JOURNAL OF CLINICAL MICROBIOLOGY, Dec. 1995, p. 3124–3128 Vol. 33, No.

12
0095-1137/95/$04.0010
Copyright q 1995, American Society for Microbiology

Evaluation of Enzyme-Linked Immunoassay for

Serological Diagnosis of Cysticercosis
L. SLOAN, S. SCHNEIDER, AND J. ROSENBLATT*
Division of Clinical Microbiology, The Mayo Clinic, Rochester, Minnesota 55905

We evaluated a commercially available enzyme-linked immunoassay (ELISA) from LMD Laboratories, Inc.,
Carlsbad, Calif., for the detection of antibodies in serum to the cysticercus of Taenia solium. The ELISA was
performed on 308 serum samples; 198 from a pool of healthy individuals, 42 from patients who had antibodies
against a variety of parasites other than T. solium, and 68 from patients suspected of having cysticercosis. All
of these 68 specimens were tested both by the ELISA and by an immunoblot method (enzyme-linked immu-
noelectrotransfer blot assay [EITB]) developed at the Parasitic Serology Laboratory of the Centers for Disease
Control and Prevention. Twenty-seven of the 68 serum samples from patients suspected of having cysticercosis
were positive by both EITB and ELISA, while 31 were negative by both assays. ELISA results for three and two
samples were considered false positive and false negative, respectively, when compared with the results of
EITB. Results for an additional five samples were considered equivocal but were technically positive because
their optical density readings were slightly above the cutoff value. Three of the 198 serum samples from the
bank of serum samples from healthy individuals were also false positive by ELISA (the EITB result for the
samples was negative). Six other serum samples from healthy individuals which had equivocal results and the
five serum samples from patients with equivocal results were EITB negative. Serum samples containing
antibodies against Echinococcus spp. frequently cross-reacted with the cysticercus ELISA antigen (13 of 16
specimens), but serum samples with antibodies against other parasites did not (2 of 26 specimens); all of these
serum samples were EITB negative. The commercially available ELISA that we describe is a simple and rapid
test. Considering all 308 specimens, the ELISA had a specificity of 93% (when samples with equivocal results
were considered negative) or 89% (when samples with equivocal results were considered positive); the sensi-
tivity was 93%.

Cysticercosis is caused by infection with the larval form
(cysticercus) of the pork tapeworm Taenia solium. It is ac-
quired by ingestion of T. solium eggs passed in the feces of
persons harboring the adult tapeworm (taeniasis). Food or
water may be contaminated with the eggs in areas with inad-
equate waste disposal or from the hands of persons with tae-
niasis. These eggs are immediately infectious when they are
ingested by humans or pigs. They hatch into larvae in the small
intestine. The larvae penetrate the intestinal wall and subse-
quently invade various tissues, where they encyst to form cys-
ticerci. Most cysticerci are located in areas (such as subcuta-
neous areas) where they do not produce any symptoms.
Clinical manifestations usually result from their presence in
the central nervous system where they can cause seizures and
other neurologic problems (neurocysticercosis [NCC]).
Cysticercosis is endemic in Latin America, Africa, and Asia,
where NCC is probably the most common parasitic infection of
the central nervous system. Evidence of NCC was found in up
to 3.8% of autopsies in Mexico (3). In recent years, the number
of cases of NCC diagnosed in the United States has markedly
increased both because of the availability of improved diag-
nostic methods such as computed axial tomographic and mag-
netic resonance imaging (MRI) scans and because of increased
levels of immigration from Latin America, where an estimated
1% of the population has antibodies to larval antigens (2). The
number of cases of NCC which were acquired locally in the
United States has also increased from a total of 15 cases re-
ported through 1985 to 7.3% of all of the cases of NCC re-
ported to the Los Angeles Department of Health Services
from 1988 through 1990 (10). Several outbreaks of locally
* Corresponding author.
acquired NCC have been reported in the United States and
were apparently caused by household contact with persons
from areas where cysticercosis is endemic who had imported
tapeworm infections (1, 8). Epidemiologic information sug-
gested that these infections were acquired from immigrants
with taeniasis. In addition, since T. solium cysticercosis in swine
is virtually unknown in the United States, the acquisition of
taeniasis by way of the pig-human cycle is very unlikely.
The diagnosis of cysticercosis is based on clinical, epidemi-
ologic, and serologic findings. MRI and/or computed axial
tomographic scans are the most sensitive and specific diagnos-
tic tools (9). However, because of their high cost and restricted
availability, they may be of limited use in developing countries
with high rates of infection. The only useful method for the
laboratory diagnosis of cysticercosis is serologic detection of
antibodies against the cysticerci. In general, serologic assays
are useful for confirming rather than establishing the diagnosis
in an individual patient (9). They may also be helpful in epi-
demiologic studies for determining the prevalence of disease in
a specific population. Until recently, such serologic testing has
only been available from the Centers for Disease Control and
Prevention (CDC) and a small number of private laboratories.
A commercially available enzyme-linked immunoassay
(ELISA) approved by the U.S. Food and Drug Administration
for the detection of antibodies against T. solium cysticerci is
being produced by LMD Laboratories, Inc., Carlsbad, Calif.
We have evaluated the accuracy of this test by using serum
samples from a pool of healthy individuals, from patients sus-
pected of having cysticercosis, and from patients with antibod-
ies against other parasitic organisms. The LMD ELISA results
for patients were compared with those obtained by the en-
zyme-linked immunoelectrotransfer blot assay (EITB) devel-
oped at CDC, which was considered the ‘‘gold standard’’ (11).

3124
VOL. 33, 1995
The EITB was performed at CDC or by using reagents licensed
by CDC to Immunetics Inc., Cambridge, Mass. Clinical infor-
mation was reviewed whenever it was available.
MATERIALS AND METHODS
Serum samples. Three hundred eight serum samples were tested for the
presence of antibodies to T. solium by the ELISA. One hundred ninety-eight
specimens were obtained from a pool of serum samples from healthy individuals
who have been determined to be free of any disease which might provide
abnormal results for most laboratory tests performed on specimens of blood. All
of these serum samples from healthy individuals were tested by the ELISA, but
because of the limited availability of the EITB and the very high probability that
they were truly seronegative, only those serum samples from healthy individuals
which were reactive by the ELISA (a total of nine serum samples) were tested by
the EITB.
Another 68 serum samples were from patients who were suspected of having
cysticercosis and whose specimens were submitted for serologic testing between
January 1991 and January 1995. All of these were tested both by the ELISA and
by the EITB. These samples were split into two aliquots upon receipt and were
frozen at 2658C. One aliquot was sent frozen to the CDC Parasitic Serology
Laboratory, which performed the EITB, and the other was held at 2658C in our
laboratory until a batch of sufficient size could be tested by the ELISA (usually
no more than 3 to 4 days). The results of the EITB were tabulated without
reference to the results of the ELISA.
An additional 42 serum samples which had been found to contain antibodies
against a variety of human parasites were tested by the ELISA and the EITB to
determine the extent of cross-reactivity which might be present. (See Table 2 for
the number of serum samples containing each type of parasitic antibody and the
test methods used to detect them.)
ELISA procedure. The ELISA was performed according to the manufacturer’s
directions by using strips of microtiter wells which were coated with porcine cyst
fluid as the antigen. The serum sample was diluted 1:64 in buffer, and 100 ml was
placed in the well. After 10 min of incubation at room temperature, the wells
were washed and two drops of enzyme conjugate (protein A-horseradish perox-
idase) were added. The strips were again incubated for 5 min at room temper-
ature, the wells were washed, and 1 drop each of substrate A and substrate B
(tetramethyl benzidine chromogen and peroxidase, respectively) was added. If
antibody to the cysticerci of T. solium is present, a blue color develops after 5
min. The blue color changes to yellow with the addition of phosphoric acid,
which is used to stop the reaction. The result can be read visually or with the aid
of a spectrophotometer and can be compared with the negative, weakly positive,
and strongly positive controls supplied with the test kit. For the purposes of the
present study, a spectrophotometer (450 nm) was used to obtain optical density
(OD) readings. An OD of $0.500 was designated by the manufacturer as the
cutoff for a positive reaction. During the course of the study it became evident
that ODs for a number of samples were slightly above the arbitrary 0.500 cutoff
but substantially below the value for the low-positive control. These results,
usually with ODs of 0.500 to 0.700 compared with low-positive control ODs of
0.850 to 1.250, were designated equivocal for the purposes of the present study.
All samples for which ODs were above 0.700 were considered positive. The total
time required to perform the ELISA was 20 to 30 min.
Clinical information. Clinical information was reviewed directly from the
patients’ medical records or from information provided by the patients’ physi-
cians on a questionnaire. Such information was available for 54 of the 68 patients
whose sera were submitted for serologic testing for cysticercosis. Clinical infor-
mation was also reviewed for the 16 (of 42) patients who had positive cysticer-
cosis serologies which appeared to be caused by cross-reactions with other
parasitic antigens. Determinations of clinical evidence of cysticercosis were based
on the patients’ residences (past and present), travel histories, other epidemio-
logic information, clinical signs and symptoms (including seizures and other
neurologic events), findings on physical examination, results of other laboratory
tests, radiographic or computed tomographic scan findings or MRI scan findings,
and therapeutic responses to treatment with praziquantel or albendazole. Pa-
tients were categorized as having findings which were not consistent with a
diagnosis of cysticercosis, having findings consistent with that diagnosis, or hav-
ing findings indicating that cysticercosis was possible but that a firm diagnosis had
not been established.
RESULTS
Antibodies against T. solium cysticerci were detected by both
ELISA and EITB in 27 of 68 serum samples from patients who
were suspected of having cysticercosis (Table 1). Adequate
clinical information was available for 25 of these 27 patients,
and in all of them the clinical evidence was consistent with the
diagnosis of cysticercosis. Thirty-one specimens were negative
by both the ELISA and the EITB. Adequate clinical informa-
tion was available for 19 of these 31 patients, and in 17 of the
ELISA FOR DIAGNOSIS OF CYSTICERCOSIS 3125
TABLE 1. Comparison of ELISA and EITB for detection of
antibodies to T. solium in sera from 68 patients suspected
of having cysticercosis
ELISA result No. of specimens with the following EITB result:
(titer, $1:64) Positive Negative Total
a b
Positive 27 8 (3) 35 (30)
Negative 2 31 (36) 33 (38)
Total 29 39 68
a
Results for five equivocal specimens with ELISA results were considered as
false positive; i.e., the ELISA result was positive but the EITB result was neg-
ative.
b
Results for five specimens with equivocal ELISA results were considered
true negatives; i.e., the results of both ELISA and EITB were negative.
19 patients the clinical evidence was not consistent with the
diagnosis of cysticercosis. One of the two other samples which
were both ELISA and EITB negative was from a patient with
a brain biopsy-proven case of cysticercosis (single cyst). The
second sample was from a patient who had a single cerebral
cyst and seizures which improved after treatment with prazi-
quantel. Both tests were then false negative with regard to the
clinical picture, but for comparative purposes these results
were considered to be true negative by ELISA in relation to
the EITB result. Three serum samples were ELISA positive
but EITB negative (false positives), and two serum samples
were ELISA negative but EITB positive (false negatives). Five
additional specimens had equivocal ELISA results and nega-
tive EITB results. Because the ODs of the samples with equiv-
ocal results are above the manufacturer’s cutoff approved by
the U.S. Food and Drug Administration, technically, these are
positive results. However, as discussed below, we do not be-
lieve that an equivocal result indicates the presence of clinical
cysticercosis. Therefore, we calculated the sensitivity, specific-
ity, and positive predictive value of the ELISA (in relation to
the EITB and only on the basis of the data for the 68 clinical
samples) both for samples with equivocal results considered
false-positive results (values are 93, 79.5, and 77%, respec-
tively) and for samples with equivocal results considered true-
negative results (93, 92, and 90%, respectively).
Two samples were considered to have false-negative results
by the ELISA method; i.e., they were EITB positive. However,
the clinical histories of these two patients did not provide
convincing evidence of cysticercosis. One patient was a resi-
dent of the United States who had traveled to Mexico and in
whom multiple brain lesions were seen on an MRI scan. How-
ever, there was no response to praziquantel treatment, and the
neurologic evaluation including brain biopsy led to a diagnosis
of multiple sclerosis. The second patient was a Mexican immi-
grant with a brain lesion seen on an MRI scan who did not
respond to praziquantel and whose lesion was thought to be
due to an arteriovenous malformation. Thus, the designation
of these ELISA results as false negatives is problematic. While
these two patients may have had prior T. solium infections
accounting for the positive EITB results, they were not con-
sidered to currently have NCC. Elimination of these false-
negative results would improve the sensitivity of the ELISA
toward 100%.
Another three specimens were considered to have false-
positive ELISA results since the EITB results were negative.
One of these patients was a Haitian immigrant who had a
clinical diagnosis of cysticercosis on the basis of a single en-
hancing brain lesion seen on an MRI scan, a recent-onset
grand mal seizure, and improvement following treatment with
praziquantel. Two other patients did not have clinical evidence
3126 SLOAN ET AL. J. CLIN. MICROBIOL.

TABLE 2. Cross-reactivity of cysticercosis serology ELISA with cysticercosis had equivocal ELISA and negative EITB results.
sera positive for other parasitesa These included four specimens from patients who were either
No. of No. of
residents of or immigrants from Mexico. One of these patients
serum samples previously had NCC which had been properly treated 1.5 years
Parasite Method
samples ELISA before the sample for the present study was obtained. Two
tested positive other patients had the recent onset of generalized seizures with
Echinococcus spp. ELISA,b immunoblotc 16 13 brain lesions seen on scans, but no definite diagnosis of NCC
Entamoeba histolytica IHAd 8 1 was established. One patient had seizures and brain lesions
Schistosoma mansoni ELISA,e immunoblotf 5 1 seen on scan, but a biopsy was nondiagnostic. The fifth patient
Trichinella spiralis Latex agglutinationg 5 0 was a Caucasian U.S. resident who was being evaluated for a
Toxocara canis ELISAb 4 0 seizure disorder. Considering the results for these five patients
Babesia microti IFAh 2 0 and the fact that 6 of the 198 samples from healthy persons
Fasciola hepatica Fast ELISAi 1 0 also had equivocal ELISA and negative EITB results, we con-
Strongyloides stercoralis ELISAe 1 0 sider that such results are not definitely indicative of current or
a
All sera were negative by the cysticercosis EITB. recent cysticercosis. In the absence of significant clinical and/or
b
ELISA by LMD Laboratories, Inc. radiographic evidence for cysticercosis, an equivocal result
c
Immunoblot (Western blot) performed at the Division of Clinical Microbi- should be considered the same as a negative one. If such
ology, Mayo Clinic, with an antigen provided by LMD Laboratories.
d
IHA, indirect hemagglutination test produced by Behring Diagnostics Inc., evidence were present, it would be reasonable to repeat the
Somerville, N.J. ELISA in several weeks to determine if seroconversion had
e
ELISA performed at Division of Parasitic Diseases, Parasitic Diseases occurred. One might also choose to test the serum sample by
Branch, CDC. another method, i.e., EITB.
f
Immunoblot (Western blot) assay performed at Division of Parasitic Dis-
eases, Parasitic Diseases Branch, CDC.
g
Test performed with latex particles and antigen produced by Difco Labora- DISCUSSION
tories, Detroit, Mich.
h
IFA, indirect fluorescent-antibody test performed at the Division of Clinical We compared the LMD ELISA for the detection of anti-
Microbiology, Mayo Clinic, by using slides containing erythrocytes infected with
Babesia microti. bodies in serum against the cysticerci of T. solium with the
i
ELISA performed in the laboratory of G. V. Hillyer, University of Puerto EITB developed at the CDC reference Parasitic Serology Lab-
Rico School of Medicine, San Juan. oratory. The results of the present study of 68 clinical speci-
mens indicate that, in relation to the EITB, this commercially
produced ELISA is a specific (specificity of 91%, or 79.5% if
equivocal reactions are considered to be false-positive reac-
of NCC and had not resided in or traveled to areas where tions) and sensitive (93%) method for the detection of such
cysticercosis is endemic. Thus, the ELISA results for one of antibodies. The data for all 308 serum samples would provide
these three specimens may not actually be false positive. Ex- a specificity of 93% (or 89% if equivocal reactions are consid-
clusion of this problematic result would improve the specificity ered to be false-positive reactions) and a sensitivity of 93%.
of the ELISA. Review of the available clinical data indicates that there is a
An additional 198 serum samples from a pool of healthy very good correlation between positivity by both tests and the
individuals were tested by the ELISA: 189 of these were neg- presence of strong clinical evidence of cysticercosis and nega-
ative, 3 were positive, and 6 had equivocal OD readings. The tivity by both tests and the absence of clinical evidence of
nine serum samples with either positive or equivocal results all cysticercosis. An exception is the fact that two patients with
had negative EITB results. Results of the study of cross-reac- NCC who had single cystic lesions on MRI scans of the brain
tivity with the 42 serum samples containing antibodies against had negative results by ELISA and EITB. The sensitivity of the
other human parasites are given in Table 2. Thirteen of the 16 EITB is known to be diminished when only one cysticercus is
patient specimens containing antibodies against Echinococcus seen on MRI scan (12).
spp. had positive ELISA results. None of these patients had In addition, the clinical information for the two samples with
clinical evidence of cysticercosis. Only 2 of the remaining 26 false-negative results by ELISA (EITB positive) revealed no
serum samples were cross-reactive in the ELISA; one cross- definite clinical evidence of current or past cysticercosis, and
reacted with antibodies to Entamoeba histolytica (the patient the data for one sample with a false-positive result by ELISA
had an amoebic liver abscess) and one cross-reacted with an- (EITB negative) were consistent with a clinical diagnosis of
tibodies to Schistosoma mansoni (the patient was an African cysticercosis. The specificity and sensitivity of the ELISA in
with a prior diagnosis of and treatment for schistosomiasis). relation to those of the EITB would be improved if this clinical
Neither patient had clinical evidence of cysticercosis. None of information was considered in reclassifying these false results
these 42 serum samples was positive by the EITB. If the indices as true results.
of accuracy of the ELISA (compared with those of the EITB) ELISA testing of 198 serum specimens from healthy indi-
are calculated for the total 308 normal, patient, and cross- viduals revealed only 3 specimens with false-positive results
reactive specimens, the sensitivities, specificities, and positive (plus 6 specimens with equivocal results). A relatively low rate
predictive values are 93, 89, and 46%, respectively (when sam- of cross-reactivity was found with 26 (2 of which [7.6%] were
ples with equivocal results were considered to be false posi- positive) of the 42 serum samples reactive for antibodies
tive), or 93, 93, and 56%, respectively (when samples with against other parasites. There was a very high rate of cross-
equivocal results were considered to be true-negative). These reactivity (13 positive specimens [81%]) with the 16 other
calculations assume that those ELISA-negative normal serum serum specimens reactive for antibodies against Echinococcus
samples which were not tested by the EITB are considered to spp. The ELISA has not been tested extensively in populations
be true negatives. The low positive predictive values are due to in which multiple parasitic infections are endemic. However,
the high rate of cross-reactivity of the ELISA with antibodies the low rate of cross-reactivity in 26 of these serum specimens,
against Echinococcus spp. the 91% specificity (79.5% specificity with equivocal reactions
Five specimens from the 68 patients suspected of having counted as false-positive reactions) with the 68 patient speci-
VOL. 33, 1995
mens, and the 93% specificity (89% specificity with equivocal
reactions counted as false-positive reactions) for all 308 spec-
imens suggest that nonspecific reactions or cross-reactions will
not be a significant problem except in patients with hydatid
disease. Moreover, since cysticercosis and echinococcosis have
dissimilar epidemiologic and clinical features, it should not be
difficult to differentiate these infections.
A relatively small number of specimens (six serum speci-
mens from healthy individuals and five serum specimens from
patients) yielded equivocal ELISA and negative EITB results.
These are technically positive ELISA reactions because the
ODs are slightly above the manufacturer’s designated cutoff of
0.500. However, our experience indicates that these should be
considered negative unless there is strong clinical evidence of
cysticercosis; in such cases, repeat testing should be done to
detect possible seroconversion or the specimen should be sent
to CDC for confirmatory testing by the EITB. Although the
ELISA does not appear to be quite as sensitive or specific as
the EITB, it is a generally reliable rapid and simple test which
requires no sophisticated or expensive equipment and can be
performed by technologists with limited experience with im-
munodiagnostic methods. This reliability, ready availability,
and short turnaround time should make the ELISA a clinically
useful test. Moreover, since the role of serology in the diag-
nosis of cysticercosis is adjunctive and confirmatory rather than
primary, the slightly diminished accuracy of the ELISA com-
pared with that of the EITB is of limited clinical significance.
A variety of different methods have been used in the immu-
nodiagnosis of NCC, including indirect hemagglutination test,
indirect fluorescent-antibody test, radioimmunoassay, comple-
ment fixation assay, counterimmunoelectrophoresis, immuno-
electrophoresis, ELISA, and EITB (6). In addition, different
antigen preparations have been used, including crude and par-
tially purified extracts of cysticerci, scolices, and cyst fluid.
Various degrees of accuracy have been reported with these
methods, but until the production of the commercial ELISA
which we evaluated, none was readily available for use in
individual diagnostic laboratories. Currently in the United
States, the EITB is the only other serologic test available to
clinicians (at CDC and licensed by CDC to at least one com-
mercial laboratory).
The EITB might be expected to be more specific than the
ELISA since the latter uses crude cyst fluid as the antigen
while the former separates seven major glycoprotein antigens
(molecular weights, 13,000 to 50,000) from extracts of cysti-
cerci; the glycoproteins are blotted onto nitrocellulose strips
and appear as separate bands (11). Antibodies to T. solium
react with at least one of these specific bands (usually with six),
whereas nonspecific or cross-reacting antibodies should not.
The sensitivity and specificity of the EITB are reported to be
98 and 100%, respectively, in patients with two or more cysts,
but the sensitivity is lower in patients with single enhancing or
calcified cysts; only 28% of patients with single lesions had
positive EITB results (12). This diminished sensitivity of the
EITB with single lesions may have played a role in the negative
results for sera from two patients by both tests when there was
clinical evidence of the presence of NCC and in one of the
false-positive ELISA results (the EITB result was negative);
the patient was a Haitian immigrant with clinical evidence of
NCC (single cyst) and a therapeutic response to praziquantel.
Several recent studies have compared the EITB and the
ELISA in the detection of antibodies against T. solium cysti-
cerci (4, 5). In general, the results indicated that the EITB was
more sensitive and specific than the ELISA. However, in one
study the specificities of the two methods were equivalent and
the usefulness of the ELISA in areas where cysticercosis is
ELISA FOR DIAGNOSIS OF CYSTICERCOSIS 3127
endemic was recognized (5). The lack of difficulty posed by
cross-reactions with echinococcal antibodies was also men-
tioned. Moreover, the ELISAs used in those studies were not
identical to the commercially produced kit which was evalu-
ated in our study. Along with other methodological differences,
the antigens used were crude extracts of cysticerci rather than
the preparation of cyst vesicular fluid used in the commercial
ELISA. It has been claimed that use of cyst vesicular fluid as
antigen improved the reproducibilities and sensitivities of im-
munoassays compared with the use of cysticercal extracts as
antigen (7). This claim must be tempered by the knowledge
that many different extraction and purification methods have
been used for the various cyst vesicular fluid and cysticercal
antigen preparations which have been described. Analysis of
cyst vesicular fluid by sodium dodecyl sulfate-polyacrylamide
gel electrophoretic chromatograms revealed some 15 distinct
protein bands with molecular masses ranging from 246 to 26
kDa (7). Immunoblots run with the chromatograms and sera
from patients with NCC demonstrated major antigen-antibody
activity in the 103-kDa band region as well as in the region of
lower-molecular-mass bands. Undoubtedly, some of the pro-
tein antigens are the same as the seven glycoproteins separated
on the EITBs, and the 103-kDa band may be a polymer of one
or several of them. The ELISA and EITB, then, may detect
antibodies to many of the same protein antigens. Of course,
positive results because of the presence of nonspecific or cross-
reacting antibodies cannot be delineated with the ELISA, but
except for Echinococcus spp., they do not seem to occur very
frequently.
Numerous questions concerning the ELISA remain unan-
swered. What is the range of NCC infection which will produce
a positive result, i.e., acute or chronic infection, number of
cysts, viable or dead, etc.? How early in the course of the
infection will ELISA reactivity appear, and how long will it
persist? What is the degree of reactivity in patients with tae-
niasis but not cysticercosis? How reliable is the ELISA with
cerebrospinal fluid? We do not have all of the answers to these
questions, but for the moment, we can say that the commercial
ELISA described here appears to be a clinically useful adjunc-
tive test for the diagnosis of cysticercosis. The test is rapid and
simple to perform and is readily available to clinical laborato-
ries.
REFERENCES
1. Centers for Disease Control. 1992. Locally acquired neurocysticercosis—
North Carolina, Massachusetts and South Carolina, 1989–1991. Morbid.
Mortal. Weekly Rep. 41:1–4.
2. de Kaminsky, R. G. 1991. Taeniasis-cysticercosis in Honduras. Trans. R. Soc.
Trop. Med. Hyg. 85:531–534.
3. Del Brutto, O. H., and J. Sotelo. 1988. Neurocysticercosis: an update. Rev.
Infect. Dis. 10:1075–1087.
4. Diaz, J. F., M. Verastegui, R. H. Gilman, V. C. W. Tsang, J. B. Pilcher, C.
Gallo, P. Torres, T. Montenegro, E. Miranda, and the Cysticercosis Working
Group in Peru. 1992. Immunodiagnosis of human cysticercosis (Taenia so-
lium): a field comparison of an antibody-enzyme-linked immunosorbent
assay (ELISA), an antigen-ELISA, and an enzyme-linked immunoelectro-
transfer blot (EITB) assay in Peru. Am. J. Trop. Med. Hyg. 46:610–615.
5. Feldman, M., A. Plancarte, M. Sandoval, M. Wilson, and A. Flisser. 1990.
Comparison of two assays (EIA and EITB) and two samples (saliva and
serum) for the diagnosis of neurocysticercosis. Trans. R. Soc. Trop. Med.
Hyg. 84:559–562.
6. Flisser, A., and C. Larralde. 1986. Cysticercosis, p. 109–161. In K. W. Walls
and P. M. Schantz (ed.), Immunodiagnosis of parasitic diseases, vol. 1.
Academic Press, Inc., New York.
7. Larralde, C., J. P. Laclette, C. S. Owen, I. Madrazo, M. Sandoval, R. Bojalil,
E. Sciutto, L. Contreras, J. Arzate, M. L. Diaz, T. Govezensky, R. M. Mon-
toya, and G. Goodsaid. 1986. Reliable serology of Taenia solium cysticercosis
with antigens from cyst vesicular fluid: ELISA and hemagglutination tests.
Am. J. Trop. Med. Hyg. 35:965–973.
8. Schantz, P. M., A. C. Moore, J. L. Munoz, B. J. Hartman, J. A. Schaefer,
3128 SLOAN ET AL.
A. M. Aron, D. Persaud, E. Sarti, M. Wilson, and A. Flisser. 1992. Neuro-
cysticercosis in an orthodox Jewish community in New York City. N. Engl. J.
Med. 327:692–695.
9. Shandera, W. X., A. C. White, J. C. Chen, P. Diaz, and R. Armstrong. 1994.
Neurocysticercosis in Houston, Texas: a report of 112 cases. Medicine73:37–52.
10. Sorvillo, F. J., S. H. Waterman, F. O. Richards, and P. M. Schantz.
1992. Cysticercosis surveillance: locally acquired and travel-related infec-
tions and detection of intestinal tapeworm carriers in Los Angeles County.
J. CLIN. MICROBIOL.
Am. J. Trop. Med. Hyg. 47:365–371.
11. Tsang, V. C. W., J. A. Brand, and A. E. Boyer. 1989. An enzyme-linked
immunoelectrotransfer blot assay and glycoprotein antigens for diagnosing
human cysticercosis (Taenia solium). J. Infect. Dis. 159:50–59.
12. Wilson, M., R. T. Bryan, J. A. Fried, D. A. Ware, P. M. Schantz, J. B. Pilcher,
and V. C. W. Tsang. 1991. Clinical evaluation of the enzyme-linked immu-
noelectrotransfer blot in patients with neurocysticercosis. J. Infect. Dis. 164:
1007–1009.