1406. Steroid-Sparing Agents to Control Inflammation in Complicated Neurocysticercosis: Three Cases

Abstract

BackgroundClinical manifestations of neurocysticercosis (NCC) are primarily due to the inflammatory response against degenerating cysts of the Taenia solium tapeworm. Inflammation can occur when cysts lose their ability to evade the host immune response during their natural life cycle or result from antihelminthic therapy. A subset can develop chronic perilesional edema requiring immunosuppressive therapy. Although guidelines recommend methotrexate (MTX) as an alternative to long-term steroids, limited information is available regarding when to start a steroid-sparing agent (SSA) and alternative SSAs in case of MTX failure or intolerance.MethodsRetrospective chart review.ResultsThree patients with complicated NCC followed at a single tertiary care center are described in this study: Patient 1 with subarachnoid NCC (age 64, female), patient 2 with subarachnoid and intraventricular NCC (age 48, male) and patient 3 with parenchymal NCC (age 43, male). Patients 1–3 were followed clinically and radiographically for 8, 1.5 and 3 years, respectively. Patient 1 was treated with antihelminthic therapy and steroids for 24 months. She was transitioned to MTX for 1 month, but developed ulcerative stomatitis, leukopenia and transaminitis. She completed a treatment course of steroids, complicated by osteoporosis. Patient 2 was treated with 12 months of antihelminthic therapy and steroids with resolution of a previously positive cysticercal antigen in spinal fluid. Imaging revealed persistent inflammation in spite of adequate antihelminthic therapy. He was started on MTX and has remained on this medication for 5 months. Patient 3 was treated with two courses of antihelminthic therapy. He developed perilesional edema despite treatment with steroids and MTX uptitrated to 20 mg weekly. Adalimumab was added to his regimen and he had a rapid radiographic resolution of edema and clinical improvement in seizures. His seizures returned during an interruption in his adalimumab treatment and again resolved with re-initiation of this medication.ConclusionSSAs are beneficial in the long-term treatment of patients with subarachnoid NCC or chronic perilesional edema. The formulation of guidelines that include multiple options for SSAs will be essential in guiding management of complicated NCC. Disclosures All authors: No reported disclosures.