Disseminated cysticercosis: clinical spectrum, Toll-like receptor-4 gene polymorphisms and role of albendazole: A prospective follow-up of 60 cases with a review of 56 published cases

Abstract

In this study, we describe clinical and imaging spectrum, and the natural course of patients with disseminated cysticercosis. How albendazole affects the course of disease has also been evaluated. We assessed the Toll-like receptor-4 gene polymorphisms, to know the reason for the apparently higher prevalence of disseminated cysticercosis in India.Sixty consecutive patients with disseminated cysticercosis were enrolled. Sixty age-and-sex-matched healthy controls were also enrolled for the purpose of genetic study. Twenty patients, who gave consent, were treated with albendazole along with corticosteroids. Forty patients did not give consent for antiparasitic therapy. Assessment for Toll-like receptor-4 gene polymorphisms (Asp299Gly and Thr399Ile genes) was done. Patients were followed for 6 months. We also performed a literature search of cases published in English language using PubMed electronic database and analyzed 56 cases thus available.There was an increased risk (6.63 fold and 4.61 fold) of disseminated cysticercosis in the presence of Asp299Gly and Thr399Ile polymorphisms in Toll-like receptor-4, respectively. The allelic frequency of Gly (11% vs. 3%, P = 0.024, odds ratio [OR] = 3.52) and Ile alleles (11% vs. 2%, P = 0.009, OR = 4.738) in disseminated cysticercosis was high. Albendazole resulted in complete disappearance of all cerebral lesions in 35% (7/20) patients and reduction in lesion load in remaining 65% (13/20) patients. No significant change in number of cysticercal lesion was noted in patients who did not receive albendazole. No major adverse reaction following antiparasitic treatment was noted. Three deaths were recorded in patients who did not receive antiparasitic treatment.Of the 56 cases reported in PubMed, 33 patients received antiparasitic treatment with follow-up data available for 31 patients. Most (24) of these patients received albendazole. A significant clinical and/or imaging improvements, on follow up, were observed in 27 patients. Of the 4 deaths recorded, 3 had a heavy parasitic load and died after praziquantel therapy.Toll-like receptor-4 gene polymorphisms are associated with an increased susceptibility to disseminated cysticercosis, in the Indian population. Albendazole treatment seems to reduce the lesion load and improve symptoms.

Figure 1

Algorithm of the study.

Figure 2

Gross image of the resected subcutaneous specimen shows a glistening cysticercus (A), the internal contents of which show the fibrotic cyst wall enclosing a pearly white scolex (B, arrow). Photomicrograph of the complete scolex (Hematoxylin & Eosin, ×50) depicts the sucker (C, arrow) and folded parenchyma.

Figure 3

Subcutaneous nodules present on left side of the chest (A), right shoulder (B), and back (C); cyst on left lateral margins of tongue (D), and pseudo muscular hypertrophy (E). Biopsy and histopathology of the lesion was consistent with cysticercosis.

Figure 4

Evaluation of dissemination of cysticerci in the eye—MRI T2—weighted axial image (A) and sagittal (B) showing cysts in extra-ocular muscles. On Fundus examination there was a subretinal cyst with retinal detachment (C) and (D). Ocular B-scans showing ocular cyst (E) and (F). MRI = magnetic resonance imaging.

Figure 5

On MRI (A) axial T2-wieghted image showing multiple cysticercal cysts having scolex in bilateral brain parenchyma, (B) T1-weighted image with hyper intense scolex. (C) Coronal and (D) Saggital images showing multiple cysts in scalp, facial, and neck musculature along with parenchymal cysts. (E) MRI with SPGR (Spoiled gradient recalled echo) contrast showing ring enhancement, (F) and (G) STIR (Short tau inversion recovery) images as whole body protocol, and (H) showing intra medullary cyst in thoracic cord. MRI = magnetic resonance imaging.

Figure 6

X-rays protocol—plain x-ray of skull, lateral view with neck (A), chest with bilateral shoulders (B), and hip with bilateral thighs (C) and (D) showing calcified granuloma as round, oblong, or cigar shaped radio-dense shadows involving the zone of muscles of the parts involved.

Figure 7

Axial T2-weighted image showing vesicular cysts (A) at baseline and (B) complete cysts resolution after albendazole therapy.