Chief Complaint: "Seizures"

Chief Complaint

“Seizures”

History of Present Illness

25-year-old male with no PMHx, BIBEMS after he had episode of tonic-clonic seizure. As per wife, who gave medical history, the patient was found down in a hotel with “his whole body shaking.”  Upon EMS arrival, he was given 5mg of Valium. On arrival to the ED, patient combative, not following commands with frothy oral secretions.  Wife endorses that patient has had weakness, dizziness, and malaise x 3 days, but no other complaints. Patient had another seizure while in the ER without regaining full consciousness.

Medical Hx: none
Surgical Hx: none
Review of Systems: otherwise negative
Social history: Drinks EtOH every 2-3 days, possible drug use as per wife. Patient migrated from Mexico 8 years ago, no recent travel.

Physical Exam

Vital Signs: T: 97.7 BP: 142/73   HR: 115   SaO2: 99% on RA   FS: 191
Gen: Combative, not following commands,
HEENT: Dilated but reactive to light, frothy oral secretions, +evidence of tongue biting
Lung: Bilateral breath sounds
Abdomen: Abrasions over LLQ
Skin: +urinary incontinence
Neuro: Moving all extremities

Patient was taken to the CT and subsequently to MRI the next day.

Questions

1. What’s the diagnosis?
2. What do the CT and MRIs show?
3. How would you treat this patient initially in the ER?

Answers

1. Based on his presentation and imaging, a presumptive diagnosis of neurocysticercosis (NCC) was made in the ED. This diagnosis should be considered in a patient with new seizures, history of living in an endemic area, and radiographic imaging with characteristic signs of infestation. Findings on imaging varies based on the location and phase of evolution of the infestation.Of note, serologic tests can be helpful but are not always necessary. Serum studies may show leukocytosis, eosinophilia, and elevated ESR. CSF should be tested using ELISA for detecting antibodies to neurocysticercosis. Other CSF abnormalities may be present if there are parasites in the basal cisterns or ventricles (look for mononuclear pleocytosis, normal or low glucose, elevated protein, and high IgG.)Regarding NCC, it is caused by a pork tapeworm. Taeniasis is when the infestation is in the intestines, NCC is for infestation in the brain. Seizures are the most common clinical manifestations of NCC.  NCC is the most common cause for seizures in young adults in or from endemic areas (Mexico, China, Southeast Asian, India, sub-Saharan Africa). The prognosis varies with the number of cysts and degree of inflammation. Patients with single lesions have a more favorable prognosis than those with multiple viable cysts.  Massive number of cysts can initially present as encephalitis, which can also be provoked by therapy when it causes a large number of cysts to degenerate simultaneously.
2. The CT shows focal vasogenic edema at the base of the right parietal lobe (as marked below). The MRI (FLAIR) shows high signal intensity in the area of vasogenic edema. Remember, with vasogenic edema the blood brain barrier is disrupted. The differential diagnosis for vasogenic edema most frequently includes primary or secondary neoplasm and cerebral abscess but can also be from parasitic infection, malignant hypertension, subacute infarction, metastases, and trauma. In Cytotoxic edema, the blood-brain barrier is intact but there is cellular dysfunction, specifically with sodium/potassium pumps that leads to cellular edema. Cytotoxic edema classically occurs in ischemic stroke, toxins, hypothermia, or hypoxia. These two forms of edema can occur simultaneously. 
3. The patient continued to seize without fully gaining consciousness and was deemed to be in status epilepticus. He was intubated, loaded with Dilantin and started on Propofol. Neurology was consulted, and the patient was admitted to the MICU. Remember to admit patients with signs of increased ICP, hydrocephalus or encephalitis presentation.  Anitparasitic medications such as Albendazole or Praziquantel can be used, but Albendazole is more effective. Use corticosteroids in combination with anti-parasitic medications in cases with multiple cysts, ventricular cysts, encephalitic presentations or multiple liver cysts.Extraparenchymal cysticerci can occur in the intraventricular or subarachnoid space leading to hydrocephalus, in which case Neurosurgery consult is needed. Other manifestations of extraparenchymal neurocysticercosis include spinal and ocular disease.

Pearls on NCC

• People may be asymptomatic for years
• Treatment depends on stage of evolution and location.
• The prognosis varies with the number of cysts and degree of inflammation.
• Admit patients with signs of increased ICP, hydrocephalus or encephalitis presentation.

References