II. Epidemiology
- Immigrants from Central America and South America comprise the greatest number of cases in the U.S.
- U.S. natives comprise 15% of Cysticercosis-related deaths
- Most common cause of acquired Epilepsy in the developing world
- Endemic regions include Asia, India, sub-Saharan africa, in additipon to Central and South America
III. Pathophysiology: Tapeworm lifecycle and pathogenesis
- Pork Tapeworm infection (Taenia solium)
- Infection originates in pigs as Tapeworm larvae (cysts)
- Key points related to Cysticercosis pathogenesis
- Tapeworms cycle between human hosts and pigs
- Ingestion of cysts does not cause Cysticercosis
- Cysticercosis is a result of fecal-oral ingestion
- Cysticercosis is not due to eating undercooked pork
- Cysticercosis occurs from infected human feces
- Can infect Vegetarians from unwashed fruit
- Humans ingest Tapeworm larvae with undercooked pork
- Pigs ingest food contaminated with infected human stool
- Humans ingest food contaminated with infected stool
- Source: Ingested Tapeworm eggs
- Infected food handlers who do not wash hands
- Household contacts with Taenia solium infection increases transmission risk
- Fruit or vegetables with infected fertilizer
- Source: Autoinoculation
- Cysticercosis occurs in similar fashion as with pigs
- Source: Ingested Tapeworm eggs
IV. Signs
- General
- Distribution
- Brain Parenchymal Neurocysticercosis (90% of cases)
- Seizures (most common, occuring in 50-80% of symptomatic patients)
- Seizure Disorder is due to Cysticercosis in 30% of cases in endemic regions
- In U.S, Cysticercosis is responsible for 2% of Seizures presenting to Emergency Department
- Del Brutto (1992) Neurology 42(2): 389-92 [PubMed]
- Headache
- Parkinsonism
- Encephalopathy (if numerous brain cysts)
- Obstructive Hydrocephalus (if ventricles involved, occurs in 20-30% of symptomatic patients)
- Papilledema may be seen in up to 28% of patients
- Chronic Meningitis (mass effect with large cysts)
- Cranial Nerve palsy (mass effect with large cysts)
- Radiculopathy (if spinal cord involved - uncommon)
- Garcia (2005) Lancet Neurol 4(10): 653-61 [PubMed]
- Seizures (most common, occuring in 50-80% of symptomatic patients)
- Skeletal Muscle lesions
- Typically asymptomatic
- Subcutaneous lesions
- Typically asymptomatic
- Eye lesions (1-3% of cases)
- Ocular lesions (e.g. vitreous lesions)
- Extraocular Muscle lesions
- Proptosis
- Visual disturbance or Vision Loss
- Brain Parenchymal Neurocysticercosis (90% of cases)
V. Imaging: Head
- MRI Brain is preferred (otherwise CT Head if MRI is not available)
- Diagnostic findings suggestive of Neurocysticercosis
- Single <2 cm lesion
- No midline shift
- Larval sucking parts (scolex) may be visible (pathognomonic)
- Differentiating cyst stage
- Viable non-degenerating cyst: Not contrast enhanced
- Degenerating cyst (symptomatic): Contrast-enhancing
- Old cysts: Calcified
- Differential diagnosis
- Tuberculosis
- Parasitic Brain Lesions (e.g. Toxoplasmosis)
- Brain Tumor
- Brain Abscess
- Other imaging modalities
- Consider MRI Brain if CT Head non-diagnostic
- Ultrasound or CT are approriate to image eye
VI. Labs
-
Cysticercal Antibody: Serum Enzyme-linked immunoblot assay (EITB)
- Test Sensitivity: >65%
- Test Specificity: >67%
- Serum more accurate than CSF titers
- Indicated if imaging is non-diagnostic
- Biopsy of infected tissue
-
Lumbar Puncture (contraindicated if CNS mass effect)
- Obtain head imaging first to exclude CNS mass effect
- Exclude other CNS diagnoses
VII. Diagnostics
- Dilated Eye Exam (fundoscopic exam)
- Indicated before initiating therapy in patients with ocular or neurologic symptoms
VIII. Differential Diagnosis
- See Intracranial Mass
- See Seizure Causes
- Brain Tumor
- Coccidiodomycosis
- Toxoplasmosis
- Mycobacterium tuberculosis
IX. Management
- Precautions: Do not start treatment without Consultation
- Treatment is individualized by multiple factors
- Antiparasitic Agents are not uniformly indicated
- Overwhelming host response could be devastating
- Use may risk morbidity or mortality in some cases
- Albendazole with Systemic Corticosteroids is typically used
- Consult infectious disease in nearly all cases
- Consult neurology and neurosurgery in CNS cases
- Skeletal Muscle lesions
- No treatment unless painful
- Consider surgical excision
- Eye: Intraocular lesions
- Consult ophthalmology
- Surgical excision for intraocular lesions
- Eye: Extraocular Muscle lesions
- Consult ophthalmology
- Surgical excision for intraocular lesions or
- Consider Albendazole with Corticosteroid (e.g. Dexamethasone)
- Brain: Subarachnoid and intraventricular lesions
- Ventricular shunt placed if Hydrocephalus
- Surgical excision for most lesions or
- Consider Albendazole with Corticosteroid (e.g. Dexamethasone)
- Brain: Parenchymal Neurocysticercosis
- Albendazole with Dexamethasone (preferred)
- Do not use in massive infection
- Not needed in calcified lesions
- Albendazole with Dexamethasone (preferred)
- Brain: Seizures
- See Status Epilepticus for acute Seizure management
- Seizure Prophylaxis continued for 6-12 months after radiographic resolution of lesions
X. Prognosis
- Brain Parenchymal disease with few cysts has better outcome than extraparenchymal involvement or numerous cysts
XI. Prevention
- See Prevention of Foodborne Illness
- Careful and frequent Hand Washing
- Wash raw fruits and vegetables before ingesting
- In endemic regions, eat only fruits and vegetables that have been cooked (or that you have peeled yourself)
XII. Resources
- CDC Cysticercosis
XIII. References
- Wang and Nguyen (2017) Crit Dec Emerg Med 31(9):13-8
- Cantey (2021) Am Fam Physician 104(3): 277-87 [PubMed]
- Garcia (2000) Infect Dis Clin North Am 14:97-119 [PubMed]
- Kraft (2007) Am Fam Physician 76:91-8 [PubMed]
- Woodhall (2014) Am Fam Physician 89(10): 803-11 [PubMed]
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Related Studies
Definition (MSH) | Infection with CYSTICERCUS, the larval form of the various tapeworms of the genus Taenia (usually T. solium in man). In humans they penetrate the intestinal wall and invade subcutaneous tissue, brain, eye, muscle, heart, liver, lung, and peritoneum. Brain involvement results in NEUROCYSTICERCOSIS. |
Definition (MSHCZE) | Onemocnění vyvolané přítomností cysticerků. U člověka ji může vyvolat Taenia solium. (cit. Velký lékařský slovník online, 2013 http://lekarske.slovniky.cz/ ) |
Definition (NCI) | A parasitic infection caused by the larval form of Taenia solium. It is a disseminated infection affecting the central nervous system, subcutaneous tissues, lungs, heart and liver. The most serious complications result from infection of the brain parenchyma. Patients may develop seizures, hydrocephalus, encephalopathy and meningoencephalitis. |
Concepts | Disease or Syndrome (T047) |
MSH | D003551 |
ICD9 | 123.1 |
ICD10 | B69 , B69.9 |
SnomedCT | 187527007, 59051007, 105684008 |
LNC | LA10450-7 |
English | Cysticercoses, Cysticercosis, Cysticercosis, unspecified, [X]Cysticercosis, unspecified, cysticercosis, cysticercosis (diagnosis), Cystercercosis, Cysticercosis [Disease/Finding], cysticercoses, [X]Cysticercosis, unspecified (disorder), Cysticerciasis, Larval taeniasis, Larval tapeworm infection, Larval teniasis, Cysticercosis (disorder), Infection by tapeworm larvae (disorder), Infection by tapeworm larvae |
Dutch | cysticercose, Cysticercose, niet gespecificeerd, Cysticercose, Cysticercosis |
Japanese | 嚢虫症, ノウチュウショウ |
Swedish | Cysticerkos |
Czech | cysticerkóza, Cysticerkóza |
Finnish | Systiserkoosi |
Russian | TSISTITSERKOZ, ЦИСТИЦЕРКОЗ |
German | Zystizerkose, nicht naeher bezeichnet, Cysticercosis, Schweinebandwurmbefall, Zystizerkose |
Korean | 낭미충증, 상세불명의 낭미충증 |
Croatian | CISTICERKOZA |
Polish | Cysticerkoza, Wągrzyca |
Hungarian | Cystircercosis, cysticercosis |
Spanish | [X]cisticercosis, no especificada, [X]cisticercosis, no especificada (trastorno), cisticercosis (trastorno), cisticercosis, infección por larvas de tenia (trastorno), infección por larvas de tenia, Cisticercosis |
Norwegian | Cysticerkose |
French | Cysticercose |
Italian | Cisticercosi |
Portuguese | Cisticercose |
Ontology: Taenia solium (C0039251)
Definition (MSH) | Species of tapeworm in the genus TAENIA, that infects swine. It is acquired by humans through the ingestion of cured or undercooked pork. |
Concepts | Eukaryote (T204) |
MSH | D041201 |
SnomedCT | 264400005, 17966003, 17894007 |
LNC | LP14847-5 |
English | Taenia solium, Tenia solium, Tenia armata, Tenia dentata, pork tapeworm, Pork Tapeworms, Tapeworms, Pork, Taenia soliums, solium, Taenia, Pork Tapeworm, soliums, Taenia, solium taenia, tenia solium, taenia solium, tapeworm pork, Taenia solium Linnaeus, 1758, Tapeworm, Pork, pig tapeworm, Pork tapeworm, Cysticercus cellulosae, Pork bladder worm, Armed tapeworm, Taenia armata, Taenia dentata, Cysticercus cellulosae (organism), Taenia solium (organism) |
Swedish | Taenia solium |
Czech | tasemnice dlouhočlenná, Taenia solium |
Finnish | Taenia solium |
Russian | TSEPEN' SVINOI, ЦЕПЕНЬ СВИНОЙ |
French | Ténia du porc, Ténia armé, Taenia solium |
Polish | Tasiemiec uzbrojony |
Japanese | カギサナダ, 有鉤条虫 |
Norwegian | Taenia solium, Svinebendelorm |
Portuguese | Tênia de Suínos, Taenia solium, Tênia de Carne Suína |
Spanish | Cysticercus celulosae (organismo), Cysticercus celulosae, Taenia solium (organismo), helminto de la vejiga porcina, tenia del cerdo, tenia solitaria, Taenia solium, Tenia del Cerdo |
German | Bandwurm, Schweine-, Schweinebandwurm, Taenia solium |
Italian | Taenia solium |
Dutch | Gewapende lintworm, Lintworm, gewapende, Lintworm, varkens-, Taenia solium, Varkenslintworm |
Ontology: Neurocysticercosis (C0338437)
Definition (NCI) | A parasitic infection with tapeworms of the genus Taenia affecting the brain. It is manifested with seizures and headaches. |
Definition (MSH) | Infection of the brain, spinal cord, or perimeningeal structures with the larval forms of the genus TAENIA (primarily T. solium in humans). Lesions formed by the organism are referred to as cysticerci. The infection may be subacute or chronic, and the severity of symptoms depends on the severity of the host immune response and the location and number of lesions. SEIZURES represent the most common clinical manifestation although focal neurologic deficits may occur. (From Joynt, Clinical Neurology, 1998, Ch27, pp46-50) |
Concepts | Disease or Syndrome (T047) |
MSH | D020019 |
ICD10 | B69.0 |
SnomedCT | 230215006, 187148002 |
English | Cysticercosis of CNS, Neurocysticercosis, NEUROCYSTICERCOSIS, CYSTICERCOSIS CNS, CNS CYSTICERCOSIS, Brain Cysticercosis, Cysticercosis, Brain, Neurocysticercoses, Central Nervous System Cysticercosis, Cysticercosis, Central Nervous System, Neurocysticercosis [Disease/Finding], neurocysticercosis, cerebral cysticercosis, cestode infection cysticercosis central nervous system, Cysticercosis of central nervous system (diagnosis), Cerebral cysticercosis, Cysticercosis of central nervous system, Cerebral cysticercosis (disorder), Cysticercosis of central nervous system (disorder), brain; cysticercosis (etiology), brain; cysticercosis (manifestation), cerebral; cysticercosis (etiology), cerebral; cysticercosis (manifestation), cysticercosis; brain (etiology), cysticercosis; brain (manifestation), cysticercosis; cerebral (etiology), cysticercosis; cerebral (manifestation) |
Portuguese | Cisticercose Encefálica, Cisticercose Cerebral, Neurocisticercose, Cisticercose do Sistema Nervoso Central |
Spanish | Cisticercosis Encefálica, neurocisticercosis, Cisticercosis Cerebral, cisticercosis cerebral (trastorno), cisticercosis cerebral, cisticercosis del sistema nerviosa central (trastorno), cisticercosis del sistema nerviosa central, Neurocisticercosis, Cisticercosis del Sistema Nervioso Central |
Swedish | Neurocysticerkos |
Japanese | シンケイノウチュウショウ, 神経嚢虫症, 脳嚢虫症, 神経嚢尾虫症, 中枢神経系嚢尾虫症, 中枢神経系嚢虫症, 嚢尾虫症-中枢神経系, 嚢尾虫症-神経, 嚢尾虫症-脳, 嚢虫症-中枢神経系, 嚢虫症-神経, 嚢虫症-脳, 脳嚢尾虫症 |
Czech | cysticercosis mozku, neurocysticercosis, Neurocysticerkóza, neurocysticerkóza, mozková cysticerkóza |
Finnish | Neurosystiserkoosi |
Russian | NEIROTSISTITSERKOZ, TSISTITSERKOZ GOLOVNOGO MOZGA, НЕЙРОЦИСТИЦЕРКОЗ, ЦИСТИЦЕРКОЗ ГОЛОВНОГО МОЗГА |
Korean | 중추신경계통의 낭미충증 |
Polish | Wągrzyca mózgu, Wągrzyca układu nerwowego |
Hungarian | neurocysticercosis |
Norwegian | Nevrocysticerkose, Cysticerkose i sentralnervesystemet |
Dutch | cerebraal; cysticercose, cysticercose; cerebraal, cysticercose; hersenen, hersenen; cysticercose, Cysticercose van centraal zenuwstelsel, neurocysticercose, Centraalzenuwstelselcysticercose, Cysticercose van het centrale zenuwstelsel, Cysticercose, hersen-, Cysticercose, neuro-, Neurocysticercose |
German | Neurocysticercosis, Neurozystizerkose, Zystizerkose des Zentralnervensystems, Zystizerkose, Gehirn, Zentralnervensystem, Zystizerkose |
French | Cysticercose cérébrale, Cysticercose neurologique, Neurocysticercose, Cysticercose du SNC, Cysticercose du système nerveux central |
Italian | Neurocisticercosi |
Ontology: Tenia solium infection (C0473878)
Concepts | Disease or Syndrome (T047) |
ICD9 | 123.0 |
ICD10 | B68.0 |
SnomedCT | 187147007, 44883008, 266160004, 240818004 |
English | Intestinal taenia solium infec, Intestinal tenia solium infec, Intestinal tenia solium infection, Tenia solium infection, Tenia solium infection, intestinal form, Taenia solium taeniasis, Tenia solium teniasis, taeniasis solium (diagnosis), taeniasis solium, Taenia solium intestine, Pork tapeworm (infection), pork tapeworm, pork tapeworm infection, tapeworm pork, Tapeworm infection: [intestinal taenia solium] or [pork] (disorder), Taenia solium infection, intestinal form (disorder), Tapeworm infection: [intestinal taenia solium] or [pork], Intestinal taenia solium infection (diagnosis), intestinal infection taenia solium, Taenia solium infection, intestinal form, Infection by Taenia solium, Pork tapeworm infection, Taenia solium infection, Armed tapeworm infection, Intestinal taenia solium infection, Intestinal taenia solium infection (disorder), Taenia solium infection (disorder), Taenia; infestation, solium (intestinal form), Tenia; infestation, solium (intestinal form), infestation; Taenia, solium (intestinal form), infestation; Tenia, solium (intestinal form), infestation; pork tapeworm, infestation; tapeworm, pork, pork tapeworm; infection, pork tapeworm; infestation, solium; Taenia infection, solium; Tenia infection, tapeworm; infestation, pork tapeworm, Taenia solium infection, intestinal form (disorder) [Ambiguous], Pork tapeworm |
Dutch | Taenia solium-infectie, intestinale vorm, Taenia solium-infectie, varkenslintworminfectie, Taenia; infestatie, solium (intestinale vorm), infestatie; Taenia, solium (intestinale vorm), infestatie; lintworm, varken, infestatie; varkenslintworm, lintworm; infestatie, varkenslintworm, solium; Taenia-infectie, varkenslintworm; infectie, varkenslintworm; infestatie, Taeniasis door Taenia solium |
French | Infection à Taenia solium, forme intestinale, Infection à Taenia solium, Infection à cestodes porcins |
German | Schweinebandwurminfektion, Taenia solium-Infektion, intestinale Form, Taenia solium-Infektion, Befall durch Taenia solium |
Italian | Infezione da taenia solium, Infestazione da Tenia solium, forma intestinale, Infezione da tenia suina |
Portuguese | Infecção por Taenia solium, Forma intestinal da infecção por Taenia solium |
Spanish | Infección por la tenia del cerdo, Infección por Taenia solium, forma intestinal, Infección por tenia solium, infección por Taenia solium, forma intestinal (trastorno), infección por Taenia solium, forma intestinal, infección por la tenia de los cerdos, infección por Taenia solium (trastorno), infección por Taenia solium, forma intestinal (concepto no activo), infección por Taenia solium, infección por tenia solium, forma intestinal (trastorno), infección por tenia solium, forma intestinal, infección por tenia solium |
Japanese | 有鉤条虫感染, 腸管寄生有鉤条虫感染, ユウコウジョウチュウカンセン, チョウカンキセイユウコウジョウチュウカンセン |
Czech | Infekce prasečí tasemnicí, Intestinální forma infekce Taenia solium, Infekce Taenia solium |
Korean | 유구 조충증 |
Hungarian | Sertés szalagférgesség fertőzés, Taenia solium fertőzés, Taenia solium fertőzés, intestinalis forma |