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CASE REPORT
Year : 2018  |  Volume : 13  |  Issue : 1  |  Page : 154-156

Isolated intramedullary spinal cysticercosis: A case report with review of literature of a rare presentation


Department of Neurosurgery and Microbiology, J.N Medical College and KLES Dr. Prabhakar Kore Hospital and Medical Research Centre, KLE University, Belgaum, Karnataka, India

Date of Web Publication6-Feb-2018

Correspondence Address:
Praful Suresh Maste
Department of Neurosurgery, KLE's Dr. Prabhakar Kore Hospital and Medical Research Centre, Nehru Nagar, Belgaum - 590 010, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1793-5482.180894

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  Abstract 


A number of parasitic infections can involve the central nervous system of which neurocysticercosis (NCC) is the most common one in developing countries. Most often the brain is involved, spine and spinal cord involvement is very rare and intramedullary involvement is rarer still. Here, we report a 30-year-old male patient, with intramedullary NCC of dorsal spinal cord.

Keywords: Albendazole, parasitic infection, spinal intramedullary neurocysticercosis


How to cite this article:
Maste PS, Lokanath YK, Mahantshetti SS, Soumya S. Isolated intramedullary spinal cysticercosis: A case report with review of literature of a rare presentation. Asian J Neurosurg 2018;13:154-6

How to cite this URL:
Maste PS, Lokanath YK, Mahantshetti SS, Soumya S. Isolated intramedullary spinal cysticercosis: A case report with review of literature of a rare presentation. Asian J Neurosurg [serial online] 2018 [cited 2022 May 26];13:154-6. Available from: https://www.asianjns.org/text.asp?2018/13/1/154/180894




  Introduction Top


Neurocysticercosis (NCC) is the most common parasitic infection of central nervous system (CNS) affecting population worldwide and caused by Taenia solium.[1],[2] Spine is an uncommon site of cysticercal infestation and intramedullary involvement is even rarer.[2] The disease is predominantly intracranial, the incidence of spinal NCC being a lowly 1.5 to 3%.[1] Spinal cysticercosis represents a distinct clinical entity. In view of limited size of the spinal canal the mass effect of these lesions is poorly tolerated and can have debilitating consequences.[1] According to the location in spine, cysticercosis has been classified anatomically as extraspinal (vertebral) or intraspinal (epidural, subdural, arachnoid, or intramedullary), of which the intramedullary type is quite rare and only 53 cases have been reported until 2010.[3],[4],[5],[6],[7] We report a 30-year-old male patient, with intramedullary NCC above the conus medullaris (D11 level) which is a unique case of isolated primary spinal intramedullary cysticercosis, without evidence of intracranial involvement.


  Case Report Top


A 30-year-old male patient presented with a low backache since 1-month, radiation of pain to the right lower limb and weakness of the right lower limb since 20 days. Neurological examination revealed, muscle strength grade III proximally and grade IV distally according to Medical Research Council (MRC) in the right lower limb and grade V in the left lower limb with impaired fine touch and pain sensation in L5 and S1 dermatome, with absent knee and ankle reflexes in the right lower limb and plantar reflex was mute on both sides.

An anatomical localization of thoracic spinal cord lesion was made. Magnetic resonance imaging (MRI) of spine revealed bulky edematous spinal cord from D4 vertebral body to D12 vertebral body along with a intramedullary ring enhancing lesion of size 1.1 cm × 0.9 cm located above the conus medullaris at the level of D11 vertebrae lesion was hypointense on T1 and hyperintense on T2 with ring enhancement on contrast [Figure 1]. Scolex could not be identified. MRI of the brain was normal.
Figure 1: Sagittal and axial magnetic resonance imaging showing T1 hypointense and T2 hyperintense intramedullary lesion at D11 vertebrae of size 1.1 cm × 0.9 cm with the bulky edematous spinal cord from D4 to D12 vertebra. On contrast, there is a ring enhancement of lesion with central hypointensity

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Differential diagnosis of spinal NCC and tuberculoma was considered. Diagnostic cerebrospinal fluid analysis by nucleic acid amplification test was positive for anti-cysticercal antibodies; a final diagnosis of spinal neurocysticercosis was made. Peripheral smear revealed neutrophilic leukocytosis and stool examination was negative for ova and cyst. The patient had no history of consumption of pork.

In view of the small size of the lesion, extensive cord edema, and demyelination; the patient was managed conservatively, and surgery was deferred. The patient was initially treated with dexamethasone followed by addition of albendazole therapy (400 mg OD). At the time of discharge patient had significant neurological improvement and MRC grade IV in the left lower limb with improved sensations in L5 and S1 dermatome. At follow-up after 6 weeks of albendazole therapy, there was a significant reduction in symptoms with improved MRC grade V. Follow-up MRI showed a reduction in the size of lesion and edema of cord [Figure 2].
Figure 2: Sagittal and axial magnetic resonance imaging showing T1 hypointense and T2 hyperintense intramedullary lesion at D11 vertebra of size 0.9 cm × 0.2 cm with widening of spinal cord from D10 to D12 vertebra. Mild enhancement of lesion is seen on contrast

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  Discussion Top


Cysticercal infestation of the CNS was first described in humans in 1550 by Paranoli.[8] Rockitansky in 1856 made first reference about intraspinal cysticercosis.[9] Compared to intracranial infestation, the incidence of spinal NCC remains very low with less than 200 cases being reported in world literature.[1] In 1963, Canelas et al. reported a 2.7% incidence of spinal NCC in 296 cases of NCC.[10] The greater incidence of brain involvement is postulated to the fact that blood flow to the brain is approximately 100 fold greater than the spine.[11],[12] An intramedullary lesion occurs as a result of direct hematogenous spread similar to what is seen in parenchymal intracranial NCC.[12],[13]

Myelopathy and radiculopathy induced by spinal cord or root compression are the usual symptoms related to spinal NCC.[10],[14],[15] Diagnosis depends on imaging and serological tests. On MRI, intramedullary cysticercosis appears as a cystic lesion within the spinal cord, lesion is hypointense on T1 with hyperintense scolex identified inside the cyst cavity, hyperintense on T2 in vesicular stage and a subtle hypointense rim may surround the intramedullary cyst on T2. In the colloidal stage the thickened cyst capsule is hyperintense on T1 and hypointense on T2. Cyst contents appear hyperintense on T1 resulting in scolex not being seen, and there is an amount of surrounding edema. If cyst degeneration is present, peripheral ring enhancement may be present.[3],[4],[16],[17] The enzyme-linked immune sorbent assay is more accurate than that of serum: Its sensitivity and specificity being 87% and 95%, respectively.[1]

Currently, the most reliable immunological test is enzyme linked immune electrotransfer blot assay that has 100% specificity for detection of antibodies in serum and cerebrospinal fluid.[18],[19] Antigen detection assays permit monitoring and follow-up of antiparasitic treatment.[20] Management includes a combination of cysticidal drugs, steroids, and surgery.[21]

Albendazole is proven to be effective in patients with intramedullary cysticercosis and is the preferred drug compared to praziquantel.[22],[23] Corticosteroids are used as adjuncts to the cysticidal therapy to alleviate symptoms due to the inflammatory reaction caused by the death of larvae.[24] Albendazole can be used as monotherapy in the conservative treatment of patients with intramedullary cysticercosis and whose clinical course is stable. The potential advantages of medical therapy alone include avoidance of surgery and treatment of surgically unreachable and multifocal lesions.[4],[5],[22],[25],[26]

Surgical treatment is indicated in patients who experience severe and progressive neurological deficit regardless of medical therapy. The excision of extramedullary lesions is often difficult because of the arachnoidal scarring secondary to cyst degeneration, but sharp dissection, gentle irrigation, and valsalva maneuvers may assist in extirpating the adherent cyst.[27]


  Conclusion Top


Intramedullary spinal cysticercosis is a rare clinical entity and a high degree of clinical suspicion is required for diagnosis. MRI and the immunological tests can be conclusive. Medical therapy with close follow-up and in case of progressive neurological deterioration surgical intervention is indicated.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Alsina GA, Johnson JP, McBride DQ, Rhoten PR, Mehringer CM, Stokes JK. Spinal neurocysticercosis. Neurosurg Focus 2002;12:e8.  Back to cited text no. 1
    
2.
Azfar SF, Kirmani S, Badar F, Ahmad I. Isolated intramedullary spinal cysticercosis in a 10-year-old female showing dramatic response with albendazole. J Pediatr Neurosci 2011;6:52-4.  Back to cited text no. 2
  [Full text]  
3.
Agrawal R, Chauhan SP, Misra V, Singh PA, Gopal NN. Focal spinal intramedullary cysticercosis. Acta Biomed 2008;79:39-41.  Back to cited text no. 3
[PUBMED]    
4.
Ahmad FU, Sharma BS. Treatment of intramedullary spinal cysticercosis: Report of 2 cases and review of literature. Surg Neurol 2007;67:74-7.  Back to cited text no. 4
[PUBMED]    
5.
Chhiber SS, Singh B, Bansal P, Pandita KK, Razdan S, Singh J. Intramedullary spinal cysticercosis cured with medical therapy: Case report and review of literature. Surg Neurol 2009;72:765-8.  Back to cited text no. 5
[PUBMED]    
6.
Gonçalves FG, Neves PO, Jovem CL, Caetano C, Maia LB. Chronic myelopathy associated to intramedullary cysticercosis. Spine (Phila Pa 1976) 2010;35:E159-62.  Back to cited text no. 6
    
7.
Kumar S, Handa A, Chavda S, Tiwari R, Abbey P. Intramedullary cysticercosis. J Clin Neurosci 2010;17:522-3.  Back to cited text no. 7
[PUBMED]    
8.
Olive JI, Angulo-Rivero P. Cysticercosis of the nervous system. J Neurosurg 1962;19:632-4.  Back to cited text no. 8
[PUBMED]    
9.
Homans J, Khoo L, Chen T, Commins DL, Ahmed J, Kovacs A. Spinal intramedullary cysticercosis in a five-year-old child: Case report and review of the literature. Pediatr Infect Dis J 2001;20:904-8.  Back to cited text no. 9
[PUBMED]    
10.
Canelas HM, Ricciardi-Cruz O, Escalante AD. Cysticercosis of the nervous system: Less frequent clinical forms. III. Spinal cord forms. Arq Neuropsiquiatr 1963;21:77-86.  Back to cited text no. 10
    
11.
Isidro-Llorens A, Dachs F, Vidal J, Sarrias M. Spinal cysticercosis. Case report and review. Paraplegia 1993;31:128-30.  Back to cited text no. 11
[PUBMED]    
12.
Kishore LT, Gayatri K, Naidu MR, Mateen MA, Dinakar I, Ratnakar KS. Intermedullary spinal cord cysticercosis – A case report and literature review. Indian J Pathol Microbiol 1991;34:219-21.  Back to cited text no. 12
[PUBMED]    
13.
De Souza Queiroz L, Filho AP, Callegaro D, De Faria LL. Intramedullary cysticercosis. Case report, literature review and comments on pathogenesis. J Neurol Sci 1975;26:61-70.  Back to cited text no. 13
[PUBMED]    
14.
Colli BO, Assirati Júnior JA, Machado HR, dos Santos F, Takayanagui OM. Cysticercosis of the central nervous system. II. Spinal cysticercosis. Arq Neuropsiquiatr 1994;52:187-99.  Back to cited text no. 14
    
15.
Cabieses F, Vallenas M, Landa R. Cysticercosis of the spinal cord. J Neurosurg 1959;16:337-41.  Back to cited text no. 15
[PUBMED]    
16.
Mathuriya SN, Khosla VK, Vasishta RK, Tewari MK, Pathak A, Prabhakar S. Intramedullary cysticercosis: MRI diagnosis. Neurol India 2001;49:71-4.  Back to cited text no. 16
[PUBMED]  [Full text]  
17.
Sharma BS, Banerjee AK, Kak VK. Intramedullary spinal cysticercosis. Case report and review of literature. Clin Neurol Neurosurg 1987;89:111-6.  Back to cited text no. 17
[PUBMED]    
18.
White AC Jr. Neurocysticercosis: A major cause of neurological disease worldwide. Clin Infect Dis 1997;24:101-13.  Back to cited text no. 18
[PUBMED]    
19.
Tsang VC, Brand JA, Boyer AE. An enzyme-linked immunoelectrotransfer blot assay and glycoprotein antigens for diagnosing human cysticercosis (Taenia solium). J Infect Dis 1989;159:50-9.  Back to cited text no. 19
[PUBMED]    
20.
Garcia HH, Del Brutto OH; Cysticercosis Working Group in Peru. Neurocysticercosis: Updated concepts about an old disease. Lancet Neurol 2005;4:653-61.  Back to cited text no. 20
[PUBMED]    
21.
Proaño JV, Madrazo I, García L, García-Torres E, Correa D. Albendazole and praziquantel treatment in neurocysticercosis of the fourth ventricle. J Neurosurg 1997;87:29-33.  Back to cited text no. 21
    
22.
Corral I, Quereda C, Moreno A, López-Vélez R, Martínez-San-Millán J, Guerrero A, et al. Intramedullary cysticercosis cured with drug treatment. A case report. Spine (Phila Pa 1976) 1996;21:2284-7.  Back to cited text no. 22
    
23.
Del Brutto OH. Single parenchymal brain cysticercus in the acute encephalitic phase: Definition of a distinct form of neurocysticercosis with a benign prognosis. J Neurol Neurosurg Psychiatry 1995;58:247-9.  Back to cited text no. 23
[PUBMED]    
24.
Sinha S, Sharma BS. Neurocysticercosis: A review of current status and management. J Clin Neurosci 2009;16:867-76.  Back to cited text no. 24
[PUBMED]    
25.
Garg RK, Nag D. Intramedullary spinal cysticercosis: Response to albendazole: Case reports and review of literature. Spinal Cord 1998;36:67-70.  Back to cited text no. 25
[PUBMED]    
26.
Parmar H, Shah J, Patwardhan V, Patankar T, Patkar D, Muzumdar D, et al. MR imaging in intramedullary cysticercosis. Neuroradiology 2001;43:961-7.  Back to cited text no. 26
[PUBMED]    
27.
Kim SK, Wang KC, Paek SH, Hong KS, Cho BK. Outcomes of medical treatment of neurocysticercosis: A study of 65 cases in Cheju Island, Korea. Surg Neurol 1999;52:563-9.  Back to cited text no. 27
[PUBMED]    


    Figures

  [Figure 1], [Figure 2]


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