Correspondence

Case 16-2002: Neurocysticercosis

N Engl J Med 2002; 347:1117October 3, 2002

Article

To the Editor:

Case 16-2002 (May 23 issue)1 describes a 41-year-old woman with generalized headache and a hemorrhagic lesion on neuroimaging; on brain biopsy, her condition was diagnosed as cerebral venous thrombosis. Several factors, however, suggest that the cerebral venous thrombosis may have been secondary to a separate, underlying process.

Given the patient's country of origin (El Salvador) and her “frequent trips back” there, along with the presence of separate intracerebral calcifications, the possibility of neurocysticercosis should have been considered in the differential diagnosis and appropriate serologic tests performed. Supporting this possibility are the absence of risk factors for cerebral venous thrombosis, the known association of intracerebral hemorrhage with neurocysticercosis,2 and the presence on neuroimaging of considerable vasogenic edema with an enhancing satellite lesion, a finding that is more compatible with the presence of neurocysticercosis than of cerebral venous thrombosis. The discussant notes the clinical features of a previous transient headache that were suggestive of increased intracranial pressure and mentions as possible causes hydrocephalus or cerebral venous or sinus thrombosis, which may have remitted spontaneously. He does not mention transient hydrocephalus, a condition associated with neurocysticercosis,3 as a possible cause. Furthermore, brain biopsy does not always reveal cysticercus,4 and the cerebral venous thrombosis may have resulted from an underlying inflammation associated with a cysticercosis lesion. It would be helpful to know whether the patient underwent or can undergo serologic testing to rule out the possibility of neurocysticercosis.

Pasquale F. Finelli, M.D.
Hartford Hospital, Hartford, CT 06102
nervline@aol.com

4 References

1
Case Records of the Massachusetts General Hospital (Case 16-2002). N Engl J Med 2002;346:1651-1658
Full Text | Web of Science | Medline

2
Alarcon F, Vanormeligen K, Moncayo J, Vinan I. Cerebral cysticercosis as a risk factor for stroke in young and middle-aged people. Stroke 1992;23:1563-1565
CrossRef | Web of Science | Medline

3
McCormick GF. Cysticercosis -- review of 230 patients. Bull Clin Neurosci 1985;50:76-101
Medline

4
Cameron ML, Durack DT. Helminthic infections. In: Scheld WM, Whitley RJ, Durack DT, eds. Infections of the central nervous system. 2nd ed. Philadelphia: Lippincott-Raven, 1997:850.

Author/Editor Response

The neurologist and the pathologist reply:

To the Editor: We appreciate Dr. Finelli's thoughtful reading of Case 16-2002. We concur that this patient probably had long-standing neurocysticercosis, on the basis of her birthplace and the calcifications seen on imaging; however, we do not see a role for serologic testing in the evaluation of her acutely evolving problem. In fact, in patients with proven single cysticercosis lesions in the brain, the sensitivity of the immunoblot assay is less than 50 percent, according to the Centers for Disease Control and Prevention (http://www.dpd.cdc.gov/dpdx/html/cysticercosis.htm).

Several features suggest that this patient's brain lesion at presentation was unrelated to the parasitic infection. The lesion seen on magnetic resonance imaging was hemorrhagic. Although intracystic hemorrhage has been reported by Alarcon et al.1 (in 1 of 31 patients), parenchymal hemorrhages are exceedingly unusual.2 In addition, the surgical specimen did not show any of the histologic features associated with cysticercosis: the organism itself, a well-defined capsule, or an acute inflammatory reaction (which often includes numerous eosinophils). We are concerned by the designation of neurocysticercosis as a cause of otherwise unexplained stroke in the absence of modern investigations of hypercoagulability and in a population in which the disease has a high prevalence.1

Finally, because of space limitations, descriptions of subsequent clinical events, including a documented pulmonary embolism and deep venous thrombosis in one leg, were edited from the case discussion. These events provide support for the supposition that this patient has a tendency toward thrombotic events. She has continued to receive anticoagulation therapy, without any further complications.

Ferdinando S. Buonanno, M.D.
Matthew P. Frosch, M.D., Ph.D.
Massachusetts General Hospital, Boston, MA 02114

2 References

1
Alarcon F, Hidalgo F, Moncayo J, Vinan I, Duenas G. Cerebral cysticercosis and stroke. Stroke 1992;23:224-228
CrossRef | Web of Science | Medline

2
Sawhney IMS, Singh G, Lekhra OP, Mathuriya SN, Parihar PS, Prabhakar S. Uncommon presentations of neurocysticercosis. J Neurol Sci 1998;154:94-100
CrossRef | Web of Science | Medline

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