A 28-year-old woman from rural Maharashtra presents to the emergency department with a 2-hour history of repetitive seizures. She had her first seizure 6 months ago while working in the field. On examination, she is post-ictal, blood pressure 140/90 mmHg, temperature 37.2°C. CT head shows a 2 cm hypodense lesion in the left parietal lobe with surrounding edema. Serology is positive for Taenia solium antibodies. She has had 4 seizures in the past 6 months, each separated by weeks of normal consciousness. What is the most appropriate next step in management?

Explanation

## Clinical Diagnosis: Neurocysticercosis with Seizures **Key Point:** This patient has symptomatic neurocysticercosis (NCC) with active seizures — a common cause of acquired epilepsy in endemic regions. The combination of recurrent seizures, imaging showing a single cystic lesion with edema, and positive serology is pathognomonic. ### Management Rationale **High-Yield:** In active NCC with seizures, antiparasitic therapy (albendazole or praziquantel) is indicated to kill the parasite and reduce seizure recurrence. However, antiparasitic drugs trigger inflammation as cysts die, potentially worsening seizures — hence corticosteroids (dexamethasone or prednisolone) MUST be given concurrently to suppress the inflammatory response. **Clinical Pearl:** The standard regimen is albendazole 15 mg/kg/day in 2–3 divided doses for 28 days, with dexamethasone 0.5–1 mg/kg/day (max 4 mg/day) or equivalent prednisolone, tapered over 2–4 weeks. ### Why This Approach? | Aspect | Rationale | |--------|----------| | **Antiparasitic choice** | Albendazole preferred over praziquantel (better CSF penetration, fewer drug interactions) | | **Corticosteroid timing** | Must start BEFORE or WITH antiparasitic to prevent paradoxical worsening | | **Antiepileptic drug** | Continue or initiate AED (levetiracetam preferred to avoid phenytoin-albendazole interaction) | | **Surgery** | Reserved for failed medical management, intraventricular cysts, or mass effect | **Mnemonic:** **ACES** for NCC management — **A**ntiparasitic (albendazole), **C**orticosteroids (concurrent), **E**pilepsy drugs (AED), **S**urgery (if needed). [cite:Harrison 21e Ch 219]