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N24) New-onset seizures and headaches following recent international travel
Review the Learning Outcomes, Hx, PE and Labs, and begin the module with your Provisional Diagnosis. Keep hitting "Next" to move through the module.
Learning Outcomes
- Articulate your relationship with the consulting diagnostic radiologists in the evaluation of a patient with seizures.
- Review the DDx considerations in a patient with seizures.
- Identify the spectrum of imaging findings in appropriate modalities for evaluating patients with seizures.
History
A 30-year man is brought to the ER after having a seizure at work. He has never had a seizure before today. He also notes new onset, intermittent headaches over the past few months. He recently immigrated to the United States from Mexico, where he lived in a rural area with poor sanitation. The patient denies any medical history other than traumatic brain injury 10 years ago after a motorcycle accident.
Physical Exam
BP: 135/86mmHg, HR 75bpm, RR 18, Temp 98.6 F, O2 saturation 98%.
General: The patient is in a post-ictal state but is otherwise alert and oriented. Full strength and intact sensation in all extremities.
Labs
None
Provisional Diagnosis
Select the Dx you believe is most appropriate
While all the above are possible, the patient may be suffering from a cerebral parasitic infection such as neurocysticercosis, which is transmitted through the fecal-oral route, considering a history of living in a region endemic for Taenia solium and exposure to poor sanitary conditions.
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Potential Acuity
What is your assessment of the likely acuity for this patient?
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The patient requires urgent workup and management considering the new onset seizures.
First Imaging Study
What is the first imaging study you will order?
A contrasted MRI can detect the presence, stages of parasitic lesions, and treatment complications like hydrocephalus.
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Pertinent Imaging Observations
Click on the links below to view images from the study, and assess these key findings as best you can.
MRI w/ & w/o contrast
These images demonstrate cysts in the:
The cyst membrane has become permeable, which is leading to surrounding edema, as evident on the FLAIR image (right image). Secondly, both the cyst and its wall exhibit signs of thickening and are brightly enhancing (left image). These characteristics align with the colloidal vesicular stage of cyst development and likely explain the onset of new symptoms in the patient.
These images demonstrate cysts in the:
These cysts with the eccentric scolex, appearing as a central dot sign, are likely cystic lesions secondary to neurocysticercosis. These cysts are likely in the end-stage quiescent nodular calcified stage as they do not have surrounding edema or enhancement.
View the full study if you'd like to take a look yourself.
Second Imaging Study
What is the next imaging study you will order?
No further imaging is required. The imaging findings along with the patient’s history are highly suggestive for Neurocysticercosis.
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What is your Diagnosis now that you have seen the imaging results?
Neurocysticercosis is caused by the ingestion of eggs from the pork tapeworm, Taenia solium, primarily through a fecal-oral route, often from contaminated food or water. In contrast, GI Taenia tapeworm infections usually result from the consumption of undercooked or raw pork that contains the larval form of the parasite.
Current Acuity
Initially, you selected and we suggested acuity.
Has your concern for this patient changed?
The patient requires urgent workup and management considering the new onset seizure.
Assessment and Plan
Please provide your assessment and plan for this patient
This is a patient presenting with a new onset seizure secondary to neurocysticercosis. Serologic testing for Taenia solium should be performed for confirmation. The management strategy involves the administration of anti-parasitic medication, including Praziquantel and Albendazole, in addition to an antiepileptic to manage seizure episodes. Given the cerebral edema and inflammation from the cyst in the colloidal vesicular stage, the use of corticosteroids should also be considered.
Lessons Learned:
- Neurocysticercosis, a leading cause of adult epilepsy globally, often presents with seizures as the initial symptom.
- ELISA and serology tests can be utilized to diagnose Neurocysticercosis in settings where neuroimaging is unavailable.
- While ingestion of Taenia cysts or larvae from raw pork causes Taeniasis, a GI infection, Neurocysticercosis arises from ingesting Taenia eggs, commonly associated with livestock-contaminated water.
- CT and MRI are the preferred imaging modalities. CT scans can identify calcifications and parenchymal cysticerci, while MRIs are better suited for detecting smaller lesions, evaluating degenerative changes, and detecting edema around calcified lesions.
- Differential diagnoses encompass conditions such as tuberculoma, pyogenic brain abscess, mycotic granuloma, primary or metastatic brain tumor, toxoplasmosis, nocardiosis, and septic emboli, all of which can mimic single or multiple ring or nodular enhancing lesions.
Socioeconomic Factors: Neurocysticercosis predominantly affects lower-income individuals, immigrants, and farmers, particularly from South America, Asia, and Africa. The risk of ingesting Taenia eggs is higher in environments where clean water is scarce and livestock roam near water sources.
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