Neurocysticercosis Dr. Abhijeet Deshmukh Dept. 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, blackou ts• No h/o memory disturbances, diplopia, weakness of limbs, loss of sensation, in co-ordination, bowel/bladder
-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
• 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) .
Previous Present 6x5x5 mm 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 systemNo 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)
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
A Kuruvilla et al.Sree Chitra Institute, Trivandrum (1986 – 1998)
Pork consumption & NeurocysticercosisUniversity 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 NEUROCYSTICERCOSISColloidal Obvious calcification on CT and MRI (T2*WI)
Cysticercus Granuloma Vs TuberculomaCysticercus Granuloma Tuberculoma• Round in shape • Irregular in shape• Cystic • Solid• 20mm or less with ring • Greater than 20mm enhancement or visible • Associated with severe scolex perifocal edema and focal• Cerebral edema not neurological deficit enough to produce midline shift or focal neurological deficit
• Cystecircus granuloma • Tuberculoma T2 W T2 W
Manifestations• Muscles: Painless • Eye: Impaired swelling. vision, may cause blindness & retinal detachment
• Heart: abnormal • Brain: most common- rhythms, failure seizures (70%), (rare) also - Confusion, - Lack of attention, - Imbalance, - Hydrocephalus
• 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
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 or Dexamethasone 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.
• Don’t drink river water directly,• Extra care in places with poor hygiene.
• Wash vegetables & • Deep freezing of fruits well. 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.
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