The diagnosis of acute kidney injury (AKI) is often hindered by the reliance on serum creatinine as a marker of kidney function, which can delay detection. Neutrophil gelatinase-associated lipocalin is a promising biomarker which increases within hours of kidney damage and could therefore improve the early diagnosis of AKI.

by Dr Ashley Garner

Clinical background
Acute kidney injury (AKI) is a common condition associated with significant morbidity and mortality. It is currently diagnosed using serum creatinine and urinary output as markers of kidney function, as defined in the recent KDIGO criteria [Fig. 1][1]. However, these are relatively late markers of AKI since they mainly reflect a decrease in glomerular filtration rate and the time required for serum creatinine to accumulate can delay diagnosis. Biomarkers that can detect structural injury to the kidney rather than a loss of function may allow better and earlier detection of AKI. Earlier diagnosis of AKI could facilitate earlier intervention, potentially reduce the risk of irreversible kidney damage and improve patient outcomes. Much research in recent years has therefore focused on the discovery of improved biomarkers for AKI and neutrophil gelatinase-associated lipocalin (NGAL) is one of the most promising candidates [2].

Pathophysiology of NGAL
NGAL is a small 25kDa protein which belongs to the superfamily of lipocalins. It is expressed in many cells including neutrophils, hepatocytes and renal tubular cells and is induced in response to pathological stimuli including infection, inflammation, ischemia and malignancy. NGAL has a functional role in the innate immune system as a bacteriostatic agent, depleting iron-binding siderophores and thereby preventing bacterial iron acquisition. The iron-binding properties of NGAL are also proposed to provide protection from oxidative stress. There is growing evidence that NGAL also acts as a growth factor in some tissues including renal epithelial cells where it modulates cell proliferation, differentiation and apoptosis and may provide protection against renal tubular damage in AKI [3].

Animal studies of AKI induced by ischemia or nephrotoxicity have shown that NGAL is one of the most upregulated proteins in the kidney and is detectable in the urine within 2–3 h. It has been reported that urine NGAL concentrations increase 25–100 fold and plasma NGAL increases 7–16 fold following AKI. Unlike serum creatinine, NGAL is not increased when there is impaired glomerular filtration without renal tubular damage, often termed ‘pre-renal’ uraemia.
Low plasma concentrations of NGAL are found in health as it is expressed at a low constant rate from various tissues. NGAL is then freely filtered at the kidney and the majority is reabsorbed in the proximal tubule, resulting in low NGAL concentrations in the urine. Following AKI, NGAL is greatly upregulated in the cells lining the ascending loop of Henle and collecting ducts of the kidney and is then excreted in the urine. The origin of the increase in plasma NGAL following AKI is less clear and there is evidence to suggest that NGAL expression is increased in other organs such as the lungs and liver following kidney injury.

Since NGAL can be produced by different tissues in response to various stimuli, it is not specific to AKI. Other common conditions that can cause elevated NGAL, and therefore complicate the interpretation of results, include sepsis, heart failure, chronic kidney disease (CKD), malignancy and urinary tract infections.

NGAL assays
Commercial CE marked assays are available for measuring NGAL in plasma, whole blood and urine. It is not clear from the literature whether any of these sample types are preferred or have better diagnostic performance but there are limiting factors for each that may require consideration. Plasma and whole blood samples are invasive and may be contaminated by haemolysis releasing NGAL from neutrophils. Urine NGAL may theoretically be more sensitive for AKI due to greater induction in renal tubular cells but can be falsely elevated in urinary tract infections due to leukocyturia and it is still unclear whether the NGAL should be corrected for urine concentration effects or whether this is unnecessary or even misleading in AKI. Although non-invasive, urine samples may be more difficult to obtain especially at specific time points or if the patient has reduced urine output.

NGAL exists in monomeric, dimeric and heterodimeric or complexed forms. It has been reported that the monomer is the predominant form produced by renal tubular cells and the homodimer is predominantly released by neutrophils. The relevance of these different forms of NGAL will depend on the extent to which NGAL assays detect them and the sample type used. Even though the monomer form may be most relevant for urine NGAL the origin of plasma NGAL in AKI is less clear and may therefore include the other forms. This variation in NGAL assays and sample types makes it difficult to directly compare study results and derive clinically relevant cut-off values. Standardization of NGAL assays using an internationally approved reference material would greatly improve this variation but this is not currently available and would require agreement on what forms of NGAL should be measured.

Research from large heterogeneous populations suggests that urine NGAL concentrations are dependent on gender, age and ethnicity. Biological variation for urine NGAL has also been reported to be as high as 84%. These factors will need to be taken into account when establishing reference intervals for NGAL although they may not be clinically significant if a cut-off value is used to diagnose AKI, especially if it greatly exceeds the expected reference intervals in health.

Clinical utility of NGAL in AKI
There is evidence that NGAL could be useful as an early diagnostic and prognostic biomarker for AKI. Many studies have demonstrated that NGAL rises 24–72 h before creatinine in patients with AKI and is associated with poorer outcomes. It is difficult to determine the diagnostic performance of NGAL for AKI in terms of clinical sensitivity and specificity however, due to the limitations of using serum creatinine as the gold standard comparator. For example, the rise in creatinine caused by pre-renal uraemia will not be associated with a raised NGAL. In addition, a multicentre pooled analysis of prospective studies has shown that patients who have raised NGAL without increases in serum creatinine are at increased risk of adverse outcomes and suggests these patients have a condition termed ‘subclinical AKI’ where there may be tubular damage without glomerular impairment [Fig. 2][4].

The majority of studies assessing NGAL testing in AKI have focused on specific patient populations at high risk of AKI: namely post-cardiac surgery, post contrast infusion, intensive care and emergency admissions.
The advantage of using NGAL in post-surgery or post-contrast patients is that the time of insult is known and therefore NGAL can be measured at set time points for the early detection of AKI and timely intervention. It is more difficult to determine the best application of NGAL in ICU patients in regard to the timing and frequency of tests and it is less clear whether earlier detection can improve outcomes in these patients frequently complicated by multi-organ failure. In the emergency admissions setting NGAL has fewer advantages over serum creatinine since early detection (within hours) is less likely to be applicable. Also NGAL, like creatinine, can be raised in CKD so may require multiple measurements to detect AKI but more patients are likely to have had a previous creatinine result than an NGAL result.

Although there is an abundance of observational studies showing that AKI can be detected earlier using NGAL compared to serum creatinine there is an absence of randomized clinical trials to demonstrate that using NGAL instead of current practice will improve patient outcomes or provide cost benefits. This is probably the biggest barrier to the adoption of NGAL testing in routine practice and better treatments and interventions may be required to overcome it. This would suggest that one of the most important roles for NGAL and earlier biomarkers of AKI is in the discovery and development of effective interventions and therapeutics.
Another consideration regarding interventions for AKI is that NGAL only detects renal tubular damage, it does not distinguish between different causes. However, effective treatments may require the underlying cause to be determined and therefore further biomarkers may be needed to differentiate between causative factors and indicate the most appropriate intervention.

Conclusion
A large number of clinical studies suggest that NGAL may provide an early diagnostic and prognostic biomarker for AKI. However, further randomized clinical trials comparing the use of NGAL to standard practice are required to show cost benefits or improvements in patient outcomes. It seems that even if biomarkers like NGAL enable us to detect AKI earlier, this alone may not be sufficient to improve patient care but hopefully they will facilitate the development of better interventions that will eventually lead to improved outcomes for patients with AKI.

References
1. Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney Int. Suppl. 2012; 2: 1–138.
2. ADQI Consensus on AKI Biomarkers and Cardiorenal Syndromes. Contrib Nephrol. Basel: Karger, 2013; 182: 13–29.
3. Schmidt-Ott KM, Mori K, Li JY, Kalandadze A, Cohen DJ, Devarajan P, Barasch J. Dual action of neutrophil gelatinase-associated lipocalin. J Am Soc Nephrol. 2007; 18: 407–413.
4.  Haase M, Devarajan P, Haase-Fielitz A, Bellomo R, Cruz DN, Wagener G, Krawczeski CD, Koyner JL, Murray P, Zappitelli M, Goldstein SL, Makris K, Ronco C, Martensson J, Martling CR, Venge P, Siew E, Ware LB, Ikizler TA, Mertens PR. The outcome of neutrophil gelatinase-associated lipocalin-positive subclinical acute kidney injury: a multicenter pooled analysis of prospective studies. J Am Coll Cardiol. 2011; 57(17): 1752–1761.

The author
Ashley Garner PhD
Department of Blood Sciences,
Leeds Teaching Hospitals Trust, Leeds, UK

E-mail: Ashley.Garner@leedsth.nhs.uk

Autoimmune diseases affect approximately 5 % of the population of developed countries with an increasing incidence. Analysis of disease-associated autoantibodies (AAb) plays a significant role in the differential diagnosis thereof. Indirect immunofluorescence (IIF) has been established as the gold standard for AAb screening in particular for systemic rheumatic diseases. In the recommended two-tier approach for antibody serology, confirmatory testing by molecular assay techniques such as ELISA is required to confirm positive findings by screening using IIF. To cope with the constantly increasing demand for AAb testing, new efficient diagnostic approaches are required. Thus, a new generation of IIF assays have been developed to combine screening and confirmatory testing on one platform for the simultaneous detection of AAb by cell-based and bead-based assays in one reaction environment.  The multiplex analysis of antineutrophil cytoplasmic antibodies (ANCA) for the differential diagnosis of vasculitides will be discussed as a first application of this novel approach.

by Dr. Christina Fritz, Mandy Sowa and Dirk Roggenbuck

ANCA-associated vasculitis
Vasculitis is an inflammation affecting blood vessel walls and resulting in their damage, fibrinoid necrosis, tissue ischemia and necrosis, and finally vessel rupture with bleeding into the surrounding tissue [1, 2]. Due to etiological factors, systemic vasculitis is differentiated into primary and secondary vasculitis. Primary systemic vasculitis of particularly small vessels often has an autoimmune pathogenesis accompanied by the occurrence of ANCA [3,5-8]. Those so called ANCA-associated systemic vasculitides (AASV) comprise microscopic polyangiitis (MPA), eosinophilic granulomatosis with polyangiitis (EGPA or Churg-Strauss syndrome) or granulomatosis with polyangiitis (GPA or Wegener’s granulomatosis)[1, 2, 4]. In contrast, secondary vasculitis occurs in 5 – 10 % of patients with rheumatoid arthritis or with other autoimmune diseases (e.g., systemic lupus erythematosus [SLE], Sjögren’s syndrome). In addition, vasculitis can occur in patients suffering from infections such as HIV or hepatitis C.
In general, an acute AASV generally requires immunosuppressive treatment with high doses of cortisone. In severe cases, cyclophosphamide is recommended. Once remission is achieved, methotrexate, azathioprin, cotrimoxazol, leflunomid or mucophenolate mofetil are used as maintenance therapy.

Diagnosis of ANCA-associated vasculitis
According to the international consensus statement for the assessment of ANCA, IIF on ethanol-fixed human neutrophils (ethN) is followed by confirmation with antigen-specific molecular immunoassays [6-8]. IIF reveals two ANCA patterns sub-classifying ANCAs into cytoplasmic ANCA (cANCA) and perinuclear ANCA (pANCA). Regarding the autoantigenic target of ANCA, c and pANCA are directed against proteinase 3 (PR3) and myeloperoxidase (MPO), respectively. A positive cANCA pattern confirmed by the presence of PR3-ANCA is pathognomonic for GPA[5], whereas a positive pANCA pattern confirmed by MPO-ANCA is decisive for MPA and EGPA. Furthermore, the corresponding ANCA titres are strongly associated with activity of disease in patients suffering from GPA and MPA.
As a matter of fact, IIF is currently the only technique to provide a single reaction environment for the combined screening and confirmation of ANCA.  Simultaneous detection of c and pANCA along with PR3- and MPO-ANCA would overcome time-consuming single parameter detection by different techniques [10].

The use of multiplexing bead-based IIF assays for the simultaneous detection of single ANCA reactivities provides the ideal reaction environment to be combined with ethN-based ANCA testing. The corresponding principle is based on a covalent surface immobilization of MPO and PR3 on microbeads coded by size and fluorescence. The differentiation in size and/or intensity of a red fluorescence dye filling entirely each microbead population generates a novel reaction environment for parallel analyte analysis [11] (figure 1).

Combination of cell-based and microbead based ANCA assessment by CytoBead assay
The CytoBead assay is a unique combination of a conventional cell-based immunofluorescence assay with multiplexing microbead technology in one reaction environment. A newly designed microscopic glass slide with triple parted wells is employed to fix ethN in the middle compartment and PR3- as well as MPO-coated microbeads in the right-hand compartment of the slide (figure 2). Thus, anti-PR3 antibody positive sera show a positive cytoplasmic fluorescence on ethN and a green fluorescence halo on the surface of PR3-coated microbeads (9 µm). In contrast, anti-MPO antibody positive sera demonstrate a perinuclear fluorescence pattern on the immobilized ethN and a fluorescence halo on the surface of MPO-coated microbeads (15 µm) (figure 2). A reference microbead population (12 µm) is integrated for particle differentiation. This assay set offers the possibility of classical evaluation by a simple fluorescence microscope as well as automated analysis by interpretation systems like the AKLIDES^®.

A recent clinical study with classical ANCA testing revealed a relative sensitivity and specificity of 98 % and 99.2 % for the novel CytoBead ANCA assay, respectively. Remarkably, the CytoBead ANCA assay showed a better discrimination of GPA and MPA patients in contrast to the classical anti-MPO and anti-PR3 ELISA. The detected cut-off values were determined on the basis of fluorescence intensity given in arbitrary units [AU] (personal communication).

Conclusion and future perspectives
The increasing demand for cost-effective autoimmune diagnostics requires new multiplexing technologies combining screening and confirmatory testing in one reaction environment. Thus, the novel CytoBead technology is a promising opportunity to accomplish this goal as demonstrated for the comprehensive assessment of ANCA. Automated digital immunofluorescence employed by recently established novel diagnostic interpretation system solutions such as Aklides even offers quantification and standardization of ANCA detection. The CytoBead technology provides an ideal reaction environment for the multiplexing of antinuclear antibody assessment and the simultaneous detection of celiac disease-specific antibodies. 

References
1. Watt RA, Scott DG. Recent advances in classification and assessment of vasculitis. Best Pract Res Clin Rheumatol. 2009; 23: 429-443
2. Jeanette JC, Falk RJ. Small-vessel vasculitis. N Eng J Med. 1997; 337: 1512-23
3. Gross WL, Trabant A, Reinhold-Keller E. Diagnosis and evaluation of vasculitis. Rheumatology (Oxford). 2000; 39: 245-52
4. Waller R, Ahmed A, Patel I, Luqami R. Update on the classification of vasculitis. Best Pract Res Clin Rheumatol. 2013; 27: 3-17
5. Bosch X, Guilabert A, Font J: Antineutrophil cytoplasmic antibodies. Lancet 2006, 368:404-18
6. Jennette JC, Falk RJ, Bacon PA, Basu N, Ferrario F, Flores-Suarez LF, Gross WL, Guillevin L, Hagen EC, Hoffman GS, Jayne DR,  Kallenberg CG, Lamprecht P, Langford CA, Lugmani RA, Mahr AD, Matteson EL, Merkel PA, Ozen S, Pusey CD, Rasmussen N, Rees AJ, Scott DG, Specks U, Stone JH, Takahashi K, Watts RA: 2012 revised International Chapel Hill Consensus Conference Nomenclature of Vasculitis. Arthritis Rheum. 2013, 65:1-11
7. Jennette JC, Falk RJ, Andrassy K, Bacon PA, Churg J, Gross WL, Hagen EC, Hoffman GS, Hunder GG, Kallenberg CG: Nomenclature of systemic vasculitides. Proposal of an international consensus conference. Arthritis Rheum 1994, 37:187-92
8. Savige JF, Gillis DF, Benson E, Davies DF, Esnault VF, Falk RJ, Hagen EC, Jayne D, Jennette JC, Paspaliaris B, Pollock W, Pusey C, Savage CO, Silvestrini R, van der Woude F, Wieslander J, Wiik A: International Consensus Statement on Testing and Reporting of Antineutrophil Cytoplasmic Antibodies (ANCA). Am J Clin Pathol 1999, 111:507-13
9. Merkel PA, Polisson RP, Chang Y, Skates SJ, Niles JL: Prevalence of antineutrophil cytoplasmic antibodies in a large inception cohort of patients with connective tissue disease. Ann. Intern. Med. 1997, 126;866
10. Choi HK, Liu S, Merkel, PA, Colditz GA, Niles Jl: Diagnostic performance of antineutrophil cytoplasmic antibody tests for idiopathic vasculitides: metaanalysis with a focus on antimyeloperoxidase antibodies. J. Rheumatol. 2001, 28:1584
11. Grossmann K, Roggenbuck D, Schröder C, Conrad K, Schierack P, Sack U: Multiplex Assessment of Non-Organ-Specific Autoantibodies with a Novel Microbead-Based Immunoassay. 2011, Cytometry Part A! 79A: 118”125

Author
Dr. Christina Fritz*, Mandy Sowa and Dirk Roggenbuck
Medipan GmbH, Ludwig-Erhard-Ring 3,
15827 Dahlewitz,
Germany

*Corresponding author
E-mail: c.fritz@medipan.de

Which is the most common parasitic disease of the nervous system, which affection is the leading cause of seizures and acquired epilepsy in the developing world but still preventable? The answer: neurocysticercosis. An orphan disease suffering from the absence of a real ‘gold standard’ diagnosis. Meanwhile, many laboratories perform immunodiagnosis but what is its real value and what can it tell us?

by Dr Jean-François Carod

What is neurocysticercosis?
Cysticercosis of the central nervous system (neurocysticercosis) is caused by the larval stage (cysticerci) of the pork tapeworm Taenia solium. When people eat undercooked pork containing viable cysticerci, they develop an intestinal tapeworm infection (Fig. 1). Humans can also become intermediate hosts, however, by directly ingesting T. solium eggs shed in the feces of human carriers of the parasite. These eggs then develop into cysticerci, which migrate mostly into muscle (causing cysticercosis) and into the central nervous system where the cysticerci can cause seizures and many other neurological symptoms, neurocysticercosis (NCC). NCC is a major cause of epilepsy in endemic countries. It is the most important neurological disease of parasitic origin in humans. The pathogenesis is unclear but symptoms seem to correlate with the stage of the cyst. Starting as a viable entity, the cyst then gradually degenerates and become calcified. Seizures seem to appear at the degenerating and calcified stage but treatment is effective on the living cysts. Human cysticercosis is endemic in the Andean area of South America, Brazil, Central America and Mexico; China, the Indian subcontinent, South-East Asia; and Sub-Saharan Africa including Madagascar.

Why do we need to diagnose it?
Diagnosing NCC is required in the event of unexplained encephalitic disorders such as first onset of seizures in countries where NCC is endemic or in patients travelling in countries where NCC is endemic and who may have been at risk of infection (e.g. exposed to NCC risk factors, such as inadequate hand and food hygiene).

How can it be diagnosed?
The diagnosis of cysticercosis of the central nervous system involves the interpretation of non-specific clinical manifestations, such as seizures, often with characteristic findings on computed tomography (CT) or magnetic resonance imaging (MRI) of the brain, and the use of specific serological tests (Fig. 2). Diagnostic criteria based on objective clinical, imaging, immunological and epidemiological data have been proposed but are not generally used in areas endemic for the disease [1].

Serology is indicated for the diagnosis of T. solium seropositivity. But from a positive serology to the assessment of NCC diagnosis, there is a huge gap. A positive T. solium serology is not predictive for a neurological localization and serology may remain positive years after the end of the infection.
No single test can lead to a definitive diagnosis of NCC. CT-scan or MRI may be performed on the presentation of clinical symptoms that could be attributed to NCC (first onset of seizure, unexplained headache…) for people who were exposed to NCC risk factors. Imaging may show typical ring lesions with or without inflammation and calcification. However, the image is not pathognomonic of NCC unless hooks (scolex) are visible inside the ring. Thus, serology may give the clue if positive. A positive serology (antibody) may be confirmed by Western-blot or electro-immuno transfer blot (EITB), which show the typical bands specific of T. solium glycoproteins. Antigen detection in the blood can also be performed. This test is specific for T. solium and does not require laboratory confirmation. Both antigen and antibody assays can be performed in the cerebrospinal fluid (CSF). The presence of antibody or antigen in the CSF may contribute towards the assessment of the neurological localization of the disease. In developing countries, the regions most affected by T. solium infection, CT-scan and, of course, MRI are unaffordable, if ever available.

What are the current laboratory tools?
The laboratory diagnosis of cysticercosis is basically the immunodiagnostic based firstly on antibody detection with ELISA (enzyme-linked immunosorbent assay) or immunoblot.
The detection of antibodies against T. solium is a common method of infection diagnosis, but presents many limitations as a single cyst carrier may not be easily detected. Commercially available tests include essentially ELISA and Western-blots. Western-blots are the ‘gold standard’ assays for the detection of specific antibodies against T. solium. The reference Western-blot assay remains the one developed at the Centers for Disease Control (CDC), Georgia, USA, by Tsang et al. [2]. It employs a specific fraction of T. solium cysts. Many of the components have been identified and cloned. The test is very specific for exposure and/or disease and to confirm the diagnosis. Both ELISA tests and Western-blot relay on antigens that have varied significantly throughout the years (Fig. 3) [3]. Historically, the first assays used crude soluble extracts, then purified proteins such as lentil lectin glycoproteins (LLGPs) Recent trends, though not yet commercialized, tend to emphasize the use of recombinant proteins. Designing recombinant antigens requires a proteinomic approach (Fig. 4) that is now frequently used in development units. Current studies propose the use of nanobodies for diagnostic purposes. These evolutions increased both the sensitivity and the specificity of the tests.

Another available technique is based on the detection of circulating parasitic antigens using monoclonal antibodies [4]. This test is capable of detecting single cyst carriers and is more specific than available antibody ELISA tests. Its main advantage is its ability to monitor the response to cysticidal therapy.

Understanding the performance assessment of T. solium detection tests
Most commercially available ELISA tests have been evaluated by poor methodology. Assessing that a performance evaluation used the proper method means ensuring that the study used a serum bank of parasitologically-defined sera to assess test sensitivity. Defined cysticercosis sera should ideally include the following sera: two or more viable cysts, single viable cysts, degenerating cysts, calcified cysts.
Each series should be initially tested separately. A parasitologically-defined sera should correspond to the Del Brutto criteria [1]. In the absence of a true ‘gold standard’ for the diagnosis of neurocysticercosis, positive sera (cases) should be taken from patients with (1) absolute diagnosis of NCC, or (2) probable NCC diagnosis.       
     
The test specificity should be carefully evaluated using defined negative and potentially cross-reactive sera. Negative sera (control) should be taken from the same area and if possible from people exposed to the same risk factors as the positive cases, with age and sex correlation. Negative cases are usually taken from blood donors of developed countries. Those people have not been in contact with many parasitic infections and the sensitivity of the test will not be accurate/reliable for use in developing countries. This is why specificity should not only be assessed on negative samples from Western countries but also on other parasitic infections from cysticercosis-free developing countries.

What are the new trends in laboratory tests?
If only immunodiagnostic tools based on antibody or antigen detection are currently commercialized, new approaches have been developed including molecular biology (gene amplification in CSF mostly) (Fig. 5). However, so far none constitutes a ‘gold standard’. Table 1 summarizes the pros and cons of NCC diagnosis tools.

Conclusions and future
A test is reliable and useful if it contributes to a care improvement; that is to say to an appropriate therapy for all the patients. As for NCC; the decision to treat is still subject to controversy. Furthermore, even basic serologies are unaffordable or unavailable in endemic countries, not to mention imaging. The key will be in developing a reliable rapid test able to screen infected patients and correlated to neurological lesions of cysticerci.

References
1. Del Brutto OH. Diagnostic criteria for neurocysticercosis, revisited. Pathog Glob Health 2012; 106(5): 299–304.
2. Tsang VC, Brand JA,  Boyer AE. An enzyme-linked immunoelectrotransfer blot assay and glycoprotein antigens for diagnosing human cysticercosis (Taenia solium). J Infec Dis. 1989; 159(1): 50–59.
3. Esquivel-Velázquez M, Ostoa-Saloma P, Morales-Montor J, Hernández-Bello R, Larralde C. Immunodiagnosis of neurocysticercosis: ways to focus on the challenge. J Biomed Biotechnol. 2011; 2011: 516042. Doi:10.1155/2011/516042.
4. Garcia HH, Harrison LJ, Parkhouse RM, Montenegro T, Martinez SM, Tsang VC, Gilman RH. A specific antigen-detection ELISA for the diagnosis of human neurocysticercosis. The Cysticercosis Working Group in Peru. Trans R Soc Trop Med Hyg. 1998; 92(4): 411–414.

The author
Jean-François Carod Pharm D, MSc
Laboratoire de Biologie Médicale, GCS de l’ARC Jurassien, Centre Hospitalier Louis Jaillon, 2 Montée de l’hôpital, 39200 Saint-Claude, France.
E-mail: jean-francois.carod@ch-stclaude.fr