CASE REPORT

Neurocysticercosis Presenting with Epilepsia

Partialis Continua: A Clinicopathologic
Report and Literature Review
Shin-Joe Yeh,1 Ruey-Meei Wu1,2*

Neurocysticercosis, a disease caused by a tapeworm larva in the central nervous system, is the leading
cause of acquired epilepsy in undeveloped regions of the world. In Taiwan, after improvements in sanitation,
tapeworm infection became very rare except in mountain areas inhibited by aborigines. However, in recent
years, immigration from other Asian countries has increased rapidly, and parasite infection of the central
nervous system may again become an important cause of adult-onset epilepsy in clinical practice. Here, we
describe a 27-year-old female Thai immigrant who presented with adult-onset epilepsia partialis continua
of the right upper extremity. Electroencephalography showed epileptiform discharge in the left central
region, while brain magnetic resonance imaging showed a small enhanced lesion in the left premotor
cortex. She underwent operation and pathology of the mass revealed a degenerated cysticercus. In this article,
we provide detailed neuroimaging findings, pathologic report, and literature review of this parasitic infection
of the central nervous system. This case calls for physicians to be aware of cysticercosis as an etiology of
adult-onset epilepsy in immigrants from endemic countries. [J Formos Med Assoc 2008;107(7):576–581]

Key Words: epilepsia partialis continua, epilepsy, neurocysticercosis, Taenia solium, tapeworm

Neurocysticercosis, the leading cause of acquired to neurocysticercosis.2 The 2003 World Health
epilepsy worldwide, is caused by Taenia solium Organization regarded T. solium as an important
infection in the central nervous system.1 There issue in global public health.3 The WHO has cal-
are an estimated 50 million cases of cysticercosis culated that over 50,000 deaths due to neuro-
worldwide.2 Most cases occur in less developed cysticercosis occur each year.5 In Taiwan, after
countries, such as parts of Asia, Latin America, improvements in public sanitation, T. solium in-
sub-Saharan Africa, and parts of Oceania. In Asia, fection has been rare in recent decades except for
it is prevalent in India, Indonesia, Vietnam, China a few reported familial cases in aborigines.6
and Nepal, and the prevalence is between 1.7% However, the immigrant population from other
and 13%.3,4 However, due to increased immigra- countries in Southeast Asia is rapidly growing, so
tion and international travel, an increasing num- awareness of Taenia infection and its neurologic
ber of cases are being reported in developed complications is important. Here, we present a
countries.1,2 For example, in New Mexico and case of neurocysticercosis with clinical manifes-
California, 10% of cases presenting as seizure in an tations of epilepsia partialis continua. The life
emergency room in a large urban hospital was due cycle of the cysticercus and the pathogenesis of

©2008 Elsevier & Formosan Medical Association

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
Department of Neurology, National Taiwan University Hospital and 2National Taiwan University College of Medicine,
Taipei, Taiwan.

Received: March 15, 2007 *Correspondence to: Dr Ruey-Meei Wu, Department of Neurology, National Taiwan
Revised: April 13, 2007 University Hospital, 7 Chung-Shan South Road, Taipei 100, Taiwan.
Accepted: August 7, 1007 E-mail: robinwu@ntu.edu.tw

576 J Formos Med Assoc | 2008 • Vol 107 • No 7


the infection in the central nervous system are
reviewed. A detailed differential diagnosis of the
neuroimaging findings in this case is described.
Case Report
A 27-year-old Thai woman attended our neuro-
logic clinic with the chief complaint of intermit-
tent twitching of the right elbow for 12 hours,
which occurred about 20 days after a 1-minute
episode of clonic movement in her right wrist,
with clear consciousness. The second episode con-
sisted of stereotyped, semirhythmic, clonic flex-
ion movement of her right wrist that lasted for
1–2 minutes, which then involved her right elbow,
and finally her right shoulder. This was followed
by frequent clonic flexion movements of her right
elbow, initially occurring every 10–20 minutes,
then becoming more frequent and finally per-
sistent. She could not control the movement.
Of note, the clonic movement did not disappear
during sleep. Prior to these episodes, she had no
medical disease, headache, fever, head trauma, or
previous seizure. Her personal history showed
that she had immigrated to Taiwan with her fam-
ily to work 4 years previously and returned to her
homeland every year. Her last visit to Thailand
was 1.5 years ago; while there, her drinking water
was obtained from a well in a field.
On physical examination, she did not have
fever, neck stiffness, or lymphadenopathy. The
A B
Fp2-F4
F4-C4
C4-P4
P4-O2
Fp1-F3
F3-C3
C3-P3
P3-O1
Fp2-F8
F8-T4
T4-T6
100μV
Fp1-F7
1 sec
F7-T3
T3-T5
Figure 1. Electroencephalographic findings in the reported case while awake. (A) There were frequent regional semi-
rhythmic slow waves at 1–3 Hz, 25–50 μV in the left central region, with occasional lateralization or extension to the right
side. There was one episode of clinical seizure characterized by twitching of the right upper limb, not associated with elec-
trophysiologic changes. (B) Hyperventilation induced occasional generalized sharp waves with possible phase reversal at C3.
J Formos Med Assoc | 2008 • Vol 107 • No 7
Neurocysticercosis presenting with epilepsia partialis continua
neurologic examination showed clear conscious-
ness, mild weakness in the right upper limb graded
4 on the Medical Research Council grading sys-
tem, and increased tendon reflex and hypesthesia
in the right upper limb. Epilepsia partialis con-
tinua was diagnosed clinically,7,8 the lesion site
probably being in the left motor cortex, near the
central vertex area.
Awake electroencephalography (EEG) was per-
formed. The background activity consisted of sym-
metrical alpha rhythm in the posterior head area,
with an adequate alerting response to eye opening.
There were frequent regional semirhythmic slow
waves at 1–3 Hz, 25–50 μV in the left central re-
gion, with occasional lateralization or extension
to the right side. There was an episode of clinical
seizure characterized by twitching of the right
upper limb, but the EEG pattern did not change
during the attack (Figure 1A). In addition, hyper-
ventilation induced an episode of generalized
sharp waves with phase reversal at C3 (Figure 1B).
These EEG findings suggested a focal lesion in the
left central region.
Brain magnetic resonance imaging (MRI)
showed a well-defined rim-enhanced nodule with
a mural nodule in the left posterior frontal lobe,
with marked perifocal edema (Figure 2). There
was no signal change in the lesion on diffusion-
weighted image or apparent diffusion coefficient.
Tumor or granuloma was considered. Blood tests,
including white blood cell count with a differen-
tial count (eosinophils, 4.2%), C-reactive protein,
Fp2-F4
F4-C4
C4-P4
P4-O2
Fp1-F3
F3-C3
C3-P3
P3-O1
T4-C4
100μV
C4-Cz
1 sec
Cz-C3
C3-T3 07:20
577
S.J. Yeh, R.M. Wu
A B
tumor markers, and anti-HIV antibody titer, were
all within normal limits.
Her seizure was completely controlled with
valproic acid (1000 mg/day) on the second day
of hospitalization. The lesion in the left premo-
tor area was excised by craniotomy, and pathol-
ogy showed a partially degenerated cysticercus
(Figure 3). The stools were checked twice for
parasite ova and were negative. She received praz-
iquantel for 2 weeks after the operation. Inter-
mittent paresthesia on the right side of the body
was well controlled by increasing the dosage of
valproic acid to 1500 mg/day.
Discussion
A 27-year-old Thai woman had a late-onset
seizure with continuous clonic convulsion in her
right elbow. EEG study showed an epileptogenic
578
Figure 2. Magnetic resonance imaging findings.
(A) T1-weighted image shows a hypointense
lesion, with (B) ring enhancement with contrast.
(C) T2-weighted image shows perifocal edema
in the left posterior frontal lobe.
focus in the left central area, which was compati-
ble with the clinical impression of epilepsia par-
tialis continua. No epileptiform activity was
recorded during attack; this discrepancy between
motor convulsion and electrophysiologic find-
ings may be due to multiple closely allied small
groups of neurons firing asynchronously or the
discharge focus being deeply seated in the in-
folded cortex.8 MRI revealed a single enhanced
mass with perifocal edema in the left premotor
area. For a single brain lesion causing focal
seizure, the differential diagnoses include tumor,
granuloma, and pyogenic abscess;8 the character-
istic brain MRI findings are summarized in the
Table.9–13 Unexpectedly, the pathologic findings
of the mass lesion showed a partially degener-
ated cysticercus (Figure 3). The cysticercus in this
case was probably T. solium, because there is no
report that T. saginata produces cysticercosis in
the human brain.14
J Formos Med Assoc | 2008 • Vol 107 • No 7
 Neurocysticercosis presenting with epilepsia partialis continua

A B

Figure 3. (A) Pathologic findings of a partially degenerated cysticercus in the brain (hematoxylin & eosin, 10×). (B) The
partially degenerated cysticercus was surrounded by inflammatory infiltrates of lymphocytes, plasma cells and numerous
eosinophils (hematoxylin & eosin, 40×).

Table. Magnetic resonance imaging (MRI) sequence findings in the differential diagnosis of a single enhanced lesion in the brain
MRI sequence Abscess9 Necrotic tumor9 CNS lymphoma*10 Tuberculoma11 Cysticercosis12,13

T1WI Hypointense Hypointense Iso- or hypointense Iso- or hyperintense Iso- or hyperintense,

hole-with-dot

T2WI Hyperintense Hyperintense Iso- or hypointense Iso- or hypointense Iso- or hyperintense,

hole-with-dot

Ring enhancement on (+) (+) Thick & (+) With little or no (+) (+)
T1WI with contrast irregular ring perifocal edema

DWI Hyperintense Hypointense Hyperintense Hyperintense Isointense

ADC Low value High value Low value

*CNS lymphoma in an immunocompromised patient. CNS = central nervous system; T1WI = T1-weighted image; T2WI = T2-weighted image; DWI =
diffusion-weighted image; ADC = apparent diffusion coefficient.

Human cysticercosis of T. solium is caused by Adult worms in human intestine

accidental ingestion of its eggs. Its lifecycle is shown (definite host)
(Taeniasis)
in Figure 4. The cysticercus (larva) hatches from
eggs in the human stomach and enters various
tissues through the blood stream. If it enters the Eggs in human feces
central nervous system, it may lodge in the paren-
chyma, ventricle, or cistern, resulting in different
Pig ingests Human ingests
clinical manifestations. In parenchymal neuro- the eggs the eggs
cysticercosis, there are four histopathologic stages
on neuroimaging, these being the viable stage,
Cysticercus in pig muscles Cysticercus in human
colloidal stage, nodular-granular stage, and calci- (intermediate host) brain, eyes, muscle, etc.
fied stage.13 Staging depends on the viability of the (cysticercosis)
cysticercus and the host inflammatory response.
In the viable stage, the larva elicits little or no Human eats Cysticercus dies
inflammatory response, so it is always asympto- undercooked pork

matic. Computed tomography (CT) or MRI shows Figure 4. The lifecycle of Taenia solium.

J Formos Med Assoc | 2008 • Vol 107 • No 7 579

S.J. Yeh, R.M. Wu
a vesicle containing a small eccentric nodule,
which is the scolex (head). The “hole-with-dot”
imaging is pathognomonic to cysticercosis.13 There
is little or no perilesional edema or enhancement
due to mechanisms for successful escape from the
host’s immunologic system. After several years, the
larva dies and an inflammatory response occurs.1
The fluid in the vesicle becomes opaque, so this
stage is called the colloidal stage. On imaging, the
wall of the cyst is thickened, with perifocal edema
and contrast enhancement. Later, the cyst develops
into a granuloma, which is the nodular-granular
stage. On MRI, it is signal-devoid on T1- and T2-
weighted images and surrounded by a hyperintense
rim and perifocal edema. Finally, the granuloma
becomes a calcified nodule. The calcified stage is
better seen on CT; on MRI, the calcified nodule
is not readily visible, but perifocal edema and
contrast enhancement can be seen. In our patient,
the neurocysticercosis was a parenchymal form
and in the colloidal stage (Figure 3).
The symptoms of parenchymal neurocysticer-
cosis are mainly due to the inflammatory response
induced by the degenerated or calcified cyst. Seizure
is the most common manifestation; others include
encephalitis, meningitis, intracranial hyperten-
sion, or focal neurologic signs.15 If the cysts are
in the ventricle or basal cistern, they may result
in hydrocephalus by blocking the circulation of
cerebrospinal fluid, in focal signs due to direct
compression, or in stroke due to endarteritis.
It was unclear how and where the patient
ingested the eggs of T. solium. The lifespan of a
cysticercus in the human brain is estimated to be
several years,1 and they usually do not cause symp-
toms until they are dying. Taenia infection is rare
in Taiwan6 but common in Thailand, with the
prevalence ranging from 0% to 18.2% in a study
assessed by worm purging.16 In rural areas in
Thailand, open-air defecation occurs and contam-
inates the water supply, soil and vegetation.17
This patient did not eat uncooked vegetables, but
her drinking water was from a well that might
have been contaminated by Taenia eggs. It might
be one of the possible sources of her parasite
infection.
580
In summary, the patient was a female Thai
immigrant with neurocysticercosis who presented
with epilepsia partialis continua. This case report
highlights the importance of Taenia infection as an
etiology of late-onset focal seizure in immigrants
from endemic countries.
Acknowledgments
We thank Associate Professors of Parasitology Kua-
Eyre Su and Shiou-Jeng Ong for their comments
on Taenia solium infection.
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