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A man with numbness and limb weakness

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Q1: What is the diagnosis?

The diagnosis is spinal (cervical) intramedullary cysticercosis. The MRI scan (fig 1; see p355) shows a cyst located in the intramedullary region. Cervical laminectomy with removal of the cyst was done. Histopathology examination (fig 2; see p355) proved the lesion to be a cysticercus cyst with scolex (larval cyst).

Q2: What are the treatment options?

The treatment of spinal intramedullary cysticercosis could be surgical, medical (that is, cysticidal therapy) or both, based on location and stage of the cyst as also on the experience of the physician. Surgical treatment includes laminectomy with removal of the cyst. Cysticidal drugs given are albendazole in a dose of 15 mg/kg body weight for 14–30 days or praziquantel 50 mg/kg body weight for 15 days along with steroids to reduce the perilesional oedema and to prevent neurological deterioration during the course of cysticidal drugs. Administration of cysticidal drugs before or after surgery is a point of personal preference for the individual doctor as no systematic evaluation has been possible due to the rarity of the disease.

Discussion

Intramedullary cysticercosis is a rare manifestation of neurocysticercosis,1 and fewer than 50 cases have been reported. The cysts are commonly located in spinal subarachnoid space and rarely at intramedullary locations. The majority of reported cases have cysts in the dorsal cord, which is in accordance with the regional blood flow to the spinal cord. In 90% of reported cases of intramedullary cysticercosis due to neurocysticercosis the patients were between 20 and 45 years of age. The duration of symptoms varied from a week to 10 years. The mode of spread of intramedullary cysticercosis is either haematogenous or ventriculoependymal.2 MRI studies help in diagnosing and correctly correlating the pathological diagnosis of neurocysticercosis (including intramedullary cysticercosis).3

Treatment modalities like drug therapy (cysticidal drug)/surgery, or both, can be planned according to the pathological stage and location of the cyst as seen on MRI. Since the cysticidal drugs albendazole and praziquental were shown to be effective in parenchymal brain cysticercosis, these drugs have been considered potentially useful in patients with intramedullary cysticercosis. Successful management of intramedullary cysticercosis by cysticidal drugs alone has also been reported in the literature.4

In the present case when the diagnosis of intramedullary cysticercosis was established on MRI, surgery was undertaken due to its location in cervical segment, and this was followed by albendazole therapy (15 mg/kg × 28 days). The patient showed complete neurological improvement with resolution of the intramedullary lesion.

It is concluded that with present generation MRI and also successful surgical/drug management, the outcome of intramedullary cysticercosis is not as dismal as was reported earlier, and patients with paraplegia also have a favourable outcome.

Final diagnosis

Spinal (cervical) intramedullary cysticercosis.

References

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