ChrisCPilot: Cysticercosis
August 24th 2006 14:27
Final Clinical Impression
Rebecca Adler, aged 29, presented to Princeton-Plainsboro Hospital with a history of first seizure one month ago, with loss of ability to speak.
Non-responsive to radiation treatment (for possible brain tumours)
Given high dose steroid to treat inflammation (for possible Dx of cerebral vasculitis)
Further assessments revealed tapeworm infestation of the brain, bloodstream and muscles, due to frequent ingestions of undercooked ham (supporting the final Dx of Cysticercosis.
Evidence for our final clinical impression is:
Hx:
Presenting Hx: Seizure first occurring 1 month before presenting at hospital.
Loss of verbal abilities.
Deterioration of mental status & focal neurologic deficits.
Family Hx: No family history of brain tumours
Mother passed away 3years ago due to heart attack
Dad broke his back doing construction
Examination:
Present deterioration of mental status
Normal neurological examination after administration of steroid
Another episode of seizure, with intermittently altered mental status and verbal skills following administration of steroid.
Further deterioration with loss of functioning of lower limbs, including the bladder.
Signs of increased intracranial pressure occur, e.g. visual changes, vomiting, and confusion.
Investigation:
Protein markers for the three most prevalent brain cancers: negative
MRI: showing nonspecific lesion in the brain
CAT scan: failed to show anything conclusive
MRI with gadolinium contrast: not completed due to acute oedema of the airways-possible allergic reaction to gadolinium
Blood thiamine level: normal- rule out Wernickie's encephalopathy
Mildly elevated SED rate: possible cerebral vasculitis? (Note: SED rate= "the rate at which red blood cells settle out in a tube of blood under standardized conditions; a high rate usually indicates the presence of inflammation")
Normal eosinophil count: only 30% of patients with tapeworm infestation show abnormal eosinophil count
Plain X-ray showing cigar-shaped calcifications in the thigh and calf muscles- evidence of tapeworm larvae
Follow up:
Patient was treated with albendazole*, 2 pills with meals every day for at least a month. Last seen to be responding well to treatment, with no side effects. Regained normal neurological functions.
* Decreases ATP production in worm, causing energy depletion, immobilization, and finally death. These agents can provoke an inflammatory response in the central nervous system. Thus, if either drug is given, the patient must be started on high-dose glucocorticoids.
Effectiveness of therapy can be monitored via radiographic imaging. The size of the active lesions should decrease within 3-6 months.
Notes on tapeworms:
Taenia solium, also called the pork tapeworm, is a cyclophyllid cestode in the family Taeniidae. It infects pigs and humans in Asia, Africa, the Philippines, Latin America, parts of Southern Europe, and pockets of North America. In Muslim countries, and in Jewish communities, it is found only very rarely, due to religious dietary restrictions.
Three absolute criteria for Dxing T. solium infection:
1. Histologic demonstration of the parasite
2. Direct visualization of the parasite on funduscopic examination
3. Evidence of cystic lesions showing the scolex on CT scan or MRI
Credits: Info and images obtained from Emedicine, Wikipedia, Answers.com and Twiztv.com
Rebecca Adler, aged 29, presented to Princeton-Plainsboro Hospital with a history of first seizure one month ago, with loss of ability to speak.
Non-responsive to radiation treatment (for possible brain tumours)
Given high dose steroid to treat inflammation (for possible Dx of cerebral vasculitis)
Further assessments revealed tapeworm infestation of the brain, bloodstream and muscles, due to frequent ingestions of undercooked ham (supporting the final Dx of Cysticercosis.
Evidence for our final clinical impression is:
Hx:
Loss of verbal abilities.
Deterioration of mental status & focal neurologic deficits.
Family Hx: No family history of brain tumours
Mother passed away 3years ago due to heart attack
Dad broke his back doing construction
Examination:
Present deterioration of mental status
Normal neurological examination after administration of steroid
Another episode of seizure, with intermittently altered mental status and verbal skills following administration of steroid.
Further deterioration with loss of functioning of lower limbs, including the bladder.
Signs of increased intracranial pressure occur, e.g. visual changes, vomiting, and confusion.
Investigation:
Protein markers for the three most prevalent brain cancers: negative
MRI: showing nonspecific lesion in the brain
CAT scan: failed to show anything conclusive
MRI with gadolinium contrast: not completed due to acute oedema of the airways-possible allergic reaction to gadolinium
Blood thiamine level: normal- rule out Wernickie's encephalopathy
Normal eosinophil count: only 30% of patients with tapeworm infestation show abnormal eosinophil count
Plain X-ray showing cigar-shaped calcifications in the thigh and calf muscles- evidence of tapeworm larvae
Follow up:
Patient was treated with albendazole*, 2 pills with meals every day for at least a month. Last seen to be responding well to treatment, with no side effects. Regained normal neurological functions.
* Decreases ATP production in worm, causing energy depletion, immobilization, and finally death. These agents can provoke an inflammatory response in the central nervous system. Thus, if either drug is given, the patient must be started on high-dose glucocorticoids.
Effectiveness of therapy can be monitored via radiographic imaging. The size of the active lesions should decrease within 3-6 months.
Notes on tapeworms:
Taenia solium, also called the pork tapeworm, is a cyclophyllid cestode in the family Taeniidae. It infects pigs and humans in Asia, Africa, the Philippines, Latin America, parts of Southern Europe, and pockets of North America. In Muslim countries, and in Jewish communities, it is found only very rarely, due to religious dietary restrictions.
Three absolute criteria for Dxing T. solium infection:
1. Histologic demonstration of the parasite
2. Direct visualization of the parasite on funduscopic examination
3. Evidence of cystic lesions showing the scolex on CT scan or MRI
Taenia solium
Cysticercosis
Credits: Info and images obtained from Emedicine, Wikipedia, Answers.com and Twiztv.com
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