Millairy Neurocysticercosis

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2-year, 10-month-old boy from rural India had 2 episodes of generalized tonic clonic convulsions associated with fever followed by progressive loss of motor functions and cognitive deterioration over the course of 7-10 days. Findings of our examination revealed tonic posturing: hypereflexia, a positive Babinski sign, and power in all 4 limbs was grade 2/5. He had no previous history of seizures, ear discharge, or tuberculosis contact. Fundus revealed mild papilledema but no evidence of intraocular invasion (crucial for treatment approach). Magnetic resonance imaging of the brain revealed multiple cyst-like lesions with surrounding vasogenic edema strongly suggestive of extensive neurocysticercal lesions in the vesicular stage (Figures 1 and 2; Figure 2 available at www.jpeds.com). Findings of com-puted tomography imaging performed 1 month after admission, in view of the patient’s worsening sensorium and respiratory distress, revealed massive hydrocephalus requiring a ventriculoperitoneal shunt (Figure 3; available at www.jpeds.com). The child was treated with albendazole, intravenous steroids, anticonvulsants, and praziquantel. At present, the child is free of seizures, with improvement in sensorium and muscle power of 3/5 on discharge. Although parenchymal neurocysticercosis is common, an encephalitic presentation is rare. Neurocysticercosis is

considered unusual in young children because of its long incubation period (average 7 years).1 When it does occur in children younger than 3 years of age, they tend to develop multiple cysts (“miliary cysticercosis”), which may be attributed to an immature immune system.2 The myriad manifestations of neurocysticercosis include seizures, focal neurologic deficits, visual loss, dystonia, dementia, and hydrocephalus.3 In regions in which Taenia solium is endemic, neurocysticercosis should be an important differential diagnosis in children with encephalitis. Although some reports suggest that cysticidal therapy is contraindicated in cysticercus encephalitis,4,5 it has been found that with careful management of cerebral edema and concurrent use of corticosteroids, parasiticidal therapy may improve clinical outcome in an otherwise-fatal neurologic disorder.6,7 n Suba Sundaresan, MBBS, MD Mukesh Sanklecha, MBBS, MD, DNB Department of Paediatrics Bombay Hospital Institute of Medical Sciences and Research Mumbai, India

References available at www.jpeds.com

Figure 1. Magnetic resonance imaging of the brain revealed multiple cyst-like lesions.

J Pediatr 2014;165:1270. 0022-3476/$ - see front matter. Copyright ª 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpeds.2014.07.039

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References 1. Stamos JK, Rowley AH, Hahn YS, Chadwick EG, Schantz PM, Wilson M. Neurocysticercosis: report of unusual pediatric cases. Pediatrics 1996;98: 974-7. 2. Ostrosky-Zeichner L, Esta~ nol B. Immunopathogenesis of neurocysticercosis: is damage mediated by the host immune response? Int J Parasitol 1999; 29:649-50. 3. Singhi P, Ray M, Singhi S, Khandelwal N. Clinical spectrum of 500 children with neurocysticercosis and response to albendazole therapy. J Child Neurol 2000;15:207-13.

4. Singhi P. Neurocysticercosis. Ther Adv Neurol Disord 2011;4: 67-81. 5. Garcıa HH, Evans CA, Nash TE, Takayanagui OM, White AC Jr, Botero D, et al. Current consensus guidelines for treatment of neurocysticercosis. Clin Microbiol Rev 2002;15:747-56. 6. Thomson AJG. Multifocal cysticercal encephalitis: 50 cases plus review. Pediatr Rev Commun 1993;7:1-25. 7. Aulakh R. Cysticercotic encephalitis: a case report. Int J Sci Res Publications 2013;3.

Figure 2. Magnetic resonance imaging of the brain revealed multiple cyst-like lesions.

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Figure 3. Computed tomography imaging performed 1 month after admission.

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Millairy neurocysticercosis.

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