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Abstract

  1. Top of page
  2. Abstract
  3. Case Report
  4. Discussion
  5. Conclusion
  6. Declaration of Interests
  7. References

A woman with a history of cured breast cancer and multiple trips to India presented with a cervical nodule. Primarily suspected as metastasis of breast cancer, histopathology, however, showed the scolex of Taenia solium. Although the patient was neurologically asymptomatic neuroimaging showed multiple cysts. During treatment with praziquantel, albendazole, and dexamethason the patient developed seizures.

Neurocysticercosis (NCC), caused by the tapeworm Taenia solium, is the most common helminthic disease of the central nervous system (CNS).[1] After ingestion of viable eggs the larvae form of the tapeworm is able to migrate in any part of the body. Symptoms may develop because of local inflammation due to parasite cysts at the site of involvement. Therefore, parasitic invasion of the CNS can result in various neurological symptoms but often presents as focal or generalized seizures.[2] In T solium endemic areas, NCC is the most common cause of acquired epilepsy.[3, 4] The global burden is concentrated to low-income countries with poor hygiene and inadequate sanitation in sub-tropical and tropical areas, where risk factors for their transmission are common.[1, 4] Reports from non-endemic areas in Europe and the United States have been considered a result of increased immigration.[5, 6] NCC in travelers, however, is still a rare phenomenon and has been estimated to 1 : 275,000 clinical diseases per travel episode to an endemic region.[7] This is in contrast to the high seroprevalence and clinical disease rates among local populations in endemic areas.[3, 8] We report a case of NCC, primarily suspected as metastasis of breast cancer, with subcutaneous nodule in a woman with travel history to India.

Case Report

  1. Top of page
  2. Abstract
  3. Case Report
  4. Discussion
  5. Conclusion
  6. Declaration of Interests
  7. References

A 63-year-old woman with a medical history of breast cancer presented with a subcutaneous, non-tender nodule measuring 4.5 × 3.5 cm on her right sternocleidomastoid muscle. Ten years earlier, she had been treated for breast cancer of the right breast with lumpectomy, radiation, and tamoxifen. The patient showed no recurrence of breast cancer. She had no chest pain, cough, night sweats, or fever. Clinical examination and routine laboratory diagnostics were completely unremarkable.

Subsequent surgical excision and histopathological examination showed the scolex of T solium within a pseudocyst (Figure 1). Investigation of serum with Cysticercus IgG Western blot assay revealed positive results. She reported frequent travel to Goa, India over the past few years, where she always stayed for approximately 3 weeks in a small hostel. During the last decade she traveled every 2 years to Goa for holiday reasons (mean time spent aboard was 4.5 months) but had no other trips to the tropics. T solium proglottids and eggs were not detected by routine stool samples analysis for ova and parasites. Computed tomography (CT) of the head revealed multiple calcified lesions in both cerebral hemispheres up to 6 mm in size, without perilesional edema and physical examination did not reveal any neurological abnormalities. Further CT scans of the chest and the abdomen revealed no pathological findings. The patient was started on oral therapy with praziquantel (600 mg single dose), followed by albendazole (400 mg twice a day) for 21 days and dexamethason (8 mg per day) for 21 days.

image

Figure 1. Histopathology showed the scolex of Taenia solium within a pseudocyst.

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After 3 weeks she developed two episodes of generalized seizures and was therefore admitted to the hospital for medical observation. Laboratory tests showed eosinophilia with 6% eosinophils (reference value −5.0%) and repeated CT scans of the head showed an increasing number of degenerating parasites as well as perilesional edemas. Dexamethason therapy (8 mg per day) was started again and continued for another 14 days. Thereafter seizures resolved and the patient's condition improved slowly as she was suffering from headache and vertigo, which persisted for several months.

Discussion

  1. Top of page
  2. Abstract
  3. Case Report
  4. Discussion
  5. Conclusion
  6. Declaration of Interests
  7. References

This case demonstrates that travelers going to T solium endemic regions are at risk to develop NCC. Therefore, it is interesting that just a few cases of NCC in travelers have been published so far despite the high disease burden among local populations. It has been estimated that 29% of patients with epilepsy in popular tropical travel destinations suffer from NCC.[4, 7, 9] Seizures and headache are the principal clinical manifestations of NCC in travelers with an interval between presentation and travel activity of 6 months to 12 years.[7, 10] NCC most often occurs in long-term travelers with a mean time spent aboard of 56.6 ± 56.1 months. Most of these travelers with NCC present with a single cysticercus granuloma.[10] A primarily asymptomatic disease with multiple brain lesions in a short-term traveler, as presented in our case, is rarely described in travelers with NCC. Therefore, diagnosis may be challenging for physicians, especially when clinical presentation mimics other diseases. Subcutaneous nodule and history of breast cancer may mislead clinical diagnosis at the beginning as illustrated by our case. Therefore, travel history is of the utmost importance and NCC should be kept in mind in travelers with a travel history to T solium endemic areas presenting with subcutaneous nodules and, in particular, associated seizures. Serology for cysticercosis, however, may be negative in cases of subcutaneous infections when cysts are encapsulated and antigen release may be limited. Also eosinophilia count may be found within normal ranges at initial presentation due to a reduction in the local inflammatory response. Recent advances in neuroimaging and serologic diagnostic techniques have led to increased recognition of NCC. Calcifications are easily seen in non-contrast CT; however, cystic lesions, if any, are better characterized with intravenous contrast agent during the cerebral CT scan or MRI to better visualize the inflammatory reaction around parasites.[11, 12] Parasites totally calcified do not respond to cestocidal treatment and treatment may initially fail to decrease incidence of seizures. Our patient developed two episodes of seizures after initiation of cestocidal treatment. This illustrates the risk of developing seizures when viable or degenerating parasites are present in the CNS and cestocidal treatment is administered. For antiparasitic treatment praziquantel (50 mg/kg/day for 2 weeks) or albendazole (15 mg/kg/day for 1 to 4 weeks) is commonly used; however, treatment strategies are controversially discussed. Albendazole shows a stronger cysticidial activity and a better CNS penetration in comparison to praziquantel. Recent studies showed that the combination of praziquantel and albendazole increased the albendazole plasma concentration and therefore may improve the clinical outcome.[13] To control treatment-induced inflammation and therefore to reduce the likelihood of seizures we also started dexamethason treatment.[14-16]

Conclusion

  1. Top of page
  2. Abstract
  3. Case Report
  4. Discussion
  5. Conclusion
  6. Declaration of Interests
  7. References

NCC should be kept in mind in patients with a travel history to T solium endemic areas suffering from seizures associated with subcutaneous nodules.

Declaration of Interests

  1. Top of page
  2. Abstract
  3. Case Report
  4. Discussion
  5. Conclusion
  6. Declaration of Interests
  7. References

All authors do not have any conflict of interest to disclose.

References

  1. Top of page
  2. Abstract
  3. Case Report
  4. Discussion
  5. Conclusion
  6. Declaration of Interests
  7. References