Difficult Diagnosis E. ALEXANDRA BROWN, MD ASSISTANT PROFESSOR OF - PowerPoint PPT Presentation

2/16/2018 Disclosures  I have nothing to disclose. Difficult Diagnosis E. ALEXANDRA BROWN, MD ASSISTANT PROFESSOR OF NEUROLOGY, UCSF DIRECTOR, ZUCKERBERG SAN FRANCISCO GENERAL NEUROLOGY CLINIC 54F with 6 month history of headache 54F with 6 month history of headache ICHD-3 Criteria: Migraine without Aura -Out of medical care x 7 years -Out of medical care x 7 years -Headaches are 2-3 days per month -Headaches are 2-3 days per month -Pulsating, severe, bitemporal location -Pulsating, severe, bitemporal location -Nausea, photophobia, phonophobia -Nausea, photophobia, phonophobia -Previously relieved by rest and OTCs -Previously relieved by rest and OTCs -OTCs no longer help -OTCs no longer help -Neuro exam reportedly normal per PCP -Neuro exam reportedly normal per PCP Cephalalgia 2013;33:629-808. 1

2/16/2018 54F with 6 month history of headache 54F with 6 month history of headache ICHD-3 Criteria: Migraine without Aura -Out of medical care x 7 years -Out of medical care x 7 years -Headaches are 2-3 days per month -Headaches are 2-3 days per month -Pulsating, severe, bitemporal location -Pulsating, severe, bitemporal location -Nausea, photophobia, phonophobia -Nausea, photophobia, phonophobia -Previously relieved by rest and OTCs -Previously relieved by rest and OTCs -OTCs no longer help -OTCs no longer help -Neuro exam reportedly normal per PCP -Neuro exam reportedly normal per PCP Cephalalgia 2013;33:629-808. Red flags Neurology consultation further details  What features should worry you about secondary headache? ∙ Awakens from sleep with occipital headache x 1 year ∙ No previous headache history  -Systemic symptoms (fevers, chills, weight loss, HIV, cancer) ∙ Born in Mexico  -New headache in an older patient >50 y.o. ∙ Has not been taking any medications for HA  -Abrupt onset reaching maximum intensity in < 1 minute ∙ Neurological exam reveals right dysmetria  -Exacerbated by positioning or Valsalva  -Abnormal neurological/fundoscopic exam MRI brain with and without Gad was performed Nye BL, Ward TN. Headache 2015 Oct: 1301-1308. 2

2/16/2018 Neurocysticercosis  CNS infection by larval form of pork tapeworm Taenia solium  Most common helminthic CNS infection  A leading cause of acquired epilepsy worldwide  Clinical presentation depends on:  Location of cysts  Stage of parasite  Host immune response T1 T2 FLAIR Post Gad T1 Garcia HH, et al. Lancet Neurol. 2014;13: 1202-15. Endemic regions Q1: How do humans become infected with neurocysticercosis? A. Eating undercooked pork containing viable 46% cysticerci B. Ingesting food or water contaminated with 33% human feces containing T. solium eggs 19% C. Ingesting food or water contaminated with porcine feces containing T. solium eggs D. Transmission through blood from an infected 2% 0% person . e . . . . . . . v i . . . . o E. None of the above v d d n i b g e e a n a t a t a i n n m e n h a i m i m i o t t r f n a a f o o t t d e c n n o n o o o k c c l o r r r b N o e e h p t t d a a u g e w w o k r r r o o o h o d d t c o o n e r o d o o i f f s n g g s i u n n m Garcia HH, et al. Lancet Neurol. 2014;13: 1202-15. g t i t i s n s s n e e a t i g g a n n T r E I I 3

2/16/2018 Life cycle of Taenia solium Life cycle of Taenia solium Taeniasis: 1 parasite, ∙ Adult tapeworm 2 infections infection Taeniasis ∙ Human eats undercooked pork and containing viable Cysticercosis cysticerci Kraft R. Am Fam Physician. 2008 Mar 15;77(6):748. Kraft R. Am Fam Physician. 2008 Mar 15;77(6):748. T. Solium Cyst Stages of Development Life cycle of Taenia solium Cysticercosis: Vesicular Granular nodular Colloidal Calcified ∙ Viable ∙ Begins Degeneration ∙ Degenerates further ∙ Dead ∙ Infection caused by larval ∙ Non-enhancing ∙ Ring enhances ∙ Ring enhances ∙ Punctate Ca 2+ stage of tapeworm T. ∙ Scolex=“hole-with-dot” ∙ +/- Scolex ∙ No Scolex ∙ No Scolex solium ∙ No edema ∙ Less edema ∙ Edema ∙ Minimal/No Edema Garcia. Lancet Neurol. 2014;13: 1202-15. Del Brutto OH. Scientific World Journal 2012;2012:159821. Sinha S, et al. Journal of Clinical Neuroscience 2009;16: 867-76. Kraft R. Am Fam Physician. 2008 Mar 15;77(6):748. Zhao JL, et al. Radiology of Infectious Disease 2015;1:94-102. 4

2/16/2018 NCC brain locations Subarachnoid NCC  Excessive T. solium larval growth  enlarged multiloculated cysts ( racemose =“bunch of grapes”)  MRI spine should be performed in basal subarachnoid NCC  High risk asymptomatic spinal cord Parenchymal Extraparenchymal involvement. If present  treat surgically Intraventricular (usually 4 th ventricle) Usually gray-white junction (consensus) Subarachnoid (basal cisterns, sylvian fissure) Can manifest as seizures Can manifest as hydrocephalus, focal neurological deficits, complications of ↑ ICP Callacondo et al. Neurology 2012;78(18):1394-1400. Garcia HH, et al. Clin Microbiol Rev 2002;15:747-56. Sinha S, Sharma BS. Journal of Clinical Neuroscience 2009;16: 867-76. Diagnostic Criteria for NCC Immunological Diagnosis Imaging  EITB assay (Western Blot): TEST OF CHOICE (MAINSTAY)  ELISA based assay Dx Exposure Clinical Hx Presentation Serologic Testing Gripper. Acta Tropica 2017;166:218-224. 5

2/16/2018 Q2: What is the next step in this Subretinal cysts patient’s care?  Dilated eye exam is essential prior to initiating Albendazole or Praziquantel A. Start antihelminthic therapy with Albendazole 15  Antihelminthic therapy provokes inflammatory response around dying cysticerci 72% mg/kg/day for a minimum of 10 days  can lead to blindness B. Start steroid therapy with Dexamethasone 0.1  Surgical removal of cyst is treatment of choice for ocular cysts (consensus) mg/kg/day then administer Albendazole 15 mg/kg/day for a minimum of 10 days C. No indication for antihelminthic therapy given that the 15% 7% 6% appearance of these cysts does not warrant antihelminthic drugs . . . . D. Do not initiate antihelminthic therapy until further . . . . . y . . . n h i i p h m t a t n r i l i e w e m h h y i e l t p t h workup is performed c n i a a i h r n t t e r Del Brutto OH, et al. Journal Neurol Sci 2017;372:202-10. n h o a t f m i e d n t l i o a e o i i h r t t i e a n i Kori P, et al. Neurology 2013;81:135-6. t t c n s i i a d t t n o t r n r a i a t o o t S N D Padhi TR, et al. Survey of Ophthalmology 2017;16:161-89. S Q3: Which antihelminthic drug regimen is Antihelminthic drugs appropriate for a patient with NCC whose brain imaging is notable for >3 calcified cysts? Albendazole 15 mg/kg/day x 7-10 days A. 56%  Albendazole, Praziquantel - Used to treat viable cysts Albendazole 22.5 mg/kg/day x 7-10 days B. C. Combination therapy Albendazole 15 mg/kg/day x 7-10 31%  Not used for calcified cysts which are already dead days + Praziquantel 50 mg/kg/day x 7-10 days  Worsened inflammation during cyst destruction temporarily worsens symptoms D. Concurrent treatment of Dexamethasone 0.1 mg/kg/day 10% 1% 2%  Must control symptoms first (if needed, undergo lesion resection, ventricular with Albendazole 15 mg/kg/day x 7-10 days to control shunt placement, steroids, etc) There is no rush to initiate antihelminthic drugs! intracranial inflammation s s e y y v a a . . . o d d . . . b 0 5 1 a a 0 h 1 1 e e t e 7 - 7 - o l m h None of the above x t x a z a f E. y y d x o a a n e e  Give steroids simultaneously to control inflammation d d e D n / / b o g g l o f N k k A g / g / t m m p y n m e 5 5 a 1 . e r t 2 h a e 2 t e Gripper. Acta Tropica 2017;166:218-224. o l n t r z l e o a o i n t d z t e n a a r e d n r b n b i u Garcia HH, et al. Clin Inf Dis 2016;62: 1375-79. l e m c A b n A l o o C C 6

2/16/2018 Back to our case  Steroids were initiated right away  Dexamethasone 4 mg TID x 3 days, T2 FLAIR at 4 months then 2 mg TID x 2 weeks, then Prednisone 0.4 mg/kg daily T2 FLAIR at 15 months  Clinic follow-up: headaches resolved, R dysmetria resolved  Ophthalmology: no intra-ocular cysticercosis  Spine MRI with and without Gad: no cysticerci  Cysticercosis IgG Ab: 3.77 H (>0.51 is positive)  Alongside Prednisone, administered Albendazole 15 mg/kg/day x 4 weeks INITIAL T2 FLAIR  Ca+Vit D, Famotidine while receiving steroids  Return precautions given; patient closely monitored, remained asymptomatic Take home points Thank you  Antihelminthic drug treatment is NEVER the main priority, rather first address patient’s symptoms (seizures, increased ICP). There is no rush to begin antihelminthic drugs.  Pay attention to cyst stage: there is no role for antihelminthic drugs if only calcified lesions are seen .  Obtain dilated eye exam prior to initiating antihelminthic drugs; subretinal cysticerci should be surgically resected.  Administer steroids alongside antihelminthic drugs to limit inflammation that occurs with dying cysts. Happy to answer questions Garcia HH, et al. Clin Microbiol Rev 2002;15:747-56 . 7