Isolated brainstem cysticercosis: A review

Neurocysticercosis presenting with oculomotor nerve palsy: Case report and literature review

Neurocysticercosis (NCC), a central nervous system infection caused by the cystic larvae of Taenia Solium, is endemic in many low-to-middle income countries. NCC is known to have a variety of presentations depending on the size and site of involvement including chronic headaches, seizures, hydrocephalus, and ischemic insults. NCC has also been rarely associated with cranial nerve palsies. We report the case of a 26-year-old Nepalese lady who presented with isolated left-sided oculomotor nerve palsy and was found to have midbrain NCC. She was treated with anthelminthic agents and corticosteroids which led to clinical improvement. NCC can present with a variety of focal neurological syndromes. To the best of our knowledge, this is the first case report of NCC presenting with third cranial nerve palsy in the state of Qatar and the middle east. We also review the literature for other cases of NCC which presented with isolated oculomotor nerve palsy.

Cysticercosis and suicide - an example from a forensic collection

In this case from 1937, the deceased was a 52-year-old female who was suffering from systemic cysticercosis, with prominent neurological and psychiatric symptoms. Given the protracted clinical course and autopsy findings it appears likely that the disease led the woman to commit suicide by ingesting lye, a corrosive substance, and the most common way to commit suicide in Belgrade at the time. The autopsy revealed many rounded transparent cysts, attached to the dura and pia-arachnoid, as well as encapsulated in the intercostal muscles, diaphragm and muscles of the arms, legs and the trunk. Solitary cysticercosis of muscles without involvement of the central nervous system is rare: most soft tissue and muscular cysticercal infections are associated with the central nervous system. Parasites usually lodge in the cerebral cortex or the subcortical white matter, due to the high vascular supply of these areas. Psychiatric symptoms in neurocysticercosis have been frequently reported, along with cognitive decline and intellectual deterioration, depressive disorders, behavioral disturbance and psychosis. Although sporadically, the disease is present even today, and neurocysticercosis is the leading cause of epilepsy in the developing world. To maintain its lifecycle, Taenia solium requires non-industrialized pig rearing conditions, consumption of undercooked pork, and low sanitation standards. Socioeconomic and sanitary improvement and educating people about food processing, the disease and antihelminthic therapy, are important factors contributing to a significant reduction in the prevalence of this potentially eradicable disease worldwide.

Biallelic MYORG mutation carriers exhibit primary brain calcification with a distinct phenotype

Primary familial brain calcification (PFBC) is a rare neurogenetic disorder with diverse neuropsychiatric expression. Mutations in four genes cause autosomal dominant PFBC: SLC20A2, XPR1, PDGFB and PDGFRB. Recently, biallelic mutations in the MYORG gene have been reported to cause PFBC with an autosomal recessive pattern of inheritance. We screened MYORG in 29 unrelated probands negatively screened for the autosomal dominant PFBC genes and identified 11 families with a biallelic rare or novel predicted damaging variant. We studied the clinical and radiological features of 16 patients of these 11 families and compared them to that of 102 autosomal dominant PFBC patients carrying a mutation in one of the four known autosomal dominant PFBC genes. We found that MYORG patients exhibited a high clinical penetrance with a median age of onset of 52 years (range: 21-62) with motor impairment at the forefront. In particular, dysarthria was the presenting sign in 11/16 patients. In contrast to patients with autosomal dominant PFBC, 12/15 (80%) symptomatic patients eventually presented at least four of the following five symptoms: dysarthria, cerebellar syndrome, gait disorder of any origin, akinetic-hypertonic syndrome and pyramidal signs. In addition to the most severe clinical pattern, MYORG patients exhibited the most severe pattern of calcifications as compared to the patients from the four autosomal dominant PFBC gene categories. Strikingly, 12/15 presented with brainstem calcifications in addition to extensive calcifications in other brain areas (lenticular nuclei, thalamus, cerebellar hemispheres, vermis, ±cortex). Among them, eight patients exhibited pontine calcifications, which were observed in none of the autosomal dominant PFBC patients and hence appeared to be highly specific. Finally, all patients exhibited cerebellar atrophy with diverse degrees of severity on CT scans. We confirmed the existence of cerebellar atrophy by performing MRI voxel-based morphometry analyses of MYORG patients with autosomal dominant PFBC mutation carriers as a comparison group. Of note, in three families, the father carried small pallido-dentate calcifications while carrying the mutation at the heterozygous state, suggesting a putative phenotypic expression in some heterozygous carriers. In conclusion, we confirm that MYORG is a novel major PFBC causative gene and that the phenotype associated with such mutations may be recognized based on pedigree, clinical and radiological features.

Histopathologic aspects of experimental cysticercosis and in situ cytokines profile in C57BL/6 mice

ABSTRACT Neurocysticercosis (NCC) is one of the parasitic infections that most affects the central nervous system. The knowledge regarding its immunopathogenesis and pathophysiology needs broadening. Taenia crassiceps cysticerci are used as the NCC experimental model. The aim of this work was to describe the general pathological processes and the in situ cytokine profile in C57BL/6 mice inoculated intracranially with viable T. crassiceps cysticerci. The histopathology analysis showed cysticerci in the extraparenchymal and intraventricular region, mononuclear inflammatory infiltration surrounding the parasite, microgliosis and meningitis. The analysis of the in situ immune profiles showed a predominance of the Th2 response. The IL-4 and IL-10 dosages were significantly increased in the infected group. The decrease in the INF-gamma dosage reflects the immunomodulation from the cysticerci. In conclusion, a T. crassiceps NCC infection in C57BL/6 mice triggers an inflammatory response, a predominance of Th2 type in situ profile, with mononuclear inflammatory cell infiltration, meningitis and microgliosis.

Isolated brainstem tuberculomas

BACKGROUND

Isolated brainstem tuberculomas are rare lesions and account for up to 5% of all intracranial tuberculomas in endemic areas. The difficulties in diagnosis and management of this condition are sparsely reported. The aim of this study is to illustrate the nuances in managing brainstem tuberculomas, define prognosis, and demonstrate a shift in management strategies with newer imaging modalities.

METHOD

A retrospective review of 14 patients diagnosed and treated with a diagnosis of 'isolated brainstem tuberculoma' between 2011 and 2015 was done. Diagnosis was made after combining the findings at clinical history, examination, as well as imaging features. Patients were treated with steroids for 6 weeks or until they made a meaningful clinical recovery, and antitubercular therapy (ATT) for a minimum of 18 months or until there was resolution of the tuberculoma. Confirmation of tubercular pathology was done by observing if response to treatment resulted in clinical improvement, which happened in all of our cases.

RESULTS

Mean age at diagnosis was 24.7 years and nine were males. Twelve patients had a combination of cranial nerve deficits with pyramidal weakness or sensory symptoms. Mean duration of symptoms was 4.7 months and tests for human immunodeficiency virus (HIV) infection were negative in all patients. Only two patients had a previous history of tubercular meningitis. Most lesions were located in the pons with size ranging from 1 to 22.2 cm³. Eight patients showed complete resolution of the lesion at latest follow-up and the rest were still on ATT. Mean duration of ATT received for resolution of the lesion was 22 months. Almost all of our patients improved clinically on steroids and ATT.

CONCLUSIONS

Intracranial tuberculomas may present with or without meningitis. A high index of suspicion is essential, especially in endemic areas. A combination of clinical symptoms, investigations, and imaging features help in coming to a diagnosis. Biopsy of a brainstem lesion is fraught with complications. Antitubercular therapy has a very good prognosis, though the duration of therapy required may be longer.