Neurocysticercosis guidelines IDSA- Astmh-20 1 8 PDF

Preview

Summary

Guidelines ...

Description

Clinical Infectious Diseases IDSA GUIDELINE

Diagnosis and Treatment of Neurocysticercosis: 20 Clinical Practice Guidelines by the Infectiou Society of America (IDSA) and the American Soci Tropical Medicine and Hygiene (ASTMH) A. ClintonWhite Jr,1 Christina M.Coyle,2 VedantamRajshekhar, 3 GagandeepSingh,4 W. AllenHauser,5 AaronMohanty, 1 Hector H.Garcia,6 and Theodore E.Nash7 1

University of Texas Medical Branch, Galveston; 2Albert Einstein College of Medicine, Bronx, New York; 3Christian Medical College, Vellore, and 4Dayanand Medical College, Ludhiana, India; Columbia University, New York, New York; 6Instituto Nacional de Ciencias Neurologicas and Universidad Peruana Cayetano Heredia, Lima, Peru; and 7National Institutes of Health, Bethesda, Maryland

5

Keywords. Taenia solium; cysticercosis; neurocysticersosis; taeniasis.

EXECUTIVE SUMMARY

methods, background, and evidence summaries that eachneuroof the recommendations can be found online Guidelines for the clinical management of patients with text of the guidelines. Acriterion for grading e cysticercosis (NCC) were prepared by a panel of the Infectious sented in Figure1 [1]. Note that diagnosis and mana Diseases Society of America (IDSA) and the American Society patients with neurocysticercosis can be challeng of Tropical Medicine and Hygiene (ASTMH). he guidelines are expert guidelines. Due to this complexity, clini intended for infectious disease specialists, neurologists, neurologexperience with this disease should have a lo ical surgeons, internists, pediatricians, and family practitioners. consultation with an expert in the disease. These guidelines present our approaches to the diagnosis and management of patients with the different forms of neuroRECOMMENDATIONS FOR DIAGNOSIS AND cysticercosis, including viable parenchymal neurocysticercosis, BASELINE EVALUATION single enhancing lesions, calcified parenchymal neurocysticercosis, ventricular neurocysticercosis, and subarachnoid I. How should NCC be diagnosed? neurocysticercosis. Our recommendations are based on the Recommendations best evidence available. Due to the complex variations in clinical manifestations and the limitations of the literature, many 1. While there is a wide range of clinical manif of the recommendations are based on observational studies, rocysticercosis, the 2 most common clinical p anecdotal data, or expert opinion rather than randomized clinare with seizures and increased intracranial p ical trials. The approaches we describe are intended to be both graded). applicable and feasible in the United States and Canada (for 2. Initial evaluation should include careful his simplicity, referred to here as North America). The recommenexamination, and neuroimaging studies (not grade dations may not apply for settings where resource constraints 3. We recommend serologic testing with enzyme-li may limit their applicability. The executive summary below notransfer blot as a confirmatory test in patien lists the recommendations for the diagnosis and clinical manpected neurocysticercosis (strong, moderate). Enzymeagement of neurocysticercosis. A detailed description of the immunosorbent assays using crude antigen should b due to poor sensitivity and specificity (strong, m Received 4 December 2017; editorial decision 8 December 2017; accepted 19 December 2017. Correspondence: A.Clinton White, MD,Infectious Disease Division,Department of Internal Medicine,University of Texas Medical Branch,301 University Boulevard,Galveston, TX 775550435 ([email protected]). ® Clinical Infectious Diseases 2018;XX(00):1–27 © The Author(s) 2018. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: [email protected]. DOI: 10.1093/cid/cix1084

II. What imaging studies should be used to classify disease?

Recommendation

4. We recommend both brain magnetic resonance i (MRI) and a noncontrast computed tomography (CT 2017 IDSA/ASTMH Guidelines • CID 2018:XX (XX XXXX)

Downloaded from https://academic.oup.com/cid/advance-article-abstract/doi/10.1093/cid/cix1084/4885412 by guest on 22 February 2018

Figure1.

Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework for grading of evidence.

8. We suggest that patients with NCC who probably for classifying patients with newly diagnosed neurocysticinin a nonendemic area have their household mem ercosis (strong, moderate). The classification is outlined for tapeworm carriage (weak, low). Remark: This i Table 1. lic health issue and can often be addressed by th III. What additional tests should be performed prior to initiation of department. therapy?

Recommendations

IV. How should antiparasitic and anti-inflammatory therap monitored?

5. We suggest screening for latent tuberculosis infection in Recommendations patients likely to require prolonged corticosteroids (weak, 9. We recommend that patients treated with alb low). 6. We suggest screening or empiric therapy for Strongyloides >14days be monitored for hepatotoxicity and (strong, moderate). stercoralis in patients likely to require prolonged corticoster10. No additional monitoring is needed for patie oids (weak, low). combination therapy with albendazole and 7. We recommend that all patients with NCC undergo a funbeyond that recommended for albendazole monot duscopic examination prior to initiation of anthelminthic (strong, moderate). therapy (strong, moderate).

2 • CID 2018:XX (XX XXXX) • White Jr et฀al

Downloaded from https://academic.oup.com/cid/advance-article-abstract/doi/10.1093/cid/cix1084/4885412 by guest on 22 February 2018

RECOMMENDATIONS FOR THE TREATMENT OF VIABLE INTRAPARENCHYMAL NEUROCYSTICERCOSIS

VIII. What follow-up is recommended after initial antiparasitic ther patients withVPN?

Recommendation V. What is the role of antiparasitic drugs in viable intraparenchymal neurocysticercosis (VPN)?

Recommendations

20. We suggest that MRI be repeated at least every 6m until resolution of the cystic component (strong, l

11. In patients with untreated hydrocephalus or diffuse cereRECOMMENDATION FOR THE TREATMENT OF bral edema, we recommend management of elevated intra-DEGENERATING INTRAPARENCHYMAL NCC INCLUDING PATIENTS WITH SINGLE ENHANCING cranial pressure alone and not antiparasitic treatment LESIONS DUE TO NCC (strong, moderate). Remarks: The management of patients IX. What should be the initial approach to the patient with mu with diffuse cerebral edema should be anti-inflammatory enhancing lesions fromNCC? therapy such as corticosteroids, whereas hydrocephalus Recommendation usually requires a surgical approach. 12. In the absence of elevated intracranial pressure, we recom21. We recommend that patients with multiple e mend use of antiparasitic drugs in all patients with VPN lesions and seizures be initially treated with a (strong, moderate), (Table 2). 13. For patients with 1–2 viable parenchymal cysticerci, we drugs, antiparasitic therapy, and corticosteroids as in the section on viable parenchymal cysticerci (we recommend albendazole monotherapy for 10–14 days compared to either no antiparasitic therapy (strong, high) erate), (Table 2). or combination antiparasitic therapy (weak, moderate). Remarks: The usual dose of albendazole is 15mg/kg/day X. What is the role of antiepileptic medications in patients with enhancing lesions (SELs) from cysticercosis with seizures? divided into 2 daily doses for 10–14days with food. We recommend a maximum dose of 1200mg/day. Recommendations 14. We recommend albendazole (15 mg/kg/day) combined with praziquantel (50 mg/kg/day) for 10–14 days rather 22. We recommend antiepileptic drugs for all pati than albendazole monotherapy for patients with >2 viable SELs and seizures (strong, moderate). 23. In the absence of controlled data, the choice of ant parenchymal cysticerci (strong, moderate). 15. We suggest retreatment with antiparasitic therapy for drugs can be guided by local availability, cost, dru parenchymal cystic lesions persisting for 6months after the tions, and potential side effects (not graded). end of the initial course of therapy (weak, low). 24. In patients who have been seizure free for 6mont suggest tapering off and stopping antiepileptic VI. What is the role of anti-inflammatory therapy in management ofVPN? resolution of the lesion in patients with SELs w factors for recurrent seizures (weak, moderate). Re Recommendation Risk factors for recurrent seizures include residu lesions or calcifications on neuroimaging studi 16. We recommend adjunctive corticosteroid therapy begun prior to antiparasitic drugs rather than no adjunctive ther- through seizures, or >2 seizures. apy in all patients treated with antiparasitic therapy (strong, XI. What is the role of antiparasitic drugs in patients withSELs? moderate). Recommendation VII. What is the role of antiepileptic drugs inVPN?

25. We suggest albendazole therapy rather than no an sitic therapy for all patients with SELs (weak, 17. We recommend antiepileptic drugs in all NCC patients Remarks: Albendazole (15mg/kg/day in twice-dail up for 1–2 weeks) should be given with meals. with seizures (strong, low). 18. In patients with few seizures prior to antiparasitic therapy, resXII. What is the role of anti-inflammatory therapy inSELs? olution of the cystic lesion on imaging studies, and no seizures Recommendation for 24 consecutive months, we suggest that tapering off and stopping antiepileptic drugs be considered (weak, moderate). 19. In the absence of controlled data, the choice of antiepilep26. We recommend that patients with SELs treat tic drugs should be guided by local availability, cost, drug antiparasitic drugs also be treated with corticost tiated prior to antiparasitic therapy (strong, mode interactions, and potential side effects (not graded) Recommendations

2017 IDSA/ASTMH Guidelines• CID 2018:XX (XX XXXX)

Downloaded from https://academic.oup.com/cid/advance-article-abstract/doi/10.1093/cid/cix1084/4885412 by guest on 22 February 2018

XIII. How should patients with SELs be followed?

Recommendation

of parasite integrity and an inflammatory resp could prevent successful cyst removal.

XIX. What is the optimal surgical approach to management of IVN i

27. We suggest that MRI be repeated at least every 6months fourth ventricle? until resolution of cystic lesions for patients with SELs Recommendation (weak, low). RECOMMENDATIONS FOR THE TREATMENT OF CALCIFIED PARENCHYMAL NEUROCYSTICERCOSIS

34. In cases in which surgical removal of fourth ven cysticerci is possible, we recommend surgical r rather than medical therapy and/or shunt surgery ( XIV. What should the initial approach be to patients with calcified lesions suggestive of calcified parenchymal neurocysticercosis(CPN)? moderate). Recommendation XX. What is the optimal approach to adherentIVN?

28. We suggest brain MRI in patients with seizures or hydrocephRecommendation alus and only calcified parenchymal NCC on CT (weak, low). 35. We suggest shunt surgery for hydrocephalus rather XV. What is the role of antiparasitic drugs, antiepileptic drugs, and cyst removal when surgical removal is technically anti-inflammatory medications in the management of patients withCPN? (weak, low). Remark: Attempted removal of infla Recommendations adherent ventricular cysticerci is associated with risk of complications. 29. We recommend symptomatic therapy alone instead of antiparasitic drugs in patients with calcified parenchymal XXI. Does medical therapy as an adjunct to procedures or as primary t lesions (strong, moderate),Table ( 2). apy have an impact on outcome in treating patients withIVN? 30. We suggest that corticosteroids not be routinely used in Recommendations patients with isolated CPN and perilesional edema (weak, low). 36. We recommend corticosteroids to decrease brain ede XVI. Is there a role for surgical therapy in refractorycases? the perioperative period (not graded). 37. We suggest antiparasitic drugs with corticosteroid t Recommendation lowing shunt insertion to decrease subsequent shunt 31. In patients with refractory epilepsy and CPN, we suggest patients in whom surgical removal of isolated intra cysts is not possible (weak, low), but neither after s evaluation for surgical removal of seizure foci (weak, low). removal of intraventricular cysts (weak, low). Rema that intraventricular cysts may be accompanied RECOMMENDATIONS FOR THE TREATMENT OF INTRAVENTRICULAR NEUROCYSTICERCOSIS lesions with indications for antiparasitic therapy. XVII. How are extraparenchymal cysts best identified?

Recommendation

RECOMMENDATIONS FOR SUBARACHNOID NEUROCYSTICERCOSIS

32. We recommend MRI with 3D volumetric sequencing to iden-XXII. What is the role of medical therapy in subarachnoid neurocystic sis (SAN) in the basilar cisterns or Sylvian fissures? tify intraventricular and subarachnoid cysticerci in patients with hydrocephalus and suspected NCC (strong, moderate). Recommendations XVIII. What is the optimal approach to management of intraventricular neurocysticercosis (IVN) in the lateral and third ventricles?

38. We recommend that patients with subarachnoid treated with antiparasitic drugs (strong, low ), ( 3). Table Recommendation 39. We suggest that antiparasitic therapy be contin there is radiologic resolution of viable cysticer 33. When possible, we recommend removal of the cysticerci and resolution of other evidence of cysticerci (we by minimally invasive neuroendoscopy over other surgi- Responses often require prolonged therapy, which c cal or medical approaches for cysticerci of the lateral and for more than a year. third ventricles (strong, moderate), ( 3). Remark: Most 40. We recommend anti-inflammatory therapy (such a Table experts recommend that antiparasitic drugs not be used dose corticosteroids) for subarachnoid NCC initia preoperatively, as such treatment could result in disruptionto antiparasitic drugs (strong, moderate). 4 • CID 2018:XX (XX XXXX) • White Jr et฀al

Downloaded from https://academic.oup.com/cid/advance-article-abstract/doi/10.1093/cid/cix1084/4885412 by guest on 22 February 2018

41. We suggest that methotrexate be considered as a ster-XXVII. Should management be different in pregnantwomen? oid-sparing agent in patients requiring prolonged courses Recommendation of anti-inflammatory therapy (weak, low).

48. We suggest that antihelminthic therapy be defe after pregnancy (weak, low). Remarks: Pregnant pat Recommendations with elevated intracranial pressure need to be agg managed as they would be if not pregnant. Cortico 42. We recommend that patients with hydrocephalus from can be used in pregnancy when necessary. The use of an subarachnoid NCC be treated with shunt surgery in addpileptic drugs should take into account altered ition to medical therapy (strong, low). cokinetics and potential teratogenicity. Phenoba 43. We suggest that some patients may benefit from surgical valproic acid are known to have high rates of terat debulking over shunt surgery alone (weak, low). ity. Antihelminthic drugs are rarely required em and their use can usually be deferred until after RECOMMENDATIONS FOR SPINAL Methotrexate is teratogenic and should be avoid NEUROCYSTICERCOSIS 4. principles are summarized Table in XXIII. What is the role of neurosurgery inSAN?

XXIV. How is spinal neurocysticercosis (SN) best treated?

INTRODUCTION

Recommendations

In the first section, the panel summarizes background i tion relevant to the topic. In the second section, the p 44. We recommend corticosteroid treatment for patients with questions regarding the diagnosis and treatment of neu SN with evidence of spinal cord dysfunction (eg, paraparercosis (NCC), evaluates applicable clinical trial an esis or incontinence) or as adjunctive therapy along with tional data, and makes recommendations using the Gr antiparasitic therapy (strong, moderate). Recommendations, Assessment, Development and Eval 45. We suggest that both medical (antiparasitic drugs plus (GRADE) framework [1]. The following 27 clinical qu anti-inflammatory drugs) and surgical approaches be conwere answered: sidered for SN (weak, low), Table ( 3). Practice statement: There are anecdotes of good responses of spinal neurocystic- I. How should neurocysticercosis be diagnosed? ercosis to medical and/or surgical therapy. However, thereII. What imaging studies should be used to classify d are no good data supporting one approach over the other. We III. What additional tests should be performed prio suggest that management of spinal NCC should be individu- ation of therapy? IV. How should antiparasitic and anti-inlammatory alized based on symptoms, location of the cysticerci, degree be monitored? of arachnoiditis, and surgical experience. Recommendations V. What is the role of antiparasitic drugs in via for antiparasitic drugs, reimaging, and follow-up of SAN chymal neurocysticercosis? should also be considered for subarachnoid SN. VI. What is the role of anti-inlammatory therapy RECOMMENDATIONS FOR MANAGEMENT OF OCULAR CYSTICERCOSIS

VII.

XXV. What is the optimal management of ocular cysticercosis?

VIII.

Recommendation

IX. 46. We suggest that intraocular cysticerci be treated with surgical removal rather than with antiparasitic drugs (weak, X. low). RECOMMENDATIONS FOR THE TREATMENT OF SPECIAL POPULATIONS

XI.

XXVI. Should children be managed differently than adults?

XII.

Recommendation

XIII.

47. There is no evidence that management of NCC in childrenXIV. should be different than in adults with the same form of disease (strong, moderate). Dosing should be weight based.

agement of viable parenchymal neurocysticerc What is the role of antiepileptic drugs in vi chymal neurocysticercosis? What follow-up is recommended ater initial asitic therapy for patients with viable pa neurocysticercosis? What should be the initial approach to the pat multiple enhancing lesions from neurocystic What is the role of antiepileptic medi patients with single enhancing lesions from cosis with seizures? What is the role of antiparasitic drugs in pat single enhancing lesions? What is the role of anti-inlammatory therapy enhancing lesions? How should patients with single enhancing l followed? What should the initial approach be to pati calciied lesions suggestive of calciied pare neurocysticercosis? 2017 IDSA/ASTMH Guidelines• CID 2018:XX (XX XXXX)

Downloaded from https://academic.oup.com/cid/advance-article-abstract/doi/10.1093/cid/cix1084/4885412 by guest on 22 February 2018

he pathogenesis, natural history, clinical m What is the role of antiparasitic drugs, antiepileptic drugs, and anti-inlammatory medications in the and management vary with the location of the3]. cysF management of patients with calciied parenchymal example, the main clinical manifestations vary be neurocysticercosis? forms of disease (Table1). Parenchymal NCC typical XVI. Is there a role for surgical therapy in refractory cases?with seizures or headache. Ventricular NCC most o XVII. How are extraparenchymal cysts best identiied? with obstructive hydrocephalus. Subarachnoid N XVIII. What is the optimal approach to management of venent with communicating hydrocephalus, mening tricular neurocysticercosis in the lateral and third focal neurologic indings. Mixed forms are also com ventricles? to the complexity of diagnosis and management, th XIX. What is the optimal surgical approach to manageSociety for Tropical Medicine and Hygiene (ASTM ment of ventricular neurocysticercosis in the fourth Infectious Diseases Society of America (IDSA) agreed ventricles? develop guidelines for the diagnosis and manageme XX. What is the optimal approach to adherent ventric...