- Departments of Neurosurgery, Northwestern Feinberg School of Medicine, 420 East Superior Street, Chicago, Illinois, United States.
- Departments of Pathology, Northwestern Feinberg School of Medicine, 420 East Superior Street, Chicago, Illinois, United States.
- Department of Neurosurgery, University of California, Davis, California, United States.
Department of Neurosurgery, University of California, Davis, California, United States.
DOI:10.25259/SNI_363_2020Copyright: © 2020 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Ketan Yerneni, Constantine Karras, Hannah K. Weiss, Craig M. Horbinski, Orin Bloch. Intraventricular adult Taenia solium causing hydrocephalus: A case report. 18-Jul-2020;11:202
How to cite this URL: Ketan Yerneni, Constantine Karras, Hannah K. Weiss, Craig M. Horbinski, Orin Bloch. Intraventricular adult Taenia solium causing hydrocephalus: A case report. 18-Jul-2020;11:202. Available from: https://surgicalneurologyint.com/?post_type=surgicalint_articles&p=10146
Background: Neurocysticercosis (NCC) is the most common parasitic infection of the central nervous system worldwide and is caused by the larval form of the tapeworm Taenia solium. In general, T. solium larval form may be located in the neuraxis, resulting in pathology. Here, we report a rare case of female with a history of adult onset seizures presenting with adult form T. solium in the fourth ventricle, causing hydrocephalus.
Case Description: A 36-year-old female patient with a known history of adult onset seizures presented with a 1-year history of progressively worsening bilateral headaches with vertigo and intermittent nausea. A computerized tomography scan revealed ventriculomegaly and transependymal flow, with an obstruction at the level of the fourth ventricle. Outpatient magnetic resonance imaging demonstrated obstructive hydrocephalus secondary to a lobulated cystic mass within the fourth ventricle, demonstrating a gross appearance consistent with racemose NCC. The patient underwent endoscopic third ventriculostomy, and gross examination of the resected cyst revealed a mature T. solium larvae encased in a cystic membrane. Given that our patient was born and raised in Mexico but had not returned since the age of 8, NCC was an unexpected finding.
Conclusion: The present case highlights the importance of maintaining high suspicion for NCC in all patients presenting with seizures or hydrocephalus of unknown cause. Even in patients with a very remote history of residence in an endemic country, NCC can be an overlooked, underlying cause of both chronic neurologic symptoms, as well as acute, life-threatening neurologic emergencies.
Keywords: Hydrocephalus, Intraventricular, Neurocysticercosis, Taenia solium, Tapeworm
Neurocysticercosis (NCC) is a parasitic disease endemic to most of the developing world and is a major source of admissions to neurological wards, as it is a significant cause of acquired seizures and epilepsy worldwide.[
Our patient is a 36-year-old female with a history of adult onset seizures. She was born and raised in Mexico and emigrated to the United States at the age of 8. Since arriving to the United States, she had never returned to Mexico. She had her first seizure about 10 years before presentation, at which point she was placed on anti-epileptic medications that were subsequently weaned off without any further seizure activity in the past several years. No prior imaging was available for our review, but the patient denied report of any intracranial lesions that could be identified as the culprit of the adult onset seizures.
She initially presented to an outside institution with progressively worsening bilateral headaches over the past year that were associated with vertigo and intermittent nausea. The headaches were worse at night and on waking up in the morning, and they improved throughout the day. A computerized tomography (CT) scan demonstrated ventriculomegaly and transependymal flow, with evidence of obstruction at the level of the fourth ventricle. She was referred to our clinic by our neurology colleagues, where she was found to have no neurologic deficits on examination. Outpatient magnetic resonance imaging (MRI) demonstrated obstructed hydrocephalus secondary to a lobulated cystic mass within the fourth ventricle, with a streak of internal linear enhancement most consistent with racemose NCC. A worm was easily identified within the cyst on the MRI [
Given the chronic nature of the lesion and her benign clinical examination, she was scheduled for elective surgery a few weeks later. She underwent right frontal burr hole for endoscopic third ventriculostomy and placement of external ventricular drain (EVD), then she was positioned prone and underwent suboccipital craniotomy for resection of the fourth ventricular cystic mass followed by duraplasty. The cyst was removed as a single en bloc specimen, although during the process of removal, a small portion of the cyst ruptured into the ventricle – this was quickly suctioned and extensively irrigated. Gross examination [
Postoperatively, she had no neurologic deficits. Her EVD was quickly weaned with minimal drainage and low intracranial pressure, so it was removed on postoperative day 2. She underwent ophthalmologic examination, demonstrating no evidence of an active ocular infection or involvement of NCC, but concern for a chronic, inactive choroidal inflammatory process. Our infectious disease colleagues were consulted and found no other risk factors for NCC aside from living in Mexico until the age of 8, and she was negative for tuberculosis infection. Given her longstanding history of seizures, but recent presentation with an active lesion, it was felt that she may have been auto-infecting. She underwent a 21-day course of albendazole with a 14-day dexamethasone taper for protection against aseptic meningitis. She was also prescribed a single dose of praziquantel at the end of her therapy given concerns for possible auto-infection from her gastrointestinal system. On discharge, her headaches, vertigo, and nausea had completely resolved.
NCC is the most common helminthic infection of the CNS worldwide and has recently become an emerging infectious disease in the United States, particularly in areas of high rates of immigration from endemic regions of Latin America.[
NCC has been widely reported in the literature; diagnostic criteria,[
Intraventricular NCC presents more aggressively than the parenchymal form, often causing intracranial hypertension due to CSF obstruction and potential arachnoiditis.[
The management and treatment of intraventricular NCC is distinct from the parenchymal form, which is the most widely published on. Indications for surgical management of intraventricular NCC include mass effect, CSF obstruction, and ventricular cysts. Acute hydrocephalus, as manifested in the case presented here, requires emergency ventriculostomy followed by cyst resection.[
In several cases, a ventriculostomy by itself may be enough to relieve hydrocephalus without a shunt; however, external drainage is often indicated in patients with extensive disease and damage. Furthermore, ventriculitis often complicates shunt placement in patients with NCC, resulting in shunt malfunction rates that are exceptionally high – reported to be over 30% – with a high rate of postoperative mortality.[
At present, there are no clinical trials or definitively established guidelines for the anthelminthic treatment of intraventricular NCC and remain poorly resolved; lesions may spontaneously resolve, and anthelminthic agents may lead to worsening of symptoms.[
The present case highlights the importance of maintaining high suspicion for NCC in all patients presenting with seizures or hydrocephalus of unknown cause. Patients are most effectively evaluated for NCC by obtaining an MRI, serologic testing, and thorough neurologic examination. In addition, in the era of globalization and increased immigration and travel, it is critical to collect a thorough social history, including travel and residence history to any endemic country. This case illustrates that even in patients with a very remote history of residence in an endemic country, NCC can be an overlooked, underlying cause of both chronic neurologic symptoms, as well as acute, life- threatening neurologic emergencies.
Although rare in the United States, increased travel and immigration across endemic areas have increased the incidence of NCC in regions unfamiliar with the disease. Intraventricular cysticerci may be mistaken for other common intraventricular lesions, including colloid cysts. Here, we have presented an extremely rare case of an adult T. Solium within a cyst in the fourth ventricle, causing acute hydrocephalus.
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