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Isolated conus-epiconus neurocysticercosis Sir, Neurocysticercosis (NCC) occurs due to infestation by Taenia solium which is most common parasitic disease of the central nervous system. In endemic areas, the incidence of NCC is 4% in the general population. However, spinal involvement with NCC is rare with a reported incidence of only 1.5–3% of all cases. NCC is classified as extraspinal (vertebral) or intraspinal (epidural, subdural, arachnoidal or intramedullary), of which the intramedullary type is rare with less than 55 cases reported in the literature. We report a case of conus and epiconus intramedullary cysticercosis.[1]
The histopathological examination revealed a fibrous wall with a dense, mixed inflammatory infiltrate showing the presence of a single larva [Figure 3a and b]. The postoperative course was uneventful, and the patient was started on oral albendazole with steroids. He improved neurologically and his pain subsided. Albendazole was continued for 6 weeks. At a follow‑up after 6 weeks, the patient improved to near normal power with improving sphincteric functions. The intradural extramedullary form of spinal NCC is 6–8 times more common than the intra‑medullary form.[2] The former occurs as a consequence of the downward migration of the larvae from the cerebral to spinal subarachnoid space. The intramedullary form of NCC is uncommon and usually occurs through hematogenous or ventriculo‑ependymal migration [Table 1].[1,3,4]
A 40‑year‑old male patient presented with progressively worsening radicular pain in both lower limbs with weakness in the toes since 2 months. Since 15 days, he also had sphincteric disturbances. His neurological examination revealed weakness in bilateral external hallucis longus. The ankle reflexes were bilaterally brisk with positive Babinski’s sign. Non contrast magnetic resonance (MR) imaging revealed a large intramedullary lesion in the conus and epiconus region displaying heterogeneous low signal intensity on T2 and intermediate signal intensity on T1‑weighted images with ring enhancement. Rest of the spinal and brain MR screening was normal [Figures 1 and 2]. The patient underwent a D10 to D12 laminotomy with myelotomy and complete excision of the lesion. During surgery, a cystic lesion with straw colored fluid was seen.
Figure 1: Magnetic resonance imaging (MRI) dorso-lumbar spine, T1-weighted contrast images showing the lesion
Table 1: Reported cases in literature Study
Presentation
Location
Recommendations
Guedes – Correa et al.
Female with Low back pain without any deficit Spinal Cord compression with paraplegia Seizures with cord compression Brown- Sequard syndrome Pseudotumor cerebri Cauda equine syndrome Brown- Sequard syndrome Foot drop Claudication Bilateral leg pain Urinary retention Left leg pain Bilateral Leg weakness
Intramedullary
-
Intra- medullary, D10-11
Surgery in patients with Neurological deterioration
Cervico-dorsal Cauda Equina- Intra-medullary Multilevel, Extramedullary L4-5, Intradural- Extramedullary D10-11, Intramedullary L5-S1 Intramedullary T3-4 Intramedullary L4-S1, Intramedullary L1-4 Intramedullary L4-S1 , Intramedullary T12-S1, Intramedullary
Surgery in patients with Neurological deterioration Surgery in patients with Neurological deterioration Surgery in patients with Neurological deterioration Surgery in patients with Neurological deterioration -
Agale et al. Singh et al. Torabi et al. JH Seo et al. Iacoangeli, et al. Rice and Perera Paterakis et al. Gupta et al. Jang et al. Jong wutiwes et al. Park et al. Shin et al.
Neurology India / January 2015 / Volume 63 / Issue 1
119
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4.
form of primary spinal cysticercosis misdiagnosed as an arachnoid cyst. J Korean Neurosurg Soc 2014;55:226‑9. Qazi Z, Ojha BK, Chandra A, Singh SK, Srivastava C, Patil TB. Isolated intramedullary spinal cord cysticercosis. J Neurosci Rural Pract 2014;5:S66‑8. Access this article online
Website:
Quick Response Code
www.neurologyindia.com DOI:
Figure 2: Magnetic resonance imaging (MRI) dorso-lumbar (DL) spine, T2weighted images, axial cuts
10.4103/0028-3886.152686 PMID: xxxxx
Reversible onychomadesis following exposure to carbamazepine
Figure 3: (a and b) Histopathological images
Patients presenting with acute or progressive neurological deterioration due to compressive symptoms. When the diagnosis is not apparent or in the presence of mass effect, the cyst may be surgically excised.[4] The long term usage of cysticidal drugs like albendazole and praziquantel are also effective in its management. Corticosteroids are used as adjuncts to the cysticidal therapy to alleviate symptoms due to the inflammatory reaction caused by the death of larvae.[2]
Shonali A. Valsangkar, Hrushikesh Umakant Kharosekar, Deepak A. Palande, Vernon Velho Department of Neurosurgery, Sir Jamsetjee Jeejebhoy Group of Hospitals and Grant Medical College, Mumbai, Maharashtra, India E‑mail: [email protected]
References 1. 2. 3. 120
Agrawal R, Chauhan SP, Misra V, Singh PA, Gopal NN. Focal spinal intramedullary cysticercosis. Acta Biomed 2008;79:39‑41. Sinha S, Sharma BS. Neurocysticercosis: A review of current status and management. J Clin Neurosci 2009;16:867‑76. Yoo M, Lee CH, Kim KJ, Kim HJ. A case of intradural‑extramedullary
Sir, A 10‑year‑old boy presented with a history of recurrent partial seizures with secondary generalization for 2 months. His developmental milestones were normal. His past, as well as family history, were non‑contributory. He had no neurocutaneous markers, and the neurological examination was unremarkable. The electroencephalogram showed left anterior temporal focal epileptiform discharges. He was started on carbamazepine, the dose of which was slowly increased over 4 weeks to 400 mg (16 mg/kg). He was also administered folic acid 5mg daily. Three months later, his father noticed changes in the nail color. All his nails also became loose [Figure 1]. Examination revealed yellowish discoloration of all finger and toe nails with onychomadesis [Figure 2]. His blood counts and serum biochemistry were within normal limits. The KOH preparation and culture for fungus were negative. Possibility of carbamazepine induced nail dystrophy was considered, and he was shifted to levetiracetam 250 mg twice a day. Over the next 4 months, his normal nails slowly regrew. Nail changes have been associated with various systemic disorders, systemic drug exposures, and infections.[1,2] The various nail changes reported are; color changes, lateral or distal detachment of nails (onycholysis), transverse ridging (Beau’s lines), and shedding of nails (onychomadesis). Nail changes secondary to systemic disorders or drug exposures are considered when majority of nails are affected simultaneously. The various drugs causing nail changes are chemotherapeutic agents, psoralens, phenothiazines, lithium,
Neurology India / January 2015 / Volume 63 / Issue 1
Copyright of Neurology India is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Isolated conus-epiconus neurocysticercosis Sir, Neurocysticercosis (NCC) occurs due to infestation by Taenia solium which is most common parasitic disease of the central nervous system. In endemic areas, the incidence of NCC is 4% in the general population. However, spinal involvement with NCC is rare with a reported incidence of only 1.5–3% of all cases. NCC is classified as extraspinal (vertebral) or intraspinal (epidural, subdural, arachnoidal or intramedullary), of which the intramedullary type is rare with less than 55 cases reported in the literature. We report a case of conus and epiconus intramedullary cysticercosis.[1]
The histopathological examination revealed a fibrous wall with a dense, mixed inflammatory infiltrate showing the presence of a single larva [Figure 3a and b]. The postoperative course was uneventful, and the patient was started on oral albendazole with steroids. He improved neurologically and his pain subsided. Albendazole was continued for 6 weeks. At a follow‑up after 6 weeks, the patient improved to near normal power with improving sphincteric functions. The intradural extramedullary form of spinal NCC is 6–8 times more common than the intra‑medullary form.[2] The former occurs as a consequence of the downward migration of the larvae from the cerebral to spinal subarachnoid space. The intramedullary form of NCC is uncommon and usually occurs through hematogenous or ventriculo‑ependymal migration [Table 1].[1,3,4]
A 40‑year‑old male patient presented with progressively worsening radicular pain in both lower limbs with weakness in the toes since 2 months. Since 15 days, he also had sphincteric disturbances. His neurological examination revealed weakness in bilateral external hallucis longus. The ankle reflexes were bilaterally brisk with positive Babinski’s sign. Non contrast magnetic resonance (MR) imaging revealed a large intramedullary lesion in the conus and epiconus region displaying heterogeneous low signal intensity on T2 and intermediate signal intensity on T1‑weighted images with ring enhancement. Rest of the spinal and brain MR screening was normal [Figures 1 and 2]. The patient underwent a D10 to D12 laminotomy with myelotomy and complete excision of the lesion. During surgery, a cystic lesion with straw colored fluid was seen.
Figure 1: Magnetic resonance imaging (MRI) dorso-lumbar spine, T1-weighted contrast images showing the lesion
Table 1: Reported cases in literature Study
Presentation
Location
Recommendations
Guedes – Correa et al.
Female with Low back pain without any deficit Spinal Cord compression with paraplegia Seizures with cord compression Brown- Sequard syndrome Pseudotumor cerebri Cauda equine syndrome Brown- Sequard syndrome Foot drop Claudication Bilateral leg pain Urinary retention Left leg pain Bilateral Leg weakness
Intramedullary
-
Intra- medullary, D10-11
Surgery in patients with Neurological deterioration
Cervico-dorsal Cauda Equina- Intra-medullary Multilevel, Extramedullary L4-5, Intradural- Extramedullary D10-11, Intramedullary L5-S1 Intramedullary T3-4 Intramedullary L4-S1, Intramedullary L1-4 Intramedullary L4-S1 , Intramedullary T12-S1, Intramedullary
Surgery in patients with Neurological deterioration Surgery in patients with Neurological deterioration Surgery in patients with Neurological deterioration Surgery in patients with Neurological deterioration -
Agale et al. Singh et al. Torabi et al. JH Seo et al. Iacoangeli, et al. Rice and Perera Paterakis et al. Gupta et al. Jang et al. Jong wutiwes et al. Park et al. Shin et al.
Neurology India / January 2015 / Volume 63 / Issue 1
119
[Downloaded free from http://www.neurologyindia.com on Thursday, March 05, 2015, IP: 202.177.173.189] || Click here to download free Android application for this journal Letters to Editor
4.
form of primary spinal cysticercosis misdiagnosed as an arachnoid cyst. J Korean Neurosurg Soc 2014;55:226‑9. Qazi Z, Ojha BK, Chandra A, Singh SK, Srivastava C, Patil TB. Isolated intramedullary spinal cord cysticercosis. J Neurosci Rural Pract 2014;5:S66‑8. Access this article online
Website:
Quick Response Code
www.neurologyindia.com DOI:
Figure 2: Magnetic resonance imaging (MRI) dorso-lumbar (DL) spine, T2weighted images, axial cuts
10.4103/0028-3886.152686 PMID: xxxxx
Reversible onychomadesis following exposure to carbamazepine
Figure 3: (a and b) Histopathological images
Patients presenting with acute or progressive neurological deterioration due to compressive symptoms. When the diagnosis is not apparent or in the presence of mass effect, the cyst may be surgically excised.[4] The long term usage of cysticidal drugs like albendazole and praziquantel are also effective in its management. Corticosteroids are used as adjuncts to the cysticidal therapy to alleviate symptoms due to the inflammatory reaction caused by the death of larvae.[2]
Shonali A. Valsangkar, Hrushikesh Umakant Kharosekar, Deepak A. Palande, Vernon Velho Department of Neurosurgery, Sir Jamsetjee Jeejebhoy Group of Hospitals and Grant Medical College, Mumbai, Maharashtra, India E‑mail: [email protected]
References 1. 2. 3. 120
Agrawal R, Chauhan SP, Misra V, Singh PA, Gopal NN. Focal spinal intramedullary cysticercosis. Acta Biomed 2008;79:39‑41. Sinha S, Sharma BS. Neurocysticercosis: A review of current status and management. J Clin Neurosci 2009;16:867‑76. Yoo M, Lee CH, Kim KJ, Kim HJ. A case of intradural‑extramedullary
Sir, A 10‑year‑old boy presented with a history of recurrent partial seizures with secondary generalization for 2 months. His developmental milestones were normal. His past, as well as family history, were non‑contributory. He had no neurocutaneous markers, and the neurological examination was unremarkable. The electroencephalogram showed left anterior temporal focal epileptiform discharges. He was started on carbamazepine, the dose of which was slowly increased over 4 weeks to 400 mg (16 mg/kg). He was also administered folic acid 5mg daily. Three months later, his father noticed changes in the nail color. All his nails also became loose [Figure 1]. Examination revealed yellowish discoloration of all finger and toe nails with onychomadesis [Figure 2]. His blood counts and serum biochemistry were within normal limits. The KOH preparation and culture for fungus were negative. Possibility of carbamazepine induced nail dystrophy was considered, and he was shifted to levetiracetam 250 mg twice a day. Over the next 4 months, his normal nails slowly regrew. Nail changes have been associated with various systemic disorders, systemic drug exposures, and infections.[1,2] The various nail changes reported are; color changes, lateral or distal detachment of nails (onycholysis), transverse ridging (Beau’s lines), and shedding of nails (onychomadesis). Nail changes secondary to systemic disorders or drug exposures are considered when majority of nails are affected simultaneously. The various drugs causing nail changes are chemotherapeutic agents, psoralens, phenothiazines, lithium,
Neurology India / January 2015 / Volume 63 / Issue 1
Copyright of Neurology India is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
