Archives of Mental Health

CASE REPORT
Year
: 2020  |  Volume : 21  |  Issue : 2  |  Page : 116--118

Lobe-specific neuropsychiatric manifestation of neurocysticercosis


Arun Selvaraj1, Vinoth Krishna Dass2, Lakshmi Sanjay3,  
1 Professor and Head, Department of Psychiatry, Sri Manakula Vinayagar Medical College and Hospital, Puducherry, India
2 Associate Professor, Department of Psychiatry, Sri Manakula Vinayagar Medical College and Hospital, Puducherry, India
3 Junior Resident, Department of Psychiatry, Sri Manakula Vinayagar Medical College and Hospital, Puducherry, India

Correspondence Address:
Dr. Arun Selvaraj
Department of Psychiatry, Sri Manakula Vinayagar Medical College and Hospital, Puducherry
India

Abstract

Neurocysticercosis (NCC), an infectious disease has got polymorphic clinical features. Neuropsychiatric manifestation of NCC is a rare presentation, always misleads the diagnosis. A 43-year-old male, nonvegetarian presented with 1-month history of visual hallucination associated with wandering, muttering to self, irritability and suicidal ideas. Onset of symptoms was sudden and progressive in nature. Mental Status Examination revealed mild cognitive impairment (MCI). Magnetic resonance imaging showed calcified lesions of size 6–7 mm in left parietal and occipital lobe in gray-white matter junction. NCC often present with neurological features of the seizure (79%) and headaches (38%). In neuropsychiatric manifestation, depression was the most common presentation. This case report has highlighted a case presenting with psychotic features, a rare phenomenon of rare neuropsychiatric manifestation of NCC. The neuropsychiatric symptoms right-sided monocular visual hallucination and the MCI were found to be related to the prominent lesions in occipito-parietal lobe of the left hemisphere. Lobar-specific neuropsychiatric manifestation can be a presenting feature of NCC without any common neurological symptoms.



How to cite this article:
Selvaraj A, Dass VK, Sanjay L. Lobe-specific neuropsychiatric manifestation of neurocysticercosis.Arch Ment Health 2020;21:116-118


How to cite this URL:
Selvaraj A, Dass VK, Sanjay L. Lobe-specific neuropsychiatric manifestation of neurocysticercosis. Arch Ment Health [serial online] 2020 [cited 2021 Apr 11 ];21:116-118
Available from: https://www.amhonline.org/text.asp?2020/21/2/116/306865


Full Text



 Introduction



Neurocysticercosis (NCC) due to a parasitic infection has got a wide range of presentations from asymptomatic form to a severe form with diverse clinical features. The polymorphic picture of NCC always misleads the clinical diagnosis and will get confirmed mostly by Neuroimaging and Immunological assays.[1] The recent meta-analysis reported seizures (79%) and headaches (38%) are the most common presentation and the other nonspecific symptoms occur in <10% of patients with NCC.[2] Here, we report a case of NCC presenting with psychotic features, a rare clinical presentation and the symptom specifying the target lesion in the brain.

 Case Report



A 43-year-old male, married, laborer studied up to 8th standard with nonvegetarian food habit presented with complaints of fearfulness, wandering, decreased interaction, and self-care for the last 1 month. The onset of symptoms was sudden and progressive in nature. On evaluation, he reported of seeing a black image since the onset and described it as an evil spirit, making gestures in front of his eyes but denied of hearing voice of it. It persisted most of the time and was threatening and interfering in all his activities. Associated symptoms noted were irritability and suicidal thoughts secondary to the fear caused by the visual image. In the past, had a history of alcohol use amounting to dependence pattern and been abstinent for 2 years. Family history of completed suicide was found in first-degree relative. Medical history findings revealed Bell's palsy 4 months back involving the right face but recovered completely in a month following treatment with steroids and physiotherapy. Currently has been on regular treatment for hypertension and coronary artery disease. Electrocardiography and echocardiography taken recently were normal. No history of head injury, headache, or seizure disorder was reported.

On mental status examination, the patient was conscious and oriented. Attention was aroused but sustained with difficulty. On cognitive testing, had impairment in memory associated with the concrete level of thinking and poor judgment. His affect was irritable, and the thought was preoccupied with persecutory and suicidal ideations. Visual hallucination was prominent with poor insight. Interestingly the visual hallucination disappeared on closing the right eye but not on the closure of the left eye, probably indicating the left lobe involvement of the lesion. Systemic examination was normal, and no neurological deficits were found on central nervous system (CNS) examination. The assessment of symptoms with Brief Psychiatric Rating Scale and Mini-Mental Status Examination (MMSE) scales revealed a score of 84 and 24, respectively, indicating moderate psychopathology and mild cognitive impairment (MCI). On investigations Electroencephalography (EEG) record was normal. Magnetic resonance imaging (MRI) showed calcified lesions of size 6–7 mm in the left parietal and occipital lobe in gray-white matter junction without perilesional edema [Figure 1], [Figure 2], [Figure 3]. Ophthalmologic examination, including visual acuity and cornea, were normal, and no ocular cyst was found. On neurology referral, the diagnosis of Neurocysticerosis was confirmed and started on albendazole 200 mg BD for 2 weeks. Tablet Risperidone 4 mg, Tablet Trihexyphenidyl 2 mg, and Tablet Lorazepam 2 mg were added for psychotic symptoms. On follow-up after 2 weeks, the patient showed significant improvement in overall functioning and did not report visual hallucination, but the MMSE score (24) remained the same.{Figure 1}{Figure 2}{Figure 3}

 Discussion



NCC, caused by tapeworm Taenia solium, is the most common parasitic disease of the CNS. It includes four stages of cyst formation, and the calcified granuloma being the last stage has been frequently associated with neuropsychiatric manifestations. Psychiatric morbidities in NCC are mostly found in association with seizure, and the depression was found to be the common diagnosis.[3] Psychotic disorders in NCC are reported less frequently and in a literature review, it was estimated to be only 14% when compared to 52% of depression.[4] This case report has highlighted NCC with psychotic features, a rare phenomenon of rare neuropsychiatric manifestation without common neurological symptoms.

It was noted that the prominent and presenting symptom of visual hallucination of the patient was found to be correlated with MRI findings of the lesion in the left occipital lobe and parietal lobe. It is proven that both the occipital and parietal lobe have a major role in visual processing and any stimulation or injury to these regions can cause visual hallucination.[5],[6] Thus, the interesting finding of monocular visual hallucination involving a complex image on the right side (lateralizing effect) of the eye in our case report may be due to the lesion in occipito-parietal lobe of left cerebral hemisphere.

Visual seizure characterized by monocular hallucination has been reported in NCC with occipital damage.[7] However, in this case, seizure phenomenon is unlikely as the visual hallucination though monocular, had been present continuously for a month and was subsided completely on treatment with antipsychotic. Moreover, perilesional edema, which could induce seizure activity[8] is not present in this case.

Another finding of MCI, is one of the most frequent manifestations of NCC and has been reported in about 66–87% of patients with NCC.[4] MCI identified in the assessment can be due to parietal lobe pathology caused by inflammatory cytokines of parasitic infection.[9] The possibility of developing dementia in this case is sparse as it is most commonly observed in multiple parasitic vesicular lesions and also cognitive deficits due to NCC were found to be reversible.[10],[11]

In addition to emphasizing the rare neuropsychiatric manifestation of NCC, this report also highlighted the correlation between the lobar lesion and the symptoms. It clearly indicates that visual hallucination and MCI of can be a presenting feature of NCC with the lesion in occipital-parietal lobe. Although the exact biological mechanisms underlying the mental changes related to brain lesions is still under research, the above-mentioned correlations provide evidence for an involvement of organic factor in psychiatry symptomatology.

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.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Coyle CM, Tanowitz HB. Diagnosis and treatment of neurocysticercosis. Interdiscip Perspect Infect Dis 2009;2009:180742.
2Carabin H, Ndimubanzi PC, Budke CM, Nguyen H, Qian Y, Cowan LD, et al. Clinical manifestations associated with neurocysticercosis: A systematic review. PLoS Negl Trop Dis 2011;5:e1152.
3Srivastava S, Chadda RK, Bala K, Majumdar P. A study of neuropsychiatric manifestations in patients of neurocysticercosis. Indian J Psychiatry 2013;55:264-7.
4Forlenza 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.
5Paradowski B, Kowalczyk E, Chojdak-Łukasiewicz J, Loster-Niewi ńka A, Służewska-Niedźwiedź M. Three cases with visual hallucinations following combined ocular and occipital damage. Case Rep Med 2013;2013:450725.
6Poggel DA, Müller-Oehring EM, Gothe J, Kenkel S, Kasten E, Sabel BA, et al. Visual hallucinations during spontaneous and training-induced visual field recovery. Neuropsychologia 2007;45:2598-607.
7Charan KS, Madhavi Ch, Rao GH. Occipital neurocysticercosis presenting as monocular visual hallucinations and transient blurring of vision. Trop Parasitol 2013;3:166-7.
8Nash TE, Pretell EJ, Lescano AG, Bustos JA, Gilman RH, Gonzalez AE, et al. Perilesional brain oedema and seizure activity in patients with calcified neurocysticercosis: A prospective cohort and nested case-control study. Lancet Neurol 2008;7:1099-105.
9Corriveau-Lecavalier N, Mellah S, Clément F, Belleville S. Evidence of parietal hyperactivation in individuals with mild cognitive impairment who progressed to dementia: A longitudinal fMRI study. NeuroImage Clin 2019;24:101958.
10Ramirez-Bermudez J, Higuera J, Sosa AL, Lopez-Meza E, Lopez-Gomez M, Corona T, et al. Is dementia reversible in patients with neurocysticercosis? J Neurol Neurosurg Psychiatry 2005;76:1164-6.
11Rodrigues CL, de Andrade DC, Livramento JA, Machado LR, Abraham R, Massaroppe L, et al. Spectrum of cognitive impairment in neurocysticercosis: Differences according to disease phase. Neurology 2012;78:861-6.