Educational Corner – Case Report

Dubai Med J 2020;3:37–40 Received: November 23, 2019

Accepted: February 6, 2020
DOI: 10.1159/000506365 Published online: February 19, 2020

Neuropsychiatric Manifestations of
Neurocysticercosis
Nayab Mustafa Dania Al Ayyat Mazin Awad Maha Elamin Entisar Bin Haider
Samia Alkhoori
Psychiatry Department, Rashid Hospital, Dubai Health Authority, Dubai, UAE

Keywords Introduction
Psychiatry · Emergency · Neurocysticercosis · Neurology ·
Infectious disease · Tapeworm Neurocysticercosis (NCC) is known for being the
commonest and severest parasitic infection of the central
nervous system. It is also a major public health problem
Abstract in Asian, African and Latin American countries, where
A common scenario in the Emergency Department shows prevalence rates vary from 0.1 to 4%. The infection is
patients presenting with abnormal behavior and agitation. caused by the larval form of the pork tapeworm Taenia
A full workup is performed to rule out organic causes for the solium, which is transmitted feco-orally through eggs in
patients’ presentation after which they are referred to the contaminated water and food (especially raw vegetables,
Psychiatry Department for further assessment regarding undercooked and infected pork) [1].
major mental disorders. Similarly, the aforementioned pro- NCC typically first presents as seizures (70–90% of
tocol was followed for our patient and he was admitted to acutely symptomatic patients) or headache. The severity
the psychiatry ward but was later referred to the Neurology of brain pathology depends on several mechanisms in-
and Infectious Diseases Unit as he developed altered mental cluding quantity of cysts, type, and location as well as the
status. He was then diagnosed as having neurocysticercosis host’s immune response itself [2]. At the time of the first
(NCC), which is a common parasitic infection of the central seizure, most patients have an active cyst, either a vesicle
nervous system. In a multiethnic city like Dubai, NCC should cyst or a colloid cyst. NCC is reported to be responsible
always be considered as a differential diagnosis for abnormal for nearly half of the late-onset cases of epilepsy in the
behavior. Symptomatic NCC carries a mortality rate of more endemic areas [3].
than 50%, making early detection and treatment very impor- NCC has been associated with a plethora of psychiatric
tant. Hence, it is encouraged to screen patients with a high manifestations such as organic psychotic conditions [4,
pretest probability using brain CT and MRI. 5], mania, schizophrenia-like symptoms or catatonic
© 2020 The Author(s) symptoms [6]. Periodic cases of NCC have been reported
Published by S. Karger AG, Basel after assessing patients with a first episode of schizophre-
nia in the Western world [7].

© 2020 The Author(s) Nayab Mustafa

Published by S. Karger AG, Basel Psychiatry Department, Rashid Hospital, Dubai Health Authority
315 Umm Hurair Second, Oud Mehta
[email protected] This article is licensed under the Creative Commons Attribution-
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Usage and distribution for commercial purposes as well as any dis-
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 Case Report

A 31-year-old Indian male, without proof of identity in his pos-

session, was brought to the Emergency Department in Rashid
Hospital by the police after he had been discovered roadside dis-
playing abnormal behavior. He was afebrile, vitally stable and all
laboratory investigations were within normal range.
He was referred to the psychiatry team for assessment. He was
alert and oriented but refused to answer questions or make eye
contact and exhibited psychomotor retardation. Thus, he was ad-
mitted to the psychiatry ward for further evaluation.
In the ward, the patient was not agitated or aggressive but was
noted to be suspicious of others, with minimal social interaction
and limited, irrelevant verbal output. He was oriented and irre-
sponsive to the assessment of psychotic symptoms. He remained
afebrile and vitally stable with no physical complaints. During his
stay in the ward, he was prescribed antipsychotic medication (ris-
peridone) for suspected brief psychotic disorder.
As the patient showed no signs of improvement by the first
week, all laboratory investigations were repeated and nonen-
hanced CT of the brain was performed which revealed no focal
lesions or hemorrhage. By the second week, he received one ses-
sion of electroconvulsive therapy, after which he became clini-
cally drowsy. Consequently, all psychotropic medications were
discontinued and he was referred to the neurology team for fur-
ther evaluation. Electroencephalography was performed and
showed frontal intermittent rhythmic delta as well as generalized
slow wave dysrhythmia with a fast sleep-like pattern. Lumbar
puncture revealed a protein level of 70 mg/dL, glucose 78 mg/dL
and chloride 124 mmol/L for which the patient was referred to
the Infectious Diseases Unit. MRI of the brain with contrast was
then performed which revealed multiple ring-shaped lesions
Fig. 1. MRI of the brain showing multiple ring-shaped lesions of
which were T1 hypointense, T2 hyperintense and hypointense
NCC.
on FLAIR sequences, dispersed throughout the cerebral and cer-
ebellar parenchyma at the grey-white matter junction, with some
showing mild edema (Fig. 1). Ring enhancement was noted in
almost all the lesions with some showing focal intense enhance-
ment on postcontrast study, suggestive of scolex and hence NCC NCC is the most common neurological disease of par-
in the vesicular-colloidal stage. Under care of the Infectious Dis-
eases Unit, he was started on albendazole 400 mg b.d. and dexa- asitic origin. Neurological manifestations of NCC com-
methasone 2 mg i.v. t.i.d. One week later, the patient’s Glasgow monly present as seizures (80%), headache (40%), visual
Coma Scale score dropped to 3 and the pupils became dilated. changes (20%), and confusion (15%). Certain immune
He was intubated and shifted to the Intensive Care Unit for me- mechanisms are initiated in the central nervous system,
chanical ventilation support. Urgent CT of the brain was per- which cause reactive gliosis and arachnoiditis that ulti-
formed and revealed diffuse cerebral edema/diffuse global hy-
poxic ischemia. Brainstem reflexes and apnea test were conduct- mately lead to proliferative endarteritis. This causes oc-
ed, and he was announced brain dead. The patient died 1 month clusion of the arterial lumen and hydrocephalus, as a con-
later. sequence of which there is intracranial hypertension and
edema [8]. Such structural changes are heavily dependent
on the quantity of parasitic lesions as well as their loca-
Discussion tions. In addition, ventricular and subarachnoid NCC are
known to be associated with meningitis and intracranial
In a multiethnic city like Dubai, NCC should be con- hypertension, which can result in cognitive impairment,
sidered as one of the differential diagnoses for abnormal primarily attention deficit, decreased consciousness and
behavior. To the best of our knowledge, no other case re- delirium.
port has been published regarding neuropsychiatric man- The diagnosis of NCC had frequently been delayed
ifestations of NCC in this region. over the past decade due to an array of psychiatric man-
ifestations predominating at the onset of the disease. For-

38 Dubai Med J 2020;3:37–40 Mustafa/Al Ayyat/Awad/Elamin/

DOI: 10.1159/000506365 Bin Haider/Alkhoori
lenza et al. [9] reviewed 38 cases of NCC which revealed Appropriate treatment also improves psychiatric
psychiatric symptoms and cognitive decline in 65.8 and symptoms. Psychiatric consultation should be offered for
87.5% of the cases, respectively. The most recurrent non- persistent psychiatric manifestations in patients and psy-
cognitive psychiatric illness was identified as depression chopharmacological therapy should be complimentary to
in 52.6% of the cases, whereas psychosis was identified in neurological care.
14.2%. Srivastava et al. [10] also revealed major depres-
sion and mixed anxiety depression as the two most com-
mon diagnoses, constituting 36 and 18% of the cases, re- Conclusion
spectively. Mahajan et al. [4] disclosed that their patient
had had psychosis for 1 year before developing seizures It is highly recommended that NCC be considered as
and finally getting diagnosed as having NCC. In the pres- one of the possible differential diagnoses of abnormal be-
ent case report, the patient was oriented in the psychiatry havior in multicultural cities, such as Dubai, where 71%
ward but exhibited antisocial behavior, incoherent of the total population constitutes expatriates from vari-
speech and suspicion. With substantial lack of history ous countries.
available regarding prior episodes of seizures or of epi-
lepsy, it was unclear whether the patient was in a postic-
Statement of Ethics
tal state. Furthermore, no neurological signs or possible
organic etiology indicated a suspicion of brief psychotic The patient in consideration was brought forth by the police
disorder. with no identification documents in his possession. During his en-
Absolute criteria for the diagnosis of NCC constitute tire stay in the hospital, great attempts were made to locate the
biopsy of the lesion to histologically demonstrate the patient’s family but no family or close relatives could be contacted.
As the patient passed away, we were unable to obtain consent from
parasite, visualization of the subretinal cysticercus and him or any of his next of kin. The purpose of this case report is for
demonstration of the scolex within a cystic lesion on academic benefit and to save lives, hence we deem it highly impor-
neuroimaging. Confirmative neuroimaging criteria tant that this case be published.
also involve resolution of cystic lesions after cysticidal
drug therapy [11]. The choice of treatment essentially
Disclosure Statement
depends upon the cyst viability, cysticercal load and lo-
cation of cysts. For patients with 1–2 viable parenchy- The authors have no conflicts of interest to declare.
mal cysticerci, albendazole (15 mg/kg/day) monother-
apy for 10–14 days is recommended. More than 2 viable
parenchymal cysticerci warrants albendazole with pra- Funding Sources
ziquantel (50 mg/kg/day) for 10–14 days [12]. Newer
The authors have no funding sources to declare.
evidence has shown that commencement of antihel-
minthics can cause risk of exacerbated seizures and en-
cephalopathy. This is primarily due to brain edema as a Author Contributions
result of acute perilesional inflammation caused by
cysts expelling toxic materials. This phenomenon usu- The corresponding authors analyzed medical records, labora-
tory and imaging reports to write the case report. PubMed was
ally occurs between the second to fifth day of therapy
utilized to study papers on the topic at hand, with subsequent cita-
instigating larval death [13]. Thus, a course of steroids tions to strengthen the report.
has actually improved patients’ cognitive decline as it The co-authors reviewed and adjusted the report with great
reduces inflammation. consideration.

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40 Dubai Med J 2020;3:37–40 Mustafa/Al Ayyat/Awad/Elamin/

DOI: 10.1159/000506365 Bin Haider/Alkhoori