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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 3  |  Issue : 3  |  Page : 73-76

Phenotypic characteristics and diagnostic outcomes of patients presenting with and without seizure-related neurocysticercosis: A cross-sectional analysis of tertiary hospital episodes in Qatar (2015–2018)


1 Department of Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
2 Department of Medicine, Hamad General Hospital, Hamad Medical Corporation; Weill Cornell Medicine-Qatar, Doha, Qatar
3 Department of Medicine, Hamad General Hospital, Hamad Medical Corporation; Weill Cornell Medicine-Qatar; College of Medicine, Qatar University, Doha, Qatar

Date of Web Publication15-Oct-2019

Correspondence Address:
Dr. Shaikha Daoud Al-Shokri
Department of Medicine, Hamad General Hospital, Hamad Medical Corporation, P.O. Box 3050, Doha
Qatar
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/LJMS.LJMS_40_19

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  Abstract 


Background: In resource-poor settings, neurocysticercosis (NCC) is a common cause of acute presentation with seizures. There remains an uncertainty regarding its changing epidemiology in resource-rich settings such as Qatar. Patients and Methods: We carried out a retrospective review of case notes and electronic records of 2450 patients presenting to an acute admissions unit with suspected NCC between January 2015 and May 2018. Results: Of the 2450 records reviewed, 26 cases satisfied the Del Brutto criteria for NCC. The mean age at presentation was 31 ± 9.74 years, made up of an entirely male population. There was a higher proportion of patients (n = 20) presenting with seizures 76.9%, of which the most dominant subtype was generalized tonic–clonic seizures 73.7% (n = 14). Advancing age and intracerebral calcifications were associated with an increased risk of having seizures (confidence interval [CI]: 1.18–18.8, P = 0.019, and CI: 0.034–0.9, P = 0.036, respectively). Conclusion: The migrant population in Qatar continues to account for the preponderance of NCC morbidity with seizure, in its various phenotypes, the most common mode of presentation. To our knowledge, this is the most up-to-date account of this disease with interesting and changing demographics in this part of the world.

Keywords: Cysticercosis, neurocysticercosis, Qatar, seizure, taeniasis


How to cite this article:
Al-Shokri SD, Danjuma MI, Chaudhary HA, Abubeker IY, Elzouki AN. Phenotypic characteristics and diagnostic outcomes of patients presenting with and without seizure-related neurocysticercosis: A cross-sectional analysis of tertiary hospital episodes in Qatar (2015–2018). Libyan J Med Sci 2019;3:73-6

How to cite this URL:
Al-Shokri SD, Danjuma MI, Chaudhary HA, Abubeker IY, Elzouki AN. Phenotypic characteristics and diagnostic outcomes of patients presenting with and without seizure-related neurocysticercosis: A cross-sectional analysis of tertiary hospital episodes in Qatar (2015–2018). Libyan J Med Sci [serial online] 2019 [cited 2019 Nov 13];3:73-6. Available from: http://www.ljmsonline.com/text.asp?2019/3/3/73/269224




  Introduction Top


Taeniasis is a zoonotic disease caused by Taenia saginata and Taenia solium in humans which are the definitive hosts and cysticercosis in their intermediate hosts which are cattle and pigs, respectively.[1] Accidental ingestion of T. solium eggs could lead to the acquisition of cysticerci and their migration to the central nervous system causing neurocysticercosis (NCC).[2],[3] Although rare worldwide, NCC is common in the tropics and subtropics, especially resource-poor settings. Notable among these include the Indian subcontinent, Latin America, and Africa. NCC, although asymptomatic in most cases, is the leading cause of acquired seizure disorder in areas with high endemicity. The Bustos et al.[2] criteria represent the first comprehensive attempt at standardizing the diagnosis of NCC. As a diagnostic tool, it incorporates radiological, histopathological, serological, clinical, and epidemiological features of NCC. However, it is pertinent to note that NCC still remains a clinical and radiological diagnosis. Further revisions and recommendations have been incorporated in the recently issued practice guidelines for NCC.[3]

In the state of Qatar, there has been a recent rise in the migrant population, most of which are coming from NCC endemic areas. Therefore, NCC prevalence could potentially rise as the overall population increases. How this recent change in demography has impacted on the incidence, true prevalence, and other clinical/radiological phenotypes of NCC in Qatar remains unknown. There had been previous attempts at description of the NCC patient cohorts in Qatar, but most of these have been limited to case reports,[4] or NCC in the context of overall seizure burden.[5] To our knowledge, this is the most recent descriptive evaluation of the burden of NCC in a Qatari tertiary hospital setting. In this report, we have carried out an exhaustive review of NCC presentations to a tertiary hospital setting with a view to ascertain any changing trend, prevalence, and patient outcomes over a defined observation period.


  Patients and Methods Top


We retrospectively analyzed case notes and electronic records of consecutive adult patients, who are 18 years and above, presenting to the Emergency Department and Acute Medical Unit of Hamad General Hospital from January 2015 to May 2018. We abstracted data into coded subject-specific case record forms and subsequently transferred it to a study-specific database. Using the electronic records, we abstracted key variables such as demographic parameters, seizure phenotype, neuroimaging modality, and pharmacotherapy details including anticonvulsants, steroid therapy and antihelminthic medications. We also determined (from record review) if epidural puncture was done with other infestation assays, such as relevant stool assays for cysticercus (where available).

Case definition

In this study, NCC was diagnosed by the revised criteria as described by Bustos et al.[2] Radiological classification of NCC was done as reported by the hospital radiologist according to Escobar's pathological staging system. There was no subsequent alteration of this report or its re-adjudication by the study investigators.

Statistical analysis

Phenotypic characteristics of NCC lesions as well as neuroimaging frequencies were expressed as number (percentages). Demographic, clinical, and laboratory characteristics of the study population were compared using Student's t- test and Chi-squared test for parametric and nonparametric variables, respectively. Descriptive results of variables were presented as median (interquartile range), mean (standard deviation), and number (percentages) as appropriate. Correlation coefficients for all variables were determined by Spearman's correlation coefficients. Variables with P < 0.2 in univariate analyses were entered into a multivariate model for the determination of potential seizure predictors. All statistical analyses were carried out with Open source software (Jamovi, version 09.1.10,2018, Ca. USA).

Ethical considerations

Ethical approval was obtained from the Medical Research Center of Hamad Medical Corporation, Qatar (Research Approval #MRC-01-19-006).


  Results Top


The background demographic characteristics of the study population are shown in [Table 1]. A retrospective review of the total number of presentations during the study period confirmed 26 cases who satisfied criteria for NCC as per the Bustos criteria.[1],[2],[3] Of the total number of patients admitted with NCC during the observation period, the mean age at presentation was 31 ± 9.74 years, made up of an entirely male population. Older patients were more likely to have seizures than their younger gender-matched cohorts (confidence interval [CI]: 1.18–18.8; P = 0.019) [Figure 1]. There were a higher proportion of patients presenting with seizures 76.9% (n = 20), with a significant number of patients having generalized tonic–clonic seizures (GTCSs) compared to the rest of the study population 73.6% (n = 14) [Table 2]. All patients presenting with seizures were commenced on anticonvulsant therapy as monotherapy initially before discharge. Phenytoin was the drug of choice for most clinicians who managed cases evaluated by this report (54%). All of the observed NCC cases in our population were from well-established endemic areas (India, Bangladesh, and Nepal).
Table 1: Summary of patients' baseline demographic and clinical characteristics

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Figure 1: A boxplot of age as a function of seizures as a mode of presentation

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Table 2: Seizure disorder phenotype frequencies as a function of topography of neuroimaging lesions

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Topographical relationship between brain lesion and risk of seizures

All patients had prior CT and MRI brain scans. The presence of cerebral calcification on MRI imaging showed a trend toward high risk of seizures (CI: 0.034, 0.9; P = 0.036) by bivariate analysis.

Predictors of risk of seizures

By multivariate forward logistic regression (likelihood ratio), advancing age showed a trend toward association with increased risk of seizures (odds ratio: 0.12, P = 0.06).


  Discussion Top


The prevalence of reported NCC worldwide is variable and dependent on a number of local factors. It has remained a disease of less-developed countries (including sub-Saharan Africa, the Indian subcontinent, and Southeast Asia and among the migrant population in the Middle East). Indeed, all of the patient cohorts described in our study were from India, Nepal, and Bangladesh. This is the first up-to-date comprehensive report of NCC clinical phenotypes from Qatar to our knowledge. The prevalence of NCC in the population presenting with a history of seizure disorder during the study period was 0.01. It is a relatively young cohort consistent with the data from recent case reports.[4],[5] This may have to do with the fact that the study population comprised entirely of the young migrant population in the country. Seizure disorder in its various clinical phenotypes was the most common mode of presentation in our NCC cohort. There was a higher proportion (73.3%) of patients with GTCSs. In an evaluation of NCC presentation to Al-Khor General Hospital, Qatar, Purayil et al. also reported a preponderance of the GTCS phenotype in their study cohort.[6] This is consistent with recently published data from other geographical zones and health-care settings.[3],[7] We were unable to ascertain seizure semiology based on the topographical disposition of intracranial NCC lesions on neuroimaging. This had to do with the paucity of clinical electroencephalograph (EEG) data available for the requisite composite analyses.

The choice of phenytoin as the preferred anticonvulsant drugs (antiepileptic drug [AEDs]) in most of our patients presenting with seizures in this study is rather interesting. No previous reports have demonstrated the superiority of various AEDs in these cohorts of patients. The decision to not administer AEDs for patients with presentations other than seizures fits in with the current evidence.[8] In a systematic review of four clinical trials (N = 466) evaluating the propriety of AEDs in NCC patients with a single brain lesion, Sharma et al. concluded that there was no sufficient evidence to support AEDs for seizure prophylaxis in these cohorts of patients.[8] In addition, neither short-course (6 months) nor long-course (12 months) AEDs treatment duration for patients with single focal seizures was found to be superior in this review.[8]

While seizure semiology is increasing evolving as a reliable tool (despite its limitations) for identifying symptomatogenic focus of seizures, unfortunately our data are incomplete to allow for this evaluation. This is largely due to the absence of complete EEG records as alluded earlier.

Qatar is a resource-rich country with one of the highest gross domestic product ratios in the world,[9] making this disproportionately high NCC prevalence rather interesting. The fact that not a single case in our entire cohort was attributed to the local Qatari Arab population suggests that these prevalence rates are likely to change significantly with a dynamic migrant population. There are a lot of 2022 World Cup-related construction activities currently ongoing in the country, resulting in the significant rise of the country's population to its current level of 2,724,299 (from an estimate of about 2,035,000 in 2013).[10] The impact of this expected change in the country's population on NCC prevalence remains to be seen and will be a subject for future epidemiological evaluation.

The retrospective design of our study lends it to limitations associated with confounders commonly related to the investigation of such data schemes. These include incomplete records and information bias, including difficulty with establishing clinical topographical relationship of seizures with certainty.


  Conclusion Top


Seizures in various phenotypic manifestations continue to define the most common mode of presentation of NCC in our population. In multivariate analyses, only age was found to significantly predict the risk of seizures. In addition, our report supports recent publication in this area, especially in the male gender bias, and choice of phenytoin as the preferred anticonvulsant in this cohort of patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Garg RK. Diagnostic criteria for neurocysticercosis: Some modifications are needed for Indian patients. Neurol India 2004;52:171-7.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Bustos JA, García HH, Del Brutto OH. Reliability of diagnostic criteria for neurocysticercosis for patients with ventricular cystic lesions or granulomas: A systematic review. Am J Trop Med Hyg 2017;97:653-7.  Back to cited text no. 2
    
3.
White AC Jr., Coyle CM, Rajshekhar V, Singh G, Hauser WA, Mohanty A, et al. Diagnosis and treatment of neurocysticercosis: 2017 clinical practice guidelines by the Infectious Diseases Society of America (IDSA) and the American Society of Tropical Medicine and Hygiene (ASTMH). Clin Infect Dis 2018;66:1159-63.  Back to cited text no. 3
    
4.
Khan FY, Imam YZ, Kamel H, Shafaee M. Neurocysticercosis in Qatari patients: Case reports. Travel Med Infect Dis 2011;9:298-302.  Back to cited text no. 4
    
5.
Haddad N, Melikyan G, Al Hail H, Al Jurdi A, Aqeel F, Elzafarany A, et al. Epilepsy in Qatar: Causes, treatment, and outcome. Epilepsy Behav 2016;63:98-102.  Back to cited text no. 5
    
6.
Purayil N, Mohammad OH, Naushad A, Parmaba F, Chandra P. Neurocysticercosis – The Alkhor experience. J Emerg Med Trauma Acute Care 2016;2:4.  Back to cited text no. 6
    
7.
Nash T. Edema surrounding calcified intracranial cysticerci: Clinical manifestations, natural history, and treatment. Pathog Glob Health 2012;106:275-9.  Back to cited text no. 7
    
8.
Sharma M, Singh T, Mathew A. Antiepileptic drugs for seizure control in people with neurocysticercosis. Cochrane Database Syst Rev. 2015;(10):CD009027.  Back to cited text no. 8
    
9.
World Bank National Accounts Data, and OECD National Accounts Data. Available from: https://data.worldbank.org/indicator/ny.gdp.mktp.cd. [Last accessed on 2019 Feb 15].  Back to cited text no. 9
    
10.
Qatar Population; 01 October, 2018. Available from: http://worldpopulationreview.com/countries/qatar/. [Last accessed on 2019 Mar 02].  Back to cited text no. 10
    


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