1 00:00:09,304 --> 00:00:10,174 Sara Dong: Hi, everyone. 2 00:00:10,204 --> 00:00:14,044 Welcome to Febrile, a cultured podcast for all things infectious disease. 3 00:00:14,584 --> 00:00:18,544 We use consult questions to dive into ID clinical reasoning, diagnostics, 4 00:00:18,544 --> 00:00:19,804 and anti-microbial management. 5 00:00:19,804 --> 00:00:21,334 I'm Sara Dong, your host. 6 00:00:21,854 --> 00:00:26,084 Today's episode is actually a bit of a sequel or extension of a prior 7 00:00:26,084 --> 00:00:29,654 episode, which I will mention at the end if you want to refer back, so 8 00:00:29,654 --> 00:00:31,484 as not to give it away right away. 9 00:00:31,904 --> 00:00:35,624 Although you may be able to guess when I introduce our guests. 10 00:00:36,134 --> 00:00:37,394 So let's meet them. 11 00:00:38,114 --> 00:00:39,764 Christine Pho: My name is Christine Pho. 12 00:00:40,234 --> 00:00:44,884 I am a medical student in my fourth year at UT Southwestern in Dallas. 13 00:00:45,284 --> 00:00:48,354 Sara Dong: Christine is planning to apply for an internal medicine residency. 14 00:00:48,964 --> 00:00:50,314 Our second guest is Dr. 15 00:00:50,314 --> 00:00:51,334 Daniel Stanton. 16 00:00:51,850 --> 00:00:52,600 Daniel Stanton: I'm Daniel. 17 00:00:52,600 --> 00:00:57,880 I'm one of the first year fellows in infectious disease at UTMB in Galveston. 18 00:00:58,673 --> 00:01:02,033 Sara Dong: UTM B is the University of Texas Medical Branch in Galveston, 19 00:01:02,033 --> 00:01:05,873 Texas, which is where Daniel also completed medical school and residency 20 00:01:06,993 --> 00:01:09,283 And last but not least is our guest discussant 21 00:01:10,313 --> 00:01:11,663 Clinton White: Hi, I'm Clinton White. 22 00:01:11,753 --> 00:01:15,873 I'm a Professor in the Infectious Disease Division at the University 23 00:01:15,873 --> 00:01:17,533 of Texas Medical Branch. 24 00:01:17,583 --> 00:01:17,943 Sara Dong: Dr. 25 00:01:17,943 --> 00:01:22,263 White's clinical interests and expertise include parasitology, tropical medicine, 26 00:01:22,503 --> 00:01:24,663 HIV, and opportunistic infections. 27 00:01:24,993 --> 00:01:27,783 He serves on the editorial board of a number of journals and 28 00:01:27,783 --> 00:01:32,493 directs the IDSA-ASTMH guidelines committee for neurocysticercosis. 29 00:01:32,493 --> 00:01:35,863 So before we get to the case, Febrile is everyone's favorite cultured 30 00:01:35,883 --> 00:01:40,143 podcast, so we kick off the episode by having our guests share some culture. 31 00:01:40,503 --> 00:01:43,443 So really it can be anything that's brought you happiness recently. 32 00:01:43,953 --> 00:01:45,153 I'll start off with you Christine 33 00:01:45,458 --> 00:01:45,958 Christine Pho: Sure. 34 00:01:46,058 --> 00:01:52,488 I recently had the opportunity to try some Asian American fusion restaurants. 35 00:01:53,028 --> 00:01:55,298 So, I had Blood Bros. 36 00:01:55,298 --> 00:02:03,843 BBQ in Houston, which is a Texas barbecue place that also has Asian spices and 37 00:02:03,863 --> 00:02:08,933 influences, and I also got to try Cris and John in Dallas, which is a 38 00:02:08,963 --> 00:02:11,743 Mexican Vietnamese restaurant as well. 39 00:02:12,713 --> 00:02:13,003 Sara Dong: Cool. 40 00:02:13,033 --> 00:02:13,923 That sounds great. 41 00:02:15,513 --> 00:02:16,363 what about you, Daniel? 42 00:02:17,728 --> 00:02:22,508 Daniel Stanton: So, I just got back from a trip to Florida, uh, Disney World, 43 00:02:22,728 --> 00:02:28,458 and I got the opportunity to visit the Star Wars theme park section of the 44 00:02:28,458 --> 00:02:34,838 Disney World, and I, uh, was blessed to be able to make my own lightsaber. 45 00:02:35,098 --> 00:02:39,998 I'm like a huge Star Wars nerd, I got to make my own personal lightsaber finally. 46 00:02:40,178 --> 00:02:41,158 Sara Dong: And how about you Clinton? 47 00:02:42,198 --> 00:02:47,778 Clinton White: Um, yeah, I was actually a music major in college, and recently I've 48 00:02:47,778 --> 00:02:53,948 been listening to a lot of piano music, um, and particularly Chopin's Nocturne No. 49 00:02:53,948 --> 00:03:02,668 1 and some pieces by Eric Satie that have sort of a, a melancholy, uh, tone to them. 50 00:03:03,523 --> 00:03:04,383 Sara Dong: Oh, what? 51 00:03:04,383 --> 00:03:05,863 This is such a great variety. 52 00:03:06,063 --> 00:03:06,543 I love it. 53 00:03:07,363 --> 00:03:10,583 Um, well, Christine, I'll hand it over to you to tell us about 54 00:03:10,583 --> 00:03:11,623 the case and get us started. 55 00:03:12,455 --> 00:03:16,395 . Christine Pho: A 41 year old male prison inmate with a past medical history of 56 00:03:16,395 --> 00:03:21,255 hypertension presented with one year of worsening headache associated with 57 00:03:21,255 --> 00:03:22,665 nausea, vomiting, and weight loss. 58 00:03:23,510 --> 00:03:27,420 The headache is diffuse and worse while supine, radiates to 59 00:03:27,420 --> 00:03:29,010 his neck and causes stiffness. 60 00:03:30,100 --> 00:03:33,580 Over the last three months, his headache now causes him to feel pressure behind 61 00:03:33,580 --> 00:03:37,240 his eyes and he has developed nausea and vomiting several times per week 62 00:03:37,690 --> 00:03:40,130 associated with 40 pounds of weight loss. 63 00:03:40,130 --> 00:03:43,980 Patient has also had recurrent sudden falls that are associated with 64 00:03:43,980 --> 00:03:45,800 sudden movement over the past year. 65 00:03:46,590 --> 00:03:50,560 He denies any specific triggers or prodrome of symptoms before his falls. 66 00:03:51,600 --> 00:03:56,730 Denies fevers, chills, night sweats, seizures, or focal neurologic deficits. 67 00:03:58,000 --> 00:04:01,320 He has been incarcerated for five years and he works as a cook. 68 00:04:01,890 --> 00:04:04,100 He is a Mexican immigrant who came to the U. 69 00:04:04,100 --> 00:04:04,250 S. 70 00:04:04,250 --> 00:04:07,710 in his teens and last visited Mexico six years ago. 71 00:04:07,887 --> 00:04:09,977 Daniel Stanton: So I just want to say a few things that stand out 72 00:04:09,977 --> 00:04:11,647 about the case right off the bat. 73 00:04:11,747 --> 00:04:16,357 All of his symptoms kind of are painting the picture of someone that has high 74 00:04:16,397 --> 00:04:20,547 intracranial pressure, , including these, diffuse headaches that 75 00:04:20,547 --> 00:04:22,267 are worse when he's laying down. 76 00:04:22,777 --> 00:04:26,517 The pressure like features behind his eyes with nausea and 77 00:04:26,517 --> 00:04:28,207 vomiting and weight loss now. 78 00:04:28,497 --> 00:04:33,577 So it, it's just overall showing this picture of high intracranial pressure. 79 00:04:34,067 --> 00:04:38,017 It's also based on the timing and the very slow progression of things 80 00:04:38,027 --> 00:04:41,177 starting over a year ago with the worsening over the last three months. 81 00:04:41,177 --> 00:04:46,177 This is a chronic process more so than like a quickly progressive process. 82 00:04:46,187 --> 00:04:51,222 So we're thinking if infectious wise, very slow growing infections, 83 00:04:51,242 --> 00:04:57,112 things like mycobacterial, maybe neurosyphilis, um, a fungal organism 84 00:04:57,112 --> 00:05:01,832 or parasitic organism, maybe some of our opportunistic infections. 85 00:05:01,942 --> 00:05:05,212 The next things we really would want to do in this case, get a very 86 00:05:05,222 --> 00:05:09,602 detailed physical exam, particularly a neuro and a retinal exam. 87 00:05:10,237 --> 00:05:14,867 Um, then we would obviously want to go to imaging to see if there's any features 88 00:05:14,877 --> 00:05:20,517 that are changes on his anatomy from any of this increased intracranial pressure. 89 00:05:21,077 --> 00:05:25,617 After the imaging if we don't find anything, any masses, we'd do a lumbar 90 00:05:25,617 --> 00:05:30,237 puncture, really looking at the cells and the differential on the cells more 91 00:05:30,237 --> 00:05:35,497 than anything, and then establish his HIV status and syphilis serologies. 92 00:05:36,762 --> 00:05:41,842 Also, non infectious wise, things that might cause this are things like 93 00:05:42,272 --> 00:05:48,152 malignancy if they've metastasized to the leptomeninges, or vasculitis, 94 00:05:48,162 --> 00:05:49,442 things of that nature as well. 95 00:05:50,677 --> 00:05:53,797 So, you want to tell us a little bit more about the physical exam, Christine? 96 00:05:55,647 --> 00:05:59,717 Christine Pho: Sure, his physical exam was significant for an ataxic gait, 97 00:05:59,717 --> 00:06:04,657 some discomfort with neck flexion without rigidity, slight diffuse 98 00:06:04,757 --> 00:06:07,817 hyperreflexia, and bilateral papilledema. 99 00:06:07,817 --> 00:06:13,077 He didn't have any problems with mentation and no cranial nerve deficit 100 00:06:13,497 --> 00:06:20,247 or weakness, and he had negative Brudzinski's and negative Kernigs sign. 101 00:06:21,067 --> 00:06:24,857 So, we went ahead and got labs and imaging on him. 102 00:06:25,427 --> 00:06:31,957 So, his labs were significant for leukocytosis of 12, 000 white cells 103 00:06:31,957 --> 00:06:33,957 per microliter with eosinophilia. 104 00:06:35,087 --> 00:06:38,897 He also had a HIV and syphilis test that were negative. 105 00:06:39,872 --> 00:06:45,012 And he had a lumbar puncture that was performed with a CSF analysis that showed 106 00:06:45,382 --> 00:06:50,582 undetectable glucose, high protein, and an elevated white count of 47 107 00:06:50,942 --> 00:06:52,872 with a high percentage of eosinophils. 108 00:06:52,958 --> 00:06:59,008 He had a CT of the head that showed severe hydrocephalus with transcentorial flow 109 00:06:59,008 --> 00:07:01,408 of CSF but no other significant findings. 110 00:07:02,158 --> 00:07:07,408 He then had an MRI brain with and without contrast, that was 111 00:07:07,438 --> 00:07:08,998 limited by motion artifact. 112 00:07:09,933 --> 00:07:12,283 It was notable for communicating hydrocephalus 113 00:07:12,303 --> 00:07:14,263 and leptomeningeal enhancement. 114 00:07:14,788 --> 00:07:18,128 Daniel Stanton: So, with like we said before, this being a chronic 115 00:07:18,128 --> 00:07:21,818 process, we now have more evidence that there's a meningitis going on. 116 00:07:22,178 --> 00:07:25,528 The glucose consumption on the lumbar puncture, the really high 117 00:07:25,528 --> 00:07:30,408 protein with the pleocytosis and this leptomeningeal enhancement 118 00:07:30,568 --> 00:07:33,328 that's been showing up on the MRI. 119 00:07:34,078 --> 00:07:37,458 Um, this leads to a really broad differential diagnosis just 120 00:07:37,458 --> 00:07:39,308 thinking about chronic meningitis. 121 00:07:39,868 --> 00:07:45,268 Um, things like Cryptococcus, maybe some endemic fungal infections in the U. 122 00:07:45,268 --> 00:07:45,478 S. 123 00:07:45,478 --> 00:07:47,348 like Coccidioides. 124 00:07:47,758 --> 00:07:54,568 Um, Tuberculous meningitis comes into play since he's an incarcerated person. 125 00:07:55,478 --> 00:08:00,208 Um, Brucellosis could have this appearance, neurocysticercosis, and 126 00:08:00,208 --> 00:08:04,348 uh, other things like leptomeningeal cancers can also give you this kind of 127 00:08:04,428 --> 00:08:07,168 changes and appearance of meningitis. 128 00:08:07,613 --> 00:08:14,643 But because he's had this eosinophilic predominance of the pleocytosis, you think 129 00:08:14,643 --> 00:08:19,053 of a much more narrow bit of of organisms. 130 00:08:20,383 --> 00:08:25,463 The first few that come to mind are the ones you always get from a textbook. 131 00:08:25,473 --> 00:08:26,303 Things like... 132 00:08:26,953 --> 00:08:33,663 Angiostrongylus, or the rat lungworm, um, Baylisascaris, the neural larval 133 00:08:33,663 --> 00:08:37,633 migrans, and, uh, Gnathostomiasis. 134 00:08:37,933 --> 00:08:42,233 But no matter what we did on taking his history, I think we, uh, couldn't get 135 00:08:42,233 --> 00:08:47,313 him to admit to eating any snails or traveling to Southeast Asia recently. 136 00:08:47,843 --> 00:08:50,973 So we, uh, quickly dismissed those from our differential. 137 00:08:51,583 --> 00:08:55,803 Things like drug allergies were high on things we were discussing, as 138 00:08:55,803 --> 00:08:58,473 well as, uh, the neurocysticercosis. 139 00:08:59,733 --> 00:09:04,878 Clinton White: So, if you think about neurocysticercosis, the main way we make 140 00:09:04,878 --> 00:09:07,618 that diagnosis is with imaging studies. 141 00:09:07,934 --> 00:09:10,484 The CT can be done as was done in this case. 142 00:09:11,094 --> 00:09:14,124 It showed hydrocephalus and not a lot more. 143 00:09:14,894 --> 00:09:22,104 The CTs often will show cysts in the brain parenchyma or can show 144 00:09:22,104 --> 00:09:27,464 calcifications as well, neither of which was seen in this case. 145 00:09:27,494 --> 00:09:34,274 MRIs are considerably better than CT at demonstrating cysts, particularly in 146 00:09:34,274 --> 00:09:37,494 the ventricles and subarachnoid space. 147 00:09:38,024 --> 00:09:42,064 Um, there are other methods that can be used to confirm the diagnosis. 148 00:09:42,164 --> 00:09:46,974 For example, serologies can be used to suggest exposure. 149 00:09:46,984 --> 00:09:53,464 There are newer methods like antigen detection, um, quantitative PCR, and 150 00:09:53,474 --> 00:09:59,014 even in some cases are diagnosed by next generation sequencing of the spinal fluid. 151 00:10:00,399 --> 00:10:04,909 So there are newer sequences on the MRI scans, um, that can 152 00:10:04,909 --> 00:10:08,609 demonstrate things, particularly when they're missed on other sequences. 153 00:10:08,649 --> 00:10:10,619 Uh, one of them is called Fiesta. 154 00:10:10,921 --> 00:10:13,881 Daniel Stanton: Christine, you think you can tell us what we've done next? 155 00:10:15,562 --> 00:10:20,322 Christine Pho: MRI brain was repeated with three dimensional Fiesta sequence 156 00:10:20,592 --> 00:10:25,972 and showed two large cysts with visible scolixes in the fourth ventricle 157 00:10:25,972 --> 00:10:30,172 and enlargement of the cisterna magna with extensive cystic debris. 158 00:10:31,002 --> 00:10:34,982 In addition, there was multifocal subarachnoid cysts consistent 159 00:10:34,992 --> 00:10:37,712 with racemose neurocysticosis. 160 00:10:38,532 --> 00:10:43,317 An MRI spine was performed with and without contrast that 161 00:10:43,317 --> 00:10:44,757 showed no significant findings. 162 00:10:45,682 --> 00:10:50,372 We sent out labs to the CDC for neurocysticercosis enzyme linked 163 00:10:50,422 --> 00:10:56,992 immunoelectrotransfer blot, EITB, and it returned positive for both serum and CSF. 164 00:10:57,438 --> 00:11:01,123 Clinton White: So, this, uh, patient had neurocysticercosis. 165 00:11:01,203 --> 00:11:05,803 Um, a previous episode, number 64, had Dr. 166 00:11:05,803 --> 00:11:10,303 Christina Coyle discuss some aspects of neurocysticercosis. 167 00:11:10,333 --> 00:11:14,223 We'll, I'll reiterate a few of them, but focus on some things that she 168 00:11:14,223 --> 00:11:15,813 didn't have time to talk about. 169 00:11:16,463 --> 00:11:21,508 Um, it's important when you think about neurocysticercosis that 170 00:11:21,878 --> 00:11:27,098 you realize that it's a series of diseases and not just one infection. 171 00:11:27,098 --> 00:11:33,533 So if you told someone you had a Staph infection, you'd want to know, 172 00:11:33,543 --> 00:11:38,353 well, is this an abscess in the skin, or a bacteremia from a catheter, or 173 00:11:38,353 --> 00:11:41,883 endocarditis, and they'd all have a little bit different management. 174 00:11:42,563 --> 00:11:47,713 And the same is true for, uh, Taenia solium infections causing cysticercosis. 175 00:11:48,483 --> 00:11:53,648 Um, they're very different presentations, depending on whether the cysts 176 00:11:53,648 --> 00:11:55,858 are just in the brain parenchyma. 177 00:11:56,138 --> 00:12:00,438 If they are, whether they're viable cysts, degenerating cysts, 178 00:12:00,818 --> 00:12:03,958 or just residual calcifications. 179 00:12:04,008 --> 00:12:08,638 You also can have extra parenchymal cysts, which are the most serious forms of 180 00:12:08,638 --> 00:12:14,448 disease, including ones in the ventricle or ones in the subarachnoid space. 181 00:12:14,953 --> 00:12:18,813 And often you'll have multiple different forms at the same time. 182 00:12:19,113 --> 00:12:24,563 So in this case, he had both, uh, cysts in his ventricles and 183 00:12:24,563 --> 00:12:26,903 cysts in the subarachnoid space. 184 00:12:26,973 --> 00:12:31,783 So the diagnosis in this case was confirmed by the Fiesta imaging, which 185 00:12:31,783 --> 00:12:37,063 showed scolices within, uh, cystic lesions, the so called, uh, "dot and 186 00:12:37,063 --> 00:12:42,153 hole" sign, uh, which is pretty much diagnostic of neurocysticercosis. 187 00:12:42,713 --> 00:12:48,053 With neurocysticercosis, it's different from other infectious diseases in 188 00:12:48,053 --> 00:12:53,413 that the organisms are not in most cases proliferating a whole lot. 189 00:12:53,883 --> 00:12:59,558 And so the acute management, the initial management should focus on 190 00:12:59,558 --> 00:13:01,458 getting their symptoms under control. 191 00:13:02,138 --> 00:13:05,758 If they have seizures, the first order of business is to get 192 00:13:05,758 --> 00:13:07,528 them on anti seizure medicines. 193 00:13:08,178 --> 00:13:11,878 If they have hydrocephalus, that usually requires neurosurgery. 194 00:13:12,588 --> 00:13:16,858 If they have diffuse cerebral edema, it requires, uh, use of, 195 00:13:16,898 --> 00:13:18,958 uh, anti inflammatory drugs. 196 00:13:19,028 --> 00:13:22,998 So, those are all important aspects of the initial management. 197 00:13:23,058 --> 00:13:24,855 So, Christina, you want to follow up? 198 00:13:25,381 --> 00:13:29,821 Christine Pho: So just to go over his management, he was started on 199 00:13:29,821 --> 00:13:34,581 high dose dexamethasone, and then subsequently in neurosurgery, performed 200 00:13:34,581 --> 00:13:40,901 a suboccipital craniotomy, whereupon accessing the cisterna magna, enumeral 201 00:13:40,911 --> 00:13:43,831 cysts were found and were removed. 202 00:13:44,471 --> 00:13:48,131 The fourth ventricle was accessed inferiorly and the cysts removed 203 00:13:48,651 --> 00:13:49,771 and confirmed by neuroendoscopy. 204 00:13:49,781 --> 00:13:55,241 An extraventricular drain was placed and albendazole and 205 00:13:55,241 --> 00:13:57,351 praziquantel therapy was started. 206 00:13:58,431 --> 00:14:01,961 The extraventricular drain was converted to a ventricular peritoneal 207 00:14:01,991 --> 00:14:07,292 shunt and methotrexate was started inpatient with plans to taper 208 00:14:07,432 --> 00:14:09,332 the steroid slowly outpatient. 209 00:14:09,802 --> 00:14:11,462 He is currently convalescing well. 210 00:14:11,512 --> 00:14:14,992 Clinton White: So in this case, he did have, some evidence of 211 00:14:15,002 --> 00:14:19,232 communicating hydrocephalus, which can be due to inflammation, 212 00:14:19,252 --> 00:14:21,022 and he was started on steroids. 213 00:14:21,392 --> 00:14:25,472 So when we treat this disease, particularly in those with mixed forms, 214 00:14:25,472 --> 00:14:31,212 we think about the more serious forms of infection, and the treatment should focus 215 00:14:31,212 --> 00:14:36,927 on what are the most serious forms, and what requires the most intensive therapy. 216 00:14:36,927 --> 00:14:42,417 So, in this case, he can have, um, antiparasitics for the subarachnoid cysts. 217 00:14:42,437 --> 00:14:47,787 Um, but, um, actually, it's very important to, uh, look at 218 00:14:47,787 --> 00:14:49,357 the cysts in the ventricles. 219 00:14:49,927 --> 00:14:55,307 The subarachnoid and ventricular cysts, it's interesting, tend to have a longer 220 00:14:55,337 --> 00:14:57,807 subclinical period before they present. 221 00:14:57,847 --> 00:15:02,197 Um, in a series we did from Houston, they were often 8 or 222 00:15:02,207 --> 00:15:04,187 10 years after immigration. 223 00:15:04,187 --> 00:15:09,090 So, this case, he had not been back in Mexico for a long period of time. 224 00:15:10,070 --> 00:15:11,930 And that's kind of typical. 225 00:15:12,410 --> 00:15:17,200 Um, so, seizures are associated with parenchymal neurocysticercosis. 226 00:15:18,460 --> 00:15:23,970 But extraparenchymal disease is associated with hydrocephalus, such as in this case. 227 00:15:24,530 --> 00:15:29,200 One of the interesting findings on this patient is he had these, uh, periodic 228 00:15:29,210 --> 00:15:34,630 drop attacks, where, and actually, there's a term, Brun's syndrome, uh, 229 00:15:34,650 --> 00:15:39,810 based on a neurosurgeon named Brun's who described this around 1900, just after 230 00:15:39,810 --> 00:15:45,420 1900 in Germany where a cysticercosis typically in the third or fourth 231 00:15:45,420 --> 00:15:51,310 ventricle moves around when you change positions and causes a sudden onset of 232 00:15:51,340 --> 00:15:53,790 an acute, obstructive hydrocephalus. 233 00:15:54,200 --> 00:16:00,510 So that was probably going on, in the past in this case and, would be a, real 234 00:16:00,510 --> 00:16:06,490 big risk factor, um, for him not doing well if it was not addressed right away. 235 00:16:07,090 --> 00:16:12,340 So in the fourth ventricular cysts, you really don't want to treat that medically. 236 00:16:13,515 --> 00:16:18,975 And in fact, if you gave antiparasitics, it actually might interfere with his long 237 00:16:18,975 --> 00:16:21,945 term treatment, uh, so that wasn't done. 238 00:16:22,275 --> 00:16:26,525 Instead, we had a, a discussion with our neurosurgeons. 239 00:16:26,635 --> 00:16:30,415 And, um, they said, well, why don't you just treat him medically? 240 00:16:30,415 --> 00:16:33,285 And I said, well, he's got the cysts in the fourth ventricle. 241 00:16:33,715 --> 00:16:38,415 And really, if that's not taken out, he's at risk for sudden death, which 242 00:16:38,415 --> 00:16:41,785 is not something we like to happen in our patients under our care. 243 00:16:42,415 --> 00:16:46,425 Um, So because of that we discussed this with the surgeons. 244 00:16:46,875 --> 00:16:49,085 Well how do you get to the fourth ventricle? 245 00:16:49,645 --> 00:16:51,205 Well there are two approaches. 246 00:16:51,275 --> 00:16:56,575 Some cases of neurocysticercosis, they actually take a flexible neuroendoscope, 247 00:16:57,745 --> 00:17:02,345 go up through the lateral ventricles, the third ventricle, and there are 248 00:17:02,345 --> 00:17:07,205 descriptions of snaking it through the aqueduct and just pulling the cyst out. 249 00:17:08,205 --> 00:17:12,005 However, there are critical structures on each side of the aqueduct, so 250 00:17:12,005 --> 00:17:17,005 you don't really want to do that unless the aqueduct is quite dilated. 251 00:17:17,435 --> 00:17:22,185 The other approach, is to approach it from behind and do a 252 00:17:22,205 --> 00:17:24,405 craniotomy in the occipital lobe. 253 00:17:24,905 --> 00:17:31,205 And then, either by micro dissection, by stereotactic approaches, or with 254 00:17:31,255 --> 00:17:36,925 neuroendoscopy, you can get into the fourth ventricle and take the cyst out. 255 00:17:37,212 --> 00:17:42,522 So, our patient had ventricular and subarachnoid cysts, and they 256 00:17:42,522 --> 00:17:44,662 went in from a posterior approach. 257 00:17:44,972 --> 00:17:49,062 As soon as they got in the subarachnoid space, they were... 258 00:17:49,927 --> 00:17:52,767 enumerable, , cysts that sort of came out. 259 00:17:52,777 --> 00:17:57,827 And so it, he clearly had a heavy burden of, subarachnoid disease. 260 00:17:58,197 --> 00:18:01,577 The cysts in the ventricle could be removed easily. 261 00:18:02,147 --> 00:18:05,797 And if that was all that had gone on, uh, he would be cured. 262 00:18:06,477 --> 00:18:10,057 So ventricular cysticercosis, if you can take the cysts out 263 00:18:10,377 --> 00:18:11,737 and cure them, that's great. 264 00:18:11,747 --> 00:18:18,386 But he had so many cysts in the basilar cisterns and subarachnoid space, that he 265 00:18:18,386 --> 00:18:20,756 was going to require long term therapy. 266 00:18:20,986 --> 00:18:24,346 The debulking that was done in this case, uh, is helpful. 267 00:18:24,346 --> 00:18:29,526 If you've got a lot of uh, parasites that you kill in the subarachnoid 268 00:18:29,526 --> 00:18:33,976 space, it takes the body a long time to get rid of them, and so you'll have 269 00:18:34,006 --> 00:18:36,626 chronic inflammation causing problems. 270 00:18:37,821 --> 00:18:41,421 However, there are some cases that suggest maybe if you can get some of 271 00:18:41,421 --> 00:18:44,151 them out, it might improve your outcome. 272 00:18:44,648 --> 00:18:49,258 Typically, subarachnoid neurocysticcercosis has not responded 273 00:18:49,728 --> 00:18:54,418 to the regimens of anti parasitic drugs that we use for other forms 274 00:18:54,418 --> 00:18:56,758 of disease, for parenchymal disease. 275 00:18:57,538 --> 00:19:01,658 And there are three approaches that have been, um, used in this 276 00:19:01,658 --> 00:19:02,088 case. 277 00:19:02,278 --> 00:19:07,858 In Mexico, they give high dose albendazole for a month and then repeat it again. 278 00:19:08,993 --> 00:19:10,493 Some centers in the U. 279 00:19:10,493 --> 00:19:10,793 S. 280 00:19:10,793 --> 00:19:15,733 have used prolonged courses of albendazole, often lasting 281 00:19:15,733 --> 00:19:17,603 months to even over a year. 282 00:19:18,276 --> 00:19:23,036 More recently, there are studies using a combination of two anti parasitic 283 00:19:23,036 --> 00:19:26,026 drugs, praziquantel and albendazole. 284 00:19:26,686 --> 00:19:33,826 And the praziquantel is parasiticidal in itself, but even more importantly 285 00:19:33,876 --> 00:19:39,376 elevates the levels of the active metabolite of, um, the albendazole, so 286 00:19:39,376 --> 00:19:42,166 you get, uh, higher steady state levels. 287 00:19:42,756 --> 00:19:47,486 Um, so, you know, that's often required and still may require 288 00:19:47,486 --> 00:19:49,206 a long course of therapy. 289 00:19:49,826 --> 00:19:52,456 So he's gotten debulking, his antiparasitics. 290 00:19:52,846 --> 00:19:56,696 Um, it's really important that if you kill the parasites, you can 291 00:19:56,696 --> 00:19:58,356 cause worsened inflammation. 292 00:19:59,216 --> 00:20:04,606 And the inflammation really is the cause of a lot of the chronic processes. 293 00:20:04,776 --> 00:20:10,086 So it's really important to get them on anti inflammatory medicines. 294 00:20:10,406 --> 00:20:15,886 Typically, we'll start out with, uh, very, very high doses of, of steroids. 295 00:20:15,926 --> 00:20:21,116 Um, I think he was started out on 24 milligrams a day of dexamethasone. 296 00:20:21,666 --> 00:20:27,276 You don't want to keep people on that forever, and so drugs like methotrexate or 297 00:20:27,277 --> 00:20:32,886 TNF inhibitors have been used as steroid sparing agents for chronic disease. 298 00:20:33,386 --> 00:20:36,766 But he also has communicating hydrocephalus. 299 00:20:37,656 --> 00:20:42,856 And, If you just give him antiparasitics, that's still going to be present. 300 00:20:42,916 --> 00:20:49,026 And so in his case, he required, um, a placement of an external ventricular 301 00:20:49,026 --> 00:20:54,846 drain and then a ventricular peritoneal shunt to manage the hydrocephalus. 302 00:20:55,456 --> 00:20:58,626 But he also needs chronic anti inflammatory drugs 303 00:20:58,666 --> 00:20:59,806 and chronic antiparasitics. 304 00:21:01,576 --> 00:21:08,076 And, um, by the time he'd gotten his cysts out of the fourth ventricle and the ones 305 00:21:08,076 --> 00:21:11,246 from the, uh, posterior fossa removed. 306 00:21:11,426 --> 00:21:12,636 He was feeling great. 307 00:21:13,156 --> 00:21:16,286 And I saw him in the hospital and he said, why can't I go home? 308 00:21:17,356 --> 00:21:18,616 Sara Dong: Thank you so much. 309 00:21:18,856 --> 00:21:23,356 You know, we crammed up a very complex case into a fairly short timeframe. 310 00:21:23,716 --> 00:21:27,106 So I actually was hoping maybe you could give a quick overview 311 00:21:27,106 --> 00:21:28,516 and summary of the case again. 312 00:21:28,996 --> 00:21:33,046 And I'd love to hear any additional thoughts you have about how you 313 00:21:33,046 --> 00:21:37,096 follow these patients in the clinic and, as they are recovering. 314 00:21:38,851 --> 00:21:42,271 Clinton White: So, this patient had ventricular cysticercosis, 315 00:21:42,961 --> 00:21:47,539 and that's a, that's typically requires, uh, it's a surgical 316 00:21:47,539 --> 00:21:49,739 disease, it's not a medical disease. 317 00:21:50,269 --> 00:21:55,689 So if you've got obstructive hydrocephalus or hydrocephalus rather than just 318 00:21:55,689 --> 00:22:00,489 diffuse cerebral edema, that's a medical emergency and requires neurosurgery. 319 00:22:01,839 --> 00:22:06,449 Uh, the ventricular cysts can be popped out, uh, most of the time 320 00:22:06,459 --> 00:22:11,709 they're not very inflamed and, can come out easily by neurosurgery. 321 00:22:11,719 --> 00:22:15,969 The ones in the lateral and third ventricle can be removed by these 322 00:22:16,289 --> 00:22:20,974 neuroendoscopes and once you've taken them out, uh, the patient's cured. 323 00:22:21,554 --> 00:22:26,494 Um, however, subarachnoid neurocysticercosis requires more 324 00:22:26,494 --> 00:22:32,654 prolonged therapy and that includes chronic anti-inflammatory drugs, uh, 325 00:22:32,684 --> 00:22:38,924 steroids and maybe steroid sparing agents and intensive, um, antiparasitic drugs. 326 00:22:39,024 --> 00:22:43,598 We're not completely sure of the best antiparasitics, but praziquantel plus 327 00:22:43,878 --> 00:22:46,763 albendazole may be better in some cases. 328 00:22:47,783 --> 00:22:52,443 And since this disease takes a while, you need things to follow. 329 00:22:52,523 --> 00:22:56,549 And we will typically follow the MRI scan. 330 00:22:56,919 --> 00:23:02,386 But sometimes the MRI will not completely normalize. 331 00:23:03,331 --> 00:23:06,621 And so there are other things that can be followed, and there are a 332 00:23:06,621 --> 00:23:11,621 couple of tests that can be used to determine if you have viable cysts. 333 00:23:12,178 --> 00:23:18,698 Those include a quantitative PCR assay and an antigen detection assay, 334 00:23:18,718 --> 00:23:24,198 both of which can be performed in the serum or in the spinal fluid. 335 00:23:24,568 --> 00:23:30,178 And if those have turned negative, um, you can actually stop the treatment, stop 336 00:23:30,178 --> 00:23:34,788 the antiparasitic treatment, taper the steroids, and declare the patient cured. 337 00:23:36,274 --> 00:23:38,984 So, you know, this patient had a good outcome. 338 00:23:39,374 --> 00:23:43,554 It required aggressive treatment, a discussion with the neurosurgeons, 339 00:23:43,984 --> 00:23:48,754 holding off on antiparasitic drugs until the cysts in the ventricles 340 00:23:48,794 --> 00:23:54,344 were removed, and eventually starting a prolonged course of anti 341 00:23:54,344 --> 00:23:57,554 inflammatory and antiparasitic therapy. 342 00:23:58,161 --> 00:23:58,601 Thank you. 343 00:23:59,555 --> 00:24:03,155 Sara Dong: Thank you to Christine, Daniel and Clinton for joining Febrile today. 344 00:24:03,605 --> 00:24:08,855 As a quick reminder, you can also check out episode number 64, which is called 345 00:24:08,885 --> 00:24:11,355 Revenge of the Cyst and featured Dr. 346 00:24:11,355 --> 00:24:12,755 Cesar Berto and Dr. 347 00:24:12,755 --> 00:24:17,705 Christina Coyle who also discussed a different case of neurocysticercosis. 348 00:24:18,395 --> 00:24:20,225 Thanks again for listening to Febrile. 349 00:24:20,765 --> 00:24:23,825 As always, you can check out the website, febrile podcast.com where 350 00:24:23,825 --> 00:24:27,335 you'll find the Consult Notes, which are written complements of 351 00:24:27,335 --> 00:24:31,415 the show with links to references, our library of ID infographics 352 00:24:31,415 --> 00:24:32,945 and a link to our merch store. 353 00:24:33,575 --> 00:24:36,395 Please reach out if you have any suggestions for future shows or want 354 00:24:36,395 --> 00:24:37,655 to be more involved with Febrile. 355 00:24:38,015 --> 00:24:40,595 Thanks for listening, stay safe and I'll see you next time.