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encephalitis (the liform larvae may be seen in cerebral capillaries and in cerebral parenchyma) and emboli from mural thrombi arising in infected heart muscle Treatment In the treatment of trichinosis, thiabendazole, an antihelminthic agent, and corticosteroids are of particular value Thiabendazole, 25 mg/kg twice daily for 5 to 7 days, is effective in both the enteral and parenteral phases of the disease This drug prevents larval reproduction and is therefore useful in patients known to have ingested trichinous meat It also interferes with the metabolism of muscle-dwelling larvae Fever, myalgia, and eosinophilia respond well to the anti-in ammatory and immunosuppressant effects of prednisone (40 to 60 mg daily), and a salutary effect has been noted on the cardiac and neurologic complications as well Other nematodes, mainly toxocara (the cause of visceral larva migrans), strongyloides, and angiostrongyloides may rarely migrate to the brain, but each is characterized by a systemic illness, which is far more common than the neurologic one Parasitic meningitis is discussed below

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Diseases Due to Cestodes (Table 32-6)

Cysticercosis This is the larval or intermediate stage of infection with the pork tapeworm Taenia solium In Central and South America and in parts of Africa and the Middle East, cysticercosis

is a leading cause of epilepsy and other neurologic disturbances Because of a considerable emigration from these endemic areas, patients with cysticercosis are now being seen with some regularity in countries where the disease had previously been unknown Usually the diagnosis can be made by the presence of multiple calci ed lesions in the thigh, leg, and shoulder muscles and in the cerebrum The cerebral manifestations of cysticercosis are diverse, related to the encystment and subsequent calci cation of the larvae in the cerebral parenchyma, subarachnoid space, and ventricles (Fig 32-8) The lesions are most often multiple but may be solitary Before the cyst degenerates and eventually calci es, CT scanning and MRI may actually visualize the scolex Most often the neurologic disease presents with seizures, although many patients are entirely asymptomatic, the cysts being discovered radiologically It is only when the cyst degenerates, many months or years after the initial infestation, that an in ammatory and granulomatous reaction is elicited and focal symptoms arise In some patients, a large subarachnoid or intraventricular cyst may obstruct the ow of CSF, in which case the surgical removal of the cyst or a shunt procedure becomes necessary Proano and colleagues, however, have reported on a series of such cases with cysts larger than 5 cm in diameter, which they have treated medically In a more malignant form of the disease, the cysticerci are located in the basilar subarachnoid space, where they induce an

brain, leaving a visible track as it moves Subcutaneous nodules are the most common lesions This parasite is found predominantly in the Far East The nervous system may also be invaded directly by certain worms (Ascaris, Filaria) and ukes (Schistosoma, Paragonimus) These diseases are virtually nonexistent in the United States except among those who have recently returned from endemic areas Schistosomiasis, however, is of such great importance and often invades the nervous system in such characteristic ways that it is considered below in detail

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(Table 32-6 and page 1062) Schistosomiasis The ova of trematodes seldom involve the nervous system, but when they do, the infecting organism is usually Schistosoma japonicum and, less often, Schistosoma haematobium or Schistosoma mansoni It is said that Schistosoma japonicum has a tendency to localize in the cerebral hemispheres and S mansoni in the spinal cord, but there have been many exceptions The cerebral lesions form in relation to direct parasitic invasion of blood vessels and take the form of mixed necrotizing and ischemic parenchymal foci that are in ltrated by eosinophils and giant cells (Scrimgeour and Gajdusek) The lesions do not calcify Schistosomiasis is widespread in tropical regions, especially in the Nile Valley of Egypt; North American neurologists have little contact with it except in travelers who have bathed in lakes or rivers where the snail hosts of the parasite are plentiful The initial manifestation is often a local skin irritation at the site of entry of the parasite (swimmer s itch), but the patient frequently does not offer this information unless sought An estimated 3 to 5 percent of patients develop neurologic symptoms several months after exposure Headaches, convulsions (either focal or generalized), and other cerebral signs appear; with lesions of larger size, papilledema may develop, simulating a brain tumor Some types of Schistosoma infection (also called Bilharzia), mainly mansoni, tend to localize in the spinal cord, causing an acute or subacute myelitis that is concentrated in the conus medullaris The clinical picture is of a subacutely developing transverse cord lesion There is often preceding leg or radicular pain and bladder control is affected prominently This is one of the most frequent forms of myelitis in Brazil and other parts of South America We have observed a few cases in students returning from Africa; their lesions were in the conus Unless treated immediately, there may be permanent paralysis of the legs and bladder from in ammatory and microvascular destruction of the lower cord Examination of the CSF in the myelitic form discloses a pleocytosis, sometimes with an increase in eosinophils (more than half of patients), increased protein content, and sometimes increased pressure Biopsy of liver and rectal mucosa, skin tests, and complement xation tests con rm the diagnosis The role of serologic tests has not been clearly established The other major trematode, Paragonimus, has been known rarely to invade the brain, where it creates a solitary granulomatous nodule comparable to that seen in schistosomiasis Treatment This consists of praziquantel orally in a dosage of 20 mg/kg tid In one series, 8 of 9 patients with epilepsy due to cerebral schistosomiasis became seizure-free after treatment with praziquantel Surgical excision of spinal granulomatous tumors is sometimes indicated, but the results are unpredictable.

Figure 32-8 Cysticercosis on MRI Multiple small enhancing cysts and a large cerebellar cyst in a man whose presenting illness was the result of obstructive hydrocephalus The cysts are in the early stage of degeneration and have not yet calci ed

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