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 »  Abstract
 »  Introduction
 »  Case report
 »  Discussion
 »  References

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Year : 2000  |  Volume : 48  |  Issue : 3  |  Page : 260-2

Neurocysticercosis like presentation in a case of CNS tuberculosis.


Department of Neurology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, 221005, India.

Correspondence Address:
Department of Neurology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, 221005, India.

  »  Abstract

A clinical picture consisting of seizures, multiple non-tender subcutaneous nodules, and multiple 'nodular or ring' enhancing lesions in computed tomography of the brain is considered characteristic of neurocysticercosis in an endemic area. 1,2 A case with a similar clinical picture, in whom serological tests and histopathological examination of subcutaneous nodule established tuberculosis as a cause, is presented.

How to cite this article:
Garg R K, Kar A M, Kumar T. Neurocysticercosis like presentation in a case of CNS tuberculosis. Neurol India 2000;48:260


How to cite this URL:
Garg R K, Kar A M, Kumar T. Neurocysticercosis like presentation in a case of CNS tuberculosis. Neurol India [serial online] 2000 [cited 2019 Nov 21];48:260. Available from: http://www.neurologyindia.com/text.asp?2000/48/3/260/1525




   »   Introduction Top

Neurocysticercosis (NCC) is a common parasitic disease of central nervous system (CNS). The diagnosis of cerebral cysticercosis is based, primarily, on typical imaging characteristics of CT scan or magnetic resonance (MR) scan, and clinical features. The presence of subcutaneous cysts as subcutaneous nodules, usually confirms the diagnosis.[1],[2] In this report we are presenting a case with similar clinical and imaging manifestations, but serological and histopathological work-up revealed tuberculosis as its aetiology.


   »   Case report Top

A 15 years old girl presented with several episodes of left focal seizures with secondary generalisation of 15 days duration. General physical examination showed several subcutaneous nodules all over the body. These nodules were pea sized, freely mobile and non-tender. Other systemic and detailed neurological examination was normal.
Her urinalysis, haemogram, serum biochemical parameters and serum electrolytes were normal. The biochemical and cytological examination of cerebrospinal fluid (CSF) revealed proteins of 82 mg/dL, sugar of 34 mg/dL and 10 mononuclear cells/mm[3]. Electroencephalogram (EEG) showed intermittent delta activity in parieto-occipital region on the right side. The routine X-rays of chest, skull, thigh and forearm were normal. Cranial CT scan revealed multiple nodular enhancing lesions surrounded by hypodensity due to perifocal oedema [Figure. 1]. MRI also revealed multiple hyperintense ring like lesions along with surrounding oedema. These lesions were most conspicuous in T2-weighted images [Figure. 2]. ELISA for cysticercosis was negative in both serum and CSF. However, ELISA test (using M 80 - tuberculous antigen) in serum and CSF showed highly positive responses for anti-tuberculous antibodies. Histopathological examination of the biopsied subcutaneous nodule revealed tuberculous granuloma [Figure. 3].
The patient was given antiepileptic drugs along with anti-tuberculous treatment. Repeat CT scan after 3 months showed complete resolution of all the lesions. During this period she remained asymptomatic.


   »   Discussion Top

Diagnosis of cerebral cysticercosis depends on clinical suspicion and cranial imaging. The characteristic CT findings include enhancing (ring or nodular) lesions, ranging from 5 to 20 mm in diameter, which may be seen in any part of cerebral hemisphere. A punctate eccentric high density structure suggestive of scolex (which is pathognomonic of NCC), is seen in 44% of such patients.[3] Surrounding oedema may range from mild to severe. Another characteristic appearance of NCC is rounded hypointense non enhancing lesions. In several patients, multiple small calcifications dominate the CT picture.[4] In an epileptic patient, characteristic CT findings along with subcutaneous nodules is virtually diagnostic of NCC and usually does not require further workup.[2],[5] However, on CT scans, it is difficult to differentiate cysticercus granuloma from tuberculoma. Even MR imaging remains unhelpful. T2-weighted MRI scan is more helpful in showing the granulomas. There is characteristic hypointense ring with a hyperintense or isointense centre which may be surrounded by oedema; infrequently, there may be lesions with highsignal periphery and low-signal centers.[6],[7] Other evidence of tuberculosis (e.g. pulmonary tuberculosis) or cysticercosis (e.g. subcutaneous nodule) elsewhere is of great help in making a definite diagnosis. The serological tests are largely not available in peripheral centres. Biopsy of subcutaneous nodules should always be performed, if diagnosis of NCC is uncertain.[8],[9] In our case, the biopsy of subcutaneous nodules revealed tuberculosis of skin. Puri et al[10] also reported a similar patient who presented with multiple intracranial granulomas and acute miliary tuberculosis of the skin. However, the CSF examination and Mantoux test were negative.
Tuberculous infection of the skin is rare in the absence of long standing, untreated disease elsewhere.[11]
Erythema nodosum has been reported to have accompanied primary tuberculous infection in 1-5% of cases. The lesions of erythema nodosum are tender, dusky-red, nodular, and 5-20 mm in diameter and with ill defined margins. Subcutaneous nodules, as seen in the present case, were not because of erythema nodosum.[12] Occasionally, especially after cysticidal therapy, subcutaneous cysts of cysticercosis may also become acutely inflamed and swollen, but they slowly resolve and return to their original size.[9]
In case of NCC, multiple nodular ring lesions on contrast-enhanced cranial CT scan (inflamed cysts) represent dying cysts and may not require antiparasitic treatment except symptomatic treatment.[3],[13] However, in the case under report, the patient required complete course of anti-tuberculous treatment due to disseminated tuberculosis, emphasizing the need for correct diagnosis.

 

  »   References Top

1.Brown WJ, Voge M : Cysticercosis : a modern day plague. Pediatr Clin North Am 1985; 34 : 953-969.   Back to cited text no. 1    
2.Venkataraman S, Vijayan GP : Neurocysticercosis : clinical manifestations and problems in diagnosis. J Assoc Physicians India 1979; 29 : 543-549.   Back to cited text no. 2    
3.Mitchell WG, Crawford TO : lntraparenchymal cerebral cysticercosis in children: diagnosis and treatment. Pediatrics 1988; 82 : 76-82.   Back to cited text no. 3    
4.Del Brutto OH, Sotelo J : Neurocysticercosis : An update. Reviews of Infectious Diseases1988; 10 : 1075 -1086.   Back to cited text no. 4    
5.Chopra JS, Kaur U, Mahajan RC : Cysticercosis and epilepsy: a clinical and serological study. Transactions of Royal Society of Tropical Medicine and Hygiene1981; 75 : 4-9.   Back to cited text no. 5    
6.Chang KH, Lee JH, Han MH et al : The role of contrastenhanced MR imaging in the diagnosis of neurocysticercosis. American Journal of Radiology 1991; 157 : 393-396.   Back to cited text no. 6    
7.Rajshekhar V, Chandy MJ : Comparative study of CT and MRI in patients with seizures and a solitary cerebral cysticercus granuloma. Neuroradiology 1996; 38 : 542-546.   Back to cited text no. 7    
8.Cook CG : Neurocysticercosis: parasitology, clinical presentation, diagnosis and recent advances in management. QJM 1988; 256 : 575-583.   Back to cited text no. 8    
9.Wadia N, Desai S, Bhatt M : Disseminated cysticercosis: new observations including CT scan findings and experience with treatment by praziquantel. Brain1988; 111 : 597-614.   Back to cited text no. 9    
10.Puri V, Gupta RK, Maihotra V : lntracranial tuberculoma with cutaneous miliary tuberculosis. Indian Pediatrics1991; 28 : 1197-1201.   Back to cited text no. 10    
11.Daniel TM : Tuberculosis. In: Harrison's Principle of Internal Medicine. Wilson JD, Braunwald E, lsselbacher KJ, Petersdorf RG, Martin JB, Fauci AS, Root RK (Eds.) 12th Edition. McGraw Hill Inc. New York, 1991; 637-645 .   Back to cited text no. 11    
12.Seaton A, Seaton D, Leitch AG : In: Crofton and Douglas. Respiratory Diseases. 4th Ed. Blackwell Scientific Publications, Oxford, 1989; 395-422.   Back to cited text no. 12    
13.Kramer LD : Medical treatment of cysticercosis: ineffective. Arch Neurol 1995; 52 : 101-102.   Back to cited text no. 13    

 

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