Blurry Vision in Patient With Watery Diarrhea: Serendipitous Diagnosis of Neurocysticercosis

Abstract

Introduction: Neurocysticercosis, also known as disease of swine, is a common helminthic infection estimated to occur in 50,000 people worldwide. In 2013, 148 cases from United States were reported to the WHO. Humans become intermediate hosts of Taenia solium by ingesting its’ eggs from contaminated food specially undercooked pork. Common presentations of gastrointestinal involvement are abdominal pain, nausea, diarrhea or constipation which arise within 6-8 weeks after cyst ingestion. Neurologic symptoms including headaches and seizures may precede GI symptoms. A 26-year-old Guatamalan male without past medical history had lived in the U.S. for 13 years. He had not traveled abroad during this period. He was evaluated in the ED for a 3 day history of severe headaches, nausea, nonbloody emesis and watery diarrhea. Symptoms accompanied by blurry vision. On enquiry, he had suffered from headaches for over 2 years but these had not been associated with visual symptoms, fever, back pain, paresthesias, seizures, or a skin rash. He did not have recent exposure to sick contacts or animals. Physical examination including neurologic and fundoscopic exams were unremarkable except for mild diffuse abdominal tenderness. Laboratory data including CBC, CMP, ESR, HIV and viral hepatitis serologies, urine toxicology were all negative. Head CT scan detected low attenuation in the paramesencephalic cistern, along the basilar cisterns and extending into the left sylvian fissure reported as suspicious for gelatinous pseudocysts of cryptococcal meningitis. MRI imaging showed cerebral calcifications with multiple cystic lesions with widening of the left sylvian fissure and prominent lateral ventricle with the floor of the third ventricle depressed into the sella turcica suggesting a communicating hydrocephalus secondary to racemose neurocysticercosis. Serum ELISA for cysticercus antibody was weakly positive (>0.90). Stool tests were negative for ova and parasites. Cryptococcal antigen was negative. Dexamethasone, albendazole and antiseizure prophylaxis medications were initiated to treat neurocysticercosis. At two month follow up, patient was doing well with resolution of GI symptoms and improved vision. Taeniasis continues to be a serious public health problem especially in patients from Mexico, Guatemala and Peru. A high index of suspicion for neurocysticercosis is important in patients from these endemic areas who present with persistent GI and neurologic symptoms. In addition to praziquantel or albendazole, neurocysticercosis treatment includes supportive therapy with corticosteroids and seizure prophylaxis. Taeniasis is one of the top neglected tropical diseases of this decade whose eradication is a current challenge of the WHO.