A 21 year old Spanish-speaking male immigrant from Guatemala with no significant past medical history presented to the emergency department (ED) with nausea, vomiting, neck pain, and vertigo. He was noted to have bilateral horizontal nystagmus on exam. A CT scan of the head was normal, and lumbar puncture (LP) with cerebrospinal fluid (CSF) analysis demonstrated lymphocytic predominance, elevated protein, and low glucose. He was admitted to the hospital and started empirically on broad-spectrum antibiotics, dexamethasone, and antiviral coverage for meningitis. CSF cultures showed no growth, and the patient clinically improved. He was diagnosed with aseptic meningitis and discharged home without antibiotics. However, he later presented four more times to the ED with recurrent symptoms of nausea, dizziness, and back pain. When his presentation included new onset ataxia, he was again admitted to the hospital. A repeat LP demonstrated an increased opening pressure. MRI showed an enhancing fourth ventricle mass and mild obstructive hydrocephalus, along with a mass at the L2/L3 spine. He underwent ventriculostomy placement, but was found to have normal intracranial pressures. The spinal lesion was biopsied, and demonstrated reactive macrophages. CSF analysis returned positive for cysticercosis antibody by ELISA, and was confirmed by serum cysticercosis IgG/Western Blot. The patient remained stable and due to financial difficulties with albendazole treatment, it was decided to monitor the patient with outpatient follow-up.
Cysticercosis is a parasitic infection transmitted by ingestion of Taenia solium (pork tapeworm) eggs. It is prevalent in Central and South America, and in endemic regions is one of the most common helminthic infections of the central nervous system. In the US, the incidence of this disease is growing, due to the rising immigrant population. It can be challenging to diagnose, as clinical symptoms are nonspecific and can vary significantly between individuals. Parenchymal involvement of neurocysticercosis commonly presents with seizures. In extraparenchymal disease, hydrocephalus can develop if the cysts are trapped in the interventricular foramina. Diagnostic criteria for neurocysticercosis includes neuroimaging, serology, CSF analysis, and biopsy in the appropriate population. After diagnosis, the patient should be started on antiparasitic therapy, most commonly a combination of albendazole and corticosteroids. Patients that present with seizures may also require antiepileptic therapy.
The prevalence of cysticercosis is increasing in the US with the rising number of immigrants from endemic areas. Neural involvement can be the presenting manifestation with a wide range of signs and symptoms, including seizures, nausea, vomiting, ataxia, and hydrocephalus. It is important to consider this diagnosis in patients with nonspecific neurologic complaints and the appropriate exposure history.
To cite this abstract:Steinbrink J, Macari D, Larsen G, Grant P. Twisted Cyster. Abstract published at Hospital Medicine 2015, March 29-April 1, National Harbor, Md. Abstract 700. Journal of Hospital Medicine. 2015; 10 (suppl 2). https://www.shmabstracts.com/abstract/twisted-cyster/. Accessed July 23, 2019.