health education

1. Neurocysticercosis-an Indian scenario-
Neglected disease
• By Dr. Ashok Laddha
• Emergency Medicine
• Occupational health physician

2. What is NCC?
• Neurocysticercosis is a specific form of the
infectious parasitic disease CYSTICERCOSIS which
is caused by infection with PORK TAPE WORM -
Taenia solium, . Neurocysticercosis occurs when
cysts formed by the infection grow within
the BRAIN causing neurologic syndromes such
as eplileptic seziures. It has been called a "hidden
epidemic” and "arguably the most common
parasitic disease of the human nervous system”

3. Historical perspective
• Cysticercosis was first described in pigs by Aristophanes
and Aristotle in 3rd century BC. Latter it was noticed in
human by Parunoli in 1550.
• Cysticercosis has also been described in ancient Indian
medical book, the Charak Sanhita.
• NCC was first reported in a coolie from Madras, who
died due to seizure and was found to be infected with
cyst on autopsy (Armstrong 1888).
• In 1912, Krishnaswamy (1912) reported cysticerci
related case of muscle pains and subcuataneous
nodules with abundant cysticerci in the muscles, heart
and brain at autopsy

4. Facts-1
• Taeniasis is an intestinal infection caused by adult
tapeworms.
• Three tapeworm species cause taeniasis in humans,
Taenia solium, Taenia saginata and Taenia asiatica.
• T. solium causes major health problems.
• T. solium taeniasis is acquired by humans through the
ingestion of tapeworm larval cysts (cysticerci) in
undercooked and infected pork.
• Human tapeworm carriers excrete tapeworm eggs in
their faeces and contaminate the environment when
they defecate in open areas.

5. Facts-2
• Ingested T. solium eggs develop to larvae (called
cysticerci) in various organs of the human body.
When they enter the central nervous system
they can cause neurological symptons
(neurocysticercosis), including epileptic seizures.
• T. solium is the cause of 30% of epilepsy cases in
many endemic areas where people and roaming
pigs live in close proximity.
• More than 80% of the world's 50 million people
who are affected by epilepsy live in low and
lower-middle income countries.

6. Facts -3
• Humans can also become infected with T. solium
eggs by ingesting contaminated food or water or
as a result of poor hygiene.
• Major cause of death from food borne diseases
• 26.3% to 53.8% active epilepsy cases in the
developing world including India and Latin
America are due to NCC.
• Cysticercosis has been designated as a “biological
marker” of the social and economic development
of a community

7. Indian Scenario
• NCC is identified as the single most common cause of
community acquired active epilepsy
• Almost 48% of active epilepsy cases in India is due to NCC
• Major public heath problem
• About 70% cases of active epilepsy cases having SCG
(Solitary cysticercosis granuloma) :
• Cysticercosis is prevalent virtually all states of India, the
only possible exceptions being Kerala, and Jammu and
Kashmir.
• It is generally believed that the disease is more prevalent in
north than south India
• Utter pradesh having highest prevalence rate –approx-38%

8. Important note
• Cysticercosis is preventable cause of epilepsy
which creates burden through stigmatization,
Incapacitation and loss of work productivity

9. Causes of high prevalence in India
• All the biological markers for transmission of T. solium
taeniasis and cysticercosis exist in India.
• Neglected disease
• Systemic population-based studies are lacking.
• There are great disparities within the country in
geography, ethnicity ,religion rituals, income, food
habits, personal hygiene, level of education and
standards of living, which are likely to influence the
disease burden.
• There are wide variations in the frequency of
cysticercosis in India
• Under reported

10. Epidemiology
• Approximately 50 million people worldwide are
estimated to have cysticercosis infection,
• Although estimates are probably low since many
infections are subclinical and there are relatively
few population-based data on prevalence .
• Cysticercosis is endemic in many regions of
Central and South America, sub-Saharan Africa,
India, and Asia. The prevalence of cysticercosis is
higher in rural or periurban areas where pigs are
raised and sanitary conditions are suboptimal .
• It causes about 50,000 deaths each year.

11. Causative Agent
• Taenia solium
• Definitive Host---------Human
• Intermediate host-----------Pig-
• Intermediate Host----Cattle (T. saginata)

12. Teania Solium-Overview
• T. solium tapeworms are acquired by ingestion of
undercooked pork. The scolex attaches to the intestinal wall
and proglottids form at the base of the scolex. The
proglottids gradually enlarge as they are displaced from the
scolex by newer proglottids. The terminal proglottids are
shed periodically in the stool. Terminal proglottids are
typically off-white, 2 cm long, 0.5 to 1 cm wide, and 1 to
2 mm thick.
• The eggs can survive for days to months in the
environment
• In the human intestine, the cysticercus develops over 2
months into an adult tapeworm, which can survive for
years.

13. Life cycle, Biology and Transmission

14. Morbidity and Mortality
• Morbidity may result from seizures, strokes, or
hydrocephalus and from effects of long-term
treatment with anticonvulsants, steroids, or
cerebrospinal fluid shunts.
• Mortality from cysticercosis is generally
limited to cases complicated by encephalitis,
cerebral edema, hydrocephalus, and stroke.

15. Risk Factors
• Risk factors associated with cysticercosis
include the following:
• Immigration from an endemic area
• Family history of parasitic infestation
• History of travel to an endemic area
• Household visitors from an endemic area

16. High risk group
• Workers handling organic solvents
• Slaughter house workers
• Food handlers
• School children
• Agriculture workers
• Pig husbandry workers

17. Types of NCC
• Five types of neurocysticercosis are recognized
according to their location:
• Parenchymal
• Arachnoidal
• Ventricular
• Spinal
• Mixed.
• Milliary or encephalitic type

18. Types of NCC
• Parencymal
• Extra parencymal
• Extra neural—Eye /Muscle/Subcutaneous

19. Stages of parenchymal NCC
• Vesicular-- viable cysticerci with immune
tolerance by the host;
• Colloidal-- nonviable cysticerci with the host's
immune system reacting against the
degeneration of the parasite;
• Granular Nodular- nonviable cysticerci with
immune response and deposition of mineral salt
• Calcified-the sequelae of nonviable nodular
granulomas.-

20. Important note
• Extra parencymal have poor prognosis than
parechymal
• Symptoms depend on the size, number, and location of
lesions and include headaches, jacksonian epileptic
seizures, focal neurological deficit, loss of vision,
mental disturbances, and neuropsychiatric problems
produced by brain parenchymal mass effect, reactive
edema, and glial scarring. Meningitis, hydrocephalus,
ischemic cerebrovascular disease, cerebellar ataxia,
spinal cord compression, and transient paralytic
episodes can occur at times.

21. Clinical Features
• Neurocysticercosis (NCC) is frequently asymptomatic. Symptoms
are generally similar to those found with other intracranial mass
lesions, which may be consistent with increased ICP. Cysticercosis of
other tissues is almost always asymptomatic. The following
symptoms can appear years after infection begins:
• Seizures (focal or generalized) in 70-90% of patients
• Chronic headache
• Nausea and vomiting
• Vision changes
• Focal neurological complaints
• Mental status change
• Cognitive decline
• Paralysis

22. Physical Clinical presentation
• Physical findings include the following:
• Absence of fever
• Usually nonfocal neurologic examination findings
• Papilledema and decreased retinal venous pulsations
• Meningismus
• Hyperreflexia
• Nystagmus or visual deficits
• Visualization of intraocular larvae by funduscopy may
be diagnostic
• Subcutaneous nodules resembling sebaceous cysts
• Muscular pseudohypertrophy

23. Presentation of different forms of
Cysticercois
• Patients with intrasellar neurocysticercosis present with ophthalmologic
and endocrinologic manifestations mimicking those of pituitary tumors.
• Spinal neurocysticercosis is rare and may be either intramedullary or
extramedullary.
• The extramedullary form is the most frequent and is responsible of
symptoms of spinal dysfunction such as radicular pain, weakness, and
paresthesias. Intramedullary presentation may cause paraparesis, sensory
deficits with a level, and sphincter disturbances.
• Ocular cysticercosis occurs most commonly in the subretinal space.
Patients may present with ocular pain, decreased visual acuity, visual field
defects, or monocular blindness.
• Systemic cysticercosis is most common in the Asian continent. The
parasites may be located in the subcutaneous tissue or muscle. Peripheral
nerve involvement as well as involvement of the liver or spleen have been
reported

24. Abnormal Physical Findings
• Cognitive decline
• Dysarthria
• Extraocular movement palsy or paresis
• Hemiparesis or hemiplegia, which may be related
to stroke, or Todd paralysis
• Hemisensory loss
• Movement disorders
• Hyper/hyporeflexia
• Gait disturbances
• Meningeal signs

25. Investigations
• CT Scan
• MRI
• CBC
• LFT
• RFT
• ELECTROLYTES
• TEC
• STOOL EXAMINATION
• CSF Examination
• CSF ELISA
• Serum EITB
• Urine-Monoclonal antibody
• Indirect haemagglutination test
• LTT-Lymphocyte transformation test
• Endoscopy
• Neuroendoscopy

26. Diagnostic Criteria
• Absolute
• Major
• Minor
• Epidemiologic

27. Absolute Criteria
• Histologic demonstration of the parasite on a
biopsy sample from the brain or spinal cord
lesion
• Direct visualization of subretinal parasites via
funduscopic examination
• Cystic lesions showing the scolex on CT scans
or MRIs

28. Major Criteria
• Lesions highly suggestive of neurocysticercosis on
neuroimaging studies (CT scan or MRI showing cystic
lesions without scolex, enhancing lesions, or typical
parenchymal brain calcifications)
• Serum anticysticercal antibodies demonstrated by
immunoblot assay
• Resolution of intracranial cystic lesions after therapy with
albendazole or praziquantel
• Spontaneous resolution of small, single, enhancing lesions
(single ring-enhancing lesions < 20 mm in diameter in
patients with seizures, normal neurologic examination
findings, no evidence of active systemic disease

29. Minor Criteria
• Lesions compatible with neurocysticercosis on
neuroimaging studies
• Clinical manifestations suggestive of
neurocysticercosis (eg, epilepsy, focal neurologic
signs, intracranial hypertension, dementia)
• Positive findings from CSF enzyme-linked
immunosorbent assay (ELISA) for detection of
anticysticercal antibodies or cysticercal antigens
• Cysticercosis outside the CNS

30. Epidemiologic Criteria
• Evidence of a household contact with T
solium infection
• Individuals coming from or living in an area
where cysticercosis is endemic
• Household contact with an individual infected
with T solium

31. Diagnosis
• A)Definite neurocysticercosis (1 of the following)
• ---One absolute criterion
• ---Two major criteria plus 1 minor criterion and 1
epidemiologic criterion
• B)Probable neurocysticercosis (1 of the following)
• ---One major criterion plus 2 minor criteria
• ---One major criterion plus 1 minor criterion plus
1 epidemiologic criterion
• ---Three minor criteria plus 1 epidemiologic
criterion

32. Complications-1
• Migraine type headache
• Hydrocephalus
• Partial vision loss
• Paralysis
• Radiculopatathy
• Cerebrovascular complications
• Cranial nerve palsy
• Intracranial haemorrhage

33. Complications-2
• cognitive dysfunction
• psychiatric disease
• and Parkinson-like syndromes
• Thrombosis
• Endarteritis
• inflammatory aneurysms etc

34. Epileptogenic focus
• Calcified lesion

35. Vaccination
• No vaccination available

36. Treatment steps
• Symptomatic
• Supportive
• Specific
• Surgical intervention

37. Treatment approach
• Dead parasites-- the treatment is directed
primarily against the symptom
• Active parasites-- course of steroids or
immunosuppressants is recommended before
the use of anticysticercal drugs.

38. Treatment
• Treatment with albendazole (400 mg twice
daily for adults or weight-based dosing for
either adults or children) plus either
dexamethasone or prednisolone to decrease
the number of active lesions on brain imaging
studies and reduce long-term seizure
frequency.

39. Medication
• Albendazole
• Praziquntel
• Steriods
• Anti epileptic
• Diuretics

40. Indication for surgical intervention
• Calcified cyst
• Hydrocephalus
• Obstruction
• Multiple cysts in SAS
• Extraparencymal lesion

41. Prevention
• Maintenance of highest quality of personal hygiene
• Food Safety
• Access to preventive chemotherapy
• Mass drug administration
• Selective Chemotherapy
• Targeted Chemotherapy
• Health Education
• Food inspection and analysis
• Improved sanitation
• Improved Water quality—water sample testing
• Improved environmental sanitation
• Improved pig husbandry
• Chemoprophylaxis –anti helmentic drugs to pig

42. Prevention
• Slaughter house regulation
• Avoid eating raw pork-meat
• Hand wash as per who guidelines

43. lastly
• India has not yet fully organized and directed
its powerful biotechnology engine for building
up cutting edge technology—we have a
chance to be global leader