Neurocysticercosis — DTM&H MCQ

Correct answer: B — Albendazole with corticosteroids and antiepileptic therapy

A) Albendazole with corticosteroids and antiepileptic therapy is correct. The CT findings of multiple cystic lesions containing a scolex with surrounding oedema are classic for viable parenchymal neurocysticercosis (colloidal vesicular to granular nodular stage) from Taenia solium, endemic in Peru. With no signs of raised intracranial pressure, antiparasitic therapy is safe and indicated, but killing the cysts provokes an inflammatory response that can worsen oedema and precipitate or worsen seizures, so corticosteroids must be co-administered, alongside antiepileptic drugs for seizure control. This combined approach reduces the number of active lesions on repeat imaging and lowers long-term seizure recurrence. Why the other options are wrong: E. Praziquantel without anti-inflammatory cover: praziquantel is an alternative or adjunctive cysticidal agent, but giving any cysticidal drug without corticosteroid cover risks acute deterioration from cyst-death inflammation and raised intracranial pressure, and albendazole is generally preferred as first line with better CNS penetration when combined with steroids. D. Ivermectin and diethylcarbamazine: these agents target filarial nematodes (e.g. onchocerciasis, lymphatic filariasis), not the tapeworm larval stage causing neurocysticercosis, and have no cysticidal activity. A. Immediate antituberculous therapy: tuberculoma is a differential for ring-enhancing brain lesions but does not show a scolex on imaging; empirical anti-TB treatment is inappropriate when imaging is diagnostic of cysticercosis. C. Metronidazole followed by paromomycin: this regimen treats amoebic disease (e.g. Entamoeba histolytica) or luminal parasites, not tissue-invasive cysticercosis, and neither drug has activity against Taenia solium larvae. Key point: a scolex within a cystic brain lesion on imaging is pathognomonic for neurocysticercosis, and viable parenchymal disease without raised intracranial pressure is treated with albendazole plus corticosteroids and anticonvulsants, never cysticidal therapy alone.

Reference: ASTMH/IDSA Clinical Practice Guidelines for the Diagnosis and Treatment of Neurocysticercosis (2018), also reflected in BNF guidance on albendazole use in neurocysticercosis: https://www.idsociety.org/practice-guideline/neurocysticercosis/