A study on neurcognitive disorders and demographic profile of neurocysticercosis patients.

BACKGROUND: Neurocysticercosis is a common cerebral parasitic infestation, caused due to pork tapeworm infection the infestations risks parallels the socio-economic status, personal hygiene and education. The effect of NCC was assessed in neurocognition.
OBJECTIVE: To study demographic characteristics and neurocognitive domains of patients with Neurocysticercosis.
METHODS: Neurocysticercosis diagnosed patients by CT, MRI and LAMP tests. MMSE score was measured for assessment.
RESULTS: MMSE score were reduced in majority of the patients. In attention was the most common deficit found. Repeat MMSE assessment done in 6 patients showed an improvement of scores post therapy.
CONCLUSION: Cognitive involvement is common in NCC and is a major cause of morbidity. Copyright:

INTRODUCTION

Infections reveal the quality of life an individual lives. Neurocysticercosis (NCC) was first reported by Surgeon H. Armstrong in an asylum from Madras in the year 1888. Ingesting undercooked infected meat of pork, contaminated raw vegetables, and consumption of contaminated water causes this disease. It is a major health issue in Asian and Latin American developing countries. In developing countries such as Indonesia, USSR, India, China significant focus exists on the endemicity of the disease.[1] Survey done in US reports, NCC was the main cause of seizures in up to 10% of all seizures cases.[23] In Japan and South Korea, with better hygienic conditions, T. solium has been almost eradicated.

T. solium parasite passes its lifecycle in two natural hosts, definitive hosts – humans and intermediate hosts– swine. When infected pork containing cysticerci is ingested by humans it develops into worm in the small intestine. When humans get infected with the larval form it causes disseminated cysticercosis in the brain, muscles, and other soft tissues by autoinfection or by consumption of eggs from soil, contaminated foods or poor food hygiene practices.[4]

Cysticercosis affects the central nervous system (CNS) in 50%–60% cases.[5] In CNS, subarachnoid space/cisterns are most commonly affected followed by parenchyma, ventricle, and spine.[67] Disease is considered inactive if neuroradiological tests show calcification or hydrocephalus without cysts. Active/healed NCC can present with Schizophrenic psychosis, depressive psychosis, depression, mixed affective state, and Dementia.[8] New diagnostic techniques such as polymerase chain reaction (PCR) and loop-mediated isothermal amplification (LAMP) have recently been developed so that the exact diagnosis of NCC can be done for early treatment and reduced morbidity.[91011] The purpose of this study is to identify the spectrum of cognitive dysfunction in NCC and the causes behind the increasing spread of this disease in developing countries.

Aims and objective

To study demographic profile and neurological disorders of NCC patients.

METHODS

It was a prospective observational study conducted in Post Graduate Institute of Medical Education and Research, Chandigarh, a tertiary care center in North–Western India in the Department of Neurology, including emergency and Outdoor patient services. It was conducted in January 2016 and ended in April 2017. NCC patients who fulfilled Del Brutto criteria,[12] Carpio et al. criteria[13] and found positive by LAMP and PCR tests[910] were included, and patient consent was taken. Detailed Socio-demographic data was recorded of all participants. Mini-mental status examination (MMSE) was done and form was filled in detail to collect whole data for screening and assessment of the cognitive functions of patients and controls [Annexure 1]. Healthy age-matched volunteers were chosen as controls. Patients groups were further were subdivided into two groups based on lesions observed in magnetic resonance imaging (MRI) – (1) Single Lesions, (2) Multiple Lesions. Ethical clearance was obtained for the study from the institutional ethics committee.

Patients were excluded if they had other neurological disorders, substance abuse, or previous psychiatric diagnosis. Patients were matched with controls on the basis of sex and age. All patients underwent MRI/computed tomography (scan) within a period of 2 weeks. NCC patients having the disease in the active state were only included, cases in which neuro-radiological images showed evidence of calcification or inactive disease were excluded. 42 cases with solitary parenchymal lesions, 38 cases with multiple (>2) scattered parenchymal lesions were taken in the study. MMSE[141516] was done of all 80 patients and controls. MMSE of 6 patients was followed up after 1 month [Table 1].

Table 1

Comparison of mini mental status examination score of solitary and multiple cysts patients before and after treatment

Patient	MMSE before treatment	MMSE after treatment
Case 1 (solitary)	13	19
Case 2 (solitary)	16	24
Case 3 (solitary)	15	25
Case 4 (solitary)	13	20
Case 5 (multiple)	15	24
Case 6 (multiple)	20	29

MMSE: Mini mental status examination

Statistical analysis

Statistical analysis was performed by SPSS (Statistical Package for Social Sciences), version 22, IBM Corp. Released 2013. IBM SPSS. Statistics for windows Armonk, NY: IBM Corp. Descriptive data were represented using tables and variables association based on Fisher's Exact Test. P < 0.001 were considered statistically significant.

RESULTS AND DISCUSSION

Demographic profile

NCC can affects people of all age groups; In our study [Table 2] the maximum incidence was between age groups 15 and 34 years, n = 50 (62.5%), This highlights the fact that NCC affects the most productive and active groups of the society. Most patients who suffered from the disease were either employed or were students; it affects males predominantly 50 (62.5%) in contrast to females 30 (37.5%).

Table 2

Demonstrating the demographic profile of neurocysticercosis patients

Demographic distribution	%
Age (years) (%)
<14	6.25
15-24	35
25-34	27.5
35-44	10
45-54	21.25
Sex (%)
Male	62.5
Female	37.5
Socioeconomic status (%)
Upper	1.25
Middle	36.25
Lower	62.5
Food habits (%)
Vegetarian	21.25
Nonvegetarian
Pork eater	41.27
Others	37.48
Demographic distribution	No.
Area
Urban
Solitary	17
Multiple	8
Rural
Solitary	25
Multiple	13

Patients who suffered from NCC were mostly from lower socioeconomic status 50 (62.5%) and come from rural areas 55 (68.75%). This reflects the role of access to toilet facilities and poor self-hygiene practices. Dietary habits also had a direct bearing on the incidence of NCC, as it was seen more in nonvegetarians (78.75%) compared to vegetarians (21.25%). This is in accordance with the lifecycle of NCC, which requires pork eating or close contacts with pigs, indeed of 63 nonvegetarian patients 33 (52.4%) consumed pork.

Cognitive assessment

Inattention was the most common cognitive deficit seen in patients of 40% NCC. The MMSE score ranged from 15 to 30 [Table 3]. The MMSE scores have been compared to their age and gender-matched peers. MMSE identified patients with cognitive decline was higher in patients with multiple lesions. However, these findings were considered with the fact regarding the baseline premorbid intellect, language, and education barriers of the population under study. 68% of patients were not able to draw intersecting pentagons, because they were not stable. The patients were told the name of three objects, about 75% were not able to recall those three words when asked again this proved that they had lost their ability to remember, memory was affected gradually which affected their daily functions. During the assessment, they were not confident while giving response, only about 25% of patients responded confidently. Among 69 literate patients, the calculation ability decreased in about 20% of patients. About 40% of patients were not as attentive and oriented when they were questioned upon the orientation parameters. About 31% of the total patients (25 patients) use to drive a vehicle, but after the onset of the disease, only 12 patients expressed their capability to do so.

Table 3

Comparison of mini mental status examination score of patients solitary and multiple cysts with controls,(where n=42 solitary+ 38 multiple+ 80 controls=160 persons), F (Fisher’s exact test) value and P

MMSE	Patients				Control		Percentage of n	F	P
	Solitary	Multiple	Total	Percentage of patients	Total	Percentage of patients
Uneducated	7	4	11	13.8	0	0.0	6.875	22.6	0.0001*
Not in state to give	0	2	2	2.5	0	0.0	1.25
<10	0	1	1	1.2	0	0.0	0.625
10-14	0	0	0	0.0	0	0.0	0
15-19	0	2	3	3.8	2	2.5	3.125
20-24	7	7	14	17.5	11	13.8	15.625
25-29	26	21	47	58.8	56	70.0	64.375
30	1	1	2	2.5	11	13.8	8.125
Total	42	38	80	100.0	80	100.0	100.0

The observations after the MMSE test pointed out that the patients who were severely infected with NCC displayed loss of memory, affected cognitive ability, lack of attention, disorientation, which affected their professional and personal life to a great extent. Among all patients, severely infected patients required help in performing daily household chores such as bathing, eating, and even walking.

6 NCC patients appeared for routine follow-up after 2 months, their MMSE was done, which had improved in all the 6 patients [Table 1], their overall cognition improved, and were able to perform their daily chores and professional activities normally when enquired from them.

An important aspect of the disease is its psychiatric manifestation.[1718] Type of psychiatric manifestation will eventually depend upon the location, the number of cysts and stage of the NCC. The previous studies done on Psychiatric manifestations of the NCC are from case series and anecdotal reports. Cognition deficits were identified broadly based on MMSE and defined by a score of <25 in 38.75% who were literate. CNS inflammation in Multiple sclerosis and Alzheimer's dementia leads to cognitive dysfunction, similarly CNS lesions in NCC affect cognition.[1920] Cognition deficit was reversible when proper therapy was initiated.

NCC causes significant morbidity in patients which hampers their activity of daily living. Attention-deficit is common in N.C.C patients and is consistent with what other studies have found. Executive dysfunction is seen in patients suffering from prefrontal damage.[21] In cysticercosis involving the dorso-lateral prefrontal cortex (DLPFC), it results in impairment of sustained attention, memory, temporal organization, and cognitive flexibility. Lesions in the orbitofrontal cortex (OFC) generate personality changes.[2223] In travelers, migrants, and areas with endemicity of the disease, psychiatric disorders if prevail diagnosis of NCC must be considered.[24] The other aspects memory, though lesions anywhere in either DLPFC, OFC, and temporal lobes can produce memory deficits.[25]

CONCLUSION

This study reflects poor hygiene and sanitation in the community still an underlying cause for endemicity and the high burden of disease. A majority of patients were from lower socioeconomic strata and had a rural background. The majority of the disease burden was seen in the young and productive age group, thus this multiplies the economic burden on the family and society. If patients are assessed in the initial stage and they can be diagnosed then treatment at right time will not lead to the deterioration of cognitive domains of patients suffering from disease and will save them from morbidity in the years to come, thus will be beneficial for the society.

Ethical clearance

Institutional ethics committee, NK/3023/Ph.D/110.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Instructions: Score one point for each correct response within each question or activity
Maximum Score	Patient’s Score	Questions
5		“What is the year? Season? Date? Day? Month?”
5		“Where are we now? State? County? Town/city? Hospital? Floor?”
3		The examiner names three unrelated objects clearly and slowly, then the instructor asks the patient to name all three of them. The patient’s response is used for scoring. The examiner repeats them until patient learns all of them, if possible.
5		“I would like you to count backward from 100 by sevens.” (93, 86, 79, 72, 65, …)
		Alternative: “Spell WORLD backwards.” (D-L-R-O-W)
3		“Earlier I told you the names of three things. Can you tell me what those were?”
2		Show the patient two simple objects, such as a wristwatch and a pencil, and ask the patient to name them.
1		“Repeat the phrase: ‘No ifs, ands, or buts.’”
3		“Take the paper in your right hand, fold it in half, and put it on the floor.” (The examiner gives the patient a piece of blank paper.)
1		“Please read this and do what it says.” (Written instruction is “Close your eyes.”)
1		“Make up and write a sentence about anything.” (This sentence must contain a noun and a verb.)
1		“Please copy this picture.” (The examiner gives the patient a blank piece of paper and asks him/her to draw the symbol below. All 10 angles must be present and two must intersect)
30		Total