Reply to Garg et al, Smith et al, and Persichino and Miller

To the Editor—We thank Garg and colleagues for their letter [1]. Two randomized trials compared albendazole and combination therapy with simultaneous praziquantel and albendazole [2, 3]. In both cases, the radiologic response was better with combination therapy only in patients with >2 viable parenchymal cysts but not in those with ≤2 cysts. These trials were the basis for the distinction in treatment of viable parenchymal disease distinguishing patients with 1 or 2 parenchymal cysts form those with ≥3 parenchymal cysts or viable parenchymal cysticercosis. However, neither of these trials included patients with >20 cysticerci.

In terms of disseminated disease, the guidelines specifically stated that patients with diffuse cerebral edema (cysticercal encephalitis) should not be treated with antiparasitic drugs [4]. We also recommended antiparasitic therapy in all patients with parenchymal neurocysticercosis, who did not have diffuse cerebral edema. As pointed out in the letter by Garg et al, we did not specifically address nonencephalitic patients with numerous cysticerci; patients with >20 cystierci were excluded from controlled clinical trials of antiparasitic drugs. However, our reading of the literature did not suggest that these patients responded differently from other patients with multiple parenchymal cysticerci.

As noted by Garg et al, the case series by Qavi and colleagues [5] carefully documented the safety and efficacy of albendazole in this group of patients. We thank Garg and colleagues for bringing this article to our attention, which further supports our current recommendations. Although it would be optimal to be able to enroll patients with innumerable cysticerci and no cerebral edema or subarachnoid involvement in a randomized trial, the rarity of that particular presentation makes it unlikely that a trial with sufficient power could be successfully completed.

We thank Smith and colleagues [6] for their careful attention to the details of the manuscript. Indeed, the dose of praziquantel in combination with albendazole in our table [4, table 2] should have been 50 mg/kg/d.

We also thank Persichino and Miller for their comments [7] regarding screening for pregnancy for women of childbearing age. There are limited data on long courses of albendazole in pregnancy, and methotrexate is contraindicated. In most cases, it is safe to defer these treatments until after birth. We agree with their recommendations for screening for pregnancy and use of birth control in women of childbearing age.

Note

Potential conflicts of interest. A. C. W. has received royalties from UpToDate. For activities outside the submitted work, W. A. H. has served as a member of a data safety monitoring board for Neuropace. For activities outside the submitted work, H. H. G. has received research grants from the National Institute of Neurological Disorders and Stroke and the Fogarty International Center, National Institutes of Health. All other authors report no potential conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.