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Neurocysticercosis case presentation sudip mg edit
1. Presenter: Dr. Sudip Bhattacharya,
Junior Resident, Dept. of Community Medicine,
SPH,PGIMER, Chandigarh, India.
PGIMER, CHANDIGARH
2. Outline
īWhat is NCC?
īCase presentation
īPsychological and social aspect of this case
īFamily diagnosis
īManagement
Individual level
Family level
Community level
3. Neurocysticercosis (NCC)
īNeurocysticercosis (NCC) is the most common cause
of acquired epilepsy in developing countries
īCaused by Taenia solium larva
īPresents variably depending on the location and stage
of cysts in the nervous system, and the host immune
response
īParenchymal/ extraparenchymal/ others
īBiological marker of the social and economic
development of a community- major public health
problem
īDifficult to exactly estimate the disease burden of
NCC in a community study
4. Clinical features
Parenchymal (commonly in children)
īSeizures (70-90%)
īHeadache and vomiting (33%)
īRaised intracranial pressure with papilloedema (2.3â
6.6%)
īNeurodeficit (4-6%)
Principles of Internal medicine,Harrisons-18th
5. Family profile
Name Age
(years )
Sex Education Occupation Income Health status
Hariram 37 M 5th
std Works in
Godrej
factory
4,000 pm Healthy
Menadevi 35 F Illiterate Maid servant 2,500 pm Healthy
Puja 13 F 8th
std Student -- Cysticercosis
(NCC)
Sandhya 10 F 5th
std Student -- Healthy
Prince 08 M 3rd
std Student -- Healthy
Sonu 06 M 1st
std Student -- Healthy
)lo-lowerlo
Address: sector 56,#3823, Chandigarh,
6. Chief complaints
A 13 year female child presented with
h/o nausea and vomiting for 5-6 days after taking
antiepileptic medication (on carbamzepine for last 4
years)
7. History of present illness
īBefore 5-6 days she was apparently well
ī From 5-6 days nausea and vomiting started
īIt was insidious in onset and progressive in nature
īFrequency was twice in a day and occurred when she
took her routine antiepileptic medication
īIt subsided by taking medication (ondansetron)
īBefore this episode another episode of vomiting
occured 1 month back
8. Cont .
Date Episo
de
Time Involvement Seen by What was done?
2008,
summer
1 Night Generalized Grand
mother
Slapping and sniffing of
shoes
16/7/ 2009 1 1 am Generalized Mother Warming peripheries,
jaw retraction,
went to hospital
27/10/2012 1 8 pm Generalized Mother Warming peripheries,
went to hospital
28/2/ 2013 1 8 am Generalized Mother Warming peripheries,
went to PGI
16/9/2013 1 7 am Generalized Mother Jaw retraction, PGI
Seizure events
9. Cont.
īNo H/o tongue bite, drolling of saliva
īNo H/o deviation of angle of mouth
īThere was no alteration of sleep pattern/behaviour
changes/school performances
10. Cont.
īThere is history of taking antiepileptic medication
(Carbamazepine for 4 yrs)
īThere is no history of:
īFever
īGastroenteritis
īIndigestion
īBlurring of vision
īHeadache
īMenstrual problems
11. Antenatal history
īIt was not a booked case
īNo T.T. injection, IFA was taken
īNo such complications was present
īNo history of drug intake, radiation, high fever
12. Birth history
īIt was a home delivery by local aunty
īBirth weight was not measured but according to
mother puja was healthy enough
īPuja cried immediately after birth
13. Immunization history
īPuja was given 1 st dose of vaccines(2 intramuscular
and 1 oral)âwhen father came from Chandigarh
īAfter that no vaccine was given
15. Family history
Uncle of Hari Ram was a
known case of PTB
(Chandigarh)
Was under PGI follow up
(HAEMOPTYSIS)
Died at PGI due to
complications of
TB 4 years back
(RESPIRATORY
PROBLEM)
Except Puja all
are healthy in
this family
16. Personal History & Dietary History
īNon -vegetarian family , used to eat roasted pork in the
village
īNo habit of washing hand regularly before eating, after
toilet and play etc. Eats raw tomato and mulas without
washing.
īTaking 2200/2180Kcal/d and protein 40/39.6g/d as per the
requirement.
17. Duration is about for 5
minutes, it was generalized
seizure
Hari ram shifted to his
family from Bihar to
Chandigarh for better
treatment
1 st episode of convulsion occurred at the
age of 5 yrs in the village of Bihar
(2008,april)
During
open air
defecation
subsided
with local
practices
(sniffing of
shoes,
slapping)
Grandmother
of Puja sought
care from faith
healers
/mother
sought care
from local
RMP doctor
As he worked
in Chandigarh
and knows
about PGI
Treatment History
18. 2nd
episode (midnight) occured in Chandigarh
16/7/2009
(continued medicines of RMP doctors for 1 year)
They went to emergency of
Civil Hospital SAS nagar
After 5 days she was discharged with all
reports and advised for OPD check up
regularly
Treated
with Inj.
phenyto
in
Given Tab
Cabamaziepine and
Albendazole
CT scan
brain, EEG,
blood test
and chest X
ray done
(private/40
00Rs)
19. On 27/10/2012 again 3rd
episode occurs
Again they went to Civil
hospital, SAS Nagar
They referred the case
to PGI emergency
It was
uncontrollabl
e
Again treated
with Inj.
Phenytoin
20. She was admitted in
PGI(28/10/12) for 3 days
Discharged with
advice (regular
check up in NCC
clinic)
28/2/13 another episodes
occurs and treated in PGI
emergency
EEG (N)and
CT scan,
done
(calcified
granuloma in
Right Parietal
region)
Tab Carbamazepine
16mg/kg body wt.
and Calcium 500mg
OD was given
21. 4/9/13 admitted in Paediatric emergency with
vomiting at 1 pm.
Treated with Inj. Emeset, Pantop and 5% RL,
Observed for 7 hrs and discharged with advice
Seizure occurs at 7 am, 16/9/13, observed in
emergency from 8 am to 2 pm and treated
with oral phenytoin and discharged
On 19/9/13 she came with
vomiting and treated in OPD
and advised for investigations
EEG and blood
carbamazepine
level
22. Environmental History-Bihar
īHousing âkutcha, 2 rooms
īToilet âopen air
īKitchen âout side, biomass fuel
īDrinking water-from own tube well
īWaste disposal outside the house
īProblem of drinking water during summer and flood
occurs in rainy season
26. Health seeking behaviour
īMajor as well as minor illness: Civil dispensary
īPreferred civil hospital for emergency because it is
free and it is the nearest
īFor any emergency they used to come in PGI
27. Social
īThey are residing in Chandigarh for more than 5 years
īThey have no such problems faced till now
īGood personal and social support from neighbours
28. Psychological
âDoctor saab, yeh daura kab
bandh hoga ?
Paisa ka problem ho raha
hai.
Mujhe is bimari ke karan
ghar se bahar nikalna para.
Puja ki pitaji ab bahut chir
chire rahate hai,aur gussa
mujh pe nikalte hai.â
Images are not real
29. Cont. âMeri pyari beti pooja thik hogi
ki nahi? Rat ko daura ke bajah se
thik se nindh nahi ata hai.Har
mahine mei PGI jana kise pasand
hai? Ak to garib admi aur upar
se kaam bandh.Bhagban jane
uski padai ,saadi kaise hogi?
Kabhi kabar gussa ata hai fir
man ko samjhata hoon ki PGI
bale jarror thik karenge.â
Images are not real
30. Cont. âMujhe kuch pata nahi
chalti hai .Mujhe jada
kuch problem nahi
hai,kebal bar bar school
bandh karna parta
hai.Mere pitaji jada pyar
mujhe karte hai.â
Images are not real
31. Economic burden
īFor last five years they spent Rs 20,000.
īFor regular check up and medication they spent Rs
1000/month.
īIt causes mental stress to that family.
32. Examination
General
īPulse -72/min, regular Pallor-absent
īB.P.-120/74 mm of hg Cyanosis-absent
īR.R.-18/min Jaundice-absent
īAfebrile Clubbing- absent
īH.C.-49 cm
īWt-36.4 kg
īHt.-117 cm
īBMI-26.47
33. Systemic examination
īG.I.T.- No signs of dehydration present
ī Liver and spleen-NP
īResp.-B/l normal vesicular breath sounds present
īC.V.S-S1,S2 normal
īC.N.S-(H.M.F)-conscious oriented
ī Motor-normal deep tendon reflexes
ī B/l planter -flexor
ī No neck rigidity
ī Ophthalmologic examination-normal (fundoscopy not
done)
34. Investigations
īNCCT-Head(22/2/12): F/s/o calcified granuloma in
right parietal lobe. Compared to previous CT done
16/7/2009,there is no significant interval change.
īChest X Ray=normal
īEEG-normal awake EEG report
40. Diagnostic Criteria
Absolute EpidemiologyMinorMajor
1. Histological
demonstration
2. Cystic lesions
with scolex on
NI, or
3. Direct
visualisation of
ocular cysts
1. Suggestive
lesions on NI.
2. +ve sr.
immunoblot
3. Resolution of
cysts after
therapy
4.
Spontaneous
resolution ELs
1. Compatible
lesions on NI
2. Compatible
clinical
manifestations
3.. +ve CSF ELISA
4. Cysticercosis
outside CNS
1. Household
contact
2. Living in an
endemic area
3. Travel to
endemic areas.
Degrees of certainty
Definitive diagnosis : 1 Absolute or 2 Major +1 Minor+ 1 Epi.
Probable diagnosis : 1 Major+ 2 Minor or 1 Major + 1Minor+1 Epi or 3
Minor + 1 Epi.
ī.
Principles of Internal medicine,Harrisons-18th
41. Family diagnosis
ī A 13 year old girl belonging to lower middle class,
(modified Kuppuswami scale) nuclear hindu (harijan)
family suffering from Neurocysticercosis on
antiepileptic (carbamazine) medication and having
suspected drug over dose with no neurological deficit
at present.
īOther members of this family are apparently healthy
but parents are having some mental as well
economical stress.
42. Management
Individual level-
īTab Carbapazepine 16mg/kg/body weight
īTab Ondansetran 4mg stat and sos
īTo attend OPD after doing investigations
īTo attend paediatric ER sos
īDanger signs explained
īTo maintain hygeine
43. Cont.
Family level-
īGeneral hygiene (Hand) and washing of fruits and
vegetables.
īClean and safe water.
īProper cooking of meat.
īCysticidal therapy to all family members.
īFirst aid if seizure recurs and reporting to hospital.
44. Cont.
īCommunity level-
ī Education and general awareness about the zoonosis
ī Prevent roaming of the pigs to excrements
ī Use latrines and general hygiene measures (washing
hands)
ī Proper cooking of pork before consumption
ī Education and general awareness to the pig keepers
ī Municipalities should maintain strict measures
related to meat control and control use of wash
water
46. Cognition on Pork tape worm and NCC
How seizures?
Route of entry
Where does it enter
first and reside?
Consequences
How to prevent?
Curability
Timeline
47. 1.Daura ke time kya karti
ho?
2.Ye thik ho sakta hai?
3.Dabai kitna din dena
parega?
1.Hath per garam karti
hoon,jabra ko daba ke
rakhti hoon.
2.Haan.
3.Doctor saab ne teen sal
bataia tha lekin abhi bhi
dabai chal raha hai.
48. Life Cycle- Cestode: Taenia solium
(ICD 10-B68,71(NCC-B69))
NATURAL HISTORY
OF DISEASE IN
THIS CASE
īIntake of roasted
pork in village
īNo regular hand
washing habit
īUnwashed raw
vegetables
īAuto infection-
exogenous or
endogenous
NI: Neuro imaging
Crude Ag
Serum
50%-92%
70 â 95.7%
Diwan et al., 1982
Malla et al., 1992
Rosae et al.,1986
Kim et al., 1986
Why seizure occurs in NCC?
Due to blockage of blood vessels to brain.
From where the worm is coming?
Abdomen.
How it reaches abdomen?
Faeco-oral route due to unhygienic habits like eating earth (PICA) and or chalk.
How it reaches brain?
Through blood.
Classification
Kingdom : Animalia
Phylum : Platyhelminthes
Class
Order : Cyclophyllidea
Family : Taeniidae
Genus : Taenia
Species : saginata/ solium
Intestinal Taenia are among the earliest known human parasites known from prehistoric times
Second century, Galen recognized Taenia
First picture of tapeworm made by Andry in 1700
1782 Goeze found difference b/w two human species of Taenia
1845 Dujardin showed adult taenia in human arise from cysticerci in meat
1851 Kuchenmeister estabilished Life cycle
Humans are the only DHs
The eggs can survive for days to months in the environment
The adult worm attaches by their scolex to the human small intestine.
The adults produce proglottids passed with stool
The eggs are released after the proglottids are passed with the feces
Strobila
(Neck )
- short
- one-half as thickness as scolex
Strobila consists of a linear series of proglottids
Adults - The adult tapeworms have an average
length of ~3 meters, but can grow up to 8 meters