Brain, Vol. 122, No. 2, 372-373,
February 1999
© 1999 Oxford University Press
Book Reviews |
NEUROCYSTICERCOSIS: A CLINICAL HANDBOOK.
By Oscar H. Del Brutto, Julio Sotelo and Gustavo C. Roman.1998. Pp. 216. Lisse, The Netherlands: Swets and Zeitlinger.Price $88. ISBN 90-265-1513-8..
The Hospital for Tropical Diseases, London, UK
Infection is still a major cause of disease of the central nervous system. Of the 50 million people infected with cysticerci, 50 thousand will die each year, according to Professor Wadia in his introduction; not on the scale of cerebral malaria perhaps but in its home areas just as important. In 1991, in Montevideo, the neurologists of Latin America declared war on cysticercosis and expressed concern at `apathy of the public health authorities and the governments of the region regarding this disease'. This book describes itself as a clinical handbook that is addressed primarily to neurologists and neurosurgeons and should make a significant contribution to the effort to bring cysticercosis out of the woodwork. Several factors have contributed to the reawakening of interest in a disease which was recognized in pigs by early Greek, Roman and Arab physicians, and in man since the 16th century. Its epidemiology has been better understood over the past 100 years and recent stimuli include a clearer understanding of the neuro-anatomy through new imaging techniques, and new drugs for chemotherapy developed over the last 15 years. The book takes stock and reviews the disease and its impact on the individual and the community. The three authors from Ecuador, Mexico and Texas have much experience of the pathology, clinical features and management of the condition and the book distils this experience and reflects their interest.
The brief historical section is followed by a chapter on neuro-epidemiology which is largely an extensive review of the facts and figures in all endemic countries, which may roughly be defined as those where people and pigs live in close proximity under conditions of poor sanitation; an association which must have existed for tens of thousands of years as they are the only definitive and intermediate hosts of the parasite. In these areas cysticercosis doubles the rate of epilepsy, accounts for over 10% of hospital admissions and over 30% of craniotomies. Much of the data come from Mexico and Peru, where the prevalence in human autopsies may be 3% and seroprevalence up to 8%, increasing with age. The annual incidence of neurocysticercosis is 1/100 000. It is the commonest cause of adult onset epilepsy. About 10% of pigs have cysts in their muscles and the economic loss to the swine industry is serious. Taenia solium is a human intestinal worm which we get through eating `measly' pork. But we get cysticercosis through eating the eggs passed in our own or other people's faeces; so the disease can be transmitted under conditions of poor domestic hygiene anywhere in the world, even in orthodox Jewish families in New York with Latin American servants. It may also present unexpectedly as an imported infection in residents or travellers returned from endemic areas.
The chapter on the life cycle is particularly interesting because it makes the point that sometimes cysticerci in the brain do not develop scolices—the heads of potential future tapeworms. Then loose membranes form, creating the so called racemose form of the disease. The size and shape of the cysts and the nature of the inflammatory response are different in different parts of the brain which leads to diagnostic confusion. Different types of pathology carry different prognoses. It is important to know when and where cysts may die and the type of inflammation that is subsequently caused. Nor is pathology just a matter of acute inflammation; cysts slowly induce gliosis with can lead to obstruction. This chapter is essential reading. It is followed by an interesting chapter on immunopathogenesis which details the research that has gone on but does not, and maybe cannot, yet define the molecular routes to disease. In endemic countries cysticercosis is the great imitator, like syphilis was here or diabetes is now, and the clinical chapter neatly links the galaxy of symptoms and signs to the pathological anatomy. There is still much debate as to the extent to which cysts directly cause features such as epilepsy or whether they only do so when they degenerate and cause inflammation. There are focal signs, stroke, psychiatric and organic mental disorders, intracranial hypertension, basal meningitis, nerve palsies and spinal cord damage.
How many endemic countries can afford the CT and MRI scanning which is essential to define the anatomy if logical treatment is to be carried out? MRI shows more cysts, particularly young ones, but may miss old or calcified cysts. Unfortunately, the illustrations of scans do not show enough detail; a few arrows would have been useful to pick up the points made in the captions. There is an honest account of the disappointments of diagnostic serology due to poor antibody production, poor and unavailable laboratory techniques and cross-reactivity with simple worm carriers; in the end accurate diagnosis requires clinical skill and experience which the authors have distilled into a very useful table of diagnostic criteria.
Likewise there is a useful algorithm for treatment defining the role of surgery and chemotherapy with a discussion on the role of dexamethasone to prevent the possible reactions following chemotherapy and a succinct account of the problems of cysticercotic encephalitis, a rare but fatal condition. Controlled trials have at last lent support to the euphoria of the early 1980s that chemotherapy destroys cysts. The authors discuss in some detail the best way to use these drugs in terms of time and economy which are so important in poor countries. They discuss, perhaps a little uncritically, the ultimate benefits of chemotherapy and conclude `that there is no reason to leave parenchymal brain cysticercosis untreated when effective, safe and inexpensive treatment exists'.
The book ends with a chapter devoted to the special effects of neurocysticercosis on infants and children and another on prevention and public health aspects. Cysticercosis was controlled in Western Europe at the turn of the last century through legislation on pig rearing and meat inspection coupled with improved sanitation. These measures, together with education and worming human carriers, could eradicate it from endemic countries if the political will existed.
The book is well written, referenced and illustrated, poorly indexed and beautifully produced. It is an ideal small handbook for clinicians with $88 to spare. Every neurologist and Minister of Health should have a copy but I wonder how many copies will make their way into schools and libraries in endemic countries where the book would lend its greatest support to the Declaration of Montevideo.
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