A CORRELATION OF NEUROCYSTICERCOSIS AND IGG4 ANTIBODIES

Abstract

TOPIC: Critical Care TYPE: Fellow Case Reports INTRODUCTION: In endemic regions, 30% of patients presenting with epilepsy, have evidence of neurocysticercosis. In the US, between the years of 2003 and 2012, there were more than 18,000 hospitalizations for neurocysticercosis. A study done in 2002 showed that IgG4 was found in the sera of patients with cerebral cysticercosis 97.8% of the time. Reliance on immunological assays holds importance due to the lower costs in comparison to imaging studies in impoverished areas. This case presentation follows a patient with a ring-enhancing brain lesion, positive cysticercosis antibodies, and positive IgG4 cells on tissue biopsy. CASE PRESENTATION: A 56-year-old male with a past medical history of hypertension, recent head injury and no other risk factors, presented for evaluation of syncope. Before the syncopal episode, the patient was seen by the primary physician for sustained injury to his head with complaints of recurrent fevers, headache, and blurred vision. The patient was prescribed steroids and antibiotics but did not feel any improvement and ended having a syncopal episode with a brief loss of consciousness. Magnetic resonance imaging of the brain with contrast showed a 17mm right mid corona radiata/mid-lateral ventricle peripherally enhancing mass with surrounding white matter edema and centralized restricted diffusion. Patient was admitted to the intensive care unit and treated with antibiotics, steroids, and antiepileptics. Stereotactic brain biopsy showed brain parenchyma with mildly increased cellularity consisting primarily of glial cells suggestive of reactive tissue. All labs and immunological studies were negative except for positive Cysticercosis IgG Antibody. Computed tomography of the abdomen and pelvis was positive for a 3 cm low-density lesion in the right lobe of the liver for which biopsy showed rare CMV inclusions in infected cells on a background of storiform fibrosis and lymphoplasmacytic inflammation with numerous IgG4 positive cells. The patient was started on albendazole and over the course of a few days, symptoms significantly improved. DISCUSSION: Brain biopsy showed only reactive tissue, hence to ensure no other primary lesion is present, further imaging tests were ordered which led to the revelation of the liver lesion and the biopsy was pathognomonic for IGG4 related disease, however, due to a lack of other necessary diagnostic criteria (serum IgG4 above 135 and histopathology showing IGG4 positive cells greater than 40%), the conclusion was not reached. However, due to the ring-enhancing lesion and positive cysticercosis IgG antibody, neurocysticercosis was higher on the differential as IgG4 is the most commonly found antibody in serum or CSF. CONCLUSIONS: Our findings of a correlation between neurocysticercosis and IgG4, strengthen the promise of a better immunodiagnostic tool thereby fighting the issues of accessibility and cost-effectiveness for endemic areas. REFERENCE #1: O'Neal SE, Flecker RH. Hospitalization frequency and charges for neurocysticercosis, United States, 2003-2012. Emerg Infect Dis. 2015 Jun;21(6):969–76. REFERENCE #2: Huang B, Li G, Jia F, Liu F, Ge L, Li W, et al. Determination of specific IgG4 for diagnosis and therapeutic evaluation of cerebral cysticercosis. Chin Med J (Engl). 2002 Apr;115(4):580–3. REFERENCE #3: Legatowicz-Koprowska M. IgG4-related disease: why is it so important? Cent-Eur J Immunol. 2018;43(2):204–8. DISCLOSURES: No relevant relationships by Rahul Dadhwal, source=Web Response no disclosure on file for Lauren Howard; No relevant relationships by Alamgir Khan, source=Web Response No relevant relationships by Katrina Rathjen, source=Web Response No relevant relationships by Salim Surani, source=Web Response