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Neurological picture

Isolated spinal neurocysticercosis A 46-year-old woman from Brazil complained about increasing headaches for 2 weeks. On admission, she presented with neck rigidity and disorientation. The cranial MRI was unremarkable (figure 1A). The cerebrospinal fluid showed 133 leucocytes/μL with 38% eosinophils. Serum anticysticercal antibodies were 106 (ELISA, standard value ≤0). The spinal cord MRI showed one cystic lesion in the cervical subarachnoid space and multiple cystic lesions in the lumbar subarachnoid space (figure 1B–D). A diagnosis of pure spinal neurocysticercosis was made. Anthelmintic and anti-inflammatory treatment was initiated with albendazol (2×400 mg/day) and steroids (prednisone 60 mg/day) for 4 weeks. During this treatment, the patient’s symptoms improved significantly, but she complained about a persistent nuchal headache at a 6-month follow-up examination. The MRIs showed only partially resolved cysts with the cervical cyst slightly increased in size. Cysticidal drug therapy leads to complete resolution of cystic lesions in only 40% of previously untreated patients,1 2 and no controlled trials have investigated the treatment of subarachnoid disease. However, one study that investigated medical treatment of patients with giant cysts in the Sylvian fissure showed a good response to repeated courses of anthelmintic medication.3 Consequently, retreatment was suggested to the patient, and a future follow-up examination will show the efficacy of repeated anthelmintic therapy. Although neurocysticercosis is a common parasitic infection of the central nervous system, spinal involvement is described in only 0.25–5.8% of patients,4 and pure spinal neurocysticercosis without cystic lesions in the brain is a very rare entity. It was recently described that spinal involvement in neurocysticercosis is highly frequent in basal subarachnoid

neurocysticercosis, and it was therefore suggested that spinal infection probably arises from infection present in the basal cisterns.4 It was speculated that small larvae enter the subarachnoid space and settle to the basal cistern by way of gravity, and then further descend into the subarachnoid spaces of the spine including the lumbosacral space where they find adequate room to develop. This may also explain the differing pattern of cervical and lumbosacral infection. Cervical involvement often consists of unilocular cystic forms due to direct extension of cysts located in the basal subarachnoid cisterns. Conversely, lumbosacral involvement has a more varied picture including multilocular and serpentine cystic lesions.4 This pattern of distribution of cervical and lumbosacral cystic lesions can also be found in the present patient. The rare case of isolated spinal neurocysticercosis might speculatively evolve through complete migration of the larvae from the basal subarachnoid cisterns into the spinal subarachnoid space. In summary, this means that a normal cranial MRI does not rule out neurocysticercosis in all patients. Marc Hackius,1 Athina Pangalu,2 Alexander Semmler1 1

Department of Neurology, University Hospital Zurich, Zurich, Switzerland Department of Neuroradiology, University Hospital Zurich, Zurich, Switzerland

2

Correspondence to Dr A Semmler, Department of Neurology, University Hospital Zurich, Frauenklinikstrasse 26, Zurich 8091, Switzerland; [email protected] Contributors MH drafted the manuscript, AP contributed MRI interpretation, and AS revised the manuscript. Competing interests None. Patient consent Obtained. Provenance and peer review Not commissioned; externally peer reviewed. ▸ Additional material is published online only. To view please visit the journal online (http://dx.doi.org/10.1136/jnnp-2013-307142).

Figure 1 (A) Normal T1-weighted contrast-enhanced cranial MRI. (B, C) Multiple cysts in the subarachnoid space cervical (white narrow) and lumbar in sagittal T2-weighted MRIs of the spine with ring-shaped contrast-intake of the cysts in sagittal T1-weighted contrast-enhanced MRI of the lumbar spine (D).

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Neurological picture REFERENCES 1 2

To cite Hackius M, Pangalu A, Semmler A. J Neurol Neurosurg Psychiatry 2015;86:234–235. Received 25 November 2013 Revised 16 February 2014 Accepted 25 February 2014 Published Online First 1 April 2014

3 4

Nash TE, Garcia HH. Diagnosis and treatment of neurocysticercosis. Nat Rev Neurol 2011;7:584–94. Del Brutto OH, Roos KL, Coffey CS, et al. Meta-analysis: Cysticidal drugs for neurocysticercosis: albendazole and praziquantel. Ann Intern Med 2006;145: 43–51. Proano JV, Madrazo I, Avelar F, et al. Medical treatment for neurocysticercosis characterized by giant subarachnoid cysts. N Engl J Med 2001;345:879–85. Callacondo D, Garcia HH, Gonzales I, et al. High frequency of spinal involvement in patients with basal subarachnoid neurocysticercosis. Neurology 2012;78:1394–400.

J Neurol Neurosurg Psychiatry 2015;86:234–235. doi:10.1136/jnnp-2013-307142

Hackius M, et al. J Neurol Neurosurg Psychiatry February 2015 Vol 86 No 2

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Isolated spinal neurocysticercosis Marc Hackius, Athina Pangalu and Alexander Semmler J Neurol Neurosurg Psychiatry 2015 86: 234-235 originally published online April 1, 2014

doi: 10.1136/jnnp-2013-307142 Updated information and services can be found at: http://jnnp.bmj.com/content/86/2/234

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Neurological picture. Isolated spinal neurocysticercosis.

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