Page 180 - Read Online

thin-walled membrane were seen. These yellow-spotted, signal within both lateral ventricles that did not
irregularly-shaped cysts were intimately attached enhance with contrast [Figure 2]. A third cycle of
to the arachnoid or the basilar artery. Their direct albendazole and corticosteroid was administrated,
visualization led to the confirmation of the diagnosis of which produced an improvement in cognitive status,
subarachnoid neurocysticercosis. Subsequently, cysts and lower limb power and coordination.
were gently grasped and removed for histopathological
evaluation, which revealed evidence of degenerative DISCUSSION
changes and an inflammatory reaction within the
walls, mediated by nuclear macrophage and eosinophil Neurocysticercosis, caused by larvae of the tapeworm
infiltration [Figure 1]. The patient then received two taenia solium, is the most common form of parasitic brain
cycles of antihelmintic therapies with albendazole and disease globally. [1,4] It can occur in intraparenchymal,
corticosteroid. This resulted in complete resolution of intraventricular, subarachnoid, or mixed forms. [5]
the patient’s symptoms and he returned to his normal
daily activities. A major characteristic of neurocysticercosis is
heterogeneity, with the clinical manifestations
Approximately 4 months after the surgery, the patient dependent on the localization, number, and evolutional
had a recurrence of the same symptoms. Brain MRI stage of the parasites, as well as the intensity of the
again revealed evidence of hydrocephalus. A VP shunt inflammatory reaction. Patients with neurocysticercosis
was placed, resulting in no obvious improvement of may be asymptomatic, or present with a wide variety of
[1]
clinical symptoms. symptoms. Typical CSF findings of neurocysticercosis
include moderate mononuclear pleocytosis, mainly
One year later, the patient reported new symptoms of of lymphocytes and elevated protein concentrations,
motor deficiency and urinary incontinence, which led ranging from 0.5 g/L to 2.0 g/L. In most cases, CSF
to his admission to our hospital. Physical examination glucose concentrations are normal or moderately
[4]
showed he was drowsy, but oriented. He demonstrated decreased. These CSF abnormalities are not present
full strength in his arms but decreased strength in in all cases, and so cannot be used as definite
[3]
his legs. The finger-nose and heel-knee-tibia tests diagnostic criteria. Usually, neuroimaging findings of
lacked accuracy on both sides and Romberg’s sign was extraparenchymal cysticerci are subtle: the cystic walls
positive. All the left-sided deep tendon reflexes were are thin, there is often an absence of pathognomonic
pathologically brisk. Babinski’s sign was negative on scolices, central cysts are isointense to CSF and they
[3]
both sides. The patient had no sensory deficits and no do not enhancement after contrast administration.
obvious meningismus. Detection of specific serum or CSF antibodies plays a
helpful role in the diagnosis of cerebral cysticercosis,
but it cannot differentiate between viable and
Computed tomography (CT) revealed persistent
ventricular dilation. A lumbar puncture was performed degenerated parasites and is unable to confirm CNS
[6]
on this patient, and the opening pressure was now localization. The diagnosis in this case was made
normal (160 mmH O). CSF studies also demonstrated with the help of direct endoscopic visualization and
2
a significantly increased number of white blood cells histologic demonstration. Since there exist enough
with a predominance of lymphocytes, an elevated
protein level (0.81 g/L), and a decreased glucose
concentration (0.1 mmol/L). Further evaluations
for tuberculosis, bacteremia, fungal infection, and
autoimmune processes were negative. Brain MRI
indicated multiple small cysts containing a CSF-like
a b

a b c d
Figure 1: Hematoxylin and eosin stained low power field image (a) cysticercus Figure 2: Brain magnetic resonance imaging showed multiple small cysts
larva. The multiple cysts of cysticercus larva underwent degenerative changes. with cerebrospinal fluid‑like signal inside within the lateral ventricles (a and c)
High power field image (x100); (b) the wall of cysts infiltrated by multiple nuclear T1‑weighted, (b) T2‑weighted and no enhancement (d) T2‑weighted with
macrophages and eosinophils (x200) contrast‑enhanced)

172 Neuroimmunol Neuroinflammation | Volume 2 | Issue 3 | July 15, 2015 Neuroimmunol Neuroinflammation | Volume 2 | Issue 3 | July 15, 2015 173