Disseminated intracranial tuberculoma mimicking neurocysticercosis

Monocyte Gene Expression Distinguishes Enhancing Brain Parenchymal Cysticercal Granulomas From Tuberculomas

BACKGROUND

In patients with enhancing brain parenchymal lesions, parenchymal neurocysticercosis (pNCC) is often difficult to distinguish from tuberculoma, necessitating biopsy or empirical therapy.

METHODS

In a prospective study, peripheral blood monocytes were isolated from patients with definitive pNCC (n = 39) and brain tuberculomas (n = 20). Patients with tuberculomas were diagnosed by the presence of concurrent systemic tuberculosis (n = 7), pathological or bacteriological confirmation (n = 5), and resolution of typical brain lesions following a therapeutic trial of antituberculous therapy (n = 8). Expressions of 14 NCC-associated monocyte genes were determined by quantitative polymerase chain reaction and analyzed for diagnostic usefulness between the 2 groups.

RESULTS

Expression of 7 genes (TAX1BP1, RAP1A, PLCG2, TOR3A, GBP1P1, LRRFIP2, and FEZ2) was significantly higher in pNCC patients than in tuberculoma patients, with TAX1BP1 and RAP1A expressions more than 22- and 5-fold higher in pNCC patients. TAX1BP1 had the highest sensitivity of 66.7% at a specificity of 100% in discriminating pNCC from tuberculoma. A combination of TAX1BP1 and RAP1A increased the sensitivity to 84.6%, and including GBP1P1 with TAX1BP1 and RAP1A further increased sensitivity to 87.2% while maintaining specificity of 100%.

CONCLUSIONS

Expression of a panel of genes in blood monocytes distinguishes pNCC from brain tuberculomas in patients with enhancing brain lesions.

Multiple tuberculomas in an immunocompetent patient and their diagnostic challenge in a high prevalence country: Case report and literature review

CONTEXT

Intracranial tuberculomas are rare yet lethal forms of tuberculosis. Diagnosis is often difficult because of its nonspecific symptoms and radiological findings.

AIM

This study aims to perform a literature review of multiple tuberculomas to improve disease recognition and management in immunocompetent patients along with presenting a case report on the topic.

DATA SOURCES

Scopus, LILACS, Ovid MEDLINE and EMBASE.

STUDY SELECTION

Case reports and case series up to December 2018 in English, Spanish, and Portuguese focusing on intracranial tuberculomas in adult and pediatric immunocompetent patients. Data on presentation, diagnostic workup, and treatment was analyzed.

DATA EXTRACTION

Cochrane Collaboration/Cochrane Handbook and PRISMA guidelines.

RESULTS

Twenty reports involving 21 patients were included. Most patients were male (57.14%). The average age at diagnosis was 26.9 ± 14.9 years. Headache was the most common presenting symptom (52.4%; 11/21), followed by motor weakness (47.6%; 10/21) and vomiting (23.8%; 5/21). MRI was the most used image technique (17/21). Most lesions occurring in the cerebral hemispheres (16/21); we found five or more lesions in 66.6% (14/21) of the patients. The majority treated with anti-tuberculous drugs resulted in a favorable outcome.

CONCLUSIONS

Immunocompetent patients living in TB endemic areas whose clinical evaluation and neuroimaging findings are compatible with tuberculoma should undergo anti-tubercular treatment despite a lack of bacteriological confirmation.

Intraventricular neurocysticercosis presenting as Bruns’ syndrome: An uncommon presentation

Background

Though parenchymal neurocysticercosis is common and a major contributor to burden of seizures in most parts of the world, intraventricular neurocysticercosis (IVNCC) comprises 10–20% of cases and poses a diagnostic challenge to the clinician.

Case presentation

We report an adult female presenting with intermittent occipital headache, used to be worse in lying down position, and aggravated with head movements, and there was mild relief in the sitting position. Her physical examination was unremarkable, and laboratory tests were within normal limits. Her multimodal neuroimaging showed cystic lesion in the fourth ventricle suggestive of neurocysticercosis. Patient underwent neuroendoscopic removal of the cyst, and the final diagnosis was confirmed on histopathology. Post removal of cyst patient had complete resolution of her symptoms.

Discussion

Intraventricular neurocysticercosis can present as acute hydrocephalus which may clinically manifest as Bruns’ syndrome in which sudden attacks of headache vertigo and nausea or vomiting are precipitated by abrupt head movements which was observed in our patient. Multimodal neuroimaging supported by histopathology helped in confirmation of the diagnosis, thus averting an inadvertent use of unnecessary medications in such patients. Furthermore, neuroendoscopy has evolved as minimally invasive technique for extirpation of fourth ventricular cysts.

Disseminated cysticercosis in an immunocompetent individual

Cysticercosis is a major public health problem, particularly in developing countries. It is caused by the larvae of the cestode Taenia solium (pork tapeworm). It usually presents as a solitary lesion in the muscle or brain (neurocysticercosis). Disseminated cysticercosis is an uncommon manifestation, especially in an immunocompetent individual. We hereby report the case of a 31-year-old male who presented with new-onset generalized tonic-clonic seizures and who also had multiple soft-tissue swellings all over his body. Imaging studies revealed multiple cysticerci in the brain parenchyma, extraocular muscles, and muscles of all the four limbs, which was subsequently established by histopathology also. The patient was started on anticonvulsants, steroids, and albendazole following which he made a complete recovery.

Awake surgery for isolated parenchymal degenerating neurocysticercosis - Case report and focused review of misdiagnosis of neurocysticercosis

Differential diagnosis of isolated single neurocysticercosis can be difficult, and management is controversial. We report here an original surgical strategy, and review previous studies reporting misdiagnosis, using the PRISMA guidelines. A 24-year-old man was admitted to our hospital for recent memory impairment, hypoesthesia of the right hand, and recurrent focal seizures without loss of consciousness. Brain MRI revealed a single ring-enhancing parenchymal lesion in the left superior postcentral gyrus, with large perilesional edema. Since exhaustive systemic exploration was negative, surgical resection of the lesion was decided on in a multidisciplinary team meeting. To preserve eloquent brain areas, surgery was performed in awake condition. It allowed complete resolution of clinical manifestations. The diagnosis of neurocysticercosis was confirmed on pathology. This case illustrates the utility of awake surgery in degenerating neurocysticercosis in functional areas, and emphasizes the importance of including it in differential diagnosis of cystic ring-enhancing brain lesions.

Neurocysticercosis: mimics and chameleons

Neurocysticercosis is the most common parasitic neurological disease worldwide, yet in Europe, it remains relatively uncommon, with many practitioners rarely seeing a case. However, immigration and international travel mean that it is becoming increasingly recognised and diagnosed in developed countries. Being a treatable condition, it is essential to be familiar with the diagnosis and to appreciate its mimics and breadth of its possible clinical presentations.

Late-onset paradoxical reactions 10 years after treatment for tuberculous meningitis in an HIV-negative patient: a case report

Background

Although paradoxical reactions (PRs) to anti-tuberculosis (anti-TB) therapy during treatment are well-established occurrences, PRs presenting as a new lesion after the completion of treatment are extremely rare, and little is known about the management of such cases, particularly of central nervous system (CNS) tuberculosis.

Case presentation

A 27-year-old female, with a past medical history of tuberculous meningitis 10 years ago and who completed the anti-TB treatment with asymptomatic remnant tuberculomas in the basal cistern, was admitted to our hospital because of a headache and the worsening of pre-existing visual disturbance. Contrast-enhanced T1-weighted brain magnetic resonance imaging (MRI) revealed new tuberculomas in the left sylvian fissure with a diffuse low signal around it. Because repeated polymerase chain reaction and Mycobacterium tuberculosis culture presented negative results and the patient had no laboratory data suggestive of a relapse of tuberculous meningitis, she was diagnosed with late-onset post-treatment PRs and treated with oral corticosteroids, tapered off over 1 year. Eventually, the symptoms were relieved, and the tuberculomas disappeared.

Conclusions

Clinicians should consider the possibility of PRs long after the completion of tuberculous meningitis treatment. Hence, a precise MRI-based examination is imperative for the follow-up of CNS tuberculosis, and the unnecessary administration of anti-TB drugs should be avoided. The use of corticosteroids as a treatment option for post-treatment PRs is seemingly safe when the isolated M. tuberculosis is sensitive to the first-line anti-TB therapy.

Imaging and Serological-Evidence of Neurocysticercosis Among Patients with Seizures in Odisha, an Unexplored Eastern Coastal Province in India

INTRODUCTION

Neurocysticercosis being a potential to human transmitted disease, is the major cause of seizures and a public health problem in tropical countries. Though India is known to be highly endemic, there are many provinces where reports are still unavailable thereby underestimating its actual burden.

MATERIALS AND METHODS

Anti-Cysticercus IgG antibodies in sera from cases presenting with seizures were screened by ELISA in a preliminary study in Odisha state which is a province in Eastern coastal India that was never explored before. Patients presenting with recent onset of seizures within age group 5 to 50 years, either local residents of Odisha or inhabitants from other parts of the country living for at least one year period in the study area were included.

RESULTS

The present study showed 43.75% cases with seizures to be confirmed neurocysticercosis (NCC) based on serology and brain imaging. However, statistically no association was established between anti-Cysticercus antibody detection and radio imaging characteristics (location, number of lesions, and stage).

CONCLUSION

This is the first study in Odisha presenting a series of cases with serological evidence of exposure to the parasite along with imaging characteristics which was consistent with NCC. It is recommended that NCC must be considered for a differential diagnosis in each active epilepsy case irrespective of prior prevalence information in all unexplored provinces in India and other endemic regions; also a compulsory reporting is warranted in order to aid in quantifying its actual burden.