Correspondence

A Trial of Antiparasitic Treatment for Cerebral Cysticercosis

N Engl J Med 2004; 350:1686-1687April 15, 2004

Article

To the Editor:

Garcia et al. (Jan. 15 issue)1 report the results of a trial of antiparasitic treatment for cerebral cysticercosis. Previous investigations, such as the one by Carpio et al.,2 have not shown differences among praziquantel, albendazole, and prednisolone in the treatment of neurocysticercosis or in the outcome of seizures related to it. I think the control group in the study by Garcia et al. should have been treated with dexamethasone or prednisolone. We know that albendazole in combination with dexamethasone is better than placebo. But is albendazole in combination with corticosteroids better than dexamethasone or prednisolone alone?

Ignacio Rojas-Flores, M.D.
Hospital General Regional no. 1, Morelia, Michoacán, 58000 Mexico
neurojas@yahoo.com

2 References

1. 1

   Garcia HH, Pretell EJ, Gilman RH, et al. A trial of antiparasitic treatment to reduce the rate of seizures due to cerebral cysticercosis. N Engl J Med 2004;350:249-258
   Full Text | Web of Science | Medline

2. 2

   Carpio A, Santillan F, Leon P, Flores C, Hauser WA. Is the course of neurocysticercosis modified by treatment with antihelminthic agents? Arch Intern Med 1995;155:1982-1988
   CrossRef | Web of Science | Medline

To the Editor:

In their report on a randomized, controlled trial of albendazole and dexamethasone in patients with neurocysticercosis who had viable parenchymal cysts, Garcia et al. note that the frequency of adverse gastrointestinal events (including abdominal pain, nausea, and diarrhea) was significantly higher in the treatment group than in the placebo group and attribute these events to the use of dexamethasone. However, prior data on the use of dexamethasone do not support this view. A more likely explanation is the effect of albendazole on coexisting intestinal parasites. Rates of taeniasis in the community, as determined by examination of stool samples for ova, have been reported to range between 0.1 percent and 6 percent in India, Vietnam, China, and Indonesia.1 The rate is likely to be higher in patients with viable parenchymal cysts, such as the patients studied by Garcia et al. In a previous study, half the patients with Taenia solium infection who were treated with praziquantel reported abdominal pain.2

Sudhir Kumar, M.D., D.M.
Christian Medical College, 632004 Vellore, India
drsudhirkumar@yahoo.com

2 References

1. 1

   Rajshekhar V, Joshi DD, Doanh NQ, van_De_N, Xiaonong Z. Taenia solium taeniosis/cysticercosis in Asia: epidemiology, impact and issues. Acta Trop 2003;87:53-60
   CrossRef | Web of Science | Medline

2. 2

   Rim HJ, Park SB, Lee JS, Joo KH. Therapeutic effects of praziquantel (Embay 8440) against Taenia solium infection. Kisaengchunghak Chapchi 1979;17:67-72
   Medline

Author/Editor Response

We do not share Dr. Kumar's view. Abdominal pain resulting from gastritis with the use of dexamethasone or other oral corticosteroids has been well described. We do not believe that abdominal pain in our patients was related to the effect of albendazole on intestinal tapeworms. None of the eight patients who reported abdominal pain during treatment had a positive stool examination for taenia eggs or a positive enzyme-linked immunosorbent assay for taenia antigens in the stool. In contrast, there were 8 tapeworm carriers among the remaining 49 patients in the treatment group.

In response to Dr. Rojas-Flores, who asks whether it was albendazole or dexamethasone alone that killed the parasites: prospective, controlled studies in pigs have clearly demonstrated the parasiticidal effects of albendazole,1 praziquantel,1,2 and oxfendazole, a veterinary benzimidazole,3 with almost complete killing of cysticercosis cysts in treated animals, without the use of corticosteroid therapy. Similarly, in the initial studies of antiparasitic treatment in humans, both praziquantel4,5 and albendazole5 were used without corticosteroids, with similar cysticidal efficacy.

Héctor H. Garcia, M.D., Ph.D.
Universidad Peruana Cayetano Heredia, Lima 31, Peru
hgarcia@jhsph.edu

Robert H. Gilman, M.D.
Johns Hopkins University, Baltimore, MD 21205

Armando E. Gonzalez, D.V.M., Ph.D.
Universidad Nacional Mayor de San Marcos, Lima 3, Peru

5 References

1. 1

   Gonzalez AE, Garcia HH, Gilman RH, et al. Treatment of porcine cysticercosis with albendazole. Am J Trop Med Hyg 1995;53:571-574
   Web of Science | Medline

2. 2

   Torres A, Plancarte A, Villalobos AN, de Aluja AS, Navarro R, Flisser A. Praziquantel treatment of porcine brain and muscle Taenia solium cysticercosis. 3. Effect of 1-day treatment. Parasitol Res 1992;78:161-164
   CrossRef | Web of Science | Medline

3. 3

   Gonzalez AE, Garcia HH, Gilman RH, et al. Effective, single-dose treatment of porcine cysticercosis with oxfendazole. Am J Trop Med Hyg 1996;54:391-394
   Web of Science | Medline

4. 4

   Sotelo J, Escobedo F, Rodriguez-Carbajal J, Torres B, Rubio-Donnadieu F. Therapy of parenchymal brain cysticercosis with praziquantel. N Engl J Med 1984;310:1001-1007
   Full Text | Web of Science | Medline

5. 5

   Sotelo J, Escobedo F, Penagos P. Albendazole versus praziquantel for therapy for neurocysticercosis: a controlled trial. Arch Neurol 1988;45:532-534
   Web of Science | Medline