Download CT of the brain, sagittal view, without contrast

A woman with a
bifrontal
headache and
confusion
2013 July-August Featured Case
DR M Haghighi MD
History of Present Illness
• A woman in her thirties developed a progressive bifrontal
headache associated with a temperature to 100.0°F
(37.8°C). She went to sleep in the late afternoon.
• Approximately 24 hours later, her husband found her
difficult to arouse, nonverbal and non-interactive. She was
unable to arise from bed, answer questions or follow
commands, and appeared confused.
Past Medical
History
• She had previously been well.
Medications
• None.
Epidemiological
History
• She lived with her husband and young daughter, and
worked as a housekeeper. She did not drink alcohol, smoke
tobacco, or use illicit drugs.
Physical
Examination
• The patient appeared somnolent, arousable to painful
stimuli, and unable to follow commands consistently. The
blood pressure was 143/60 mm Hg, pulse 59 beats per
minute, temperature 38.3°C (101.0°F), respirations 20
beats per minute, and oxygenation 98% while breathing
room air.
• On neurological examination, the pupils were symmetric
and sluggishly reactive from 4mm to 3mm; extra-ocular
movements were grossly intact. She was able to open her
eyes and moved all four extremities spontaneously. Deep
tendon reflexes were 2+ and symmetric bilaterally. The
remainder of the examination was otherwise normal.
Studies
• Her white blood cell count was 17,900 per cubic millimeter
(reference range 4,500-11,000) with an absolute neutrophil
count of 14,770 cells per cubic millimeter (ref. 18007700). The hemoglobin and platelet counts were normal.
Other routine laboratory tests including blood levels of
electrolytes, and tests of coagulation, renal function and
liver function were normal. Serum toxicology panel was
negative.
• Urinalysis revealed a specific gravity of 1.030, trace
ketones, trace urobilinogen, 2+ protein, and 10-20 red
blood cells and 3-5 white blood cells per high power field.
Culture of the urine and blood were obtained, and were
sterile.
WHAT IS YOUR
RECOMMENDATION?
• A chest radiograph was normal. Computed tomography
(CT) of the head, performed without the administration
of contrast revealed enlargement of the lateral and third
ventricles consistent with hydrocephalus.
CT of the brain, sagittal view, without
contrast
WHAT IS YOUR PLAN?
Clinical Course
• The patient was intubated and bilateral external
ventricular devices were placed emergently, with
improvement in the severity of hydrocephalus on follow-up
CT imaging.
• Analysis of cerebral spinal fluid (CSF) obtained from the
external ventricular drains revealed a glucose level of 79
mg/dl (reference range 50-75), a normal total protein
level; 1150 red blood cells per cubic millimeter, and 2
white blood cells per cubic millimeter.
WHAT IS YOUR NEXT
STEP?
• Dexamethasone (4mg every 6 hours), levetiracetam,
ceftriaxone, vancomycin, and acyclovir were administered.
• MRI of the cervical, thoracic, and lumbar spine were
negative. An ophthalmologic examination revealed no
evidence of ocular involvement.
• Testing for serum HIV antibodies, interferongamma release assay, and mycobacterial DNA
from the cerebrospinal fluid were negative.
Cultures of the cerebrospinal fluid for bacteria,
fungi, and mycobacteria were sterile.
WHAT IS YOUR
RECOMMENDATION?
CT of the brain, sagittal view, without
contrast
• (CT) of the head, performed without the administration
of contrast revealed enlargement of the lateral and third
ventricles consistent with hydrocephalus , and
• a fluid-filled vesicular structure in the frontal horn of the
left lateral ventricle near the foramen of Monroe with a
soft-tissue density inside the cyst, and calcified densities
scattered throughout the supratentorial brain.
• On the second hospital day, magnetic resonance imaging
(MRI) of the brain was performed with the administration
of contrast .
DIFERENTIAL
DIAGNOSIS
DIFFERENTIAL
DIAGNOSIS
• Tuberculous meningitis caused by Mycobacterium tuberculosis
• Echinococcus spp.
• Aspergillus spp.
• Sarcoidosis
• Malignancy
• Cryptococcal meningitis
• Vasculitis
• Coenurosis
• Brain Abscess
• Toxoplasmosis
• MRI of the brain revealed a nonenhancing multilobed
cystic mass (28.4mm in its greatest dimension) within the
left lateral ventricle and numerous calcified foci
throughout the cerebral hemispheres, as were seen on CT.
FINAL DIAGNOSIS
• The soft-tissue density seen within the cyst on CT of the
head was consistent with a scolex, and the innumerable
calcified densities scattered throughout the supratentorial
brain were suggestive of neurocysticercosis.
• On the seventh hospital day, a left-sided mini-craniectomy
with left frontal endoscopic removal of the intraventricular
cyst was performed. The left-sided external ventricular
drain was also removed.
• Histopathological examination of the resected tissue with
hematoxylin and eosin staining revealed a cysticercus
celluosac with the encysted larva . The scolex with suckers
and hooklets were visible within the sac. Testing for
cysticercus IgG antibodies was positive in the serum and
negative in the cerebrospinal fluid.
Gross pathology of resected
intraventricular cystic lesion.
H and E stain of resected cystic mass showing
suckers and hooklets.
H and E stain of T. solium with suckers and
hooklets.
Final Diagnosis
• Intraventricular and intraparenchymal neurocysticercosis,
caused by Taenia solium infection.