The Infectious Headache- A Case of Neurocysticercosis

A 50-year-old Hispanic female presented to her primary care physician with a progressively worsening headache over a week, associated with visual disturbances, prosopagnosia and episodes of disorientation. Outpatient workup with head CT showed abnormality in the ventral aspect of the left thalamus showing 1.2 × 1 cm low density cyst with approximately 2-3 mm right-left midline shift locally. Left basal ganglia showed multiple well-defined foci of low density measuring up to 3 mm reflecting edema. On admission, pertinent physical exam findings were left sided nystagmus, positive deep tendon reflexes (DTRs) in the right lower extremity (RLE), positive Babinski on the right foot, and mild endpoint tremor dysmetria. MRI showed multiple cystic structures (Figure 1) with eccentric nodularity suggesting a scolex, with calcifications and surrounding edema (Figure 2). The largest was localized near the left anterior aspect of the third ventricle measuring 15 mm with vasogenic edema extending to left temporal lobe (Figure 3). EEG showed focal cortical disturbance (transient triphasic sharp morphology) on the left hemisphere localizing to the central temporal region, corresponding with the area of vasogenic edema and potential for epileptogenesis (Figure 4). Travel history was significant for a family vacation in Punta Cana 3 years prior, where they ate at local restaurants and street vendors. Family members also lived in close proximity, often preparing meals together. Serum antibody detection ELISA assays for Taenia solium cysticercosis (T. solium) was negative. Serum testing for Toxoplasmosis, HIV and CMV were also unrevealing. A diagnosis [1] of Neurocysticercosis (NCC) was established based on 2 Major Neuroimaging criteria: presence of cystic lesions and enhancing lesions paired with 1 Minor criteria: Clinical presentation. Treatment [2] was started as per IDSA guidelines with albendazole, praziquantel (though delayed due to lack of supply in hospital), anti-epileptic and dexamethasone. Recommendation was given for family members to be evaluated and treated upon discharge. Repeat MRI brain after one month of treatment initiation, showed a decrease to 13 mm for the largest cyst. Patient was instructed to follow up with her PCP and ID specialist for monitoring