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Taenia solium Cysticercosis — The lessons of history

  • Oscar H. Del Brutto
    Correspondence
    Corresponding author at: Air Center 3542, PO Box 522970, Miami, FL 33152-2970, United States.
    Affiliations
    School of Medicine, Universidad Espíritu Santo — Ecuador, Guayaquil, Ecuador

    Department of Neurological Sciences, Hospital-Clínica Kennedy, Guayaquil, Ecuador
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  • Héctor H. García
    Affiliations
    Center for Global Health — Tumbes and Department of Microbiology, School of Sciences, Universidad Peruana Cayetano Heredia, Lima, Peru

    Cysticercosis Unit, Instituto Nacional de Ciencias Neurológicas, Lima, Peru
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Published:August 07, 2015DOI:https://doi.org/10.1016/j.jns.2015.08.011

      Highlights

      • Natural scenarios left us valuable lessons on mechanisms of cysticercosis spread.
      • Cysticercosis may remain asymptomatic for decades after infection.
      • Once introduced in a non-endemic region, cysticercosis is difficult to eradicate.
      • Infected pork is not required for cysticercosis transmission.
      • Migrating tapeworm carriers may cause foci of infection in non-endemic areas.

      Abstract

      Human taeniasis as well as porcine and human cysticercosis — caused by the pork tapeworm Taenia solium — are ancient diseases. The fact that pigs were considered impure in the ancient Greece and that the Koran prohibited the consumption of pork, were likely related to the knowledge that cysticercosis may affect swine. Evidence suggests that human cysticercosis was also present in the ancient Egypt and Rome. During the Renaissance, the causative agent was properly identified and human cases were recognized. Confirmation that both taeniasis and cysticercosis were caused by the same parasite was provided during the 19th Century by German pathologists. During the 20th Century, bouts of human cysticercosis in non-endemic regions left us valuable lessons on the mechanisms of disease acquisition and spread. These included a large series of neurocysticercosis cases in the United Kingdom that occurred after the return of troops stationed in India (which demonstrated that symptoms may occur years after infection), the epidemic of cysticercosis-related epilepsy in the Ekari people of Papua New Guinea occurring after the gift of pigs with cysticercosis received from Indonesia (demonstrating the fast establishment of endemic transmission and the impact of cysticercosis in epilepsy frequency), and the occurrence of neurocysticercosis among members of an Orthodox Jewish community of New York City, related to Latin American Taenia carriers working in their houses (highlighting the fact that cysticercosis transmission do not require the presence of infected pigs). These lessons of history have significantly contributed to our current knowledge on this disease.

      Keywords

      1. Introduction

      Taenia solium belongs to the family Taeniidae, which includes three parasites affecting humans: T. solium (the pork tapeworm), Taenia saginata (the beef tapeworm) and Taenia asiatica, a tapeworm that is morphologically similar to T. saginata but biologically analogous to T. solium. Of these, T. solium is more relevant as a human pathogen since infection of the human nervous system with its larval form causes neurocysticercosis, a major cause of seizures and neurological disability worldwide [
      • Garcia H.H.
      • Nash T.E.
      • Del Brutto O.H.
      Clinical symptoms, diagnosis, and treatment of neurocysticercosis.
      ]. As it occurs with most ancient diseases, the history of T. solium has been surrounded by a number of myths, fortuitous discoveries, curious experiments, and natural epidemiological scenarios [
      • Grove D.I.
      A History of Human Helminthology.
      ]. We rescue here relevant episodes in the history of taeniasis and cysticercosis that left us valuable lessons on the biological cycle of T. solium as well as on mechanisms of disease acquisition and spread (Table 1).
      Table 1Major events in the history of taeniosis and cysticercosis.
      DateEvent–discovery–description
      3000–1500 BCTapeworms recognized in mummys from the ancient Egypt.
      600–500 BCThe Hebrew Bible (Leviticus) condemned pork consumption.
      400–350 BCSwine cysticercosis recognized in the ancient Greece.
      600–1000The Koran prohibited consumption of pork; Arabs and Egyptians used pumpkin seeds to treat taeniosis.
      1558First reported case of human neurocysticercosis.
      1697Recognition of cysticerci as parasites.
      1792Link between taeniasis and cysticercosis in the same patient.
      1850–1900Description of the life cycle of Taenia solium.
      1909–1911Introduction of the complement fixation test for diagnosis of cysticercosis.
      1930–1960Description of the natural history of human cysticercosis.
      1970 to dateIntroduction of neuroimaging and immune diagnostic methods; advent of specific therapy; attempts to eradicate cysticercosis.

      2. Ancient civilizations

      2.1 Pig, the impure animal

      Probably the oldest source banning pork consumption was mentioned in the third book of the Hebrew Bible (Leviticus, 11:7.8, c600–500 BC), where it was written “And the pig, because it parts the hoof and is cloven-footed but does not chew the cud, is unclean to you. You shall not eat any of their flesh, and you shall not touch their carcasses; they are unclean to you”. Ancient Greeks were familiar with the occurrence of swine cysticercosis (measly pork). Besides an anecdote mentioned in Aristophanes' (c.448–385 BC) comedy “The Knights”, where a slave suggested that the tongue of one of the main characters should be examined in the same way it was used to do with pigs, to see if he was “measled”, Aristotle (c. 384–322 BC) described in detail the presence of bladders or cysts in pig muscles that were compared with hailstones. He also noticed that this was a condition associated with free roaming, since nursing pigs do not suffer from the disease [
      • Grove D.I.
      A History of Human Helminthology.
      ,
      • Nieto D.
      Historical notes on cysticercosis.
      ,
      • Wadia N.H.
      • Singh G.
      Taenia solium: a historical perspective.
      ]. Pigs were considered impure in the ancient Greece, and it is possible that this belief inclined Muhammad (570–632 AD) to prohibit the consumption of pork at the time when the Koran was written.

      2.2 Epilepsy, the sacred disease

      Since there are evidences of the endemicity of porcine cysticercosis, human cysticercosis must have been present in the ancient Greece and Rome. The concept of adult-onset epilepsy being related to a structural disease of the nervous system can be traced back to the Hippocratic treatise “On the Sacred Disease” [
      • Daras M.D.
      • Bladin P.F.
      • Eadie M.J.
      • Millett D.
      Epilepsy: historical perspectives.
      ]. It has also been suggested that the epilepsy that distressed the Roman dictator Gaius Julius Cesar (100–44 BC) was related to cysticercosis, as it started when he was 54 years old (one year after one of his visits to Egypt) and were apparently of partial origin with secondary generalization [
      • McLachlan R.S.
      Julius Caesar's late onset epilepsy: a case of historic proportions.
      ,
      • Bruschi F.
      Was Julius Caesar's epilepsy due to neurocysticercosis?.
      ]. While Egyptians did not eat pork with the exception of one sacred day per year, human taeniasis has been well documented in the ancient Egypt. The Ebers papyrus (1500 BC) includes descriptions of tapeworms, and both Taenia spp. eggs, and T. solium cysticerci have been found in the intestine and stomach of Egyptian mummies [
      • Cox F.E.G.
      History of human parasitic diseases.
      ,
      • Bruschi F.
      • Masetti M.
      • Locci M.T.
      • Ciranni R.
      • Fornaciari G.
      Cysticercosis in an Egyptian mummy of the late Ptolemaic period.
      ,
      • Le Bailly M.
      • Mouze S.
      • da Rocha G.C.
      • Heim J.L.
      • Lichtenberg R.
      • Dunand F.
      • et al.
      Identification of Taenia sp. in a mummy from a Christian necropolis in El-Deir, oasis of Kharga, ancient Egypt.
      ]. Moreover, intestinal tapeworms were a common knowledge among Arabian and Egyptian physicians, who treated them with pumpkin seeds (Cucurbita pepo), an herbal medicine that it is still used nowadays [
      • Li T.
      • Ito A.
      • Chen X.
      • Long C.
      • Okamoto M.
      • Raoul F.
      • et al.
      Usefulness of pumpkin seeds combined with areca nut extract in community-based treatment of human taeniasis in northwest Sichuan Province, China.
      ].

      3. Unraveling taeniasis and cysticercosis

      3.1 First descriptions of human cysticercosis

      After the Catholic Church stopped condemning the practice of autopsies, human cases of cerebral cysticercosis started to be recognized. Indeed, it is generally accepted that the first recorded cases of neurocysticercosis were those described by Rumler in 1558 during the autopsy of a patient with epilepsy who had liquid-filled vesicles adherent to the meninges and by Panarolus in 1652, who found similar vesicles in the corpus callosum of a priest who had suffered from seizures [
      • Grove D.I.
      A History of Human Helminthology.
      ]. The parasitic nature of these vesicles was not documented until Malpighi, in 1697, described the scolex of the T. solium inside them. During those years, Gmelin coined the term Taenia cellulosae for the vesicles, and Zeder included them into a new genus, Cysticercus (from the Greek: kustis, cystis, bladder, and kerkos, cercos, tail). It follows that the commonly used term “cysticercus cyst” is a pleonasm, since the word “cyst” is included in the etymological definition of “cysticercus”. It was initially believed that cysticerci constituted a separate parasitic species, and it was classified as C. cellulosae due to its tendency to develop in connective tissue; this incorrect term is still widely used nowadays.

      3.2 From serendipity to rational knowledge

      Simultaneous taeniasis and cysticercosis in the same person was probably first described by the Peruvian physician and journalist Hipólito Unanue in 1792, as he wrote in the journal “El Mercurio” the case of a soldier with taeniasis who died following a major seizure [
      • Deza L.
      Hipólito Unanue y la neurocisticercosis.
      ]. As noted in the original publication, Unanue was not looking to describe a particular medical condition, but the article was written as a plea for authorities to build an anatomy amphitheater in the community for a better recognition of the causes of deaths in the population.
      During the 19th Century, German pathologists recognized the morphological similarities between the head of the adult T. solium and the scolex of cysticercus, and Küchenmeister [
      • Küchenmeister F.
      Offenes sendschreiben an die k.k. Gessellschaft der Aertze zu Wein. Experimenteller Nachweis, dass Cysticercus cellulosae innerhab des menschlichen Darmkanales sich in Taenia solium umwandelt.
      ] demonstrated that ingestion of cysticercus from pork resulted in human intestinal taeniasis, by feeding a convicted man, condemned to death, with sausages and a noodle soup both containing cysticerci obtained from a recently slaughtered pig. At autopsy, Küchenmeister found “a small Taenia that was tightly attached with its proboscis to a piece of duodenal mucosa”, as well as other nine Taenias, one of them with the complete crown of 22 hooklets in two rows typical of the rostellum of T. solium. Soon thereafter, the knowledge on the life cycle of T. solium was completed by experiments in Belgium and Germany, demonstrating that pigs develop cysticercosis after ingesting Taenia eggs obtained from proglottids passed by T. solium human carriers. These findings were further confirmed by the seminal work of Yoshino [
      • Yoshino K.
      Studies on the post-embryonal development of Taenia solium. Part I. On the hatching of the eggs of Taenia solium.
      ,
      • Yoshino K.
      Studies on the post-embryonal development of Taenia solium. Part II. On the migratory course of the oncosphera of Taenia solium within the intermediate host.
      ,
      • Yoshino K.
      Studies on the post-embryonal development of Taenia solium. Part III. On the development of Cysticercus cellulosae within the definite intermediate host.
      ] who infected himself with T. solium cysticerci to study the life cycle of the cestode.

      4. Natural epidemiological scenarios

      4.1 The legacy of British military doctors

      By the end of the 19th Century and the first two decades of the 20th Century, isolated case reports mentioned the occurrence of cysticercosis in persons with dementia or epilepsy living in or returning from different outposts of the British Empire [
      • Pye-Smith P.H.
      Case of multiple cysticercus of the subcutaneous tissues.
      ,
      • Williams D.J.
      Lunatic asylum, Kingston, Jamaica, W.I..
      ,
      • Goodliffe J.H.
      A case of Cysticercus cellulosae.
      ,
      • Waterhouse R.
      Cysticercus cellulosae in the central nervous system: with an account of two cases.
      ]. At that time, the worldwide prevalence of cysticercosis was largely unknown, but it was suspected to be present in some of the regions where those British colonies were settled, particularly the sub-Saharan Africa [
      • Preux P.M.
      • Melaku Z.
      • Druet-Cabanac M.
      • Avode G.
      • Grunitzky E.K.
      • Bouteille B.
      • et al.
      Cysticercosis and neurocysticercosis in Africa: current status.
      ] and the Indian subcontinent, where the disease was first recognized in 1888 during the autopsy of an inmate patient from the lunatic asylum in Madras [
      • Wadia N.H.
      Neurocysticercosis in Asia.
      ].
      In the 1930s — working at Queen Alexandra's Military Hospital (Millbank) in London — Colonel (later Lieutenant General) Sir William Porter MacArthur (1884–1964) and Colonel (later Brigadier) Henry Brian Frost Dixon (1891–1962) with some of their co-workers, brought to the attention of the medical community that a high number of British soldiers had been discharged during the previous decades due to epilepsy [
      • MacArthur W.P.
      Cysticercosis as a cause of epilepsy in man.
      ,
      • MacArthur W.P.
      Cysticercosis as seen in the British Army with special reference to the production of epilepsy.
      ,
      • Dixon H.B.F.
      • Smithers D.W.
      Epilepsy in cysticercosis (Taenia solium): a study of seventy-one cases.
      ,
      • MacArthur W.P.
      Cysticercosis of the brain.
      ,
      • Dixon H.B.F.
      • Hargreaves W.H.
      Cysticercosis (Taenia solium). A further ten years' clinical study covering 284 cases.
      ,
      • Dixon H.B.F.
      • Lipscomb F.M.
      Cysticercosis: an analysis and follow-up of 450 cases.
      ]. Further study of these soldiers showed that a sizable proportion of them had cysticercosis, a disease that was considered to be almost inexistent in England by that time. Interestingly, most of these soldiers started having seizures during or after serving in India, one of the countries where this parasitic disease was suspected to be endemic. While a total of 450 cases were reported [
      • Dixon H.B.F.
      • Lipscomb F.M.
      Cysticercosis: an analysis and follow-up of 450 cases.
      ], these numbers were clearly an underestimate, and it was estimated that the incidence of symptomatic cysticercosis ranged from 1.2 to 2 per 1000 men among troops stationed in India from 1921 to 1937.
      This unique epidemiological scenario, in which the circumstances of the infection could be estimated, allowed — for the very first time — a description of the natural history of human cysticercosis as well as the recognition that a sizable number of infected persons may be asymptomatic for several years or may never develop clinical manifestations at all. More than 50% of patients initiated with seizures between three and five years after returning from India. Indeed, MacArthur stated in one of his papers “For every case of cysticercosis immediately diagnosticable there are a large number which will defy diagnosis for years” [
      • MacArthur W.P.
      Cysticercosis of the brain.
      ].
      MacArthur [
      • MacArthur W.P.
      Cysticercosis as seen in the British Army with special reference to the production of epilepsy.
      ] as well as Dixon and Smithers [
      • Dixon H.B.F.
      • Smithers D.W.
      Epilepsy in cysticercosis (Taenia solium): a study of seventy-one cases.
      ] suggested that cysticerci might live longer in the brain than in muscles and subcutaneous tissues. This was based on three main facts: 1) intracranial calcifications were detected by X-ray films at a later stage than elsewhere in the body, 2) a sizable proportion of patients develop neurological symptoms (seizures) years after muscle cysts have been calcified, and 3) in some necropsies or patients experiencing surgery, cysts in the brain showed no evidence of calcification while muscle cysts had been calcified for up to five years. The latter had already been described several years before, in the seminal work of Henneberg [
      • Henneberg R.
      Die tierischen Parasiten des Zentralnervensystems. I. Des Cysticercus cellulosae.
      ].
      The British military doctors also noticed that treating the adult tapeworm might exacerbate the symptoms of cysticercosis, giving the first note of caution for the potential risks associated with mass treatment of human taeniasis at the population level [
      • MacArthur W.P.
      Cysticercosis as a cause of epilepsy in man.
      ]. It could also be recorded that some of the patients with cysticercosis were family members of the soldiers but had never been abroad, suggesting locally transmitted disease in a household contact of a soldier who was also a T. solium carrier [
      • Dixon H.B.F.
      • Lipscomb F.M.
      Cysticercosis: an analysis and follow-up of 450 cases.
      ].

      4.2 The epidemic of burns in West New Guinea

      Rural inhabitants of West New Guinea have always had a swine-breading culture. Nevertheless, the country was free of porcine cysticercosis until 1972, when people living in the Enarotali region (near the Wissel Lakes area) received a gift of infected pigs from the Indonesian government in Java. Soon thereafter, cysticerci were noticed in the flesh of local pigs slaughtered in this region, and intestinal taeniasis was diagnosed in humans. By 1974, an epidemic of burns was observed among Ekari natives of the region [
      • Subianto D.B.
      • Tumada L.R.
      • Margono S.S.
      Burns and epileptic fits associated with cysticercosis in mountain people of the Irian Jaya.
      ]. This epidemic of burns resulted from seizures occurring when persons were sleeping, causing them to fall into bonfires used to warm-up their huts during cool nights. A sizable proportion of these patients also had subcutaneous nodules that were confirmed as cysticercus by biopsy and one of them (a girl dying after a major seizure episode) had thousands of parasites in the brain parenchyma [
      • Gajdusek D.C.
      Introduction of Taenia solium into West New Guinea with a note on an epidemic of burns from cysticercus epilepsy in the Ekari people of the Wissel Lakes area.
      ]. Nine years later, a new survey showed that cysticercosis still remained endemic in the Ekari people, and started to spread to neighboring villages [
      • Bendin J.J.
      • Catford J.C.
      Epidemic of burns in New Guinea due to cerebral cysticercosis.
      ], and even nowadays, the disease is still prevalent in the region [
      • Salim L.
      • Ang A.
      • Handali S.
      • Tsang V.C.W.
      Seroepidemiologic study of cysticercosis-taeniasis in four central highland districts of Papua, Indonesia.
      ].

      4.3 Disappearing CT enhancing lesions in Indian patients: an evolving concept

      Soon after the introduction of CT in India, an increasing number of young adults with recent onset epilepsy presenting with a single, small, enhancing parenchymal brain lesion was noticed. While these lesions were initially suspected to be tuberculomas [
      • Bhargava S.
      • Tandon P.N.
      Intracranial tuberculomas: a CT study.
      ], their spontaneous resolution on serial imaging studies created confusion to the point that it was considered that they just represented rupture of the blood–brain barrier and thus, were seen as the consequence and not the cause of the seizure disorder [
      • Sethi P.K.
      • Kumar B.R.
      • Madan V.S.
      • Mohan V.
      Appearing and disappearing CT scan abnormalities and seizures.
      ]. By that time, reports from Mexico also brought to the attention of the medical community the same disturbing images, commenting on their possible cysticercotic nature and suggesting that they represented acute phases of infestation of the nervous system by these parasites [
      • López-Hernández A.
      • Garaizar C.
      Childhood cerebral cysticercosis: clinical features and computed tomographic findings in 89 Mexican children.
      ,
      • Rodriguez-Carbajal J.
      • Salgado P.
      • Gutiérrez-Alvarado R.
      • Escobar-Izquierdo A.
      • Aruffo C.
      • Palacios E.
      The acute encephalitic phase of neurocysticercosis: computed tomographic manifestations.
      ]. Controversies on etiological considerations were solved after pathological studies of biopsy specimens revealed that cysticercosis was the cause of this peculiar CT finding [
      • Chandy M.J.
      • Rajshekhar V.
      • Ghosh S.
      • Prakash S.
      • Joseph T.
      • Abraham J.
      • et al.
      Single small enhancing CT lesions in Indian patients with epilepsy: clinical, radiological and pathological considerations.
      ,
      • Rajshekhar V.
      Etiology and management of single small CT lesions in patients with seizures: understanding a controversy.
      ]. Subsequent reports from different cysticercosis endemic areas confirmed that this form of neurocysticercosis is not confined to the Indian subcontinent [
      • Mitchell W.G.
      • Crwford T.O.
      Intraparenchymal cerebral cysticercosis in children: diagnosis and treatment.
      ,
      • Del Brutto O.H.
      Single parenchymal brain cysticercus in the acute encephalitic phase: definition of a distinct form of neurocysticercosis with a benign prognosis.
      ]. Nevertheless, it remained to be understood why many of these parasites spontaneously disappear on neuroimaging studies. After years of debate, recent position papers presented arguments favoring the fact that these lesions most likely represent young or immature forms of cysticerci that are destroyed by the host immune system soon after entering the nervous system [
      • Garcia H.H.
      • Gonzalez A.E.
      • Rodriguez S.
      • Tsang V.C.
      • Pretell E.J.
      • Gonzales I.
      Neurocysticercosis: unraveling the nature of the single cysticercal granuloma.
      ,
      • Singh G.
      • Rajshekhar V.
      • Murthy J.M.
      • Prabhakar S.
      • Modi M.
      • Khandelwal N.
      • et al.
      A diagnostic and therapeutic scheme for a solitary cysticercus granuloma.
      ,
      • Del Brutto V.J.
      • Del Brutto O.H.
      • Ochoa E.
      • Garcia H.H.
      Single parenchymal brain cysticercus: relationship between age of patients and evolutive stage of the parasites.
      ].

      4.4 Cysticercosis in an Orthodox Jewish Community in New York City

      Improved neuroimaging led to a sudden increase in the numbers of neurocysticercosis cases observed in the US after 1970, mainly occurring in Mexican immigrants to the Southwestern States of Texas and California [
      • McCormick G.F.
      • Zee C.-S.
      • Heiden J.
      Cysticercosis cerebri. Review of 127 cases.
      ]. A decade after, the occurrence of neurocysticercosis among members of an Orthodox Jewish community disturbed the medical community of New York City. As expected, these people did not eat pork for religious reasons, and most of them had never been in cysticercosis-endemic countries. When experts from the Center for Disease Control and Prevention (Atlanta, GA) conducted an investigation to determine the source of infection, the most probable source of infection were T. solium carriers from Latin America. They had most likely been infecting people for whom they worked — as housekeepers — via fecal–oral contamination [
      • Schantz P.M.
      • Moore A.C.
      • Muñoz J.L.
      • Hartman B.J.
      • Schaefer J.A.
      • Aron A.M.
      • et al.
      Neurocysticercosis in an Orthodox Jewish community in New York City.
      ]. Further studies showed an increased prevalence of anti-cysticercus antibodies in members of this community which were related to widespread employment of domestic workers from cysticercosis-endemic regions [
      • Moore A.C.
      • Lutwick L.I.
      • Schantz P.M.
      • Pilcher J.B.
      • Wilson M.
      • Hightower A.W.
      • et al.
      Seroprevalence of cysticercosis in an Orthodox Jewish community.
      ]. The same scenario has more recently been noticed in some countries of the Arab World, where autochthonous cases of neurocysticercosis have been increasingly recognized in the context of wealthy Muslim families employing babysitters and housekeepers from disease-endemic areas [
      • Del Brutto O.H.
      Neurocysticercosis on the Arabian Peninsula, 2003–2011.
      ]. Both, in the US and in the Arab World (and probably in other non-endemic regions as well), T. solium carriers entering those countries every year may infect local people and may be increasing the prevalence of neurocysticercosis without the need of infected pigs [
      • Del Brutto O.H.
      • García H.H.
      Neurocysticercosis in non-endemic countries: time for a reappraisal.
      ].

      5. Comment

      These curious tales on the history of taeniasis and cysticercosis are much valued as they significantly contributed to our current knowledge on the life cycle of T. solium and on the mechanisms of disease acquisition by humans. In particular, the information revealed along the three natural epidemiological scenarios recounted in this paper greatly added to our understanding on the clinical expression of the disease in migrant populations, on the dynamics of transmission in newly endemic regions, and on the possibility of local transmission in non-endemic regions.
      Many important lessons were derived from the bout of human cysticercosis in British soldiers, including the assessment of the contribution of neurocysticercosis to the burden of seizures and epilepsy, the understanding that brain infection survives muscle and subcutaneous infection for years, and the knowledge that in many cases seizures occur years after infection, likely reflecting late degeneration of one or several brain parasites [
      • MacArthur W.P.
      Cysticercosis as a cause of epilepsy in man.
      ,
      • MacArthur W.P.
      Cysticercosis as seen in the British Army with special reference to the production of epilepsy.
      ,
      • Dixon H.B.F.
      • Smithers D.W.
      Epilepsy in cysticercosis (Taenia solium): a study of seventy-one cases.
      ,
      • MacArthur W.P.
      Cysticercosis of the brain.
      ,
      • Dixon H.B.F.
      • Hargreaves W.H.
      Cysticercosis (Taenia solium). A further ten years' clinical study covering 284 cases.
      ,
      • Dixon H.B.F.
      • Lipscomb F.M.
      Cysticercosis: an analysis and follow-up of 450 cases.
      ]. From the West New Guinea epidemic, we learned the fast, widespread, and clinically expressive introduction of infection and clinically symptomatic disease in a previous non-endemic region [
      • Subianto D.B.
      • Tumada L.R.
      • Margono S.S.
      Burns and epileptic fits associated with cysticercosis in mountain people of the Irian Jaya.
      ,
      • Gajdusek D.C.
      Introduction of Taenia solium into West New Guinea with a note on an epidemic of burns from cysticercus epilepsy in the Ekari people of the Wissel Lakes area.
      ,
      • Bendin J.J.
      • Catford J.C.
      Epidemic of burns in New Guinea due to cerebral cysticercosis.
      ,
      • Salim L.
      • Ang A.
      • Handali S.
      • Tsang V.C.W.
      Seroepidemiologic study of cysticercosis-taeniasis in four central highland districts of Papua, Indonesia.
      ]. Finally, the bout of cysticercosis among Orthodox Jews in New York City is a clear reminder that infected pork is not required for cysticercosis transmission, and migrating tapeworm carriers may be responsible for the development of foci of infection even under good sanitary conditions in a developed country [
      • Schantz P.M.
      • Moore A.C.
      • Muñoz J.L.
      • Hartman B.J.
      • Schaefer J.A.
      • Aron A.M.
      • et al.
      Neurocysticercosis in an Orthodox Jewish community in New York City.
      ,
      • Moore A.C.
      • Lutwick L.I.
      • Schantz P.M.
      • Pilcher J.B.
      • Wilson M.
      • Hightower A.W.
      • et al.
      Seroprevalence of cysticercosis in an Orthodox Jewish community.
      ]. This also explains the occurrence of locally acquired cysticercosis in areas where pig-husbandry is adequate or where it is prohibited by religious laws [
      • Del Brutto O.H.
      Neurocysticercosis on the Arabian Peninsula, 2003–2011.
      ,
      • Del Brutto O.H.
      • García H.H.
      Neurocysticercosis in non-endemic countries: time for a reappraisal.
      ]. These lessons have provided basic information to better understand the mechanisms of disease transmission and should eventually contribute to the reduction of the burden of human cysticercosis in this global world.

      Conflicts of interest

      Nothing to disclose.

      Acknowledgments

      Dr. Garcia is supported by a Wellcome Trust International Senior Fellowship in Public Health and Tropical Medicine.

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