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MANALO, Pauline, Malihan
MENDEZ, Nicole Angela, Sarmiento
ORDOÑEZ, Gio Angelo, Atalia

Neurocysticercosis presented as a solitary cystic parenchymal lesion mimicking

primary brain tumor: A case report
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Andreas Soejitnoa, I Wayan Niryanab, Ni Putu Sriwidyanic, Ni Made Susilawathia, Ni Putu Witaria, A.A. Raka
Sudewia

A. Overview of the Case:

The case report discusses a 25-year-old man from East Nusa Tenggara who arrived at
the emergency room after experiencing a seizure. He had a history of similar seizures and was
previously diagnosed with a brain abscess, treated with antibiotics and anti-seizure drugs.
However, his seizures persisted, prompting his hospitalization. Upon examination, he showed
mild papilledema, mild left hemiparesis, and focal-to-bilateral tonic-clonic seizures. Imaging
revealed a solitary lesion in the right frontoparietal cortex (Fig 1), initially suspected to be a brain
tumor, leading to surgical intervention. However, pathology revealed cysticercosis caused by
Taenia solium larvae (Fig 2a and 2b), confirming neurocysticercosis (NCC). The patient presented
a unique case of disease transmission since he did not consume any pork. However, he did
consume various undercooked meats, including horse and ox meat, a rather unusual practice in
Indonesia. Currently there has been no documented T. solium infestation among equine or
cattles.

This case underscores the challenge of diagnosing NCC, especially when it mimics a brain
tumor. Despite negative serological tests, the patient’s eosinophilia and imaging results supported
the NCC diagnosis. Treatment involved albendazole and corticosteroids after surgery, resulting
in disease resolution without seizure recurrence. It highlights the need to consider NCC in patients
with seizures and cortical brain lesions, particularly in endemic regions, and emphasizes the
efficacy of appropriate treatment in managing the condition.
 Figure 1. Axial T1 Head MRI showed an isointense lesion with perifocal brain edema in the right
frontoparietal cortex

(a) (b)
Figure 2.a. Gross examination of sectioned tissue revealed glistening cystic lesion; 2.b. microscopic
examination demonstrated Taenia solium larvae complete with its sucker
(arrow), surrounded by suppurative inflammatory reaction (100 magnification)

B. Signs and Symptoms:

The symptoms experienced by the patient include 2–3-minute partial seizures marked
by shaking movement of the left extremities, preceded by stiffness, and then became generalized.
During the convulsion, both of the patient’s eyes deviated toward the left side. The seizures were
recurring, and the patient had already experienced seizures with similar semiology twice prior to
admission. In addition, the patient also experienced a mild vascular-type headache.

Neurocysticercosis presented as a solitary cystic parenchymal lesion mimicking primary brain tumor: A case report
 Moreover, some signs observed were carried out through ophthalmoscope evaluation.
Ophthalmoscope evaluation revealed that the patient had mild papilledema (grade 1),
characterized by a mild swelling of the optic nerve. Another sign was mild left hemiparesis
(grade 4+), particularly in the leg.

C. What is pertinent?
Several signs and symptoms were positively pertinent to the diagnosis of NCC. Seizures
were the most crucial symptom for this case since they are the most common symptom of NCC
and align with the patient's history of recurring seizures. Focal neurological deficits like
hemiparesis can occur with NCC depending on the location of the lesion (Singhi, 2011). While
not specific to NCC, they indicate a lesion affecting the motor cortex, aligning with the lesion
location found in the MRI (Figure 5). Although headaches are a common symptom in many
conditions, their presence alongside seizures and hemiparesis adds to the suspicion of a
neurological issue. Mild papilledema is non-specific but can be associated with increased
intracranial pressure, potentially due to NCC.

Moreover, there were signs and symptoms that can be classified as negatively pertinent
to the case, such as the negative electroencephalogram (EEG), since it doesn't rule out NCC,
even though seizures are present. This means it couldn't be used to confirm or deny the diagnosis,
making it inconclusive and requiring further investigation. Similarly, the negative ELISA antibody
test against T. solium. Negative ELISA test in NCC is negatively pertinent because it doesn't rule
out the disease. ELISA detects antibodies, which take time to develop after infection. In early
stages or single lesions, antibody levels might be low, leading to a false negative. Moreover,
ELISA primarily detects circulating antibodies, not necessarily those specific to the brain tissue
where the parasite resides. So, despite being negative, it doesn't definitively disprove NCC.

D. Differential Diagnosis
The differential diagnosis of the case includes several possibilities. Initially, based on the
patient's presentation with seizures and focal neurological deficits, a primary brain tumor such as
oligodendroglioma was suspected due to the location and characteristics of the lesion on imaging.
Other possibilities included brain abscess, given the patient's history of previous treatment for a
brain abscess and recurrence of seizures despite treatment.

Neurocysticercosis presented as a solitary cystic parenchymal lesion mimicking primary brain tumor: A case report
 (a) (b)
Figure 3.a. Forming ring-enhanced lesion upon gadolinium administration displayed on axial;
3.b. sagittal view

Infectious causes such as tuberculoma and toxoplasmosis were also considered,

especially in regions where these infections are endemic. However, the absence of other
supporting evidence for these infections made them less likely. Malignancies, both primary and
secondary brain tumors, were also in the differential diagnosis due to the patient's age, clinical
presentation, and imaging findings.

E. Definitive Diagnosis
The brain tissue that was removed during the craniotomy for tumor excision showed signs
of fibrosis and was distributed with polymorphonuclear cells, including neutrophils, lymphocytes,
plasma cells, and histiocytes. Moreover, there were several cystic segments that contained
tapeworm larvae. Pathological testing and surgical resection that followed showed tissue fibrosis
encircled by inflammatory cells, and a cystic lesion with live T. solium larvae present possessing
its evident sucking, validating the diagnosis of an ongoing but deteriorating NCC.

The case met the diagnostic requirements for a definite parenchymal NCC, in accordance
with the currently recognized diagnosis of NCC by Carpio, et al., 2016.

F. Treatment and Management

Treatment and management for Neurocysticercosis involve a combination of
antihelminthic medication, corticosteroids, surgical procedures as needed, and long-term
monitoring to ensure effective seizure management and resolution of lesions. In this particular
case, surgical resection of the lesion was performed to remove the cyst containing the viable larva
of T. solium. Albendazole therapy, together with corticosteroid therapy, was administered 14 days
post-resection of the cystic lesion. Albendazole helped in killing the parasite larvae and reducing
the cyst burden. Antiepileptic medication was also prescribed for two years following the national
guidelines for the management of symptomatic epilepsy.

Neurocysticercosis presented as a solitary cystic parenchymal lesion mimicking primary brain tumor: A case report
 Appendix:

(a) (b)
Figure 4.a. T2 axial and; 4.b. sagittal MRI demonstrated hyperintense lesion with surrounding focal brain
edema on the same location

Figure 5. A follow-up non-contrast axial head CT scan one month after surgery showed focal hypodense
lesion in the post-resected area, suggesting encephalomalacia (arrow) with post-surgical cranial bone
defect (arrowhead)

References:
Buensalido, J. a. L., MD. (n.d.). Cysticercosis (Pork tapeworm infection) clinical presentation:
History, physical, causes. https://emedicine.medscape.com/article/215589-clinical#b1
Singhi, P. (2011). Neurocysticercosis. Therapeutic Advances in Neurological Disorders, 4(2), 67–
81. https://doi.org/10.1177/1756285610395654

Neurocysticercosis presented as a solitary cystic parenchymal lesion mimicking primary brain tumor: A case report
Soejitno, A., Niryana, I. W., Sriwidyani, N. P., Susilawathi, N. M., Witari, N. P. D., & Sudewi, A. a.
R. (2020). Neurocysticercosis presented as a solitary cystic parenchymal lesion mimicking
primary brain tumor: A case report. IDCases, 22, e01004.
https://doi.org/10.1016/j.idcr.2020.e01004

Neurocysticercosis presented as a solitary cystic parenchymal lesion mimicking primary brain tumor: A case report