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I have several comments to make about the article by Palet al 1 on neurocysticercosis and epilepsy in developing countries.
The title should refer to “neurocysticercosis in India“ because almost all examples deal with that country, despite the fact that, as the authors correctly state, it is a disease found in many developing countries. Furthermore, several statements made by the authors do not reflect the knowledge gathered in Mexico, which is summarised in this letter.
The authors indicate in the text that “Population control measures have not shown long term effectiveness” . . .”There is little epidemiological data on risk factors” . . .”Migration from the countryside and the risk of urban slums obviously influence the changing epidemiology” . . .”mass treatment with praziquantel may produce early benefit but larger term evaluation shows no lasting impact”. Sartiet al have studied exhaustively risk factors2 and evaluated control measures in Mexico; the results indicate that the main risk factor is the tapeworm carrier in the close environment, and that treatment of tapeworm carriers or health education of the community are useful control measures as evaluated at 6 and 42 months after their implementation in rural populations.3 4 Moreover, vaccines for swine cysticercosis are being successfully developed and evaluated.5
Multiple studies performed in various countries clearly show the usefulness of serological methods for diagnosis, including antigen detection, which Pal et al 1indicate was recently developed, but there are several prior references including that of 1989 by Correa et al with the same monoclonal antibodies and in the sameJournal (see Flisser2 for review). Similarly, the authors lack knowledge on the initial Mexican publications regarding the association of HLA and cysticercosis.2
Many Mexican authors have published long ago the clinical and imaging descriptions of neurocysticercosis as well as its classification.2 Furthermore the authors criticise cestocidal treatment in neurocysticercosis and state that “there is no evidence that cysticidal treatment does more good than harm”. Publications by Mexican authors2 6 clearly demonstrate the usefulness of drug treatment, as does the welfare of patients (children and adults) after such treatment seen in routine work by many neurologists in Mexico. The fact that seizures and inflammation are exacerbated during treatment is the main manifestation of a cestocidal effect, as was experimentally described in cysticercotic pigs that received treatment and had an important enhancement of the inflammatory response surrounding the parasites.2 6 Due to this, anti-inflammatory and anticonvulsive drugs are recommended in an individual based scheme.
The second part of the article— “management of epilepsy in the developing world”— misleads on the problem of cysticercosis, as it deals almost exclusively with epilepsy in children, when it is well known that the association of this syndrome with neurocysticercosis is mainly with late onset epilepsy.2 6
From these considerations, different conclusions are drawn:
Epidemiology of neurocysticercosis is quite well known (not only in Mexico but in several countries where it has been studied)
Imaging and serological diagnosis are useful tools
Cysticidal treatment is usually beneficial to patients with neurocysticercosis
Neurocysticercosis is a major cause of acquired epilepsy
Prevention measures, based on health education, targeted treatment, and swine vaccination, will probably be sufficient to control neurocysticercosis, and even to eradicate the parasite.
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