Nurocysticercosis

Neurocysticercosis

Dr. Abhijeet DeshmukhDept. of Paediatrics

PIMS & RC, Tiruvalla

Case-1

• 5 yr old boy, from Ponkunnam,

- 2 episodes of left focal seizures.- Vomiting 2 episodes

He was admitted on 1st Feb 2012

• Was apparently normal 2 days back

• 2 episodes of stiffening of left upper & lower limb with clonic jerks lasting for <5min.

• Post-ictal drowsiness – ½ hour

• Taken to local hospital- Diazepam given & referred here.

• No h/o, fever, headache, vomiting, blackouts

• No h/o memory disturbances, diplopia, weakness of limbs, loss of sensation,

in co-ordination, bowel/bladder disturbances.

-No h/o significant illness/head trauma in past.- Uncomplicated antenatal/natal/post natal period

• Normal development , good scholastic performance.

• Non vegetarian • No family h/o seizures, tuberculosis.

On Examination:

- Moderately built & nourished.- Vitals -stable,

- No facial dysmorphism / neurocutaneous markers.

• Nervous systemConscious but drowsy.No cranial nerve palsy.No sensory & motor impairment.Cerebellar signs: ataxia + horizontal nystagmus+

(? Due to Phenytoin over dose), No meningeal signs.

• Other systems : Normal

Investigations

• Hemogram – Normal - Hemoglobin : 13.1 gm/dl (13-15 ) - Packed cell volume :35 gm% (35-50 ) - Total WBC count : 10200 cells/cu mm

Differential counts : Eosinophils 20%(1-6%) Polymorphs :51%(40-75%)

Lymphocytes :29%(20-50%)

- Platelets : 2.4 lakhs/cu mm- Erythrocyte sedimentation rate : 6/hour (3-15)

• Coagulation profile – Normal- APTT:C/T:26/34.6 PT:C/T:13.6/14.9 INR:1.11

• Peripheral blood smear : Moderate eosinophilia

• Renal parameters: Normal- Blood urea :14mg% (10-50). - Serum creatinine : 0.55mg%(0.6-1.5)

• Random blood sugar : Normal• Cerebrospinal fluid Study :

- TC- 18 cells, DC- P40% L60% Protein & sugar - Normal• Serum Phenytoin level : 30.4 mcg/ml (10-20)

• Serum Ca : 9.3mg% (8.1-10.4)Serum Phosphorus : 5 mg% (4-7)

• Serum Sodium : 139 mmol/L (135-145) Serum Potassium : 4.4 mmol/L (3.2-5.5)

• Urine routine : Normal • Urine culture- No growth, • Blood Culture

• EEG : Frequent focal epileptiform activity over both

parieto occipital regions (Right >Left)

T1 Pre contrast T1 Post contrastMRI brain

Post Contrast T1 SPGR

T2 axial

• MRI Impression:Small well defined ring enhancing lesion

(10 x 9 x 10mm) with scolex seen in right posterior-temporal region suggesting Neurocysticercosis.

Additional history & investigations

• Travel h/o enquired- Was residing at Delhi for 3 years.

• Monteux test : Negative• Chest X-ray : Normal• Anticysticercal antibody IgG : Negative

- 0.2 OD units(Positive>0.5)

Diagnosis

• ACUTE SYMPTOMATIC SEIZURES• NEUROCYSTICERCOSIS – Right posterior

temporal region

Treatment

• Ceftriaxone x 7days.• Phenytoin (Serum Phenytion-30mcg/ml) Levetiracetam.• Albendazole x 3 weeks• Prednisolone x 1 Week

• On review:- Seizure free.- Levetiracetam continued (20mg/kg/day) .

6x5x5 mm

Previous Present

T1 Post contrast Axial

Case-2

• 8 year old Girl from Kodukulanji , a) Giddiness - 1 day b) 2 episodes of Left focal seizures She was admitted on 22 Apr 2012.

• Was apparently normal 2 days back,• Giddiness with 1st episode of jerky

movements of left upper & lower limb lasting for 5 minutes – subsided by self.

• Taken to local hospital - 2nd similar episode developed, subsided with Lorazepam after

10 minutes.• Blood sugar level - normal.

• No h/o fever, headache, vomiting• No h/o blackouts• No h/o memory disturbances, weakness of

limbs, loss of sensation, in co-ordination, bowel/bladder disturbances.

-No h/o significant illness/head trauma in past.- Uncomplicated antenatal/natal/post natal period

• Development-Normal, good scholastic performance

• Vegetarian • No family h/o seizures, tuberculosis.

• On Examination:- Moderately built & nourished.- Vitals -stable,

No dysmorphism / neurocutaneous markers.- Fundus -normal

Nervous system:Higher mental functionsCranial nervesSensory systems NormalMotor system No signs of meningeal irritation

Investigations

• Hemogram: Within normal range- Hb : 12.9 gm/dl (12-15) - PCV : 37.9 gm% (36-47) - TC : 7300cells/cu mm

(P-64%, L-31%, E-5%) - Platelets :2.1 Lakhs/cu mm (1.3-5)

• Serum Calcium : 9.6 mg/dl (8.1-10.4)Serum Magnesium : 1.5 mg/dl (1.9-2.5)

Serum Phosphorus : 4.45 mg/dl (4-7)

MRIT1 Post contrastT1 Pre contrast

T2 Flair

IMPRESSION Tiny ring enhancing lesion with eccentric

scolex in right high parietal para falcine space with perilesional edema.

Features suggestive of Neurocysticercosis.

DIAGNOSIS

• ACUTE SYMPTOMATIC SEIZURES.• NEUROCYSTICERCOSIS: Right parietal region • Stage II cyst

Treatment

• Phenytoin.• Prednisolone for 1 week• Albendazole for total 3 weeks.

• Follow up:- Seizure free.- Continued with Phenytoin.- Advised repeat MRI in November 2012

CYSTICERCOSIS

• Caused by larval cysts of the cestode - Taenia solium (Pork tapeworm)

• Due to ingestion of food /vegetables, uncooked pork and water contaminated with human faeces containing eggs/larvae/worm itself.

• Human is the only definitive host of the adult pork tapeworm

Epidemiology

A Kuruvilla et al.Sree Chitra Institute, Trivandrum (1986 – 1998)

Pork consumption & Neurocysticercosis

University of Transkei, South Africa

TYPES OF CYSTS

1. Cysticercus cellulosae• Less virulent form• Small (<2cm), round, thin

walled• Lodges in the parenchyma

or the subarachnoid space• Provokes minor inflammation• Often remain silent

2. Cysticercus racemose

• Refers to cysts in the subarachnoid space.

• Can cause obstruction of 4th ventricle causing raised ICP and hydrocephalus

• Intense inflammatory reaction and seizures

STAGES OF NEUROCYSTICERCOSIS

Colloidal

Obvious calcification on CT and MRI (T2*WI)

Differential diagnosisOn Neuroimaging (Nelson)

SingleNON- ENHANCINGCystic lesion

MultipleNON-ENHANCINGCystic lesions

ENHANCING lesions Calcifications

Hydatid cyst Hydatid disease Tuberculosis Tuberculosis

Arachnoid cyst Multiple metastases Mycosis Tuberous sclerosis

Porencephaly Toxoplasmosis Toxoplasmosis

Cystic astrocytoma Abscess Cytomegalovirus

Colloid cyst Early glioma

Metastases

Arteriovenous malformation

Cysticercus Granuloma Vs Tuberculoma

Cysticercus Granuloma• Round in shape• Cystic• 20mm or less with

ring enhancement or visible scolex

• Cerebral edema not enough to produce midline shift or focal neurological deficit

Tuberculoma• Irregular in shape• Solid• Greater than 20mm• Associated with severe

perifocal edema and focal neurological deficit

• Cystecircus granuloma • TuberculomaT2 W T2 W

Manifestations

• Muscles: Painless swelling.

• Eye: Impaired vision, may cause blindness & retinal detachment

• Brain: most common- seizures (70%),

also- Confusion,- Lack of attention, - Imbalance,- Hydrocephalus

• Heart: abnormal rhythms, failure (rare)

• Spinal Cord: Most dangerous form. Blocks nerve impulses, loss of motor control, weakness, paralysis

INVESTIGATIONS

• Peripheral blood smear• Stool Routine and Microscopy• Fundoscopy• CSF study• Biopsy and histopathology• Serology• X Ray• CT/MRI

• Serology :1. (EITB) Enzyme-linked immuno electro

transfer blot assay 2 or more cysts in the CNS

Sensitivity: 94% - 98% , Specificity: ~ 100%

Richards et al. (Clin Lab Med 11:1011, 1991)

2.IgM ELISA & IgG ELISA – IgM ELISA is more specific than IgG ELISA

- IgG ELISA (Easily available): Sensitivity – 67%, specificity-64% . Sensitivity varies with type of

cysticercoisis. For single enhancing lesion – 34%. Serodiagnosis - not satisfactory. Kalra

Complications

• Arteritis : 53%• Meningitis : 50%• Mass effect :10-15%• Infarction :2%–12% • Ocular Cysticercosis : 5-7% • Encephalitis

Management• Initial management : Diagnose & manage

hydrocephalus / raised intracranial tension.• Next – To control seizure activity with

antiepileptics.

• Anti parasitic drugs : - Albendazole (DOC) : 15mg/kg/day

(max 800mg/day) Oral Short course – 8 days, Long course – 28 days

• Praziquantel (Expensive) : 50-100mg/kg/day-28 days

Worsening of symptoms can occur due to dying parasites.

• Prednisolone 2mg/kg/day orDexamethasone 0.15mg/kg/day.Either with Albendazole or 3 days prior to it.

Surgical management

• Ventriculo-peritoneal shunts for hydrocephalus

• Excision of single big cysts causing mass effect.

• Ocular cysts.

Prevention

• Don’t eat undercooked pork

• Adopt Clean water services

• Don’t drink river water directly,

• Extra care in places with poor hygiene.

• Wash vegetables & fruits well.

• Deep freezing of infested pork for will kill eggs/larvae/adult worms.

Take home message

• Neuroimaging should be done for all focal seizure cases - CT/MRI evaluation.

• Detailed history should be taken.• Incidence of Neurocysticercosis is almost

equal in vegetarian & non vegetarians.• Prevention is better than cure.

Thank You !

REFERENCES• Review of neurocysticercosis Julio Sotelo M.D., and Oscar H. Del Brutto, M.D• New Concepts in the diagnosis and management of neurocysticercosis (Taenia Solium) Hector

H. Garcia, Oscar H. Del Brutto, Theodore E. Nash, A. Clinton White, Jr., Victor C. W. Tsang, and Robert H. Gilman

• Neurocysticercosis: some of the essentials Hector H Garcia, Armando E Gonzalez, Victor C W Tsang, Robert H Gilman, for the Cysticerocosis Working Group in Peru

• Diagnostic criteria for neurocysticercosis: Some modifications are needed for Indian patients Garg Ravindra Kumar

• Medical Management of Neurocysticercosis Garg RK• Current Consensus Guidelines for Treatment of Neurocysticercosis. Garcia et al • Rate of spontaneous resolution of a solitary cysticercus granuloma in patients with seizures

Vedantam Rajshekhar, MCh• Differential diagnosis between cerebral tuberculosis and neurocysticercosis by magnetic

resonance spectroscopy.Cysticercosis working group in Peru• Harrison Textbook of Medicine 19th Edition• Bailey and Love’s Short Practice of Surgery 21st edition• Rudolph’s Pediatrics 21st edition• Nelson’s Textbook of Pediatrics• Others: D. Sharada et al, Carpio et al, Sotelo et al, Chorobski et al