Neurocysticercosis: diagnostic dilemma.

A 7-year-old Nepalese boy with unremarkable past health was admitted in July 2013 with a 2-week history of headache, dizziness, and vomiting that subsided spontaneously. On admission, he was afebrile with unremarkable neurological and fundal examination. He had been living in Nepal until the age of 5 years and then immigrated to Hong Kong. He recently travelled to Nepal but had otherwise no contact history with pigs or febrile persons. Blood tests were unremarkable except mildly elevated erythrocyte sedimentation rate of 26 mm/h. Lumbar puncture yielded normal cerebrospinal fluid (CSF) white cell count, and protein and glucose level. Culture of blood and CSF was negative. Initial contrast computed tomographic brain showed two subcentimetre (7 mm and 9 mm) left parieto-occipital adjacent rim-enhancing lesions (Fig a) with T1-weighted hypointense and T2weighted/fluid-attenuated inversion recovery hyperintense signal on contrast magnetic resonance imaging (MRI) [Fig b]. Significant perifocal oedema and mass effect with compression on the left occipital horn was noted. Magnetic resonance spectroscopy showed a significant lipid-lactate peak (Fig c), decreased N-acetylaspartate, and no elevated choline. No amino acid peak was identified. Perfusion imaging with arterial spine labelling showed no elevated regional cerebral blood flow (Fig d). Contrast MRI of the spine showed no leptomeningeal enhancement, intradural nor extradural spinal mass lesions. Subsequent extensive investigations of blood (including anti-Taenia solium immunoglobulin G), CSF, urine and stool for tuberculosis and T solium were performed, and all results were negative. Overall review of the clinical presentation, travel history, laboratory and imaging findings, and the two cerebral rim-enhancing lesions were suggestive of an infective process, in particular, neurocysticercosis or tuberculosis. After thorough investigations and interdepartmental discussions, it was decided to treat the patient as a probable case of neurocysticercosis and a course of empirical albendazole and prednisolone was prescribed. The patient remained asymptomatic after Hong Kong Med J 2016;22:616–8 DOI: 10.12809/hkmj154524