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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 21  |  Issue : 1  |  Page : 55-58

An unusual presentation of neurocysticercosis as psychosis with tics


1 Senior Resident, Department of Psychiatry, Akash Institute of Medical Sciences and Research Centre, Bengaluru, Karnataka, India
2 Associate Professor, Department of Psychiatry, Akash Institute of Medical Sciences and Research Centre, Bengaluru, Karnataka, India
3 Assistant Professor, Department of Psychiatry, Akash Institute of Medical Sciences and Research Centre, Bengaluru, Karnataka, India
4 Associate Professor, Department of General Medicine, Akash Institute of Medical Sciences and Research Centre, Bengaluru, Karnataka, India

Date of Submission30-Jan-2020
Date of Decision12-Feb-2020
Date of Acceptance18-Feb-2020
Date of Web Publication03-Jul-2020

Correspondence Address:
Dr. Krishna Kumar Anjana
Department of Psychiatry, Akash Institute of Medical Sciences and Research Centre, Devanahalli, Bengaluru - 562 110, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AMH.AMH_6_20

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  Abstract 

Neurocysticercosis (NCC) is an infection caused by the larval stage of the parasite, Taenia solium. Seizures, psychosis, Parkinsonism, and other movement disorders have been described in the literature pertaining to NCC; however, no reports were available on tics. A young female presented to the outpatient department with headache, psychotic symptoms, and tics for a duration of 15–20 days. On examination, she was noted to have fluctuating orientation and was hypervigilant. She also presented with irrelevant speech, ideational perseveration, paranoid ideation, visual/auditory hallucinations, and motor/vocal tics. Following a detailed evaluation with investigations such as magnetic resonance imaging of the brain and ELISA, a diagnosis of NCC with psychosis and tics was made. She was treated with mannitol, steroids, albendazole, and antipsychotics. Psychosis and tics improved within 1 week of treatment. This case highlights an uncommon presentation of NCC as well as the significance of a high index of suspicion and the need for a careful workup to catch these cases.

Keywords: Movement disorders, neurocysticercosis, psychosis, tics


How to cite this article:
Anjana KK, Suresh VC, Poornima C, Madhuvan HS. An unusual presentation of neurocysticercosis as psychosis with tics. Arch Ment Health 2020;21:55-8

How to cite this URL:
Anjana KK, Suresh VC, Poornima C, Madhuvan HS. An unusual presentation of neurocysticercosis as psychosis with tics. Arch Ment Health [serial online] 2020 [cited 2020 Aug 4];21:55-8. Available from: http://www.amhonline.org/text.asp?2020/21/1/55/288920


  Introduction Top


Neurocysticercosis (NCC) is one of the most common neuroparasitic infections, especially in developing countries. More common presentation is late-onset epilepsy, with very few case reports on psychiatric complications.[1],[2] Psychosis is a rare manifestation of NCC observed in <5% of the cases.[2],[3] Forlenzo reviewed 38 cases of NCC and reported psychosis in 14.2% of cases.[4] There have been multiple case reports from India about NCC presenting as psychosis.[1],[2],[3]

A wide variety of movement disorders have been reported in patients with NCC, such as parkinsonism, choreoathetosis, hemichorea, myoclonus, blepharospasm, and ataxia.[5] However, the presentation of psychosis with tics has not been previously reported in the psychiatric literature. Hence, this case highlights an uncommon presentation of NCC.


  Case Report Top


A 29-year-old nonvegetarian female of lower socioeconomic status, a homemaker, educated up to the 7th grade presented to the outpatient department with complaints of headache and memory disturbances for 15–20 days which was associated with irrelevant talk, restlessness, confusion, paranoid ideation, and inability to sleep or eat.

Admission was considered as the patient was restless and the family had difficulty in managing her at home. She was hypervigilant, extremely anxious, irritable, and had fluctuating levels of orientation. She had hallucinations of both auditory (hearing voices of people) and visual (reptiles on the walls). She also presented with abnormal movements on the face and frequent sniffing more than normal. The patient reportedly had a well-adjusted premorbid personality and no personal or family history of any psychiatric illness. She had no known medical problems and took no medication. There was no history of head trauma, loss of consciousness, seizures, weakness or dysphagia, and no other focal neurological deficits. There was no history of any anxiety, depressive or obsessive compulsive features, substance abuse, or stressful events before the onset of illness.

On physical examination, the patient was poorly built and nourished with a body mass index of 17.2. She was conscious and disoriented only to time and place. Vitals were normal. She also had pallor. Cardiovascular, respiratory, and per abdomen examinations were normal. On central nervous system (CNS) examination, the motor and sensory system was normal, and cranial nerves were intact. Cerebellar system examination revealed positive Romberg's and tandem walking was impaired. Motor and vocal tics was present with no other abnormal involuntary movements.

On mental status examination, she was poorly kempt, hyper-vigilant, speech was irrelevant at times, ideational perseveration, emotional lability, paranoid ideation, visual and auditory hallucination, impaired memory, and judgment with absent insight.

Computed tomography scan was done to rule out organic cause which revealed multiple calcified lesions throughout brain parenchyma and few lesions showing perilesional edema [Figure 1].
Figure 1: Computed tomography scan of the brain showing areas of multiple calcified lesions involving brain parenchyma

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Magnetic resonance imaging (MRI) was done to confirm the diagnosis and the report revealed”Multiple focal discrete sub-centimeter parenchymal ring-enhancing lesions in bilateral cerebral hemispheres with significant perilesional edema in bilateral frontal, right ganglio capsular, and left parietal regions” [Figure 2]. Spectroscopy revealed the evidence of increased choline and lipid lactate peak noted [Figure 3]. Laboratory investigations included complete blood count, serum electrolytes, liver and renal function tests, serology for human immunodeficiency virus, all of which were within the normal limits. The stool examination did not show any ova or cysts. X-ray chest and ultrasound abdomen were normal. The patient was examined to look for subcutaneous nodules over the trunk, both thighs, and calves; however, no nodules were present. The ELISA to IgG antibody against Taenia solium glycoprotein in serum was positive. Cerebrospinal fluid examination could not be done as the patient's family did not consent for the same. The patient was provisionally diagnosed with a case of NCC with psychotic symptoms, excluding the other causes such as tumors, tuberculomas, toxoplasmosis, and fungal granuloma.[3],[6]
Figure 2: Magnetic resonance imaging of the brain (plain with contrast) showing typical ring-enhancing lesions with perilesional edema

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Figure 3: Spectroscopy image showing increased choline and creatine levels and lipid lactate level peak noted

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Yale Global Tic Severity Scale (YGTSS) was applied, which revealed a total score of 55.

The patient was started on 2 mg of tablet risperidone for the control of psychotic symptoms and tics. Physician opinion was sought for further management, and the patient was started on intravenous mannitol BD for 3 days with regular monitoring of vitals. The patient was also started on injection dexamethasone 4 mg intravenously TID for 2 days and was later tapered. Oral antiepileptic was initiated as a prophylactic measure. Tabletalbendazole 400 mg twice daily was started from the 3rd day for 14 days as per the protocol for the treatment of NCC.[7] The patient was also referred to ophthalmology for fundus examination to rule out eye involvement. Psychosis and tics improved within 1 week of treatment and YGTSS score dropped to 3 and MMSE score was 30 at the end of 14 days.


  Discussion Top


Taenia solium infections are endemic in many parts of the developing world.[4],[8] NCC is caused by the cyst which is the larval stage of the worm. It enters the CNS by ingestion of its eggs from contaminated hand water or food. Clinical signs vary depending on the size and stage of the parasites and location of lesions. Stepien and Chorobski observed mental changes in 28% of cases and recorded loss of orientation in space and time as well as visual and auditory hallucinations as the most frequent symptoms.[9] Psychosis has been reported in <5% of the cases.[1],[2],[3]

Psychiatric symptoms associated with NCC are believed to be due to mechanical alterations in CSF pressure and inflammatory injury of the brain parenchyma.[1],[8] A wide variety of movement disorders have been reported in patients with NCC. These movement disorders could be possibly due to cysts in the basal ganglia or due to compression of the small perforating vessels as suggested by the sudden onset and rapid improvement of the involuntary movements.[5],[10]

To the best of my knowledge, our case on NCC presenting as psychosis with tics is a rare manifestation. However, the diagnosis could not be confirmed as the patient did not consent for CSF examination and the MRI was of poor quality. The patient did not come for follow-ups after the 1st-month visit. Hence, a repeat scan could not be done.

This case highlights an uncommon presentation of NCC as well as the significance of a high index of suspicion and the need for a careful workup to catch these cases.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgment

The authors gratefully acknowledge Dr. Manju Prakash, Principal, AIMS and RC, Dr. Sreeja, Associate Professor, Department of Microbiology, AIMS and RC, Dr. Chaitra, Department of Radiology, for the encouragement and support to carry out this study and also the patient for consenting to report the case.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Shriqui CL, Milette PC. You drive me crazy: A case report of acute psychosis and neurocysticercosis. Can J Psychiatry 1992;37:121-4.  Back to cited text no. 1
    
2.
Mahajan SK, Machhan PC, Sood BR, Kumar S, Sharma DD, Mokta J, et al. Neurocysticercosis presenting with psychosis. J Assoc Physicians India 2004;52:663-5.  Back to cited text no. 2
    
3.
Verma A, Kumar A. Neurocysticercosis presenting as acute psychosis: A rare case report from rural India. Asian J Psychiatr 2013;6:611-3.  Back to cited text no. 3
    
4.
Forlenza OV, Filho AH, Nobrega JP, dos Ramos Machado L, de Barros NG, de Camargo CH, et al. Psychiatric manifestations of neurocysticercosis: A study of 38 patients from a neurology clinic in Brazil. J Neurol Neurosurg Psychiatry 1997;62:612-6.  Back to cited text no. 4
    
5.
Alarcón F, Cedeño Y, de Yébenes JG. Parkinsonism and other movement disorders in 23 cases of neurocysticercosis. Parkinsonism Relat Disord 2017;42:47-53.  Back to cited text no. 5
    
6.
Del Brutto OH, Nash TE, White AC Jr., Rajshekhar V, Wilkins PP, Singh G, et al. Revised diagnostic criteria for neurocysticercosis. J Neurol Sci 2017;372:202-10.  Back to cited text no. 6
    
7.
White AC Jr., Coyle CM, Rajshekhar V, Singh G, Hauser WA, Mohanty A, et al. Diagnosis and treatment of neurocysticercosis: 2017 Clinical practice guidelines by the Infectious Diseases Society of America (IDSA) and the American Society of Tropical Medicine and Hygiene (ASTMH). Clin Infect Dis 2018;66:e49-75.  Back to cited text no. 7
    
8.
Garcia HH, Nash TE, Del Brutto OH. Clinical symptoms, diagnosis, and treatment of neurocysticercosis. Lancet Neurol 2014;13:1202-15.  Back to cited text no. 8
    
9.
Stepien L, Chorobski J. Cysticercosis cerebri and its operative treatment. Arch Neurol Psychiatry 1949;61:499-527.  Back to cited text no. 9
    
10.
Bhatia R, Desai S, Garg A, Padma MV, Prasad K, Tripathi M. Isolated facial myokymia as a presenting feature of pontine neurocysticercosis. Mov Disord 2008;23:135-7.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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