American Journal of Emergency Medicine xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Acute neurocysticercosis presenting as suicidal ideation☆,☆☆ Abstract This is a case of a 36-year-old Spanish-speaking Hispanic man who was brought to a busy suburban New Jersey emergency department (ED) by family members for altered mental status. By report, patient was noted by family to be “not acting normal” at home, when he went into his bathroom and locked the door. A brief time thereafter, he emerged smelling of bleach and with confused speech. The family surmised that he tried to commit suicide by drinking bleach and emergently brought the patient to the ED. After initial vital signs (pulse of 104 beats per minute, blood pressure of 141/68 mm Hg, respiratory rate of 20 breaths per minute, temperature of 37°C, pulse oxygenation (Ox) of 100%), patient was transported by wheelchair to a monitored bed in the ED, with a working chief complaint of bleach ingestion with suicidal ideation. However, while being escorted by nursing staff and his family, patient had a generalized tonic-clonic seizure lasting approximately 4 minutes. At that time, 2mg lorazepam was given intramuscularly (IM), as the patient did not yet have vascular access. Shortly thereafter, the patient awoke and immediately became severely agitated, striking at medical staff while yelling incoherently in Spanish. Five-milligram IM haloperidol was given, while intravenous (IV) access was obtained. Because of persistent agitation, yelling, and pulling out of the IV line, 5-mg haloperidol IM was redosed, this time with added 50-mg diphenhydramine IM, and 2-mg lorazepam IV was redosed once IV access was regained. By this time, patient became calmer, and further history and physical as well as laboratory and radiologic information could be obtained. As per family, patient had no other medical history, no surgical history, no allergies, and other than being sad lately, had no other complaints. On physical examination, lungs were clear, heart was tachycardic, abdomen was soft, and patient was moving all extremities before medication administration. Because of agitation, further cranial nerve or sensation was unable to be tested at the time of presentation. Laboratory data returned with a cell count of 15.8 white blood cells, with a differential significant for 14% eosinophils. Chemistry was significant for a CO2 of 15, glucose of 153, normal kidney function, slightly elevated sodium of 147, normal potassium (3.5), and chloride (105). Liver enzymes and urinalysis were normal. Salicylates and acetaminophen levels were negative as was alcohol and a 7-item urine drug screen. Arterial blood gas (ABG) showed a pH of 7.42, PCO2 of 36, PO2 of 350 (fraction of inspired oxygen of 100% on a nonrebreather mask), and HCO3 of 23. Portable chest xray was negative for acute pulmonary findings and a normal heart boarder. ☆ “Acute neurocysticercosis presenting as suicidal ideation” has not been previously published, is not under consideration by a different medical journal, and is approved for publication by the sole author. It is agreed that, if accepted, it will not be published elsewhere (including electronically), in any language, without the written consent of the copyright holder. ☆☆ None of the authors has any conflict of interest to declare.
At this time, without a clear indication of toxic ingestion, it was felt that computed tomography (CT) of the brain was necessary. After CT was performed (representative figures 1-5), an initial reading by radiology of “neurocysticercosis in vesicular phase, multiple lesions on left, with the largest in left parietal measuring 1.5 × 1.5 cm with moderate edema” was reported. After a consultation with an infectious disease physician, 10-mg dexamethasone IV was ordered, but albendazole 500 mg was held, until antiseizure prophylaxis could be initiated (levetiracetam 500 mg was starting later that evening). At that time, patient was admitted to the intensive care unit with a diagnosis of “altered mental status, rule out (R/O) bleech ingestion, new onset seizure, neurocysticercosis”. Computed tomography axial slices of the brain demonstrate multiple thin walled cysts with some demonstrating focal isoattenuating nodules consistent with a scolex. Fig. 1 depicts a low attenuation cerebrospinal fluid (CSF) cystic lesion involving the right frontal cortex. Another cystic lesion (Fig. 2) is present in the left frontal lobe with a small focal nodule. The left occipital lobe demonstrates a similar cystic lesion with a nodule posteriorly. On Fig. 3, there is further depiction of the left frontal lobe lesion with a focal nodule within it. There is another, different, cystic lesion with a well-circumscribed margin and a nodule on the outer margins of the left parietal cortex. The nodule appears to demonstrate a calcification within it. A well-circumscribed cystic lesion (Fig. 4) is present near the left parietal vertex measuring 1.5 × 1.5 cm. No nodules or calcifications are present. There is a small amount of surrounding vasogenic edema. Another image of the left parietal vertex cystic lesion (Fig. 5) depicts a focal nodule in its outer margins with further demonstration of the associated vasogenic edema. These 5 images are consistent with a case of neurocysticercosis in the vesicular phase. The patient responded appropriately to medication, had no further incidents of seizures, and was cleared psychiatrically from any suspicion of suicidal ideation. After a short course in the hospital, he was discharged home on antiepileptic medications and antiparasitic treatments. Neurocysticercosis in humans occurs when larvae of the tapeworm Taenia solium settle into brain tissue where they mature and eventually degrade, prompting an inflammatory response. T solium enters the body though the ingestion of undercooked pork and is most prevalent in rural areas of Central and South America, sub-Saharan Africa, India, and Asia where pigs are raised [1]. Sudden onset of seizures is the most common manifestation of this infection, and due to immigration rates, neurocysticercosis continues to be diagnosed in a small number of seizure cases in US EDs [2]. Pigs serve as an intermediate host for the hermaphroditic parasite, whereas humans are its definitive host. Pigs ingest embryos found in food or water contaminated by an infected human's feces. T solium then migrates through the intestinal wall into the blood stream, ultimately settling into muscle tissue of the pig where it develops into a cysticercus [3]. When a human eats raw or undercooked pig meat containing these cysticerci, he or she becomes the definitive host. Taenia
0735-6757/© 2015 Elsevier Inc. All rights reserved.
Please cite this article as: Martin JF, et al, Acute neurocysticercosis presenting as suicidal ideation, Am J Emerg Med (2015), http://dx.doi.org/ 10.1016/j.ajem.2015.04.070
2
J.F. Martin et al. / American Journal of Emergency Medicine xxx (2015) xxx–xxx
Fig. 1. Low attenuation cystic lesion involving the right frontal cortex.
cysticerci attach to the human intestinal wall with the hooks of their scolex and lengthen in proglottids or segments, which can each hold anywhere from 50 000 to 100 000 eggs [4]. These embedded cysticerci can remain in the intestine asymptomatically for years. However, once ingested, T solium larvae may also penetrate the bowel wall and independently travel to other parts of the body, including the brain [5]. Embedded Taenia has evolved complex means of remaining undetected by the immune systems. Cysticerci secrete a variety of compounds including taeniaestatin (a parasite serine proteinase inhibitor), paramyosin, sulfated polysaccharides, and secretory proteases that inhibit or divert host immune responses [6]. However, eventually, the parasite dies and begins to degrades, prompting an inflammatory response. Immune attacks on cysticerci located in brain parenchyma are generally associated with seizures, whereas those in the extraparenchymal regions typically result in hydrocephalus. Obstructive hydrocephalus occurs when cysterci in the ventricles become trapped in the foramena or aqueduct. In the subarachnoid space, cysticerci may enlarge and cause mass effect or an inflammatory response, which may lead to chronic arachnoiditis. Arachnoiditis due to neurocysticercosis may then be accompanied by hydrocephalus, vasculitis, meningitis, and strokes [6]. Radiographically, neurocysticercosis may present in 5 distinct stages, which span the life cycle of the parasite in the brain parenchyma. (1) Noncystic: this is radio-occult on both CT and magnetic resonance imaging (MRI). (2) Vesicular: this is the stage that was seen in the patient being discussed. Computed tomography imaging commonly shows a 10- to 20-mm cyst measuring CSF attenuation. The cyst walls
Fig. 2. Cystic lesion in left frontal lobe with small focal nodule. A second cystic lesion in left occipital lobe, with a nodule posteriorly.
Fig. 3. Further depiction of left frontal lobe cystic lesion as well as a different left parietal cortex cyst with calcification.
are thin and smooth, and there is little surrounding edema. A small isoattenuating nodule may be seen within the cyst compatible with a scolex. On MRI, the cyst matches CSF signal intensity on both T1 and T2 imaging. The scolex may appear as isointense or hypointense on T1 and isointense/hyperintense T2-weighted imaging. No enhancement is present on either modality. (3) Colloidal vesicular: on CT, the cyst maybe hyperattenuating and demonstrate enhancement. Mild edema may be present. On MRI, the cysts are slightly hyperintense on both T1- and T2-weighted imaging. There is increased edema, and the cyst will demonstrate mild enhancement after gadolinium administration. (4) Granular nodular: on both CT and MRI, this stage is similar to the colloidal vesicular stage but with more surrounding vasogenic edema and thicker margins and increased wall enhancement. (5) calcified nodular: CT demonstrates calcified nodules in the absence of edema and enhancement. Magnetic resonance imaging demonstrates hypointense nodules compatible with calcifications [7]. Approximately 50 million people worldwide are estimated to have cysticercosis infection, although estimates are probably low due to the prolonged silence of infection and lack of data on indigenous populations [8]. In the United States, neurocysticercosis is diagnosed during work-ups for sudden onset of adult seizure. In a prospective study of 1800 patients presenting with seizures to 11 US EDs over a 2 year period, neurocysticercosis was the etiologic agent in approximately 2% of cases. Neurocysticercosis was observed more frequently in EDs of Los Angeles, Phoenix, and Albuquerque (5.7%), which had a higher proportion of immigrant Hispanic patients than other hospitals [2]. This case is important in that it serves to demonstrate the need to maintain a broad differential diagnosis. The family was adamant that the patient had ingested bleach, and that was why they brought him to the ED. The patient was certainly altered mentally and combative,
Fig. 4. Well-circumscribed lesion in left parietal vertex with surrounding vasogenic edema.
Please cite this article as: Martin JF, et al, Acute neurocysticercosis presenting as suicidal ideation, Am J Emerg Med (2015), http://dx.doi.org/ 10.1016/j.ajem.2015.04.070
J.F. Martin et al. / American Journal of Emergency Medicine xxx (2015) xxx–xxx
3
James F. Martin MD Emergency Medical Associates of NY and NJ, Emergency Medicine Education Director—Monmouth Medical Center, Long Branch, NJ Corresponding author. E-mail address: [email protected] Jessica Vidas MS Emergency Medical Associates of NY and NJ, Monmouth Medical Center, Long Branch, NJ Ali Baday MD Department of Radiology, Monmouth Medical Center, Long Branch, NJ
Fig. 5. Further image of left parietal vertex lesion with vasogenic edema.
http://dx.doi.org/10.1016/j.ajem.2015.04.070 References
so there was a significant suspicion for suicidal ideation complicated by a toxic ingestion. However, during the course of the work-up, CT depicted evidence accounting for the new onset seizure. After stabilization and through a translator, patient remarked that he had been feeling “bad,” but that he had gone into the bathroom to clean his work shoes with bleach—it is surmised that he might have had his first seizure at that time, spilling the bleach, and while in his postictal phase exited the bathroom in a confused state, prompting his family to bring him to the hospital. Furthermore, neurocysticercosis is not a common finding in New Jersey, so it was not in the immediate differential; however, with increased international travel and migration, this case serves as a reminder that historically geographic diseases can certainly be seen in unusual locales.
[1] Willingham III AL, Engels D. Control of Taenia solium cysticercosis/taeniosis. Adv Parasitol 2006;61:509. [2] Ong S, Talan DA, Moran GJ, Mower W, Newdow M, Tsang VC, et al. Neurocysticercosis in radiographically imaged seizure patients in U.S. emergency departments. Emerg Infect Dis 2002;8:608. [3] Del Brutto Oscar H, García Héctor H. Taenia solium: biological characteristics and life cycle. Cysticercosis of the human nervous system (11-21). Berlin: Springer; 2013. [4] Coyle CM, Mahanty S, Zunt JR, Wallin MT, Cantey PT, White Jr Clinton A, et al. Neurocysticercosis: neglected but not forgotten. PLoS Negl Trop Dis 2012;6:e1500. [5] Stringer JL, Marks LM, White Jr AC, Robinson P. Epileptogenic activity of granulomas associated with murine cysticercosis. Exp Neurol 2003;183:532. [6] White AC, Jr Robinson P, Kuhn R. Taenia solium cysticercosis: host-parasite interactions and the immune response. In: Freedman DO, editor. Immunopathogenetic aspects of disease induced by helminth parasites. Basel: Karger; 1997. p. 209. [7] Kimura-Hayama ET, Higuera JA, Corona-Cedillo R, Chávez-Macías L, Perochena A, Quiroz-Rojas LY, et al. Neurocysticercosis: radiologic-pathologic correlation. Radiographics 2010;30:1705–19. [8] Budke CM, White Jr AC, Garcia HH. Zoonotic larval cestode infections: neglected, neglected tropical diseases? PLoS Negl Trop Dis 2009;3:e319.
Please cite this article as: Martin JF, et al, Acute neurocysticercosis presenting as suicidal ideation, Am J Emerg Med (2015), http://dx.doi.org/ 10.1016/j.ajem.2015.04.070
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Acute neurocysticercosis presenting as suicidal ideation☆,☆☆ Abstract This is a case of a 36-year-old Spanish-speaking Hispanic man who was brought to a busy suburban New Jersey emergency department (ED) by family members for altered mental status. By report, patient was noted by family to be “not acting normal” at home, when he went into his bathroom and locked the door. A brief time thereafter, he emerged smelling of bleach and with confused speech. The family surmised that he tried to commit suicide by drinking bleach and emergently brought the patient to the ED. After initial vital signs (pulse of 104 beats per minute, blood pressure of 141/68 mm Hg, respiratory rate of 20 breaths per minute, temperature of 37°C, pulse oxygenation (Ox) of 100%), patient was transported by wheelchair to a monitored bed in the ED, with a working chief complaint of bleach ingestion with suicidal ideation. However, while being escorted by nursing staff and his family, patient had a generalized tonic-clonic seizure lasting approximately 4 minutes. At that time, 2mg lorazepam was given intramuscularly (IM), as the patient did not yet have vascular access. Shortly thereafter, the patient awoke and immediately became severely agitated, striking at medical staff while yelling incoherently in Spanish. Five-milligram IM haloperidol was given, while intravenous (IV) access was obtained. Because of persistent agitation, yelling, and pulling out of the IV line, 5-mg haloperidol IM was redosed, this time with added 50-mg diphenhydramine IM, and 2-mg lorazepam IV was redosed once IV access was regained. By this time, patient became calmer, and further history and physical as well as laboratory and radiologic information could be obtained. As per family, patient had no other medical history, no surgical history, no allergies, and other than being sad lately, had no other complaints. On physical examination, lungs were clear, heart was tachycardic, abdomen was soft, and patient was moving all extremities before medication administration. Because of agitation, further cranial nerve or sensation was unable to be tested at the time of presentation. Laboratory data returned with a cell count of 15.8 white blood cells, with a differential significant for 14% eosinophils. Chemistry was significant for a CO2 of 15, glucose of 153, normal kidney function, slightly elevated sodium of 147, normal potassium (3.5), and chloride (105). Liver enzymes and urinalysis were normal. Salicylates and acetaminophen levels were negative as was alcohol and a 7-item urine drug screen. Arterial blood gas (ABG) showed a pH of 7.42, PCO2 of 36, PO2 of 350 (fraction of inspired oxygen of 100% on a nonrebreather mask), and HCO3 of 23. Portable chest xray was negative for acute pulmonary findings and a normal heart boarder. ☆ “Acute neurocysticercosis presenting as suicidal ideation” has not been previously published, is not under consideration by a different medical journal, and is approved for publication by the sole author. It is agreed that, if accepted, it will not be published elsewhere (including electronically), in any language, without the written consent of the copyright holder. ☆☆ None of the authors has any conflict of interest to declare.
At this time, without a clear indication of toxic ingestion, it was felt that computed tomography (CT) of the brain was necessary. After CT was performed (representative figures 1-5), an initial reading by radiology of “neurocysticercosis in vesicular phase, multiple lesions on left, with the largest in left parietal measuring 1.5 × 1.5 cm with moderate edema” was reported. After a consultation with an infectious disease physician, 10-mg dexamethasone IV was ordered, but albendazole 500 mg was held, until antiseizure prophylaxis could be initiated (levetiracetam 500 mg was starting later that evening). At that time, patient was admitted to the intensive care unit with a diagnosis of “altered mental status, rule out (R/O) bleech ingestion, new onset seizure, neurocysticercosis”. Computed tomography axial slices of the brain demonstrate multiple thin walled cysts with some demonstrating focal isoattenuating nodules consistent with a scolex. Fig. 1 depicts a low attenuation cerebrospinal fluid (CSF) cystic lesion involving the right frontal cortex. Another cystic lesion (Fig. 2) is present in the left frontal lobe with a small focal nodule. The left occipital lobe demonstrates a similar cystic lesion with a nodule posteriorly. On Fig. 3, there is further depiction of the left frontal lobe lesion with a focal nodule within it. There is another, different, cystic lesion with a well-circumscribed margin and a nodule on the outer margins of the left parietal cortex. The nodule appears to demonstrate a calcification within it. A well-circumscribed cystic lesion (Fig. 4) is present near the left parietal vertex measuring 1.5 × 1.5 cm. No nodules or calcifications are present. There is a small amount of surrounding vasogenic edema. Another image of the left parietal vertex cystic lesion (Fig. 5) depicts a focal nodule in its outer margins with further demonstration of the associated vasogenic edema. These 5 images are consistent with a case of neurocysticercosis in the vesicular phase. The patient responded appropriately to medication, had no further incidents of seizures, and was cleared psychiatrically from any suspicion of suicidal ideation. After a short course in the hospital, he was discharged home on antiepileptic medications and antiparasitic treatments. Neurocysticercosis in humans occurs when larvae of the tapeworm Taenia solium settle into brain tissue where they mature and eventually degrade, prompting an inflammatory response. T solium enters the body though the ingestion of undercooked pork and is most prevalent in rural areas of Central and South America, sub-Saharan Africa, India, and Asia where pigs are raised [1]. Sudden onset of seizures is the most common manifestation of this infection, and due to immigration rates, neurocysticercosis continues to be diagnosed in a small number of seizure cases in US EDs [2]. Pigs serve as an intermediate host for the hermaphroditic parasite, whereas humans are its definitive host. Pigs ingest embryos found in food or water contaminated by an infected human's feces. T solium then migrates through the intestinal wall into the blood stream, ultimately settling into muscle tissue of the pig where it develops into a cysticercus [3]. When a human eats raw or undercooked pig meat containing these cysticerci, he or she becomes the definitive host. Taenia
0735-6757/© 2015 Elsevier Inc. All rights reserved.
Please cite this article as: Martin JF, et al, Acute neurocysticercosis presenting as suicidal ideation, Am J Emerg Med (2015), http://dx.doi.org/ 10.1016/j.ajem.2015.04.070
2
J.F. Martin et al. / American Journal of Emergency Medicine xxx (2015) xxx–xxx
Fig. 1. Low attenuation cystic lesion involving the right frontal cortex.
cysticerci attach to the human intestinal wall with the hooks of their scolex and lengthen in proglottids or segments, which can each hold anywhere from 50 000 to 100 000 eggs [4]. These embedded cysticerci can remain in the intestine asymptomatically for years. However, once ingested, T solium larvae may also penetrate the bowel wall and independently travel to other parts of the body, including the brain [5]. Embedded Taenia has evolved complex means of remaining undetected by the immune systems. Cysticerci secrete a variety of compounds including taeniaestatin (a parasite serine proteinase inhibitor), paramyosin, sulfated polysaccharides, and secretory proteases that inhibit or divert host immune responses [6]. However, eventually, the parasite dies and begins to degrades, prompting an inflammatory response. Immune attacks on cysticerci located in brain parenchyma are generally associated with seizures, whereas those in the extraparenchymal regions typically result in hydrocephalus. Obstructive hydrocephalus occurs when cysterci in the ventricles become trapped in the foramena or aqueduct. In the subarachnoid space, cysticerci may enlarge and cause mass effect or an inflammatory response, which may lead to chronic arachnoiditis. Arachnoiditis due to neurocysticercosis may then be accompanied by hydrocephalus, vasculitis, meningitis, and strokes [6]. Radiographically, neurocysticercosis may present in 5 distinct stages, which span the life cycle of the parasite in the brain parenchyma. (1) Noncystic: this is radio-occult on both CT and magnetic resonance imaging (MRI). (2) Vesicular: this is the stage that was seen in the patient being discussed. Computed tomography imaging commonly shows a 10- to 20-mm cyst measuring CSF attenuation. The cyst walls
Fig. 2. Cystic lesion in left frontal lobe with small focal nodule. A second cystic lesion in left occipital lobe, with a nodule posteriorly.
Fig. 3. Further depiction of left frontal lobe cystic lesion as well as a different left parietal cortex cyst with calcification.
are thin and smooth, and there is little surrounding edema. A small isoattenuating nodule may be seen within the cyst compatible with a scolex. On MRI, the cyst matches CSF signal intensity on both T1 and T2 imaging. The scolex may appear as isointense or hypointense on T1 and isointense/hyperintense T2-weighted imaging. No enhancement is present on either modality. (3) Colloidal vesicular: on CT, the cyst maybe hyperattenuating and demonstrate enhancement. Mild edema may be present. On MRI, the cysts are slightly hyperintense on both T1- and T2-weighted imaging. There is increased edema, and the cyst will demonstrate mild enhancement after gadolinium administration. (4) Granular nodular: on both CT and MRI, this stage is similar to the colloidal vesicular stage but with more surrounding vasogenic edema and thicker margins and increased wall enhancement. (5) calcified nodular: CT demonstrates calcified nodules in the absence of edema and enhancement. Magnetic resonance imaging demonstrates hypointense nodules compatible with calcifications [7]. Approximately 50 million people worldwide are estimated to have cysticercosis infection, although estimates are probably low due to the prolonged silence of infection and lack of data on indigenous populations [8]. In the United States, neurocysticercosis is diagnosed during work-ups for sudden onset of adult seizure. In a prospective study of 1800 patients presenting with seizures to 11 US EDs over a 2 year period, neurocysticercosis was the etiologic agent in approximately 2% of cases. Neurocysticercosis was observed more frequently in EDs of Los Angeles, Phoenix, and Albuquerque (5.7%), which had a higher proportion of immigrant Hispanic patients than other hospitals [2]. This case is important in that it serves to demonstrate the need to maintain a broad differential diagnosis. The family was adamant that the patient had ingested bleach, and that was why they brought him to the ED. The patient was certainly altered mentally and combative,
Fig. 4. Well-circumscribed lesion in left parietal vertex with surrounding vasogenic edema.
Please cite this article as: Martin JF, et al, Acute neurocysticercosis presenting as suicidal ideation, Am J Emerg Med (2015), http://dx.doi.org/ 10.1016/j.ajem.2015.04.070
J.F. Martin et al. / American Journal of Emergency Medicine xxx (2015) xxx–xxx
3
James F. Martin MD Emergency Medical Associates of NY and NJ, Emergency Medicine Education Director—Monmouth Medical Center, Long Branch, NJ Corresponding author. E-mail address: [email protected] Jessica Vidas MS Emergency Medical Associates of NY and NJ, Monmouth Medical Center, Long Branch, NJ Ali Baday MD Department of Radiology, Monmouth Medical Center, Long Branch, NJ
Fig. 5. Further image of left parietal vertex lesion with vasogenic edema.
http://dx.doi.org/10.1016/j.ajem.2015.04.070 References
so there was a significant suspicion for suicidal ideation complicated by a toxic ingestion. However, during the course of the work-up, CT depicted evidence accounting for the new onset seizure. After stabilization and through a translator, patient remarked that he had been feeling “bad,” but that he had gone into the bathroom to clean his work shoes with bleach—it is surmised that he might have had his first seizure at that time, spilling the bleach, and while in his postictal phase exited the bathroom in a confused state, prompting his family to bring him to the hospital. Furthermore, neurocysticercosis is not a common finding in New Jersey, so it was not in the immediate differential; however, with increased international travel and migration, this case serves as a reminder that historically geographic diseases can certainly be seen in unusual locales.
[1] Willingham III AL, Engels D. Control of Taenia solium cysticercosis/taeniosis. Adv Parasitol 2006;61:509. [2] Ong S, Talan DA, Moran GJ, Mower W, Newdow M, Tsang VC, et al. Neurocysticercosis in radiographically imaged seizure patients in U.S. emergency departments. Emerg Infect Dis 2002;8:608. [3] Del Brutto Oscar H, García Héctor H. Taenia solium: biological characteristics and life cycle. Cysticercosis of the human nervous system (11-21). Berlin: Springer; 2013. [4] Coyle CM, Mahanty S, Zunt JR, Wallin MT, Cantey PT, White Jr Clinton A, et al. Neurocysticercosis: neglected but not forgotten. PLoS Negl Trop Dis 2012;6:e1500. [5] Stringer JL, Marks LM, White Jr AC, Robinson P. Epileptogenic activity of granulomas associated with murine cysticercosis. Exp Neurol 2003;183:532. [6] White AC, Jr Robinson P, Kuhn R. Taenia solium cysticercosis: host-parasite interactions and the immune response. In: Freedman DO, editor. Immunopathogenetic aspects of disease induced by helminth parasites. Basel: Karger; 1997. p. 209. [7] Kimura-Hayama ET, Higuera JA, Corona-Cedillo R, Chávez-Macías L, Perochena A, Quiroz-Rojas LY, et al. Neurocysticercosis: radiologic-pathologic correlation. Radiographics 2010;30:1705–19. [8] Budke CM, White Jr AC, Garcia HH. Zoonotic larval cestode infections: neglected, neglected tropical diseases? PLoS Negl Trop Dis 2009;3:e319.
Please cite this article as: Martin JF, et al, Acute neurocysticercosis presenting as suicidal ideation, Am J Emerg Med (2015), http://dx.doi.org/ 10.1016/j.ajem.2015.04.070
