Neurocysticercosis — DTM&H MCQ

Correct answer: E — Albendazole with corticosteroids and antiepileptic therapy

The correct answer is E, albendazole with corticosteroids and antiepileptic therapy. This patient has viable parenchymal neurocysticercosis (multiple cysts with a visible scolex and surrounding oedema on MRI, in a patient from an endemic area with new focal seizures), and ocular disease has already been excluded by fundoscopy, which is the essential prerequisite before giving cysticidal drugs. Albendazole is the anthelmintic of choice because it achieves better CNS penetration and cyst clearance than praziquantel, but killing viable cysts provokes an inflammatory response around the dying parasite that can worsen oedema, raise intracranial pressure and precipitate seizures, so corticosteroids (typically dexamethasone or prednisolone) must be co-administered, alongside antiepileptic drugs to control the presenting seizures. This combined approach reflects current international and UK-applicable practice for symptomatic viable parenchymal neurocysticercosis. Why the other options are wrong: D. Metronidazole followed by paromomycin: these are agents used for intestinal protozoal or luminal parasitic infections (e.g. amoebiasis), not for Taenia solium cysticerci, and have no activity against neurocysticercosis. C. Immediate ventriculoperitoneal shunt for every case: shunting is reserved for hydrocephalus or intraventricular disease causing raised intracranial pressure, not for uncomplicated viable parenchymal cysts, and performing it routinely exposes patients to unnecessary surgical risk. B. Doxycycline and rifampicin: this combination is used for brucellosis, not for larval tapeworm infection of the brain. A. Praziquantel alone without anti-inflammatory cover: praziquantel is less effective than albendazole for parenchymal disease, and omitting corticosteroids risks a severe inflammatory reaction as cysts die, worsening cerebral oedema and seizures. Key point: In viable parenchymal neurocysticercosis, always exclude ocular cysts first, then treat with albendazole plus corticosteroids and antiepileptics to control the inflammatory response triggered by cysticidal therapy.

Reference: IDSA/ASTMH 2017 Clinical Practice Guidelines for the Diagnosis and Treatment of Neurocysticercosis (Clinical Infectious Diseases, 2018;66(8):e49-e75), endorsed as the basis for antiparasitic plus anti-inflammatory management of viable parenchymal neurocysticercosis used in UK tropical medicine teaching (e.g. Manson's Tropical Diseases); https://academic.oup.com/cid/article/66/8/e49/4885412