Correspondence

Combined antiparasitic treatment for neurocysticercosis

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Diagnosis of neurocysticercosis is improved with neuroimaging and serodiagnosis. However, differences in the number and location of lesions with neuroimaging, and the clinical polymorphism of presentation, make neurocysticercosis a complex disease. Therefore, a single therapeutic approach is not expected to be useful in every patient with neurocysticercosis.1,2 The results of the randomised clinical trial done by Hector Garcia and colleagues3 in which the combination of albendazole plus praziquantel increased the parasiticidal effect in patients with multiple brain cysts could represent a shift in management of multicystic parenchymal neurocysticercosis. We report our difficult experience in management of multicystic parenchymal neurocysticercosis through the

following clinical case. On April 19, 2011, a 22-year-old man was admitted to the Emergency Unit of Cayenne Hospital, French Guiana, France, for weakness and headaches after an episode of generalised tonic-clonic seizure. He was originally from Guinea-Bissau and had lived in French Guiana since March, 2011. He had worked in a farm with pigs for several years and reported a history of chronic headaches. The table presents details of the patient’s management during his admission to hospital and follow-up at the Infectious Diseases Unit. We combined the patient history, physical examination, serodiagnosis, and CT scan showing scattered microcalcifications to retain the neurocysticercosis hypothesis. On April 29, 2011, we confirmed the diagnosis with MRI and high-resolution sonography showing multicystic viable lesions in the brain and subcutaneous and intramuscular cysts containing echogenic scolex (appendix). We gave a standard oral dose of albendazole and corticosteroids for 21 days. 6 months later, we noted a persistence

of cystic viable lesions on the MRI from Oct 23, 2011. Furthermore, the patient presented symptomatic subcutaneous and intramuscular cysts with scolex shown by high-resolution sonography. Thus, we gave him a repeated course of standard doses of albendazole on Dec 20, 2011. On Aug 22, 2012, he had malaise, and we did a MRI showing persistence of viable cysts. He was finally successfully treated with a combination of albendazole and praziquantel at standard doses on Nov 11, 2012. Further neuroimaging surveillance showed residual calcifications on a CT scan and no viable cyst on MRI on Sept 14, 2013. We strongly recommend bitherapy of antiparasitic drugs for treatment of multicystic parenchymal neurocysticercosis. We declare no competing interests. We thank Mathieu Nacher for his helpful comments on the manuscript.

*Aba Mahamat, Philippe Abboud, Magalie Demar, Daniel JeanBourquin, Félix Djossou [email protected]

Clinical examination/symptoms

Biology/CT scan

Serology (serum and cerebrospinal High-resolution sonography/treatment fluid)/MRI

April 19, 2011

Symptoms: headaches, weakness after seizure; parameters: temperature: 37·1°C, weight: 69 kg, SBP: 110 mm Hg, DBP: 70 mm Hg; examination: no neurological deficit, subcutaneous nodules on back, front, and left-upper quadrant

Leucocytes: 11·1 g/L (normal: 4–10); neutrophil count: 9·11 g/L (1·5–7·5); eosinophil count: 0·07 g/L (0·03–0·46); platelets: 320 g/L (150–450); lactic acid: 2·2 mmol/L (0·5–2·2); creatinine: 84·5 μmol/l (80–133); creatine kinase: 313 U/L (38–174)

Antibodies anti-Taenia solium: 17·1 (normal: 27 viable intraparenchymental and Albendazole 15 mg/kg per day and ventricular cysts corticosteroids 1 mg/kg per day

Oct 23, 2011

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Viable cysts

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Dec 20, 2011

Upper back pain, pruritis, and new subcutaneous nodules

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Antibodies anti-T solium: 12·6 (normal 23 viable cysts

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Nov 13, 2012

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Albendazole (15 mg/kg per day) and praziquantel (50 mg/kg per day)

March 29, 2013

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Combined antiparasitic treatment for neurocysticercosis.

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