Epidemiology of Neurocysticercosis at Stony Brook University Hospital, Long Island, NY

Amy Spallone, MD1, Robert Chow, MD1, Luboslav Woroch, DO2, Keith Sweeney, MD3, Luis A. Marcos, MD, FAPC, MPH1

1. Department of Medicine, Division of Infectious Diseases, Stony Brook University Hospital, Stony Brook, NY 2. Department of Radiology, Stony Brook University Hospital, Stony Brook, NY 3. Department of Pathology, Stony Brook University Hospital, Stony Brook, NY

•Neurocysticercosis (NCC) is an infection with the larval pork tapeworm Taeniasolium, which is acquired through a fecal-oral route. 1-6,8,9

• It is the most common cause of preventable, acquired neurologic disease, aswell as the leading cause of new-onset seizures among low-income adults indeveloping countries. 1-2,4,7

•NCC is endemic in Latin America, Asia, sub-Saharan Africa, and parts ofOceania. 1, 8-10

• Prevalence of NCC is poorly understood in the US as only half of casesdiagnosed by CT are seropositive.5,13

• In the US, NCC is considered a neglected parasitic infection of poverty, affectingprimarily Hispanic populations, where poverty reaches greater than 20%.5, 7,8

• NCC has emerged as an important infection in the US due to rising immigrationfrom endemic regions and a target for public health action. 1-6,8,9,11

• It is estimated that the US health care system spent nearly one-billion dollars inthe last decade on hospitalizations due to NCC. 11

1. Evaluate the presence of taeniasis and NCC among individuals who receivedcare at Stony Brook University Hospital from 2005-2015

2. Describe, for the first time, the prevalence of NCC on Long Island3. Attempt to quantify the burden of disease among Long Island’s immigrant

population4. Emphasize the lack of systematic screening for NCC among close contacts of

NCC patients5. Highlight NCC as a growing clinical and public health issues that requires

better reporting and surveillance

BACKGROUND

METHODS

Figure 2: Study demographics

IMAGES & FIGURES

1. Coyle, CM, Mahanty, S, Zunt, JR, et. al. “Neurocysticercosis: Neglected but not Forgotten.” PLoS Negl Trop Dis 6(5): e1500. 2012.2. Serpa, JA, White, AC. “Neurocysticercosis in the United States.” Pathogens and Global Health 106(5). 2012.3. Del La Garza, Y, Graviss, EA, Daver, NG, et. al. “Epidemiology of Neurocysticercosis in Houston, Texas.” Am. J. Trop. Med. Hyg. 73(4). 2005.4. Serpa, JA, Graviss, EA, Kass, JS, et. al. “Neurocysticercosis in Houston, Texas: An Update.” Medicine 90(1). 2011.5. White, C. “Neurocysticercosis: Update on Epidemiology, Pathogenesis, and Management.” Annu. Rev. Med. 51. 2000.6. Sorvillo, FJ, DeGiorgio D, Waterman, SH. “Deaths From Cysticercosis, United States.” Emerg Infect Dis. 13(2). 2007.7. Mahanty, S, Garcia, HH. “Cysticercosis and neurocysticercosis as pathogens affecting the nervous system.”Progress in Neurobiology 91. 2010. 8. Garcia, HH, Gonzalez, AE, Evans, CAW, et. al. “Taenia solium cysticercosis.” The Lancet. 361. 2003.9. Hotez, PJ. “Neglected Infections of Poverty in the United States of America.” Neglected Tropical Diseases. 2(6). 2008.10. Hotez, PJ, Bottazzi, ME, Franoc-Paredes, C, et. al. “The Neglected Tropical Diseases of Latin American and the Caribbean: A Review of Disease

Burden and Distribution and a Roadmap for Control and Elimination.” Neglected Tropical Diseases. 2(9). 2008.11. O’Neal, SE, Flecker, RH. “Hospitalization Frequency and Charges for Neurocysticercosis,United States, 2003-2012.” Emerg Infect Dis. 21(6). 201512. Rosai, Juan. Rosai and Ackerman’s Surgical Pathology. Tenth Ed, Mosby Elsevir, 201113. Del Brutto, OH. “Diagnostic criteria for neurocysticercosis, revisted.” Pathog Glob Health. 106(5). 2012

• AsthefirstepidemiologicstudyofNCConLI,weconcludethatNCChasemergedasanimportantparasiticinfection,primarilyamongcommunitieswithhighernumbersofHispanicimmigrant.

• Ourpatientpopulationwaspredominantlyyoung,healthymaleswhowouldnothavesoughtmedicalcareifnotforcomplicationsofNCC.

• WerecognizeNCCasanimportantcauseofmorbidityamongCentralandSouthAmericanimmigrants,arapidlygrowingdemographicinLI.

• Thereisanurgentneedforearly,targetedscreeningpracticesinordertoachieveprompttreatmentandpreventionofsignificant,lifealteringneurologicsequelae.

Figure 4: Country of origin for NCC patients

RESULTS

CONCLUSIONS

584

PURPOSE

• We identified 44 patients with NCC (31 definitive, 13 probable).• The median age was 30.5 years (range: 4-94), male to female ratio 1.3:1, and36 (81.4%) patients identified as Hispanic, Latino, or Central American. Figure2

•Parenchymal cysts were found in 39 (88.6%) patient, 11 (25%) hadextraprenchymal cysts Image 3 & 4, and nearly 40% presented with seizures.

•Nearly one-quarter of patients resided in a zip code where the Hispaniccommunity accounts for 65% of the local populace. Figure 3

•Country of origin was available for 29 patients; the majority (69%) emigratedfrom Central America. Figure 4

• Serologic evidence of T. solium was found in 8 patients, 4 had positive CNSanticysticercal antibodies, and 7 showed resolution of an intracranial cyst aftercysticidal drug therapy.

•Approximately 40% of patients were uninsured in this study. Figure 2•No taeniasis or deaths were reported during our study period.

•A retrospective medical chart review was performed from 2005-2015 usingICD-9 and ICD-10 codes for “NCC,” “cysticercosis,” and “taeniasis” at StonyBrook University Hospital. Data collected included demographics, medicalhistory, laboratory results, imaging, treatment, and outcomes.

Image 1 Individualcyst,circumscribedbyarubbery,fibrouspseudocapsule (yellowarrow),containingasinglelarvalscolex(bluearrow).

Image 2 Theparasite’smainstructurefeaturesaprominentinvestingtegument,calledacuticle(blackarrow),aggregatedsubcuticularcells,smoothmusclefibers,andfoursuckers.Onepicturedtotheleft(redarrow).

StudyDemographicsGenderMaleFemale

(25) 56.8%(19)43.2%

AverageAge 30.5years

Average yearsinUS(immigrationtohospitalization)

4.4years(range26days- 30yrs)

EthnicityHispanicLatinAmericanCentralAmericanIndianUnknownDominicanAmericanorAlaskanIndianGuatemalanNotLatino

52%20.4%9%6.8%4.5%2.3%2.3%2.3%

TravelHistoryTravel toendemicregionNotravelhistoryUnknown

36.4%9.1%54.5%

TreatmentAlbendazole ± PraziquantelSteroidsSurgeryCombination(antiparasitic ± steroids ± surgery)

(18)41.0%(17)38.6%(8)18.2%(15)34.1%

InsurancestatusSelf payMedicareorMedicaidCommercialWorker’sComp

(17)38.6%(15)34%(9)20.4%(1)2.4%

REFERENCES

Guatemala31%

USA7%

Peru4%

Ecuador17%

ElSalvador28%

Honduras10%

DominicanRepublic

3%

Image 3 AxialFLAIR(Left)andcoronalT1(Right) - Multiplevesicularphasecystswithscolex (whitearrows).Noedemainsurroundingparenchyma.

DiagnosticCriteriaforNCCAbsolutecriteria Histology ofcysticerci (Image1&2),cysticlesionsshowingthescolex on

neuroimagingstudies(Image 3),andparasitesonfundoscopic exam.

MajorcriteriaLesionshighlysuggestiveofNCConneuroimaging,positiveserumenzyme-linkedimmunoelectrotransfer blot(EITB)foranticysticercal antibodies,resolutionofintracranialcysticlesionsaftercysticidal drugtherapy,andspontaneousresolutionofsingleenhancinglesions(Image5).

MinorcriteriaLesionscompatiblewithNCConneuroimaging,suggestiveclinicalmanifestations,positivecerebrospinalfluid(CSF)ELISAforanticysticercalantibodiesorcysticercal antigens,andcysticercosis outsidethenervoussystem.

EpidemiologiccriteriaEvidenceofahouseholdcontactwithTaenia solium,individualsfromcysticercosis endemicareas,andhistoryoftraveltodisease-endemicareas.

Diagnostic Criteria for NCC

Figure 3: NCC Patients’ town of residence in eastern Long Island by zip code

Definitivediagnosis:• 1absolutecriterion• 2major+1minor+1

epidemiologicalcriteria

Probablediagnosis:• 1major+2minorcriteria• 1major+1minor+1epidemiological

criteria• 3minor+1epidemiologicalcriteria

Figure 1: Revised Diagnostic Criteria for NCC (Del Brutto, 2012)

See Figure 1

Image 4 (Left)Multipleracemosecystswithinthethirdand4thventricles(yellow).(Right)RacemoseNCCwithinbasalcisternsandcisternamagna(blue)withhydrocephalusoflateral(white)and3rd ventricles(red).

Image 5 (Left) 2011,AxialT2showingfocusofcalciuminrightoccipitallobe(blue).(Right)Followupscan2014,axialflairshowingresolutionofsmallcystwithsmallfocusofcalcium(blue)andsurroundingedema(yellow).