Diagnosis at first sight
Hydrocephalus and intracranial hypertension in a woman from Ecuador
Hidrocefalia e hipertensión intracraneal en una mujer de Ecuador
Javier Nieto-Moragasa,
, Cristina Carratob, Roser García-Armengolc, Gema Fernández-Rivasd
Corresponding author
a Department of Clinical Laboratory, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain
b Department of Pathology, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain
c Department of Neurosurgery, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain
d Department of Clinical Microbiology, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain
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"entidad" => "Department of Neurosurgery, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Department of Clinical Microbiology, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Hidrocefalia e hipertensión intracraneal en una mujer de Ecuador" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 699 "Ancho" => 900 "Tamanyo" => 195237 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Photomicrograph of hematoxylin and eosin staining of extracted tissue. A microvillous tegument and a reticular matrix with calcareous bodies are detected.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case description</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 40-year-old woman from Ecuador presented to the emergency department (ED) with headache, vomiting, drowsiness, confusion and incoherent speech. She lives in Spain since 2001 and she carries a ventriculoperitoneal shunting since 1993, placed in Ecuador because an obstructive hydrocephalus of unknown origin. In 2013, she consulted repeatedly the ED because hydrocephalus valve mismatches requiring a valve replacement. Laboratory test in peripheral blood showed C-reactive protein level of 34.90<span class="elsevierStyleHsp" style=""></span>mg/dl and 7800<span class="elsevierStyleHsp" style=""></span>neutrophils/dl. Cerebro-spinal fluid (CSF) analysis showed 260<span class="elsevierStyleHsp" style=""></span>red blood cells/μl, 300<span class="elsevierStyleHsp" style=""></span>leukocytes/μl with a differential of 42% of eosinophils, a protein level of 1.5<span class="elsevierStyleHsp" style=""></span>g/l and positive xanthochromia. Gram stain of CSF showed no microorganisms and was inoculated onto chocolate blood agar and blood agar plates and incubated in an aerobic atmosphere at 37<span class="elsevierStyleHsp" style=""></span>°C with negative result after 48<span class="elsevierStyleHsp" style=""></span>h. Computed tomography (CT) confirms valve dysfunction excluding left ventricular and showed some parenchymal and periventricular calcifications. The patient underwent emergency valve replacement with proximal catheter placement. MRI postintervention (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) showed some punctate supratentorial calcifications and two spherical multi-septate lesions with a CSF similar density placed periventricular in the left ventricle. One of the multi-septate lesions supposedly responsible of the symptoms was removed surgically (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>) and some histological cuts were made of it (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Evolution</span><p id="par0010" class="elsevierStylePara elsevierViewall">A sample of CSF was sent to the Parasitology Unit of the <span class="elsevierStyleItalic">Instituto de Salud Carlos III</span> (Madrid, Spain) to detect by enzyme-linked immunoassay<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a><span class="elsevierStyleItalic">Taenia solium</span> antigen and immunoglobulin G (IgG). Both antigen and IgG against <span class="elsevierStyleItalic">T. solium</span> tests were positive and it was confirmed with a polymerase chain reaction (PCR) targeted to a <span class="elsevierStyleItalic">T. solium</span> DNA on CSF.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a> Parenchymal and periventricular calcifications, two spherical multi-septate lesions, the presence of anticysticercal antibodies in CSF and been residing in an endemic country, where the patient had already showed intracranial hypertension, lead to the neurocysticercosis diagnosis.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Antiparasitic drugs were no recommended at this stage of the disease and the treatment with parenteral dexamethasone was needed till a progressive neurological improvement. Sequelae included language disorder and slow mental activity that improved with neurocognitive rehabilitation.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Final comment</span><p id="par0020" class="elsevierStylePara elsevierViewall">Differential diagnosis of a cystic brain lesion must contemplate primary neoplasm, metastasis (lung and breast neoplasms are the most common cause), brain abscess, tuberculoma and neurocysticercosis (NCC).</p><p id="par0025" class="elsevierStylePara elsevierViewall">Cysticercosis is defined as the infection caused by the larval stage of <span class="elsevierStyleItalic">T. solium</span> once swallowing eggs found in contaminated food, being in contact with human feces of a person who has an intestinal tapeworm or by autoinfection. <span class="elsevierStyleItalic">T. solium</span> is a two-host zoonotic cestode and human could be definitive and intermediate host; the last case is when cysticercosis occurs. <span class="elsevierStyleItalic">T. solium</span> is found worldwide and parasitosis occurs in regions where humans eat undercooked pork or live in close contact with pigs. NCC is endemic in sub-Saharan Africa, most part of Asia, included China, and Latin America countries. NCC will be developed when onchospheres reach the central nervous system which can be classified in parenchymal and extraparenchymal, depending on the location of the cysts. Seizure is the most common clinical manifestation of parenchymal cysticercosis, caused in 30% of cases by NCC in endemic zones, included Latin America countries.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">3,5</span></a> Extraparenchymal NCC occurs when cysts are placed in subarachnoid space or in the ventricular system, leading obstruction of CSF flow, producing intracranial hypertension and hydrocephalus. Mobile extraparenchymal cysts can be the reason of irregular symptoms, such as intracranial hyper/hypotension and sudden death.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">3,4</span></a> Mononuclear pleocytosis and eosinophilia in CSF could be detected in patients with active inflammation.</p><p id="par0030" class="elsevierStylePara elsevierViewall">In 2017, diagnostic criteria for NCC were edited<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">5,6</span></a> and organized in three categories with many levels of certainty: absolute, neuroimaging and clinical/exposure criteria. Histological confirmation of parasites, evidence of subretinal cysts, and demonstration of the scolex within a cyst are absolute criteria for NCC diagnosis. Cystic lesions without scolex, multilobulated cysts and calcifications are categorized as neuroimaging major criteria. Clinical/exposure criteria include detection of anticysticercal antibodies or cysticercal antigens by enzyme-linked immunoelectrotransfer blot or enzyme-linked immunosorbent assay and residing in endemic areas.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">1,6–8</span></a> A definitive diagnosis can be made in those having one absolute criteria or two major neuroimaging criteria plus exposure criteria.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">5,6</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Patients with extraparenchymal cysts and hydrocephalus secondary to the NCC are candidates to place ventricular shunts or to remove cysts from the ventricles. However, a high mortality exists (up to 50% in two years) related to the number of surgical interventions to change the shunt.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">2,3</span></a> There is no evidence antiparasitic drugs could contribute to improve calcified cysts resolution. Viable and degenerating cysts can promote a severe immunological response and acute episodes should be treated with corticosteroids (e.g. dexamethasone).<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">5,6</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Funding</span><p id="par0040" class="elsevierStylePara elsevierViewall">This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflict of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare that there is no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Case description" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Evolution" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Final comment" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Funding" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interest" ] 5 => array:2 [ "identificador" => "xack399974" "titulo" => "Acknowledgments" ] 6 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1069 "Ancho" => 900 "Tamanyo" => 78936 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Magnetic resonance image (MRI) showing a multi-septate nodule (white arrow) producing an expansion of the atrium.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 737 "Ancho" => 900 "Tamanyo" => 84772 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Macroscopic morphology of a nodular structure extracted surgically.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 699 "Ancho" => 900 "Tamanyo" => 195237 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Photomicrograph of hematoxylin and eosin staining of extracted tissue. A microvillous tegument and a reticular matrix with calcareous bodies are detected.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0045" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Detection of <span class="elsevierStyleItalic">T. solium</span> antigens and anti-<span class="elsevierStyleItalic">T. solium</span> antibodies in paired serum and cerebrospinal fluid samples from patients with intraparenchymal or extraparenchymal neurocysticercosis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S. Rodriguez" 1 => "P. Dorny" 2 => "V.C. Tsang" 3 => "E.J. Pretell" 4 => "J. Brandt" 5 => "A.G. 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Paris" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1128/JCM.01554-10" "Revista" => array:6 [ "tituloSerie" => "J Clin Microbiol" "fecha" => "2011" "volumen" => "49" "paginaInicial" => "195" "paginaFinal" => "200" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21068283" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack399974" "titulo" => "Acknowledgments" "texto" => "<p id="par0050" class="elsevierStylePara elsevierViewall">Authors thank Silvia Roure and Parasitology Unit of <span class="elsevierStyleItalic">Instituto de Salud Carlos III</span> for their work and to guide us through the process.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/0213005X/0000003700000004/v1_201903260635/S0213005X18302052/v1_201903260635/en/main.assets" "Apartado" => array:4 [ "identificador" => "8596" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Diagnóstico a primera vista" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/0213005X/0000003700000004/v1_201903260635/S0213005X18302052/v1_201903260635/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0213005X18302052?idApp=UINPBA00004N" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 3 | 1 | 4 |
| 2024 October | 13 | 6 | 19 |
| 2024 September | 13 | 6 | 19 |
| 2024 August | 22 | 5 | 27 |
| 2024 July | 13 | 7 | 20 |
| 2024 June | 20 | 10 | 30 |
| 2024 May | 13 | 6 | 19 |
| 2024 April | 24 | 34 | 58 |
| 2024 March | 35 | 35 | 70 |
| 2024 February | 22 | 24 | 46 |
| 2024 January | 20 | 16 | 36 |
| 2023 December | 25 | 34 | 59 |
| 2023 November | 30 | 20 | 50 |
| 2023 October | 35 | 34 | 69 |
| 2023 September | 14 | 11 | 25 |
| 2023 August | 25 | 9 | 34 |
| 2023 July | 16 | 89 | 105 |
| 2023 June | 12 | 34 | 46 |
| 2023 May | 38 | 8 | 46 |
| 2023 April | 40 | 4 | 44 |
| 2023 March | 26 | 15 | 41 |
| 2023 February | 13 | 23 | 36 |
| 2023 January | 16 | 9 | 25 |
| 2022 December | 29 | 13 | 42 |
| 2022 November | 28 | 22 | 50 |
| 2022 October | 27 | 25 | 52 |
| 2022 September | 33 | 37 | 70 |
| 2022 August | 34 | 26 | 60 |
| 2022 July | 19 | 12 | 31 |
| 2022 June | 27 | 14 | 41 |
| 2022 May | 39 | 14 | 53 |
| 2022 April | 56 | 30 | 86 |
| 2022 March | 99 | 21 | 120 |
| 2022 February | 73 | 18 | 91 |
| 2022 January | 49 | 17 | 66 |
| 2021 December | 38 | 24 | 62 |
| 2021 November | 44 | 29 | 73 |
| 2021 October | 46 | 17 | 63 |
| 2021 September | 37 | 9 | 46 |
| 2021 August | 45 | 10 | 55 |
| 2021 July | 30 | 17 | 47 |
| 2021 June | 31 | 7 | 38 |
| 2021 May | 22 | 11 | 33 |
| 2021 April | 39 | 29 | 68 |
| 2021 March | 46 | 11 | 57 |
| 2021 February | 27 | 8 | 35 |
| 2021 January | 23 | 17 | 40 |
| 2020 December | 45 | 5 | 50 |
| 2020 November | 24 | 13 | 37 |
| 2020 October | 20 | 14 | 34 |
| 2020 September | 33 | 11 | 44 |
| 2020 August | 36 | 18 | 54 |
| 2020 July | 24 | 6 | 30 |
| 2020 June | 20 | 9 | 29 |
| 2020 May | 23 | 17 | 40 |
| 2020 April | 16 | 9 | 25 |
| 2020 March | 32 | 13 | 45 |
| 2020 February | 25 | 10 | 35 |
| 2020 January | 26 | 12 | 38 |
| 2019 December | 33 | 17 | 50 |
| 2019 November | 25 | 12 | 37 |
| 2019 October | 25 | 9 | 34 |
| 2019 September | 1 | 4 | 5 |
| 2019 August | 2 | 11 | 13 |
| 2019 July | 5 | 20 | 25 |
| 2019 June | 1 | 15 | 16 |
| 2019 May | 4 | 61 | 65 |
| 2019 April | 65 | 35 | 100 |
| 2019 March | 60 | 14 | 74 |
| 2018 November | 1 | 0 | 1 |
| 2018 July | 0 | 8 | 8 |
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