Some issues in the treatment and management of Tapeworm found living inside a patient (Part 3)

Pathological analysis of Spirometra spp. lesions from surgical specimens and biopsies of tissues infected with the larvae. Based on histopathological analysis of 16 cases of human spirochetal disease, there was a remarkable difference between spirochetal disease involving different tissues.

Continued Part 2

Urogenital sparganosis

Genital tapeworm disease, subcutaneous nodules appear in the groin, vulva or scrotum like tumors.

Figure 9.
(A) Initial abdominal CT scan shows a cystic mass in the right peritoneal cavity (arrow).
(B) A distinct ribbon-like hypoechoic lesion with a hypoechoic border around the interior of the cyst was detected by ultrasound (arrow).
(C) CDFI shows no blood flow;
(D) Postoperative pathologic findings show fluke tissue and calcification

The larvae usually develop into abnormal nodules 1‐2 cm in diameter and the surrounding tissues show signs of pain and swelling. These small tumors, papules, and nodules can exist for several months to several years without any symptoms, then suddenly become painful. Some patients report having granulomas and small nodules that move for many years. The disease has common forms such as single or multiple forms at the same time.

Clinical symptoms also vary according to the location of the worm, which can be found in the skin and mucous membranes. Symptoms may include elephantiasis from the lymph nodes, peritonitis from intestinal perforation, and brain abscess from parasitic sites in the brain.

‐ Pleuropulmonary sparganosis

Migratory tapeworms can cause irritation, causing the patient to have a dry, non‐productive cough, similar to Loffler’s syndrome, causing damage to the pleura and lung parenchyma.

‐ Gastrointestinal sparganosis

Tapeworms can cause intestinal obstruction and worms can be found and removed from the intestinal wall, breast tissue, scrotum, epididymis, urethra, bladder, abdominal cavity, and heart.

‐ Proliferative sparganosis

This form of the disease is usually caused by S. proliferum, usually starting as subcutaneous tumors in the thighs, shoulders, neck, and even spreading everywhere and to other organs such as the intestines, muscles, lungs, abdomen, and brain. Small tumors can open due to the ulceration process or when shallow incisions are also detected. The infection progresses over 5‐25 years, with deaths reported in some cases worldwide.

When there is a co‐infection or a single infection with the above‐mentioned gnathostomiasis, symptoms may appear because the larvae will secrete fluid causing inflammation and necrosis in that area wherever they move, so the patient will have sharp pains in the corresponding organ. If the larvae move to the skin, they will form lumps, which when touched move under the skin and change position quickly, disappear quickly, sometimes causing swelling and itching in many areas, so the patient is easily misdiagnosed as having a skin allergy.

Some cases have found tapeworm larvae in the intestinal wall, kidney, bladder, lungs, chest cavity, heart and brain tissue. When tapeworm larvae penetrate deep into the internal organs, the prognosis is very serious.

Pathological anatomy

Pathological examination of lesions caused by Spirometra spp. from surgical specimens and biopsies of tissues infected with tapeworm larvae.

Based on histopathological analysis of 16 cases of human cysticercosis, there was a remarkable difference between the cysticercosis involving different tissues. Most of the histopathological changes in cysticercosis were characterized by tissue necrosis and inflammation and granulomas with or without associated worms were found within.

Some cases have significant changes in the overall neutrophil count, especially eosinophils, plasma cells, and lymphocytes in or near the lesion.

Tunnel formation is accompanied by surrounding histiocytes due to host tissue reaction and these findings are completely distinguishable from the tissue lesions of cysticercosis, which are usually more nodular and self‐limited. Several features are prominent on the slides of taeniasis. Squeezed calcospherules showing cytoplasm of proliferating macrophages and giant cells are of diagnostic value in taeniasis in the absence of worms, especially when these data are measured in conjunction with tissue lesions.

Detection, Diagnosis

Cysticercosis is typically diagnosed after removal of the worm from the lesion, although infection may be diagnosed through eosinophil counts or visualization of the worm in the lesion parenchyma.

If biopsy is successful and surgical procedure is not feasible, ELISA test for anti‐sparing antibodies is used. Theoretically, preoperative diagnosis can confirm the diagnosis with a history of exposure to the pathogen, migrating larval lesions, pain, and the presence of subcutaneous nodules.

Tapeworms usually present as a single nodule, whereas other tapeworm infections such as pork tapeworm larvae may present as multiple nodules. Overall, preoperative diagnosis is rare.

Determining the location of the lesion by computed tomography ( CT) or magnetic resonance imaging (MRI) will help diagnose tapeworm disease well, especially cerebral tapeworm. Incision and removal of the lesion and identification of the species of tapeworm to make a definitive diagnosis. In the case of cerebral tapeworm, ELISA test of cerebrospinal fluid or serum test will be very helpful for diagnosis, but is usually confirmed after the tapeworm has been caught. CT scan helps support clinical diagnosis, often the lesion has the characteristics of hypoechoic, dilated ventricles, abnormal nodules, many areas of calcification. Experts recommend repeating CT scan to assess changes in size as well as the location of the lesion to indicate timely treatment if the lesion is still present.

Diagnosis is still based on the detection of eggs, but specific diagnosis is still finding larvae or adult tapeworms in lesions removed from minor surgery. Some authors have identified the species of tapeworm that causes eye disease as the only species Spirometra mansoni through histopathological examination. However, morphology does not allow for specific diagnosis because the cystic larvae do not have any characteristic morphology. Histopathology can only determine when the tapeworm is removed from the eye as cystic larvae. The fastest diagnostic method is molecular diagnosis, RFLP‐PCR.

CT and MRI are particularly useful in diagnosing brain cysticercosis because of the images that are shown in the brain parenchyma. Through a retrospective analysis of 25 cases of brain cysticercosis from 2000‐2006, Song et al. found several features that can be applied as a diagnostic framework in the future without the need for biopsy or tissue dissection. The most common feature found on MRI is the tunnel sign, which shows the migration of the cysticercosis, while the most common image is a fused circular polyangulation, or multiple rosary patterns (usually 3‐6 rings). General ultrasound with various probes has also been shown to be useful in diagnosing cysticercosis in soft tissues and some organs.

Song’s studies also suggest that additional data from clinical history, ELISA tests, and MRI or CT scans are sufficient to diagnose cysticercosis. However, these lesions are sometimes easily confused with those of tuberculosis. In a case of brain cysticercosis that remained undiagnosed for 4 years, imaging showed a circular cluster of lesions due to the migration from the right to the left side of the brain; the cysticercosis was eventually found by biopsy.

Differential diagnosis & confusing situations

In some atypical cases, clinicians may consider other diseases for differential diagnosis based on the location of different organs and tissues in the human body. Some diseases may need to be differentiated from taeniasis. A history of eating raw or undercooked snake or frog meat may increase the priority of a clinical diagnosis of taeniasis.

Biopsy is often necessary to differentiate cysticercosis from other diseases.

• For subcutaneous and mucosal tapeworm disease:
  • Diagnosis of pork tapeworm larvae is required;
  • Malignant tumors in muscle or nerve tissues;
• For brain cysticercosis:
  • Brain tumor,
  • Pork tapeworm larvae in the brain,
  • Lung flukes in the brain;
  • Cerebral schistosomiasis;
  • Meningoencephalitis;
  • Tuberculosis;
  • Other inflammatory granulomas.
  • Eye tapeworm
  • Stye (hordeolum);
  • Acute uveitis;
  • Ocular cellulitis.

Figure 12.
(A) Magnetic resonance imaging of the sacral spinal cord shows a loculated cystic lesion (arrow) attached to the left cauda equina.
(B) An intraoperative image shows the elongated white worm head (white arrow) removed from the cyst. Note the pseudosegmentation (black arrowhead).
(C) Tissue section of the plerocercoid segment showing pale purple‐stained segments of calcified bodies (hematoxylin and eosin; magnification ×400).
(D) Contrast‐enhanced MRI of the brain shows cerebral white matter edema of the left temporal and left occipital regions with tunneling (arrows) indicating migration of the worm through this tissue.

Treatment and Case Management

In general, infection with one or more tapeworm larvae is best removed surgically. Medical treatment of tapeworm infection is praziquantel (PZQ), prescribed at a relatively high dose of 120‐150 mg/kg body weight for 2 days. However, PZQ has had limited success in many reports in the medical literature and this is a matter of concern.

Treatment of common tapeworm species may have overlap showing efficacy against species, but against amoebas the efficacy of PZQ is limited. If PZQ is used to treat amoebas, it would also be beneficial to treat other common human tapeworm infections.

PZQ is the drug of choice for treating tapeworms, although its efficacy is not fully known, and surgical removal of the tapeworm from the lesion is the best treatment. Public health interventions should focus on water and food hygiene, as well as health education about the disease in rural areas where frog poultices are commonly used.

‐ Surgical removal of tapeworm larvae helps cure the disease, but the recurrence rate is not yet specifically recorded. PZQ is effective when given at a total dose of 120‐150mg/kg body weight, for 2 days or more. However, PZQ treatment also shows some limited success in some reports;

‐ The brain form of tapeworm disease requires surgical removal of the tapeworm, PZQ is not effective on adult tapeworms parasitizing the central nervous system(?), the combination of PZQ and mebendazole (MEB) is not effective in killing tapeworm larvae;

‐ There is currently no treatment for the progressive form of the disease. All attempts at surgical removal of S. proliferum worms have been unsuccessful because the larvae have spread widely throughout the body tissues;

‐ Clinically, the diagnosis of cysticercosis is certain when the larvae are detected and removed by dissection, which is also the way to treat and eliminate the larvae. If the location of the lesion does not allow surgical intervention, Novarsel 0.3‐0.45g/kg/day can be used for 45 days.

Some authors suggest that after removing the worm, use albendazole to prevent the spread of the larvae and some recommend using internal medicine only when the head of the worm is still in the patient’s eye, because the worm develops by forming a chain of segments (strobilation) in the neck area behind the head of the worm. If the head of the worm is removed, there is no need to use internal medicine with albendazole. Only Sparganum proliferum has the ability to spread through branching and asexual reproduction. In addition, it is worth noting that areas of latent endemicity of pork tapeworm larvae such as China are important. However, monitoring and surveillance after treatment are always necessary.

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(continued) Part 4

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Author: Dr. Huynh Hong Quang
(IMPE Quy Nhon)