61261ournal ofNeurology, Neurosurgery, and Psychiatry 1997;62:612-616 Psychiatric manifestations of neurocysticercosis: J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.62.6.612 on 1 June 1997. Downloaded from a study of 38 patients from a neurology clinic in Brazil Orestes Vicente Forlenza, Antonio Helio Guerra Vieira Filho, Jose Paulo Smith Nobrega, Luis dos Ramos Machado, Nelio Garcia de Barros, Candida Helena Pires de Camargo, Maria Fernanda Gouveia da Silva Abstract developing countries of Asia, Africa, Latin Objective-To determine the frequency America, and central Europe, where prevalence and features of psychiatric morbidity in a rates vary from 0-1 to 4-0%.2 8 It may also be cross section of 38 outpatients with neuro- found in urban areas of developed countries cysticercosis. among ethnic subgroups.9 12 Methods-Diagnosis of neurocysticerco- The two host life cycle of the cestode sis was established by CT, MRI, and CSF involves humans as definitive hosts and swine analysis. Psychiatric diagnoses were as intermediate hosts. The adult intestinal form made by using the present state examina- of the parasite is acquired by eating under- tion and the schedule for affective disor- cooked pork contaminated with cysticerci,13 14 ders and schizophrenia-lifetime version; whereas cysticercosis is usually acquired by a cognitive state was assessed by mini men- fecal-oral mechanism-that is, by the ingestion tal state examination and Strub and of Taenia solium eggs shed in the faeces of a Black's mental status examination. human carrier. Contaminated water and food Results-Signs of psychiatric disease and (especially raw vegetables) are the most com- cognitive decline were found in 65-8 and mon sources of infection.19 16 The digested eggs 87-5% of the cases respectively. Dep- release embryos that actively penetrate the ression was the most frequent psychiatric mucosa of the upper digestive system and enter diagnosis (52-6%) and 14-2% of the the blood stream. They lodge in muscle, fat, patients were psychotic. Active disease nerve, and eye tissues, and become encysted for and intracranial hypertension were asso- several years.8 The degeneration of the cysts, ciated with higher psychiatric morbidity, which may be spontaneous or induced by and previous history of mood disorders antiparasitic drugs, is accompanied by inflam- was strongly related to current depres- mation, fibrous encapsulation, and calcium sion. Other variables, such as number deposition. Brain pathology is based on several and type of brain lesions, severity of neu- different mechanisms, depending on the num- ropsychological deficits, epilepsy, and use ber, type, and location of the cysts, as well as of steroids did not correlate with mental the host's immune response. 17 19 disturbances in this sample. The clinical picture often includes seizures http://jnnp.bmj.com/ Conclusions-Psychiatric abnormalities, and hydrocephalus. Mental disturbances are particularly depression syndromes, are typically present in the course of the disease frequent in patients with neurocysticerco- and were extensively studied by psychiatrists at Department of sis. Although regarded as a rare cause of the beginning of the century. Mental syn- Psychiatry dementia, mild cognitive impairment dromes that could mimic schizophrenia, major O V Forlenza A H G V Filho may be a much more prevalent neuropsy- affective disorders, and dementia have been chological feature of patients with neuro- positively reported,20 but few recent studies on October 1, 2021 by guest. Protected copyright. Department of Neurology cysticercosis. The extent to which organic have tried to describe the psychopathology J P S Nobrega mechanisms related to brain lesions may associated with neurocysticercosis with appro- L dos Ramos Machado underlie the mental changes is yet priate instruments for psychiatric assessment. Department of unclear, although the similar sex distrib- Radiology N G de Barros ution of patients with and without depres- sion, as well as the above mentioned Methods Department of Psychology, University correlations, provide further evidence of In the present study, 38 non-selected consecu- of Sao Paulo Medical the part played by organic factors in the tively admitted outpatients from the Section of School, Sao Paulo, cause of these syndromes. Neuroinfectious Diseases of the Hospital das Brazil C H P de Camargo Clinicas University of Sao Paulo (HCF- M F G da Silva (J Neurol Neurosurg Psychiatry 1997;62:612-616) MUSP) were assessed between January 1993 Correspondence to: and April 1994. The age range was restricted to Dr Orestes V Forlenza, between 18 and 60 old. Patients with Projeto Terceira Idade, years Instituto de Psiquiatria, Keywords: neurocysticercosis; organic mental disor- other neurological or medical conditions that Hospital das Clinicas da ders; depression; psychosis could as well as Faculdade de Medicina da present psychiatric symptoms, Universidade de Sao Paulo, those on drug therapies that could affect the Rua dr Ovidio Pires de is the most common mental state the ones for the Campos S/N, Cep 05403- Neurocysticercosis para- (except necessary 010 Sa Paulo-SP, Brazil. sitic infection of the human CNS' and is caused treatment of epilepsy or intracranial hyperten- Received 11 November 1996 by the infection of nerve tissues by the larval sion) were excluded, as well as current alcohol and in revised form misusers. 23 January 1997 form of the pork tapeworm Taenia solium. It and substance Accepted 30 January 1997 occurs endemically in the rural areas of the Aetiological diagnosis was ascertained by Psychiatric manifestations ofneurocysticercosis: a study of38 patientsfrom a neurology clinic in Brazil 613 positive immunological tests in CSF and tomo- Active neurocysticercosis was hence diagnosed J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.62.6.612 on 1 June 1997. Downloaded from graphic findings suggestive of neurocysticerco- for 29 patients (76&3%). sis (small, multiple, and scattered calcifications Radiographic data showed that 20 patients or cystic, contrast enhanced or not, lesions (52 6%) had parenchymal cysts or calcifications within the brain parenchyma).'5' Brain MRI only. Ventricular and cysternal cysts occurred was performed to provide more sensitive imag- in five (13-2%), and the remainder had sub- ing of patients with cystic lesions, both for diag- arachnoid (5-3%) or miscellaneous lesions nostic accuracy and detection of parenchyma (28 9%). Parenchymal lesions were usually oedema.21-23 multiple and scattered, in different stages of Cases were classified according to the main evolution. Only five patients had a single cyst, site of lesion location in the CNS (parenchyma, 15 had two to five, and six had more than 20 ventricular, subarachnoid, and miscellaneous brain lesions (one with more than 300). Both neurocysticercosis), and also according to dis- hemispheres were equally affected, including ease activity.'8 Cases were considered inactive if lesions in all cortical areas and subcortical neuroradiological images showed only calcifica- structures (thalamus and basal ganglia). tions or hydrocephalus without cysts, in the Psychiatric diagnosis was based on previous absence of signs of inflammation in the CSF (before this cross section) and current evidence analysis. Active disease included all cases in of mental disease and also on signs of cognitive which cysts (with or without parenchyma decline. Fifteen patients had no evidence of inflammation) could be found in neuroimaging previous mental disease and 23 patients studies or cases with inflammatory CSF (60 5%) had a positive psychiatric history (increased CSF cells, pleocytosis, and increased according to the SADS-L interview. Among protein concentrations ) .24 these, 42 research diagnostic criteria (RDC) Current mental state was evaluated by the were met, which indicates that more than one present state examination (PSE)25 26 and the diagnosis was possible for some patients in this mini mental state examination (MMSE).'7 lifetime assessment (table 1). Depressive disor- Previous psychiatric history was assessed with ders (including major, minor, and intermittent the schedule for affective disorders and schizo- depression) were the most common of these phrenia-lifetime version (SADS-L).28-31 A findings (15 patients). brief neuropsychological test was performed Thirteen patients (34 2%) were presumed with Strub and Black's mental status examina- mentally healthy by the PSE (index of defini- tion (MSE)," which evaluates attention, mem- tion < 5), whereas 25 (65 8%) had mild or ory, language (including reading and writing), moderate psychiatric manifestations compatible visuospatial abilities, executive functions with at least one psychiatric diagnosis. The PSE (including praxis and motor functions), and subscores suggested that non-specific neurotic higher cognitive functions. Psychiatric diag- syndromes (NSNs) were possibly the main psy- noses were based on the total PSE scores and chopathological tendency among the cases allocation in the PSE syndromes and classes for analysed, occurring in at least 75% of the test each patient. Patients with suspected psychi- group, and achieving here the highest scores. atric disease were submitted to the DSM-III-R The PSE subscores for specific neurotic syn- diagnostic criteria.33 Due to the high prevalence dromes (SNRs) and behaviour, speech, and of illiteracy among the users of the HCFMUSP others (BSOs) occurred in at least 25% of the http://jnnp.bmj.com/ facilities,