Limitations of Using Radiological Imaging to Determine Treatment Success in Neurocysticercosis
Jasleen Bains1, Margaret Wilson2, Elana Farrell2, Arantxa Boluarte3, Soonmee Cha2, Felicia Chow2
1University of California, Berkeley, 2University of California, San Francisco, 3University of Washington
Background:
Neurocysticercosis (NCC) is a helminthic infection of the central nervous system caused by larval cysts of Taenia Solium. Although an undetectable T. solium antigen is used as confirmation of cure in cases of extraparenchymal (e.g., subarachnoid and intraventricular) disease, limited information exists regarding the evolution of radiological findings throughout treatment.
Design/Methods:
We reviewed medical records of 6 patients with successfully treated extraparenchymal NCC seen at University of California San Francisco between 2015 and 2021. Treatment success was defined as undetectable T. solium antigen and TsolR13 PCR from CSF after anti-helminthic therapy.
Results:
A 44-year-old Latino man presented with 1 month of progressive headache, nausea, and vomiting. Brain MRI demonstrated multiple cystic lesions in the fourth ventricle and prepontine cisterns. T. solium antigen and TsolR13 qPCR were positive from CSF. He was started on albendazole with a dexamethasone taper, although treatment was complicated by poor adherence due to persistent nausea and emesis. After 6 months of stop-and-start therapy, the patient stopped treatment with no improvement in nausea and emesis. An MRI after 3 months off treatment showed increased enhancement of a cystic lesion with worsened edema of the cerebellum and brainstem. He completed another 9 months of treatment until repeat T. solium antigen and TsolR13 qPCR from CSF were undetectable. Repeat MRI after treatment completion demonstrated stable to smaller cystic lesions with persistent enhancement. The patient has continued to do well with no new symptoms.
We reviewed 5 similar cases of successfully treated extraparenchymal NCC. In all cases, anti-helminthic therapy was stopped when T. solium antigen was undetectable. Patients did well clinically despite radiological imaging showing persistent cystic lesions/enhancement.
Conclusions:
Patients with successfully treated NCC frequently have persistent abnormalities on MRI. While imaging may be useful to assess treatment response, residual post-treatment findings are common and do not necessitate ongoing anti-helminthic therapy.
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