CLINICAL COMMUNICATION TO THE EDITOR
Incidental Cerebral Toxocarosis as Confirmed by Cerebrospinal Fluid Cytology To the Editor:
CASE REPORT A 19-year-old man was struck by a first unprovoked seizure in March 2012. Clinical investigation was normal. Electroencephalography showed generalized 3-5/s (poly)spike/wave paroxysms consistent with juvenile myoclonic epilepsy. Cranial magnetic resonance imaging (MRI) revealed multiple cystic lesions (Figure 1). Laboratory investigations were normal except for 10% eosinophilia on blood cell count. Funding: AE gratefully acknowledges support by Wilhelm-RouxProgram of Martin-Luther-University and by Novartis-Pharma GmbH. Conflict of Interest: MEK and AS declare no conflict of interest. AE declares no conflict of interest beyond that given in the Funding statement. Authorship: AE and MEK examined the patient, including electroencephalogram-analysis and cerebrospinal fluid cytology. AS took the magnetic resonance images. All authors contributed to the manuscript. Requests for reprints should be addressed to Alexander Emmer, MD, Department of Neurology, Martin-Luther-University, Halle-Wittenberg, Ernst-Grube-Str. 40, Halle (Saale) 06120, Germany. E-mail address: [email protected]
0002-9343/$ -see front matter Ó 2015 Elsevier Inc. All rights reserved.
Cerebrospinal fluid showed a mild pleocytosis of 6 round cells per mL with 2% eosinophilic granulocytes. Furthermore, hematoxylin/eosin staining showed multiple eggs containing different larval stages of Toxocara (Figure 2), whereas Toxocara canis serology was negative. No other organ was involved. Treatment comprised albendazole 400 mg 3 times/d for 1 month and valproic acid (600 mg 2 times/d). A follow-up cerebrospinal fluid examination showed normal findings. The patient is in a good condition and seizure free.
DISCUSSION Toxocarosis is a worldwide zoonotic helminth infection.1 Although almost each organ of the host may be affected, the central nervous system is a preferred target.1 In the present case, toxocarosis would have gone undiagnosed without manifestation of the concomitant seizure disorder. The cystic lesions as seen in MRI resemble enlarged perivascular Virchow-Robin spaces. Also, the serological diagnostic was negative. This may be due to the fact that only the central nervous system was involved. Serological negativity has also been documented in patients with ocular larva migrans.1 In conclusion, in asymptomatic cases with cranial MRI findings that look like enlarged Virchow-Robin spaces, toxocarosis should be considered as a differential diagnosis even when serological tests are negative.
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The American Journal of Medicine, Vol 128, No 10, October 2015
Figure 1 Magnetic resonance imaging demonstrates multiple cystic lesions (arrows) (A, B) T2-weighted and (C, D) T1-weighted. Cystic lesions were not gadolinium enhanced (D).
Alexander Emmer, MDa Alexey Surov, MD, PhDb Malte E. Kornhuber, MD, PhDc a
Department of Neurology Martin-Luther-University, Halle-Wittenberg Halle, Germany b Department of Radiology Martin-Luther-University, Halle-Wittenberg Halle, Germany c Department of Neurology Martin-Luther-University, Halle-Wittenberg Halle, Germany
http://dx.doi.org/10.1016/j.amjmed.2015.06.009 Figure 2 Composite cerebrospinal fluid cytologic image showing various stages of Toxocara.
Reference 1. Strube C, Heuer L, Janecek E. Toxocara spp. infections in paratenic hosts. Vet Parasitol. 2013;193:375-389.
Incidental Cerebral Toxocarosis as Confirmed by Cerebrospinal Fluid Cytology To the Editor:
CASE REPORT A 19-year-old man was struck by a first unprovoked seizure in March 2012. Clinical investigation was normal. Electroencephalography showed generalized 3-5/s (poly)spike/wave paroxysms consistent with juvenile myoclonic epilepsy. Cranial magnetic resonance imaging (MRI) revealed multiple cystic lesions (Figure 1). Laboratory investigations were normal except for 10% eosinophilia on blood cell count. Funding: AE gratefully acknowledges support by Wilhelm-RouxProgram of Martin-Luther-University and by Novartis-Pharma GmbH. Conflict of Interest: MEK and AS declare no conflict of interest. AE declares no conflict of interest beyond that given in the Funding statement. Authorship: AE and MEK examined the patient, including electroencephalogram-analysis and cerebrospinal fluid cytology. AS took the magnetic resonance images. All authors contributed to the manuscript. Requests for reprints should be addressed to Alexander Emmer, MD, Department of Neurology, Martin-Luther-University, Halle-Wittenberg, Ernst-Grube-Str. 40, Halle (Saale) 06120, Germany. E-mail address: [email protected]
0002-9343/$ -see front matter Ó 2015 Elsevier Inc. All rights reserved.
Cerebrospinal fluid showed a mild pleocytosis of 6 round cells per mL with 2% eosinophilic granulocytes. Furthermore, hematoxylin/eosin staining showed multiple eggs containing different larval stages of Toxocara (Figure 2), whereas Toxocara canis serology was negative. No other organ was involved. Treatment comprised albendazole 400 mg 3 times/d for 1 month and valproic acid (600 mg 2 times/d). A follow-up cerebrospinal fluid examination showed normal findings. The patient is in a good condition and seizure free.
DISCUSSION Toxocarosis is a worldwide zoonotic helminth infection.1 Although almost each organ of the host may be affected, the central nervous system is a preferred target.1 In the present case, toxocarosis would have gone undiagnosed without manifestation of the concomitant seizure disorder. The cystic lesions as seen in MRI resemble enlarged perivascular Virchow-Robin spaces. Also, the serological diagnostic was negative. This may be due to the fact that only the central nervous system was involved. Serological negativity has also been documented in patients with ocular larva migrans.1 In conclusion, in asymptomatic cases with cranial MRI findings that look like enlarged Virchow-Robin spaces, toxocarosis should be considered as a differential diagnosis even when serological tests are negative.
e36
The American Journal of Medicine, Vol 128, No 10, October 2015
Figure 1 Magnetic resonance imaging demonstrates multiple cystic lesions (arrows) (A, B) T2-weighted and (C, D) T1-weighted. Cystic lesions were not gadolinium enhanced (D).
Alexander Emmer, MDa Alexey Surov, MD, PhDb Malte E. Kornhuber, MD, PhDc a
Department of Neurology Martin-Luther-University, Halle-Wittenberg Halle, Germany b Department of Radiology Martin-Luther-University, Halle-Wittenberg Halle, Germany c Department of Neurology Martin-Luther-University, Halle-Wittenberg Halle, Germany
http://dx.doi.org/10.1016/j.amjmed.2015.06.009 Figure 2 Composite cerebrospinal fluid cytologic image showing various stages of Toxocara.
Reference 1. Strube C, Heuer L, Janecek E. Toxocara spp. infections in paratenic hosts. Vet Parasitol. 2013;193:375-389.
