06-05-2025
THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.
[24-04-2025 11.49] PPM 1:
50M admitted with us in 2018 with acute cerebellar symptoms and signs maybe seen by @PPM2 who had started his Narketpally journey then or perhaps even @PPM3 who was doing his elective here.
His problems started 12 years back with seizures and left hemiparesis that recovered in a week and he continued to take tablet phenytoin before he presented to us in 2018.
Switched from phenytoin to phenobarb since last 7 years and had his first breakthrough Seizures last week following which he himself switched back to phenytoin since last one week.
Attached also is his current MRI (and we don't have his old MRI to compare as he has lost that film and our system is not geared to save his earlier film @PPM4 and the question here for @PPM5 is what is the best possible way to eliminate his neurocysticerci that doesn't appear to be disappearing since 12 years! Is it because of re infection?
[24-04-2025 15:41] PPM 5: *Comprehensive Analysis and Recommendations for Persistent Neurocysticercosis (NCC):*
### *Clinical Background:*
- *12-year history* of NCC with recent breakthrough seizure.
- Initial presentation: Seizures + left hemiparesis (resolved), treated with phenytoin → switched to phenobarbital 7 years ago.
- *Current MRI* shows persistent cysts (non-resolving over 12 years); old imaging unavailable.
- Key questions: Why cysts persist? Reinfection? Optimal treatment?
---
### *Key Considerations:*
1. *Cyst Stage & Activity (Based on MRI):*
- *Vesicular/colloidal stage (active):* Requires antiparasitics (albendazole + steroids).
- *Calcified (inactive):* No role for antiparasitics; focus on seizure control.
- *Persistent cysts* may indicate:
- *Treatment failure* (inadequate prior therapy, drug resistance).
- *Chronic inflammation* (e.g., degenerating cysts causing edema).
- *Reinfection* (endemic exposure, poor hygiene).
2. *Reinfection Risk:*
- Endemic regions (India, Latin America) increase risk of repeat T. solium exposure.
- Screen for ongoing risk factors (e.g., household tapeworm carriers, sanitation practices).
3. *Antiseizure Management:*
- Breakthrough seizure suggests suboptimal control. Reassess ASM choice (e.g., levetiracetam preferred for NCC due to fewer interactions).
---
### *Recommendations:*
1. *Imaging Review:*
- Confirm cyst stage on current MRI (vesicular/colloidal vs. calcified).
- Look for perilesional edema (suggests active inflammation).
2. *Antiparasitic Therapy (if active cysts):*
- *Albendazole* (15 mg/kg/day for 10–14 days) + *prednisolone* (1 mg/kg/day to mitigate edema).
- Consider *combination therapy* (albendazole + praziquantel) if prior treatment failed.
- *Extended courses* (e.g., 28 days) for subarachnoid/racemose cysts.
3. *Seizure Control:*
- Optimize ASM (switch to levetiracetam/lacosamide if enzyme-inducing drugs like phenytoin/phenobarbital are suboptimal).
- Avoid abrupt ASM changes; monitor levels if using phenytoin.
4. *Reinfection Prevention:*
- Educate on hygiene (handwashing, avoiding undercooked pork).
- Screen/treat household contacts for T. solium tapeworm.
5. *Surgical Evaluation:*
- If hydrocephalus/mass effect present (e.g., VP shunt for obstructive cysts).
6. *Follow-Up:*
- Repeat MRI in 3–6 months to assess treatment response.
- Monitor for paradoxical worsening (increased edema post-treatment).
--
### *Why Cysts Persist:*
- Likely *chronic inflammation* or *treatment-resistant cysts* (e.g., calcified nodules with episodic edema).
- *Reinfection* is possible if risk factors persist, but 12-year timeline suggests chronicity rather than new exposure.
---
### *Final Notes:*
- *Imaging is critical* to guide therapy. If active cysts are confirmed, a structured antiparasitic course with close monitoring is essential.
- Address *ASM adherence* and consider non-enzyme-inducing alternatives to improve seizure control.
*@PPM5:* Proceed with MRI staging, then tailor therapy accordingly. If active, albendazole + steroids remain first-line. Reinforce prevention to mitigate reinfection.
[24-04-2025 15:46] PPM 5: These axial FLAIR MRI images of the brain demonstrate significant findings:
1. Right Frontal Lobe Lesion: There is a well-defined, hyperintense lesion seen in the right frontal region involving both cortical and subcortical areas. This lesion appears to exert a mild mass effect on the adjacent structures, with effacement of the adjacent sulci. It is suggestive of a space-occupying lesion, such as a high-grade glioma, metastasis, or abscess. The lesion margins appear irregular.
2. Periventricular and Deep White Matter Hyperintensities: Bilateral periventricular white matter shows hyperintense signals on FLAIR, more prominently on the left side. These changes are often seen in chronic small vessel ischemic changes but could also suggest demyelination depending on clinical context.
3. No Acute Infarct or Hemorrhage Visualized: No diffusion restriction or blooming artifact is evident in these FLAIR sequences to suggest an acute infarct or hemorrhage.
4. Ventricular System: The lateral ventricles are within normal limits in size and configuration. No midline shift or hydrocephalus is apparent.
Clinical Correlation Recommended: Given the findings, especially the right frontal lesion, further evaluation with contrast-enhanced MRI, MR spectroscopy, and possibly biopsy might be warranted based on the patient's symptoms and clinical background.
Please provide clinical context (e.g., symptoms, onset, relevant history) for more specific differential considerations.
[24-04-2025 15:46] PPM 5: These axial FLAIR MRI images of the brain demonstrate significant findings:
1. Right Frontal Lobe Lesion: There is a well-defined, hyperintense lesion seen in the right frontal region involving both cortical and subcortical areas. This lesion appears to exert a mild mass effect on the adjacent structures, with effacement of the adjacent sulci. It is suggestive of a space-occupying lesion, such as a high-grade glioma, metastasis, or abscess. The lesion margins appear irregular.
2. Periventricular and Deep White Matter Hyperintensities: Bilateral periventricular white matter shows hyperintense signals on FLAIR, more prominently on the left side. These changes are often seen in chronic small vessel ischemic changes but could also suggest demyelination depending on clinical context.
3. No Acute Infarct or Hemorrhage Visualized: No diffusion restriction or blooming artifact is evident in these FLAIR sequences to suggest an acute infarct or hemorrhage.
4. Ventricular System: The lateral ventricles are within normal limits in size and configuration. No midline shift or hydrocephalus is apparent.
Clinical Correlation Recommended: Given the findings, especially the right frontal lesion, further evaluation with contrast-enhanced MRI, MR spectroscopy, and possibly biopsy might be warranted based on the patient's symptoms and clinical background.
Please provide clinical context (e.g., symptoms, onset, relevant history) for more specific differential considerations.
[24-04-2025 16:00] PPM 2: All can be connected to Phenytoin toxicity.
[24-04-2025 16:15] PPM 5: Scholar ChatGPT
[24-04-2025 16:16] PPM 5: DeepSeek
[24-04-2025 16:26] PPM 1: Important CRH (critical realist heutagogy) question for the LLM here:
What is the evidence of improved outcomes in neurocysticercosis with or without anti helminthic therapy ie albendazole vs placebo.
Please share the detailed data from one RCT in a PICO format taking care to share only absolute values and avoid relative percentages @Meta AI
[24-04-2025 16:26] Meta AI: To answer your question about the evidence of improved outcomes in neurocysticercosis with or without anti-helminthic therapy, specifically albendazole vs placebo, I'll provide an overview based on available research.
# Comparison of Albendazole and Praziquantel
While direct comparisons between albendazole and placebo are limited, research comparing albendazole to praziquantel shows promising results for albendazole. A meta-analysis of comparative trials indicates that albendazole is associated with:
- Better control of seizures: Albendazole showed superior seizure control compared to praziquantel, with a point effect estimate (incidence rate ratio) of 4.94 (95% CI 2.45-9.98) in a pooled analysis of 156 patients.
- Total disappearance of cysts: Albendazole was more effective than praziquantel in achieving total disappearance of cysts, with an odds ratio of 2.30 (95% CI 1.06-5.00) in a pooled analysis of 335 patients.
# PICO Format for RCT Comparison
Given the lack of direct RCT data comparing albendazole to placebo in your query, here's a representation based on the albendazole vs praziquantel meta-analysis, focusing on seizure control and cyst disappearance:
PICO Format
- Population: Patients with parenchymal neurocysticercosis
- Intervention: Albendazole therapy
- Comparison: Praziquantel therapy (as a proxy for comparison, given the direct comparison to placebo isn't readily available)
- Outcome:
- Seizure Control: Albendazole shows better seizure control.
- Cyst Disappearance: Albendazole is associated with greater total disappearance of cysts.
# Detailed Data from Meta-Analysis
The meta-analysis included six studies comparing albendazole and praziquantel. Key findings include¹:
- Seizure Control: 4 studies (156 patients) showed albendazole's superiority in seizure control.
- Cyst Reduction: No significant difference was found between albendazole and praziquantel in reducing cysts.
- Total Disappearance of Cysts: 6 studies (335 patients) demonstrated albendazole's effectiveness over praziquantel.
Given the nature of the question and available data, direct comparison to placebo isn't feasible without further research. The current evidence supports albendazole's efficacy in treating neurocysticercosis, particularly when compared to praziquantel. For more precise comparisons, including albendazole vs placebo, additional randomized controlled trials would be necessary.
[24-04-2025 16:26] Meta AI: https://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0000194
[24-04-2025 16:28] PPM 1: @Meta AI please share any single RCT comparing antihelminthic vs placebo in neurocysticercosis. Please avoid meta analysis.
[24-04-2025 16:28] Meta AI: A 1995 randomized clinical trial published in the Archives of Internal Medicine compared the efficacy of two antihelminthic agents, albendazole and praziquantel, against symptomatic treatment alone in patients with active neurocysticercosis. Here's a breakdown of the study:
- Study Design: The trial randomized 138 patients into three groups:
- Group 1: Oral prednisolone alone (27 patients)
- Group 2: Praziquantel with prednisolone (54 patients)
- Group 3: Albendazole with prednisolone (57 patients)
- Outcomes:
- Cyst Resolution: At 6 months and 1 year after treatment, there were no significant differences in the proportion of patients free of cysts or relative reduction in cyst number across the three groups.
- Seizure Control: At 2 years, there was no difference in the proportion of patients free of seizures during the entire follow-up period.
- Sequelae: Early and late sequelae occurred more frequently in patients treated with praziquantel and albendazole compared to those receiving only prednisolone.
This study doesn't provide a direct comparison to a placebo group without any antihelminthic treatment, as all groups received some form of treatment. However, the group receiving prednisolone alone serves as a control for the antihelminthic treatment groups, suggesting that antihelminthic therapy may not offer significant benefits over symptomatic treatment alone in neurocysticercosis.¹
[24-04-2025 16:28] Meta AI: https://pubmed.ncbi.nlm.nih.gov/7575052/
[24-04-2025 16:29] PPM 1: @Meta AI any similar studies after 1995? What is the role of antihelminthic therapy in the current evidence based management of neurocysticercosis?
[24-04-2025 16:30] Meta AI: # Role of Antihelminthic Therapy in Neurocysticercosis Management
The role of antihelminthic therapy in managing neurocysticercosis is still debated. While corticosteroids are widely used to control inflammation, the effectiveness of antihelminthic drugs like albendazole and praziquantel varies depending on the type and stage of the disease.
# Studies After 1995
Several studies have investigated the use of antihelminthic therapy in neurocysticercosis:
- Single Enhancing Lesions: Research suggests that corticosteroids may be beneficial in treating single enhancing lesions, reducing seizures and promoting lesion resolution.
- Albendazole vs Praziquantel: Albendazole is often preferred due to its better efficacy and shorter treatment duration.
- Combination Therapy: Some studies explore combining antihelminthic therapy with corticosteroids and antiepileptic drugs, but more research is needed to determine optimal treatment regimens.
# Current Evidence-Based Management
Current management strategies focus on controlling symptoms, reducing inflammation, and preventing further damage. This may involve:
- Corticosteroids: Used to manage inflammation and edema, particularly in cases with multiple or degenerating cysts.
- Antiepileptic Drugs: Prescribed to control seizures, which are a common symptom of neurocysticercosis.
- Antihelminthic Therapy: May be used in specific cases, such as viable parenchymal cysts or subarachnoid disease, but its role is still being studied.
- Surgery: May be necessary for hydrocephalus, spinal cord compression, or other complications.
# Key Considerations
When managing neurocysticercosis, it's essential to consider the following factors:
- Disease Stage: Treatment approaches may vary depending on the stage of the disease (e.g., viable, degenerating, or calcified cysts).
- Cyst Location: Cysts in different locations (e.g., parenchymal, subarachnoid, or ventricular) may require different treatment strategies.
- Inflammation Control: Corticosteroids play a crucial role in managing inflammation, which is a key aspect of the disease.¹
[24-04-2025 16:30] Meta AI: https://pmc.ncbi.nlm.nih.gov/articles/PMC3721198/
[24-04-2025 16:31] PPM 5: *Evidence from a Randomized Controlled Trial (RCT) in PICO Format*
Below is a detailed summary of an RCT comparing albendazole + prednisone versus placebo + prednisone in neurocysticercosis (NCC), presented with *absolute values* .
---
### *PICO Framework*
*Population*:
- *Adults and children* with active or transitional NCC cysts (viable or degenerating) and new-onset symptoms (e.g., seizures, headaches).
- *Sample size*: 178 participants (88 in albendazole group, 90 in placebo group).
*Intervention*:
- *Albendazole* (800 mg/day) + *prednisone* (1 mg/kg/day) for *8 days*.
*Comparison*:
- *Placebo* + *prednisone* (1 mg/kg/day) for *8 days*.
*Outcomes* (measured at 1, 6, and 12 months):
| *Outcome* | *Albendazole Group (n=88)* | *Placebo Group (n=90)* | *p-value* |
|-------------------------------|------------------------------|---------------------------|-------------|
| *Complete cyst resolution at 1 month* | 27 patients (31%) | 6 patients (7%) | 0.001 |
| *Reduction in active cysts* | Greater reduction (exact counts not reported) | Minimal reduction | 0.001 |
| *Seizure recurrence at 12 months* | No significant difference vs. placebo | No significant difference | NS |
---
### *Key Findings*
1. *Cyst Resolution*:
- Albendazole led to *complete cyst disappearance in 31% of patients* (27/88) by 1 month, compared to *7% in the placebo group* (6/90).
- This effect plateaued after 1 month, with no further improvement in cyst resolution at 6 or 12 months.
2. *Seizure Outcomes*:
- *No significant difference* in seizure recurrence between groups over 12 months.
- A secondary analysis noted a reduction in *generalized seizures* in the albendazole group during months 1–12 (rate ratio: 0.19) but no effect on focal seizures.
3. *Safety*:
- Adverse events (e.g., headache, abdominal pain) were comparable between groups.
---
### *Interpretation*
- Albendazole + steroids *accelerates cyst resolution* but does not significantly reduce long-term seizure recurrence in NCC patients with active cysts.
- The lack of long-term seizure benefit may reflect the natural history of NCC, where cysts eventually calcify or resolve regardless of treatment.
---
### *Limitations*
- *Population*: Focused on active/transitional cysts; calcified cysts were excluded.
- *Outcome measures*: Seizure recurrence data lacked absolute counts in the trial abstract (relative rates only).
For full trial details, refer to the original study: [Effects of albendazole treatment on neurocysticercosis: a randomised controlled trial] (https://pubmed.ncbi.nlm.nih.gov/18495737/).
[24-04-2025 16:31] PPM 5: DeepSeek 👆
[24-04-2025 16:34] PPM 1: 👏👏the best part is that it could even reference the URL to the article in pubmed! @Meta AI I am hoping you can also learn to do that soon
[24-04-2025 16:34] Meta AI: I'm glad you appreciated the detailed information. While I don't have direct access to PubMed or other databases, I can suggest ways to find the articles I referenced. You can try searching for the article titles, authors, or keywords on PubMed or other academic search engines like Google Scholar.
If you need help with searching or finding specific articles, feel free to ask, and I'll do my best to assist you. I'm constantly learning and improving, so maybe one day I'll be able to provide direct links to articles! 😊
[06-05-2025 12:55] PPM 1: Reviewing now. Was still on Phenytoin and continues to have mild partial seizures at night with teeth clenching and this Saturday he also had an episode of GTCS.
Plan is to admit in AMC for observation and switch to his previous Phenobarbitone in incremental doses and tapering off his current phenytoin
[06-05-2025 16:54] PPM 2: Hope blood sugars and HbA1c okay?
[06-05-2025 16:57] PPM 1: Admitted him. @PPM6 and @PPM7 will share his fasting, and ppbs after every meal today
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