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Neurocysticercosis Kansas Journal of Medicine 2010 Neurocysticercosis Neurocysticercosis 1 Andrew H. Kerstein, D.O. 2 Andrew D. Massey, M.D. University of Kansas School of Medicine-Wichita 1Department of Psychiatry and Behavioral Sciences 2Department of Internal Medicine Introduction Cysticercosis is caused by the larval appears to be high psychiatric morbidity in stage of Taenia solium (T. solium ).1 Clinical untreated cases. syndromes related to this parasite are divided into neurocysticercosis (NCC) and Case Report extraneural cysticercosis (ECC). NCC, in A 44-year-old, right-handed, employed, turn, is divided into parenchymal and married, Hispanic, solely Spanish speaking extraparenchymal forms. Tissue cysticerci male presented to the emergency room of a develop from onchospheres, which are community hospital with a headache and invasive larvae transformed from Taenia seizure-like activity. The patient had eggs, over a period of three to eight weeks intermittent headaches over the past two following ingestion of T. solium. Cysticerci years, but they had become more frequent in typically remain in this stage for many recent weeks. On the day of presentation to years. the emergency room, the patient developed a The Taenia species has a number of very severe headache that atypically did not sophisticated mechanisms to evade resolve. He attributed the headache to paint destruction by the human body including fumes he inhaled while painting his house production of serine proteases. Symptoms that day. Over the course of the day, his develop when the body eventually attacks wife noted that he was having difficulty the cyst and kills it. In general, parenchymal finding words, was increasingly somnolent, cysts are associated with seizures and and confused. He experienced two headache, while extraparenchymal cysts are generalized tonic clonic seizures later that associated with symptoms of elevated day, each lasting 60 to 90 seconds, and was intracranial pressure (e.g., headache, nausea, transported to the local emergency room. and vomiting) and may be accompanied by Subsequently, he was transferred to a altered mental status. regional medical center for further Neurocysticercosis is a leading cause of evaluation. seizures in developing countries. Persons The patient’s medical history was with a history of living in or traveling to notable for gout, appendectomy, chole- endemic areas or those living in close cystectomy, and vasectomy. His family association to persons known to have history included diabetes mellitus and cysticercosis deserve further evaluation of hypertension. He was employed at a this as an etiology of a seizure or psychiatric chicken and beef processing facility in disorder. Limited study exists on neuro- Western Kansas. He had no tobacco, psychiatric manifestations. However, there alcohol, or illicit drug use history. The 52 Kansas Journal of Medicine 2010 Neurocysticercosis patient was born and lived in Mexico before x-ray and electroencephalogram were moving to the United States about 10 years normal. Magnetic resonance imaging of the prior to presentation. He last visited Mexico brain, with and without contrast, revealed a during the summer less than two years 19.5 mm x 12.5 mm x 16.5 mm left before presentation. posterior temporal cyst with small nodule The presenting vital signs included (see Figures 1a and 1b). Vasogenic edema temperature of 97.2o F, pulse of 80 bpm, was noted with the margins measuring blood pressure of 110/60 mmHg, height of approximately 3 cm in average diameter. 5’9’’, and weight of 99.7 kg. His Mini- The characteristics of the lesion suggested Mental State Examination revealed mild cysticercosis. A diagnosis of neuro- cognitive impairment with a score of 23. He cysticercosis was made. The patient’s had difficulty concentrating and was unable history of being from an endemic area, to spell the Spanish equivalent of “world” exposure to poor sanitation, and the backwards. His visual fields were full and characteristics of the clinical presentation central visual acuity was 20/20 OU. helped form the diagnosis. Strength and tone in upper and lower Initially, the patient was given IV extremities were normal. Coordination and dexamethasone and loaded with fine motor movements were normal. fosphenytoin because of the seizure episodes Vibratory and cold sensation and two-point and brain edema. His mental status rapidly discrimination were normal. His tendon improved. He was discharged from the reflexes were not brisk and his plantar hospital after three days. He was given a responses were flexor. course of albendazole and an oral All blood and urine tests were normal. prednisone taper upon hospital discharge. The cysticercosis IgG antibody was He was scheduled for a repeat MRI two negative. HIV, Strongyloides antibody, months later and was followed by an TSH, and TB tests were normal. A skeletal infectious disease specialist. 53 Kansas Journal of Medicine 2010 Neurocysticercosis Discussion References The life cycle of T. solium , the 1 White AC Jr. Clinical manifestations and tapeworm causing NCC, is complicated and diagnosis of cysticercosis. January 2010. humans are a dead end host with swine as an Accessed at: http://www.utdol.com. intermediate host. 2 Poor sanitary conditions 2 Cook GC, Zumla AI. Manson’s Tropical in developing countries have been the Diseases. 21st Edition. Oxford: W.B. environment characterized as where the Saunders, 2003. species is endemic, however, that need not 3 Schantz PM, Moore AC, Munoz JL, et. al. be the case. Individuals with no history of Neurocysticercosis in an Orthodox Jewish pork consumption or travel to endemic areas community in New York City. N Engl J also can develop NCC. In a report of four Med 1992; 327:692-695. cases in an Orthodox Jewish community 4 White AC Jr. Treatment of cysticercosis. (whose dietary laws strictly prohibit January 2010. Accessed at: http:// consumption of pork), infection was www.utdol.com. transmitted by domestic workers who 5 Levenson JA. Textbook of Psychosomatic recently had emigrated from Latin American Medicine. Washington, DC: American countries where T. solium is endemic.3 Psychiatric Publishing, 2005. Pharmaceutical treatments for cysti- 6 Mahajan SK, Machhan PC, Sood BR, et cercosis are most commonly albendazole al. Neurocysticercosis presenting with and praziquantel.4 Albendazole (15 mg/kg psychosis. J Assoc Physicians India 2004; per day ~ 800 mg/day in two divided doses) 52:663-665. facilitates the destruction of parenchymal 7 Forlenza OV, Filho AH, Nobrega JP, et al. cysticerci. Praziquantel (50 to 100 mg/kg Psychiatric manifestations of neuro- per day in three divided doses) is an cysticercosis: A study of 38 patients from alternative to albendazole, but also is used in a neurology clinic in Brazil . J Neurol cases of infection in the gastrointestinal tract Neurosurg Psychiatry 1997; 62:612-616. and elsewhere aside from the central nervous system. Keywords : neurocysticercosis, cysticercosis, Psychiatric manifestations have been taenia solium, psychiatry, case report recognized as depression, psychosis, and cognitive decline. 5 Psychosis may be seen in up to 5% of patients. 6 In a series of studies conducted in Brazil, psychiatric disorders occurred in 65.8%, evidence of cognitive decline in 87.5%, depression in 52.6%, and psychosis in 14.2% of patients.7 A point of medical and public health interest is that cysticercosis and neuro- cysticercosis are not reportable diseases in Kansas or most others states. This case may serve as encouragement for authorities to reconsider the importance of this disease to be added to the list of reportable diseases. 54 .
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