluid than praziquantel4.

Simultaneous use of anticysticercal drugs and glucocorticoids is particularly useful in patients with subarachnoid cysticerci. The acute inflammatory reaction within the subarachnoid space that develops in response to the destruction of parasites may cause occlusive endarteritis of small penetrating vessels around the cysts5. I believe that the concomitant administration of glucocorticoids is mandatory in the treatment of subarachnoid cysticerci with albendazole.

Oscar H. Del Brutto, M.D.
Hospital Luis Vernaza, Guayaquil, Ecuador

5 References

1. 1

   Case Records of the Massachusetts General Hospital (Case 8-1993). N Engl J Med 1993;328:566-573
   Full Text | Web of Science | Medline

2. 2

   Del Brutto OH. Diagnosis and management of cysticercosis. J Trop Geogr Neurol 1992;2:1-9
   

3. 3

   Del Brutto OH, Sotelo J, Aguirre R, Diaz-Calderon E, Alarcon TA. Albendazole therapy for giant subarachnoid cysticerci. Arch Neurol 1992;49:535-538
   Web of Science | Medline

4. 4

   Jung H, Hurtado M, Sanchez M, Medina MT, Sotelo J. Plasma and CSF levels of albendazole and praziquantel in patients with neurocysticercosis. Clin Neuropharmacol 1990;13:559-564
   CrossRef | Web of Science | Medline

5. 5

   Del Brutto OH. Cysticercosis and cerebrovascular disease: a review. J Neurol Neurosurg Psychiatry 1992;55:252-254
   CrossRef | Web of Science | Medline

Author/Editor Response

The discussants reply:

To the Editor: The patient under discussion received praziquantel because of a report of its effectiveness in the treatment of a case of racemose cysticercosis1 and the fact that albendazole is available in the United States only through the manufacturer (SmithKline Beecham, United Kingdom), with prior approval of the Food and Drug Administration. The use of albendazole and glucocorticoids by Del Brutto and colleagues2,3 to treat five patients with subarachnoid cysticercosis successfully represents an important advance in the management of a disease that otherwise is difficult to treat, even surgically. Simultaneous administration of glucocorticoids, however, may not prevent cerebral infarction4 or increased intracranial pressure2 due to the inflammatory reaction that follows the destruction of parasites. Further experience is necessary to define fully the effectiveness and safety of this regimen.

When seen 16 months after treatment with praziquantel, the patient was asymptomatic and had normal findings on neurologic examination, although magnetic resonance imaging showed no change in the size or number of subarachnoid cysts. Her relatively uncomplicated clinical course suggests that subarachnoid cysticercosis can be mild.

James H. Maguire, M.D.
Brigham and Women's Hospital, Boston, MA 02115

John W. Henson, M.D.
Massachusetts General Hospital, Boston, MA 02114

4 References

1. 1

   Baily GG, Levy LF. Racemose cysticercosis treated with praziquantel. Trans R Soc Trop Med Hyg 1989;83:95-96
   CrossRef | Web of Science | Medline

2. 2

   del Brutto OH, Sotelo J. Albendazole therapy for subarachnoid and ventricular cysticercosis. J Neurosurg 1990;72:816-817
   CrossRef | Web of Science | Medline

3. 3

   Del Brutto OH, Sotelo J, Aguirre R, Diaz-Calderon E, Alarcon TA. Albendazole therapy for giant subarachnoid cysticerci. Arch Neurol 1992;49:535-538
   Web of Science | Medline

4. 4

   Woo E, Yu YL, Huang CY. Cerebral infarct precipitated by praziquantel in neurocysticercosis -- a cautionary note. Trop Geogr Med 1988;40:143-146
   Medline