There are two important caveats to our attack rate estimate: the first caveat is that some cases may not have been reported to the authors of this study because of misdiagnosis or misinterpretation of imaging studies and attack rate may actually be higher. In Israel, practically all patients presenting with new onset neurologic symptoms such as new onset seizures, severe headaches, or focal deficits undergo extensive neuroimaging studies. Thus, although there may be an initial

delay in diagnosis, most symptomatic NCC patients in Israel were probably reported Everolimus ic50 due to characteristic clinical and neuroimaging findings and referral to specialized neurology/neurosurgery centers.7 On the Gemcitabine price other hand, the second caveat is that some of the cases may have been acquired in Israel and not during travel. Despite the fact that Israel is not endemic for NCC, immigrants from

endemic areas may transmit the disease.12 In this case, the actual travel-related attack rate is even lower then calculated. This would strengthen our conclusion that NCC is a rare condition in travelers. The low attack rate we found among Israeli travelers is in parallel with the paucity of reports of NCC in travelers. We thoroughly reviewed the literature beginning in 1980 and found that only 10 other cases were reported (Table 3).14–23 This is in contrast to the high seroprevalence and clinical disease rates among local populations in endemic areas. For example, in Latin America T. solium seroprevalence of over

6% to 10% has been reported, with a NCC clinical disease rate mafosfamide as high as 5% among seropositive individuals.3 Thus travelers might either have less exposure or mild exposure which does not lead to the clinical syndrome of NCC. One report in the literature found a positive serologic test for T. solium antibodies in 8.2% of 73 Peace Corps volunteers in Madagascar. In this report, two brain cysts were found in one asymptomatic seropositive volunteer.24 There are no other studies regarding seroprevalence of T. solium in travelers. Since most western travelers come from regions regarded nonendemic for NCC, they should be regarded as having NCC-naÏve immunological status and positive serology is probably an accurate marker of infection. We suspect that, due to the fecal–oral nature of transmission of NCC, a significant percentage of seroprevalence would presumably be found if traveler populations to endemic countries were to be tested, and the low incidence of clinical NCC in travelers may be attributed to a low parasite burden as compared with an endemic population. Other differences, such as genetic factors, may also explain the difference. Most of our patients were males despite the fact that women comprise nearly half of the total number of Israeli travelers to countries endemic for cysticercosis.