Concurrent Extraparenchymal and Spinal Neurocysticercosis in an Immunocompetent Patient Treated for Obstructive Hydrocephalus and Spinal Cord Compression

Abstract

Introduction: Neurocysticercosis (NCC) is a condition caused by infection of the central nervous system (CNS) by Taenia solium, or pork tapeworm, larvae. Despite commonly infecting the CNS, it may be easily misdiagnosed for more common pathologies, such as arachnoid cysts or tumors. Though most frequently seen in endemic areas, immigration patterns are altering its traditional distribution. Extraparenchymal neurocysticercosis (including ventricular, spinal, and subarachnoid types) carries a poorer prognosis Objective: We present a case of NCC presenting in a young immunocompetent patient which was initially thought to be an arachnoid cyst due to non-pathognomonic imaging results and symptoms. This case illustrates a challenging NCC diagnosis. Case Report: A 24-year-old male without known past medical history presented with 2 years of chronic headache, 2 months of blurry vision in the left eye, and 1 week of progressive nausea and vomiting found to have aqueductal stenosis with obstructive hydrocephalus and bilateral 1.5 cm, peripherally-enhancing cystic lesions of the cerebellopontine angle with associated mass effect, initially described as arachnoid cysts, as well as a left sided foramen magnum cyst. He had an external ventricular drain placed and later underwent ventriculoperitoneal shunt (VPS) insertion. He presented 10 days later with sepsis symptoms and the initial workup was concerning for tuberculosis-associated meningitis and he underwent shunt externalization and re-internalization after clinical improvement, though he was lost to follow up. Two months later he presented with acute urinary retention and right sided weakness. He had spinal cord compression of the cervicothoracic and thoracolumbar spine due to cystic lesion and underwent right C7-T1 and T10-T11 hemilaminotomies for cyst resection, with pathology consistent with NCC. Conclusion: Neurocysticercosis (NCC) is a complex disease which is largely overlooked and is increasing in prevalence in non-endemic areas such as the United States. NCC has various symptoms and presentations depending on location and progression of larval development, which may mimic more common pathologies. The clinical manifestations depend on the parasite load and the host’s immune response regarding their location in CNS and their evolutionary stage. There are two types of NCC, the parenchymal and the extraparenchymal form. The extraparenchymal racemose NCC has the worst prognosis among all forms of NCC with mortality ranging between 30% and 80%. This reinforces the need for a broad differential diagnosis in these scenarios, as well as the importance of close Infectious Disease follow up for patients diagnosed with concurrent cranial and spinal NCC.